A bit shocked........Is this how it really is in the NICU?

[DrJ2B]

Hey all!

I shadowed in the NICU in Italy and I was a little shocked at what I saw in terms of procedures done on neonates. It all seemed so barbaric. For one thing, they did not use anesthesia or pain killers or anything on the babies when they were doing painful procedures. A few examples:

1) One baby had suspected neonatal hemochromatosis. They needed to get a bone marrow aspirate and a lip biopsy/tissue sample. I think the reason for the later was that the area seems to be a good area to find evidence of iron overload or concentration in cells. Anyway, they did both procedures back to back without any form of anesthesia/pain killers/medication to decrease the pain. I saw the baby grimace in pain. I wanted to say something, but, of course, that would not have been appropriate. The peds heme/onc took a few aspirates from the baby's thigh region then another doctor used a scalpel and took a few tissue samples from the baby's lip.

2) One baby who had just been delivered via c-section and who the doctors knew had a congenital diaphragmatic hernia was intubated, but her oxygen saturation was too low considering that the highest level possible of oxygen was being delivered. They suspected a pneumothorax so they did a chest x-ray which confirmed this so they had to put in a chest tube. They took a tool which looked like a screw driver and the attending told the resident to push it swiftly into the right part of the baby's chest. It seemed to freakin' barbaric. I could not believe that nothing was used to help the baby. It must have hurt like hell.

I am very interested in neonatology and I would really like to know if this is the norm or are these procedures done differently in the U.S. I could not even explain how awestruck I was. I realize that some procedures are very painful, but there must be something you can give a neonate to help with the pain, either by numbing it or relieving it. I am only going to start my second year in medical school so I do not know much about neonatology but hope to shadow some neonatologists this coming year. I would appreciate any clarification. I was just so upset and shocked and I hoped the same thing does not happen in the US.

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[kickazzz2000]

I have been instructed to drop my notes and pen and "get a god damn needle in the chest now" (by my fellow) when the neonate we had just brought back from the delivery room was tachypneic and transilluminating. you do not have time to flip around with a suspected pneumo.

for the bone marrow, our program generally sedates the kids, but in the past i believe that they did not. that kinda sucks cause generally a bone marrow is not as emergent.

 

[drv]

PAIN MANAGEMENT IN NEONATE IS ONE OF THE MOST DEBATED TOPICS.
If you areinterested to know there are many articles written on it. If it is an emergency then you may not have time ..but mostly its lack of knowledge. But now people are becoming more and more aware.following link will help you. there are many such detailed articles on the topic.


http://www.cps.ca/ENGLISH/statements/FN/fn00-01.htm

regards
DRV

 

[oldbearprofessor]

Hey all!


I am very interested in neonatology and I would really like to know if this is the norm or are these procedures done differently in the U.S. I could not even explain how awestruck I was. I realize that some procedures are very painful, but there must be something you can give a neonate to help with the pain, either by numbing it or relieving it. I am only going to start my second year in medical school so I do not know much about neonatology but hope to shadow some neonatologists this coming year. I would appreciate any clarification. I was just so upset and shocked and I hoped the same thing does not happen in the US.

Greetings:

When I started in neonatology, people were just beginning to understand neonatal pain. I can't remember the exaxt year, but in the early 1980's there was even a 60 Minutes report on doctors doing surgery on babies without pain medicine. This rapidly changed in the early and mid-80's.

More recently, there have been major changes in how we view the world of the preterm or otherwise ill infant. Programs of developmental care, often referred to as NIDCAP programs (easy to look up if you're interested) have led to new insights into multiple ways of improving the care of infants, including efforts, both pharmacological and non-pharmacological to control pain.

For example, positioning a baby with his legs flexed and hands to his face can be very comforting. Using sucrose water for routine procedures such as blood draws and LP's. Regular assessment of babies using established pain scales ("CRIES" and "PIPP" if you want to look them up) have become a standard in many hospitals. Other things like decreasing lighting in nurseries and decreasing ambient noise have also been instituted.

Now, it is certainly the case, that like in other areas of medicine, emergencies can occur in which procedures are done with inadequate pain relief. A tension pneumothorax in a hypoxic infant in the delivery room would certainly qualify as one. Unfortunately, chest tube placement is never a great thing to have to do in an emergency and often there is no time or access for adequate narcotic pain relief beforehand. That doesn't mean that attention shouldn't be paid to pain relief as soon as possible.

With regard to what you saw, I can't comment on what I didn't see. However, it is generally true that some of our concepts in this area have not been universally adopted. I spend much of my time in developing countries introducing some of these ideas and they are not necessarily accepted everywhere, even in the US or Europe. Ultimately, if you see inappropriate pain managment in one hospital - look elsewhere, you might see something very different. I am sure that quiet, darkened nurseries, with good positioning of babies and careful attention to developmental care will become the standard globally, but it may take a while.

Regards

OBP

 

[HowUdoin]

OBP,

I was curious about how often are you confronted with an ethical issue ie. keeping a neonate alive despite a grim prognosis, or life of hardship. And does this wear on you? Thanks for your time.

 

[oldbearprofessor]

OBP,

I was curious about how often are you confronted with an ethical issue ie. keeping a neonate alive despite a grim prognosis, or life of hardship. And does this wear on you? Thanks for your time.

In a large NICU, ethical dilemmas are extremely common. There are ALWAYS babies in the NICU whose care involves difficult ethical dilemmas. Some are relative straight forward and/or self-resolving: For example (not a real case), a baby is born with a lethal condition such as Potter's sequence and needs lots of ventilatory support. Do you keep the baby alive using such support for several days while waiting for the mother/grandparents, etc can get to see the baby or for the parents to have more time with their baby? Who decides? What is the line between helping parents and making a baby with a hopeless condition suffer?

Such cases are much less difficult to deal with than the long-term ones. What does one do about a baby with terrible necrotizing enterocolitis who has no living bowel? Should the family be offered interstinal transplantation as a hope and maximum support given to the baby. What if, as can happen, the baby improves clinically and is ventilator-free but has no functioning intestine? Can you withdraw TPN and "starve the baby?" How much is this the choice of the parents vs the medical team? How much influence should the medical team use in getting the parents to do what the medical team thinks is most ethicial?

Even tougher are cases in which the basic medical problems are compounded by uncertainty in neurological prognosis. And of course, if there is a difficult family situation, that adds another layer of ethical complexity.

In broad, over-generalizing terms, people new to the NICU world (med students, residents, new nurses, etc) tend to push for more rapid withdrawal of care. I like to make sure they sit in on these conversations with the family when after making my case for withdrawal of care, the family members say something like "Are you absolutely 100% certain my baby won't have a miracle cure?" or "Why are you asking me about this, of course I want my baby posted for a heart/gut/pulmonary transplant if that will save his life?" Not infrequently this comment is made in a baby who has a very bad neurological prognosis as well as a major health problems.

There are ways to work through this, but it takes a lot of patience, persistance and even then, sometimes, situations continue on long after they shouldn't.

This is not necessarily a fun part of neonatology, but it is a real and very frequent part of it in the large NICU world, especially in academic referral centers. But, it isn't a terrible part of it either, except in the most difficult of cases. Resolving one of these situations for the best is an accomplishment that can bring satisfaction like providing good medical care.

It is, however, much more "wearing" - tiring/stressful, than putting in an art line

Regards

OBP