#361 - Dr. Isabella Eiler - Exploring risk factors related to obtaining umbilical cord blood gas samples

Hello friends 👋

In this episode, I had the pleasure of speaking with Dr Isabella Eiler from the Medical College of Wisconsin, Milwaukee, Wisconsin. She is originally from the Milwaukee area and first attended the Medical College of Wisconsin for medical school. She then went on to complete her pediatric residency at the Indiana University School of Medicine. In this episode of Rupa's Fellows Friday, Dr. Isabella Eiler discusses her journey in neonatology, particularly her interest in NeuroNICU and hypoxic ischemic encephalopathy (HIE). She shares insights from her research on missed opportunities for neonatal assessments and the importance of multidisciplinary collaboration in improving patient care. Dr. Eiler emphasizes the significance of mentorship during fellowship and the impact of social determinants on neonatal follow-up care. She also reflects on the challenges faced in research and offers valuable advice for future neonatology fellows.

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Short Bio: Dr. Isabella Eiler is a third-year neonatology fellow at the Medical College of Wisconsin in Milwaukee. She received her medical degree from the Medical College of Wisconsin. Her research has focused on neonatal medicine investigating what factors predispose neonates to thrombi formation with a central line as well as studying how parents reading to their child in the NICU affected their language and development. She has volunteered to provide health room needs for local elementary schools and raised money to donate infant sleep sacks to promote safe sleep in her institution’s nursery. She enjoys spending time in nature, hiking, practicing archery, and played Division 1 golf at Butler University.

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The transcript of today's episode can be found below 👇

Srirupa

Hello everyone, welcome to another episode of Rupa's Fellows Friday. I am delighted to welcome Dr. Isabella Eiler, who is our third-year fellow at the Medical College of Wisconsin at Milwaukee. She's originally from Milwaukee and did her medical school at the Medical College of Wisconsin and went on to do her pediatric residency at Indiana University. Welcome to our show. I'm so excited to highlight you and all the fantastic things that you've done through your three years of fellowship. Tell me how you got interested in Neuro NICU. So tell me a little bit about where that interest started, and we'll talk about this very cool project that you're involved in.

Isabella Eiler

Yeah, so it actually stems back to college days where I shadowed at Children's Wisconsin, which is our children's hospital affiliated with the Medical College of Wisconsin. I saw a baby that was flown in for therapeutic hypothermia and watched the team work in such an acute fashion and all the synchrony that has to go into all the different things that need to happen prior to starting the cooling process. I was just mesmerized by the whole thing. As you can imagine, as a college student who had no idea about anything in the medical field, it was even more enticing. And so ever since then, I've been interested in Neuro NICU, with a specific focus on hypoxic ischemic encephalopathy or HIE.

SrirupaI

always feel like being in college and medical school is the best time because you have so many possibilities from then on. And so you get interested in so many wonderful things in medicine. And I'm so glad you got interested in neonatology and specifically HIE. That's fantastic.

So just to get a little bit more information about your project: you did this amazing study where you looked at missed opportunities for neonatal assessments for umbilical cord sampling. I would love to understand and know more about this project, because I think as neonatologists, we face this so much. We know that a baby potentially might be at high risk for a perinatal hypoxic event, and yet there are times that we may not have cord gas data. And there are times we may still have cord gas data, but we may not have done a Sarnat exam. So I’d love to hear what you found and how this project came about.

Isabella Eiler

In medical school, I met Susan Cohen, who's my current mentor in the fellowship program. When I matched at the Medical College of Wisconsin during the last parts of my residency, I started to attend their twice-monthly Neuro NICU meetings. I got to hear about projects aiming to improve documentation and evaluation of infants affected by HIE who had poor cord gases. I wanted to take it a step further and look at how we could increase the number of cord gases being done, because our institution does not practice universal cord gas sampling. Some institutions do, and others have stricter guidelines. Ours is more based on provider discretion. So I looked at whether in high-risk deliveries we’re actually obtaining cord gases for infants who would benefit from that added evaluation with a Sarnat exam.

Ultimately, I did a retrospective cohort review of 2019 and 2020. Of over 6,000 deliveries, around 11% qualified as high-risk deliveries. As a team, we defined high risk as including umbilical cord prolapse, placental abruption, shoulder dystocia, expedited delivery (C-section or instrumentation), or if the infant was depressed at delivery (specifically, a five-minute Apgar score ≤5). We then looked at how many had a cord gas attempted and how many had an arterial sample result. I wanted to track attempts as well, because sometimes labs are clotted or get lost. We found that 61% of our high-risk deliveries had cord gases attempted, and of those, 50% had an arterial sample result. So without strict guidelines, there's inconsistency in which deliveries get gases.

We looked at intrapartum factors that were more likely to have a cord gas drawn. We saw that category III fetal heart tracings, meconium-stained amniotic fluid, emergency C-sections, and instrumentation (especially vacuum-assisted deliveries, over forceps deliveries) were more likely to have cord gases drawn. Now we want to work with our OB team to develop a QI project and create a more structured guideline to improve this process.

Srirupa

That's fantastic. What do you envision your protocol doing in terms of improving the current practice?

Isabella Eiler

I think it's about identifying those factors before the delivery occurs. If NICU is present, we’re also trying to improve the consistency: if we’re there, there should be a cord gas drawn so we can assess the infant more appropriately in those first moments. Also, if there's a concerning tracing (not necessarily category III, but still worrisome) that should prompt a cord gas sample.

