brain dead

[amberdt03]

Remember that I work on a neonatal/pediatric transport team.

so we get called to a hospital for a newborn whose mom's uterus ruptured. the baby was down for approx 50min before being revived. after being revived the baby's pH was 6.5. we got there pretty much all we had to do was switch over the meds to our pumps, put him on our vent, and load and go. even to me, the baby didn't look like he had anything going on "up there" and i've only been doing this since october. so we go to mom's room to get consent and to let her see him, and she doesn't appear to know that her baby probably isn't going to make it. she never really asked how he was doing, but appeared very happy to see him.

so here's my question. would you tell her about the brain damage, or not? we didn't, and we didn't make it seem like he was in bad shape. one of the nurses went over the consent, and told her that we were transporting him so he could be at a children's hospital. now i'm in no position to say anything, but one of the nurses i was with has been with the team for 16years and the other for 2-3years.

after we got done tranferring him to our nicu, i was asking the nurses what the plan would be for the little one and one of them said that they would keep him alive for about a week to perform all the necessary brain function tests, and then try and get the mom to donate the organs.

 

[Epi-do]

It is not the transport teams job to tell the mom the baby is brain dead. From what you are saying it sounds as if there haven't been any tests done yet to conclusive determine if the baby is brain dead or not. The transport teams job is to safely move the patient from one location to another. It is the job of the physicians to go over test results, prognosis, and treatment plans with the mother.

 

[JPINFV]

so here's my question. would you tell her about the brain damage, or not? we didn't, and we didn't make it seem like he was in bad shape. one of the nurses went over the consent, and told her that we were transporting him so he could be at a children's hospital. now i'm in no position to say anything, but one of the nurses i was with has been with the team for 16years and the other for 2-3years.

Do you have any evidence other than the hairs on the back of your neck that there is or is not any brain damage?

 

[amberdt03]

It is not the transport teams job to tell the mom the baby is brain dead. From what you are saying it sounds as if there haven't been any tests done yet to conclusive determine if the baby is brain dead or not. The transport teams job is to safely move the patient from one location to another. It is the job of the physicians to go over test results, prognosis, and treatment plans with the mother.

i know it's the physician's job to alert the mother, i just felt like we were giving her false hope that everything was going to be ok, even without saying anything really.

as soon as we got to our nicu the neonatologist put some electrodes on the kid's forehead and hooked it up to a machine to get an initial measurement of blood flow. the nurse was telling me they like it to be at a ten, and it was around 3-4. don't really know what the machine was, didn't think to ask. they were going to do a eeg and a cat scan the next day. i don't know what other tests are necessary to determine whether or not someone is brain dead.

 

[amberdt03]

Do you have any evidence other than the hairs on the back of your neck that there is or is not any brain damage?

just the look in his eyes, i don't even know how to explain it. and the nurses i work with who've seen this numerous times and stated it. and i would assume that because he was done for approx 50 minutes isn't the greatest thing.

 

[VentMedic]

Often the doctors will give 24 - 72 hours to see how well the baby responds. Tests will be repeated with up to 3 EEGs and brain perfusion studies that may be done to document change. Then, the doctors will give the mother their prognosis. In the meantime, care will be supportive while allowing the parents to still have hope but expressing some possible outcomes. In other words, hope for the best but prepare for the worst.

Post code on anyone, we don't always know what our efforts will bring and sometimes with experience you do get that sinking feeling. But, sometimes you are pleasantly delighted at being wrong.

 

[Epi-do]

i know it's the physician's job to alert the mother, i just felt like we were giving her false hope that everything was going to be ok, even without saying anything really.

I am willing to bet the doctors have talked to her about the prognosis and testing that will be done over the next couple days. Maybe mom is just in denial at this point, or maybe she is happy that even though she knows the most likely outcome she still gets to have a couple days with her baby. Between the hormones associated with pregnancy and childbirth, and the emotions of a normal delivery, let alone one where something goes wrong, it is hard to say exactly what the mom may have been thinking.

As long as you didn't tell her "everything is going to be ok" or something similar, you haven't done anything to intentionally/knowingly give her false hope. You took appropriate care of her child given the circumstances, and nothing more. Even though you most likely will never hear directly from the mom, when it is done and over, I am sure she will appreciate the care you gave her newborn during such a difficult time.

