Teaching intubation with cadavers: generosity at a time of loss.

The baby seemed impossibly small. His estimated fetal weight based on ultrasound had only been a little over one pound, and now, at the moment of his birth, he looked even smaller. His mother had been brought to the hospital in premature labor two days earlier. Shortly after admission, she and her husband had met with me. The three of us spoke at length about outcomes, options, and decisions that must be made. I was willing to attempt resuscitation and intensive care measures, and equally willing to withhold them and provide only comfort care. But the couple asked that everything possible be done to try to save their child, and I agreed to do so. The birth occurred in the early afternoon. A large team from the newborn intensive care unit attended. When he was delivered, the baby was not breathing and his heart rate was very low, so endotracheal intubation was immediately attempted. Intubation of a baby this small is often very difficult, and there is clearly a learning curve. In an academic unit such as this one, the first attempt at a procedure is often done by a trainee. But given the infant's remarkably small size and the presumed difficulty of the procedure, I assigned the task to an experienced practitioner. Nevertheless, the first two attempts at intubation were unsuccessful, and finally I intubated on the third attempt. The infant responded well to the resuscitation--his heart rate increased, as did the oxygen saturation of his blood--and he was taken to the NICU. Although the infant initially stabilized, over the next day his respiratory status deteriorated, as is often the case with extremely preterm infants. Despite our efforts, it eventually became clear that he could not survive. The nurse and I discussed the situation with the parents, and all agreed it was time to remove the monitors, endotracheal tube, and ventilator so that the baby could be held by his parents in his final minutes. The nurse and I stayed with the couple as they sat together in a private room, taking turns holding and kissing their son. Words of condolence were expressed. Pictures were taken. Questions were answered. I asked if the parents wanted a few minutes alone with their baby, but they did not. After about thirty minutes I held a stethoscope to the baby's chest, heard no heartbeat, and told them he had died. They kissed their son goodbye, and the nurse took the body away. "Let me tell you again how very sorry I am that we were unable to save Jeremy," I said. "He was a beautiful child, just born too early." "We know you all tried your best, and we appreciate it," the father said. "And we couldn't have lived with ourselves if we hadn't tried. Please tell everybody thanks." "I will. And I want you to know that you can contact me at any time with questions or concerns--in a day, a month, a year, whenever you think of them. But there are a couple more things I need to talk to you about right now," I said. "The first is, whenever a baby dies, we offer an autopsy to the parents." I briefly explained what this would entail and what we might learn, but the parents declined, and I told them that was fine. "The second thing I want to talk about," I continued, "is the tube in his mouth that went into his trachea, so we could get air into his lungs. As you know, he needed it placed very quickly after he was born in order to have any chance of survival, but getting it placed is tricky in a baby this small. The first person who tried couldn't do it, despite being very experienced. Thankfully we managed to get it in quickly, and so we were able to at least give him a chance. But this can be a very difficult procedure, and we work hard to be sure that the staff is as good at it as possible." I paused a moment. "I'd like to ask your help with that. Would you give us your permission to use Jeremy's body--gently and respectfully--to show some of the staff how to place the tube, so they would have a chance to practice? …