Failure....

Following up my triumphant post with this one is hard.  I can't stop thinking about it though. 

There are two teams that we "round" with in the morning, each with it's own set of patients.  My patients are all with team A, which we had already rounded with.  We were currently rounding with team B when the pager went off "Term 40 wk infant.  Forceps." Usually there are two attendings and when something like this happens the second attending, the one not rounding would go, but as chance would have it we were short staffed on B with only one attending for the day.  Being an easy delivery and me with no patients to present for team B, I thought nothing of it and opted to go by myself so the team would be able to keep rounding.  I should have known...

I get into the room and the nurse gives me report, basically it's as simple as that pager made it sound.  This mother has no risk factors what-so-ever, except that the baby is having trouble descending and they might have to pull it out with a device that looks similar to large stainless steel salad prongs, in which case they would need my team (high risk delivery).  I wait several minutes trading small talk and jokes with my team of nurses and respiratory therapists.  The OB doc finally decides to make the delivery a bit easier and do a cut on the vaginal opening (basically it makes it a bigger hole for the baby to come through).  I hear the 18 year old dad murmur a quiet, "Awesome..." as the doctor cuts his significant others genitals, my team exchanges questionable glances.  With that cut suddenly the baby is "crowning" (you can see it's head).  As it comes out to the neck a gush of fluid rushes out with it...it has thick meconium...suddenly this is a real high risk delivery.  I run through my head what we need and quickly order them to get the special aspirator and intubation tubes in case, God forbid, we would have to intubate him. 

Meconium is baby poop.  When the baby is older (like this one) and it is stress, sometimes it will have a bowel movement inside of the uterus.  The baby then risks aspirating this when it takes it's first breaths.  This is a very serious thing (see Tickle Me ECMO post). 

I've seen meconium deliveries before, every time the baby was born through it, it would cough a little and start crying.  My attendings had told me that if they ever come out and are not crying and the heart rate is low, you need to act fast.  What you should do is pull out your scope and temporarily intubate, put a suction tube down into the trachea and quickly remove any meconium plugging the airways.  I KNEW this...I even talked myself through it as soon as I saw the meconium.  (The moment I saw the meconium I had the head attending paged to the room, but it happened to fast for him to help). 

For whatever reason, the baby came over and I issued the orders.  We checked heart rate, deep suctioned, and put him on blow by.  Just as I was suctioning for the second time the baby sputtered and started whailing (THANK GOD!!!).  Suddenly this very blue floppy baby turned peak and became a very irritated, very pink newborn (which is a VERY good thing).  As the baby stabilized my attending came in with the other residents and everyone congratulated me on managing this baby, a job I really never should have managed on my own...honestly though every praise I received felt false...I knew they all meant it, but deep down I knew what had really happened, for whatever reason I froze up and instead of doing what I was supposed to do, I did what I was comfortable with.  I may have kept that baby alive, but it was by shear dumb luck...my hesitation and cowardice could have really hurt him.  When we were alone outside and I was running through the delivery with the attending, I couldn't help it...I had to know if I had really not done what I was supposed to.  I ran the whole scenario through to him and he confirmed what I knew from the very beginning when I saw the baby covered in that thick green goop, I shouldn't have hesitated in scoping that kid and suctioning him out. 

Thinking back to why I didn't I at first I thought of a lot of different reasons.  I was uncomfortable doing it (I had only done it twice and only one time successfully - all on stable children, not like this).  Nobody else on the team suggested it.  The baby did fine without it.  Maybe the baby didn't need it.  What I finally ended up concluding was that I failed.  I failed in being the leader I was supposed to be.  I should have been the confident leader, but when the time came I didn't make the decision I knew that was right, instead, I made the decision I was comfortable with.  I failed my attending who trusted that I could handle this (true the child was alright...but not because of me).  Most of all my courage failed me, I wasn't the bold, confident leader that I was called to be in there...I was a scared out of my mind peon that doesn't deserve to call himself a doctor.  Maybe I'm being to harsh on myself, but everytime I think of what happened today I cringe...today I failed.

Newbie Doc

Tomorrow's another day though, maybe God will give me the chance to make up for it.