 

[amberdt03]

As long as you didn't tell her "everything is going to be ok" or something similar, you haven't done anything to intentionally/knowingly give her false hope.

ok. for some reason, even though nothing was said to that nature, i still feel like we were giving false hope. i guess it was her "hormones" that was just making the mom smile the entire time we were in there or the fact that she just got to see her kid, like you mentioned. i still haven't gotten used to the dying kids or seeing the kids that you know are going to die.

 

[VentMedic]

ok. for some reason, even though nothing was said to that nature, i still feel like we were giving false hope. i guess it was her "hormones" that was just making the mom smile the entire time we were in there or the fact that she just got to see her kid, like you mentioned. i still haven't gotten used to the dying kids or seeing the kids that you know are going to die.

YOU don't know for sure the prognosis is poor when you initially pick up a baby.

We will sometimes work on a baby who is s/p code for over 4 hours before we can even move the infant to the transport isolette and then several more hours in the NICU. Some babies give us surprising results depending on the etiology of what caused the code. We don't give up hope as a transport team until we are in the NICU and all has been done. To tell a parent immediately that there is no hope is very, very wrong and will put them through unnecessary stress. They will now be miles away from their baby believing it is dead when that may not be the case at all. If the baby's prognosis changes during transport or upon arrival at the hospital or sometime there after, the mother's hospital will be notified so that the necessary professionals and family are there for support.

Telling a mother prematurely would be like a lab telling you that your HIV test is positive before doing the second test to confirm that result.

Once the child is examined further, the mother will be given a more accurate prognosis and again, there will be professionals and hopefully family present when this is done. For a transport team to tell a mother the baby has little hope and then run off is not appropriate. The transport team's primary concern is to get the baby to the NICU and not to spend another hour consoling the mother after you give her devastating news. If her physician at that hospital wants to do that, he/she will be there to answer questions YOU can not at that time. That physician will also see that the mother is provided with the appropriate care after receiving the news. Essentially, you have two patients to be concerned about but the baby is the one that requires the most attention from you. Let the mother have a warm and tender moment to remember and not see "death" by your words when she looks at her baby which may be the first and last time.

We also try to take a photo of that moment and would like the mother to be smiling despite all the technology her baby is hooked up to. Usually it will be with a Polaroid camera so the mother will have a copy before we depart. When a baby dies at the hospital, we will again try to pose the child to look like they are sleeping peacefully without the technology for more photos to give the parents.

 

[amberdt03]

We also try to take a photo of that moment and would like the mother to be smiling despite all the technology her baby is hooked up to. Usually it will be with a Polaroid camera so the mother will have a copy before we depart. When a baby dies at the hospital, we will again try to pose the child to look like they are sleeping peacefully without the technology for more photos to give the parents.

we don't take pics but we fully encourage the parents and family to and allow them to do so. now let me ask you this. we had a call about 3 weeks ago for 23 week gestation twins. twin a was 290 grams and twin b was 480grams. the dr. at the sending hospital worked on both twins for 3 hours only to have both twins taken away from the family to pretty much die the next day without them there. both of them had grade 4 bleeds. the mom had a c-section, so obviously she couldn't leave. one of the nurses, took twin b out of the isolet so mom could hold her, because he knew there wasn't much of a chance. i'm pretty sure twin a was allowed to be held too. the next day when i came in, they(transport nurses and neonatologist were saying that what the dr. should have done was tell mom, sorry there's nothing that can be done, clean up both babies and allow her to hold them so she could be with them both.



so here's my question vent, what would your hospital do, would ya'll refuse the transport or just tell her that ya'll were going to do everything that could be done.

 

[VentMedic]

We will not even leave our NICU unless we know we have viable life to transport. 23 weeks is considered viable and 480 grams in not a bad weight.

Since the decision was made by the doctor at the sending facility with ACCEPTANCE from the neonatologist given which dispatched the team, the obligation to do what could be done was there. If the neonatologist felt that that the babies had such a poor prognosis, he/she should have discussed that with the sending doctor. Saying the babies should not have been sent after the fact is hindsight on the neonatologist's part.

Once the babies are placed on life support and their care is beyond the capability of that hospital, there may be no other choice at that time but to take them to a higher level of care. We transport many babies that have bad prognoses but we will keep them alive once life support has been initiated until the family can have everything thoroughly explained to them and allow them to be part of the final decision. If not, nature or the ethics committee will assist in that decision.

