Lessons in Crisis Management from the Precipitous Delivery of my Own Newborn

18 hours into a scheduled induction, my wife vomited while being rolled over in bed (apparently watching your legs move when you can’t feel them from an epidural is pretty disorienting). After the bed was cleaned up, a brand new nurse on her 3rd day of orientation was left behind to put the fetal monitor back on. Five minutes and an entire bottle of gel later, she couldn’t find the baby on the monitor. I suggested nicely that she get some assistance from her preceptor. As she went to walk out of the room, we all of a sudden heard…

A SQUISH.

As I jumped up from my book, I thought out loud: “what the hell was that?!?”

I lifted my wife’s gown up and saw the upper half of a purple apneic newborn sticking out from the perineum, just lying there limp on the bed. The nurse orientee started screaming and running around in circles (not a terribly effective stress response, it turns out). I hadn’t delivered nor resuscitated a newborn since residency, but fortunately acted nonetheless. I pulled him the rest of the way out, then started drying him off with the bedsheets, flicking his feet and rubbing his immobile chest and back. Clear fluid was coming out of his nose and mouth. I caught the nurse during one of her frantic orbits and redirected her to the baby warmer, told her to turn it on and grab me the bulb suction. I suctioned out the overflowing nose and mouth, and continued to stimulate and dry the baby.

Around the time he started sputtering and crying, a couple other staff came in the room. None of the them knew how to get a hold of a provider, nor anyone in the NICU. Shortly thereafter, he was pinking up and crying vigorously. I know time slows or flies under stress, but it was a few minutes between “the squish” and when someone who could competently take him off my hands showed up. Luckily for all of us, he didn’t require any additional support, nor has any (that we know of) sequelae as a result of his dramatic entrance into this world.

What can be learned from this bloody mess?

This is a very personal story, and one that is still raw in many ways after all of this time. I share it because I hope others can benefit from these lessons learned. These apply not only to precipitous deliveries, but also to other crises and unexpected situations.

Stay calm or get calm

Box/tactical breathing is an effective way to calm yourself down

I don’t have to tell those of you in the medicine or aviation or tactical business the importance of keeping your cool when “it” hits the fan. When crisis occurs without warning, if you don’t automatically go into performance mode, you need to intentionally slow yourself down in order to function effectively and think clearly. I was, to my great relief, quite calm and methodical throughout this situation, which does not come naturally to me. I’m usually in the camp that recognizes the stress and brings myself back down from the red quickly.

This tenet has a natural contrast in the reaction of the orientee nurse. (For the record, I hold no ill will towards her; she was left in a terribly vulnerable position by her preceptor and organization). She freaked out and lost all ability to be functional. Perhaps if she had at least screamed louder it would have caught the attention of some additional assistance. In that moment of stress, her hands and brain were not functional; she was in flight mode. Staying calm helped me reach deep (I mean, deeeeep) in my brain for what to do in the moment, and gave me the gross motor skills to get the resus moving forward.

I read a great book called The Obstacle is the Way, and one powerful passage from it sticks in my mind - in a stressful situation, ask yourself:

“Does getting upset provide [me] with more options?”

It goes on to read: “Sometimes it does. But in this instance? No, I suppose not. If an emotion can’t change the condition or the situation you’re dealing with, it is likely an unhelpful emotion. Or, quite possibly, a destructive one.”

Take charge

Earlier this year, I finished my officer training for the Air Force (which is a story for another blog). During those weeks, I repeatedly heard the phrase: “If you are in charge, take charge.” A crisis demands leadership, someone to get the ball rolling and direct it towards the goal. In this case, I didn’t have a lot of choice in the matter, as the only trained person in the room. Instead of staying passive and introspective, I became vocal, giving orders and specific directions to the orientee nurse, as well as the other staff that trickled in. They didn’t know my secret doctor identity until later, but I came off as in charge and knowledgeable, and they got on board. This is perhaps more important in a group of clinicians, all of which have ideas and want to lead. Someone, and only one person, needs to take charge quickly, and lead out of crisis (integrating the inputs of others, of course).

Do the basics well

My memory of the nuances of neonatal resuscitation with the cute diagrams and flow charts was very fuzzy at the time. What I did have was an intuitive and functional understanding of the basics of delivery and resuscitation, which got me most of the way.

Back in EMT school, my instructor correctly asserted that in order to be a great paramedic one day, you had to be a great EMT first. It was those “basic” skills which would be the bedrock of our work at the higher level. How many emergency medicine residents or young paramedics do you know who are solid with a laryngoscope, but can’t get a good BVM seal to save their own life, let alone their patient’s? In training, learners can get fixated on the tips and tricks, the sexiness of certain procedures and conditions, before the basic concepts and maneuvers are truly internalized. The basics must be mastered and continually practiced.