We also have something in the NICU that is sort of half way between full life support and terminating life support called "No acceleration of care". It means we will no longer titrate ventilator or medications up to support life once we have reached a certain point. It is an easier way for parents to deal with ending their baby's life if they can not deal with removing life support.

We as a team are comfortable enough with handling critical babies to allow parents to touch or even hold the infant. Those nurses made the correct decision. Parents see past the technology and even disfiguring abnormalities to bond even for a few moments with their baby. If done smoothly and with compassion, neither giving a lot of hope nor taking it away, the family will have a tender moment and a good memory.

 

[amberdt03]

YOU don't know for sure the prognosis is poor when you initially pick up a baby. If her physician at that hospital wants to do that, he/she will be there to answer questions YOU can not at that time. Let the mother have a warm and tender moment to remember and not see "death" by your words when she looks at her baby which may be the first and last time.

oh and i know that i have no right in anyway to say anything. 1, cause i'm not qualified, and 2 its not my job. i was talking about the nurses, one of which as been on the team for most of my lifetime.

 

[VentMedic]

oh and i know that i have no right in anyway to say anything. 1, cause i'm not qualified, and 2 its not my job. i was talking about the nurses, one of which as been on the team for most of my lifetime.

I meant you as a team. Since the nurses did not say anything, that validates some of my statements. They do not have the time or even the equipment to do all the tests to make that determination. Nor, has enough time passed to know if the brain and body will recover. The teams job is to get the patient from point A to point B. You can be liable for whatever misinformation you give out that causes more stress or harm.

Even in the hospital, it is neither the RNs or the RRTs that tells a patient their child is dying. That is why the physicians make the big bucks. We are there to provide supportive care or to see that the family and professionals what can do it best are nearby.

 

[amberdt03]

We will not even leave our NICU unless we know we have viable life to transport. 23 weeks is considered viable and 480 grams in not a bad weight.

really, i don't think that we normally accept anything under 24 weeks, i could be wrong though. i think that the main problem was the grade 4 bleeds more than the fact that they were 23 weeks.

Since the decision was made by the doctor at the sending facility with ACCEPTANCE from the neonatologist given which dispatched the team, the obligation to do what could be done was there. If the neonatologist felt that that the babies had such a poor prognosis, he/she should have discussed that with the sending doctor. Saying the babies should not have been sent after the fact is hindsight on the neonatologist's part.

yeah i was thinking that if the neonatalogist at our hospital didn't think the kids were viable then why would she accept the transfer? she seemed kinda ticked about it when i saw her the next day.

Once the babies are placed on life support and their care is beyond the capability of that hospital, there may be no other choice at that time but to take them to a higher level of care. We transport many babies that have bad prognoses but we will keep them alive once life support has been initiated until the family can have everything thoroughly explained to them and allow them to be part of the final decision. If not, nature or the ethics committee will assist in that decision.

i think that the dad came to our hospital the next day to terminate life support. one of the nurse's was saying that because the dr at the sending facility revived them, that to the parents it would feel like they were "killing them" by having to sign off for termination of life support.

We also have something in the NICU that is sort of half way between full life support and terminating life support called "No acceleration of care". It means we will no longer titrate ventilator or medications up to support life once we have reached a certain point. It is an easier way for parents to deal with ending their baby's life if they can not deal with removing life support.

i wander if our hospital offers something similar, i'm gonna have to ask.

We as a team are comfortable enough with handling critical babies to allow parents to touch or even hold the infant. Those nurses made the correct decision. Parents see past the technology and even disfiguring abnormalities to bond even for a few moments with their baby. If done smoothly and with compassion, neither giving a lot of hope nor taking it away, the family will have a tender moment and a good memory.

yeah, this family needed a good memory. apparently they've had a hard time getting pregnant, and they've had a couple of miscarriages and then to get pregnant again with twins, only to lose both of them is just tragic.

 

[amberdt03]

I meant you as a team. Since the nurses did not say anything, that validates some of my statements. They do not have the time or even the equipment to do all the tests to make that determination. Nor, has enough time passed to know if the brain and body will recover. The teams job is to get the patient from point A to point B. You can be liable for whatever misinformation you give out that causes more stress or harm.

Even in the hospital, it is neither the RNs or the RRTs that tells a patient their child is dying. That is why the physicians make the big bucks. We are there to provide supportive care or to see that the family and professionals what can do it best are nearby.

oh ok. thanks for clearing that up for me. you know after being with this team even for just a short time, it kinda makes me scared to have kids.