In the case of my baby’s situation, the basics were recognizing immediately that he was in trouble, getting him out, drying and stimulating, suctioning out the copious secretions, and getting a warm receiving/resus area ready.

By no means am I suggesting that you stop at the basics and slack off on developing true expertise for your day to day work; master it all, but the basics should be etched in stone.

Work with what you got

I feel privileged to have worked and trained at public and county-style hospitals, where the equipment was often cobbled together, the contents of surgical trays were always changing, and the exam and procedural spaces were limited. I used whatever I could get my hands on, saw patients anywhere, and did many procedures by the headlamp I brought from home. As such, I’ve never been particular about how I get from point A to B, and am unfazed by non-standard environments. On the other hand, I know some docs that get cranky without their favorite type of suture and the bed at just the right height, or when things don’t go exactly as planned.

With my slippery bloody baby in front of me, I would have loved to have been fully gowned and have access to an OB kit, a team of seasoned nurses, and a NICU team down the hall. Instead I had my bare hands, fresh bed sheets, and whatever I could dig up in the unprepped delivery room. Fortunately, this lack of ideal resources didn’t bother me; in fact, the lack of equipment to choose from probably preserved some of my limited cognitive bandwidth and allowed me to focus on the task at hand.

Lack of comfort and familiarity abound in a crisis situation, and this can mentally and technically handicap those who are out of their comfort zone. Your stress level, and your patients, will suffer. Flexibility and improvisation are the names of the game in a crisis, and perfect is truly the enemy of the good (with apologies to Voltaire).

Run at what scares you

We all have our areas of medicine in which we are less certain, less comfortable. There are those age groups of patients, or conditions, or procedures some hope they’ll never encounter on this or any shift. At the pointy end of the spear you never know what you may face, and you need to be ready to deal with anything. Instead of avoiding those things which scare you, charge headlong at them and learn.

In emergency medicine training, we get (at least I did) pretty minimal training in emergency childbirth and neonatal resuscitation. I hadn’t delivered a baby since residency, more than several years ago. Coincidentally, I had been training to join my institution’s HEMS team, which was trying to carve out a niche in high risk OB and neonatal transports. I couldn’t imagine two types of transports I was less qualified to do. My personal stance is that if a service is going to put a doctor on an aircraft or ambulance, that physician had better bring serious expertise. Flight medics and nurses are amazing and extremely capable, so the doctor should really add value. In response to my lack of comfort, I put in an uncanny number of hours learning and training, from basic neonatal resus and procedures through neonatal vent management. That exposure came in real handy on the afternoon my kiddo shot out into the world.

Hope is not a strategy when it comes to medicine. Don’t hope that you will be able to get by and manage what scares you when the time comes. Don’t just hope it will never present itself. Run at it – see every case you can, train, listen to podcasts, talk to seasoned vets… become an expert.

Debrief with all involved

It’s commonplace for us to debrief, even informally, with members of the team after tough cases. This can be extremely helpful to clear up misconceptions, identify areas of learning, and start to process what happened.

When things go sideways, do we routinely debrief with the patient, family, or other staff involved in the case? (I’m not suggesting including family or the patient in the initial team debrief here).

Do you know how many staff members, unit/hospital leaders, and providers came by to talk to my wife and I after our little episode in the delivery room? Exactly zero. Not once did anyone come by to see how we were doing with what happened, to offer explanation or apology. Our midwife, who had previously been quite attentive, completely ghosted us; she only swung by very quickly a day later to drop off a prescription. We definitely never saw that ill-fated nurse orientee again.

When we met with our primary obstetrician two weeks later, he had not been informed about the incident, and was dumbfounded at our tale. To his credit, our OB (coincidentally, the chair of the department) took this quite seriously. Within the next month, he instituted new policies regarding supervision of orientees, as well as unit-wide OB crisis management training.

My wife as patient, and I as family, had important observations and opinions which were never sought by the staff. We also never heard the perspective of those in attendance, to help us understand where they were coming from, or what happened from their end. This would have helped provide some closure for all involved, shined a light on gaps in knowledge and procedure to mitigate crisis in the future, as well as decrease the stress on everyone.

In all fairness, this was only a near miss. I’m sure we would have had more discussions if I wasn’t in the room, and the baby was in the NICU with a hypoxic brain injury. However, it was a near miss that exposed some system and staff issues.

Look around and think outside of your immediate sphere when it comes to debriefing next time; who else might be affected? That police officer who saw you do a finger thoracostomy on scene may be really freaked out. The first-in EMT who put her soul into CPR for that shooting victim may be heartbroken and confused when you stopped chest compressions as part of your traumatic arrest protocol. Definitely consider talking to the patient and/or family who experienced it all, when appropriate.