Srirupa

That’s amazing. I’m sure that gives you opportunities for a lot of multidisciplinary collaboration with the OB team. One thing that stood out when I was reading your bio was that you received a grant from the Kern Community Foundation for Well-Being and Social Connection, specifically to increase multidisciplinary relationships between Neo and MFM fellows. That's fantastic. I think we all need someone to advocate for that relationship, because we work so closely with them. Tell me more about that and what you wish to do with the grant.

Isabella Eiler

Yeah, it was awesome. We utilized the grant last year, and it basically allowed funds for our programs to support fellows being off service for a day so we could all get together and get to know each other. So now, when I go to a delivery that an MFM fellow is attending, I know their face, I know who they are, and that improves care. There's more trust, more communication. If I ask for a cord gas that wasn’t originally planned, there’s less questioning because they understand where I’m coming from. We’re trying to evaluate this infant at risk for HIE.

Srirupa

Absolutely. And I feel like we should replicate that at every institution. MFM and pediatric surgery are two areas that we as Neo fellows work closely with. So any support to build better collaboration is fantastic.

Now, I want to take this opportunity to also help future Neo fellows understand how the first year of fellowship looks. For the most part, you'd probably agree that the first year is about figuring out who would be a good mentor and what area within neonatology resonates with you. You found your niche in Neuro NICU. So a two-part question: how did you find your mentor, and what would you have done if you didn’t have someone specific to Neuro NICU?

Isabella Eiler

Yeah, I got lucky. I met Susan Cohen when I was a medical student and wanted to work with her again when I returned for fellowship. I think talking to your program director once you match is important and say, “Hey, this is my interest. Is there someone doing research in that area?” Starting those conversations even before arriving on campus helps, because the first six months are already busy with clinical work and studying for boards. If your institution doesn’t have someone in your niche, like Neuro NICU, look for collaborators in related fields, like neurology for neonatal research, infectious disease if that’s your interest, etc. You can partner with someone outside neonatology and still pursue meaningful research in your area.

Srirupa

That’s amazing. I see that you’ve had a couple of first-author publications, some during residency and fellowship, which is fantastic. One article I noticed was on the impact of social determinants of health on follow-up in neonates requiring neurocritical care. Tell me about that project, because I do think there are many factors that play a role in access to appropriate care.

Isabella Eiler

Yes, I did that project during residency at Indiana University School of Medicine with my mentor Beatrice Stefanescu, who’s still a great friend. Our Neuro NICU had a specific follow-up clinic, and we wanted to improve attendance. Our institution has a wide geographic reach throughout Indiana, but the clinic was in central Indianapolis. We found that public insurance vs. private, lower zip-code-associated income, and living farther from the clinic were associated with worse attendance. The team is now working on interventions during the NICU stay to address those gaps and ensure better follow-up.

Srirupa

That’s amazing. Given your strong record of first-author publications, when is your current project getting published?

Isabella Eiler

Yes! We're currently writing the manuscript. We added data from an additional year that still needs to be analyzed, so once that’s done, we’ll move forward with submission.

Srirupa

That's awesome. So where are you taking your interest in neurocritical care from here? Third year is such an exciting time and so many directions to go.

Isabella Eiler

I'm planning to continue focusing on neuro and acute care research. I’ll be returning to Indiana University School of Medicine, working at Riley Hospital with Beatrice Stefanescu. I hope to expand our tools for assessing HIE and conduct more clinical and prospective research to improve outcomes for these infants.

Srirupa

That’s fantastic. Your life has come full circle, going back to Indiana where your pediatric journey started. I always want this podcast to also highlight the challenges of doing research during fellowship. What were some challenges you faced, and how did you tackle them?

Isabella Eiler

Yeah, I think one of the challenges is that when you think of a research project, you kind of think of it in your own silo. Expanding that to work with the MFM colleagues, OB colleagues in general, and the newborn nursery meant that I wasn’t just thinking of the problem from a NICU perspective and asking, “How can I get more numbers?”

Sure, we could always do universal umbilical cord blood gas sampling, but we also needed to work with our OB team to consider cost, the technical aspects of who’s drawing the labs, and how to best serve all three specialties affected by increasing sampling. I think knowing early on that this would be a challenge, I made it a priority to ensure that everyone had a place at the table. Including them in my research group from the beginning was how I started to tackle that: making sure I was talking to the OB team and the newborn nursery team, and ensuring that our efforts aligned across specialties to better serve our patients.

Dr. Brock Polnaszek joined our team back in October of last year and has been really enthusiastic about improving this project. We’re currently doing a survey at our institution to assess perspectives on umbilical cord blood gas sampling. We have some preliminary results, and we're looking at what people have identified as barriers to obtaining the gas, hoping to target those areas from a QI perspective.

Srirupa

Yeah, that’s amazing. I think you tend to develop such great relationships as you face these challenges too and trying to understand all the nuances of your research. It seems like that’s worked out really well for you. And it sounds like you have a fantastic relationship with your mentor. What are some of the lessons you’ve learned from your mentor that you hope to carry forward?

Isabella Eiler

I've learned a lot of lessons from her, which has been great. One of the biggest is really learning how to pivot in your work. If you hit a challenge, that doesn’t mean you have to stop all the work you've done so far. You need to figure out how you can shift and move forward in a new way. I feel like that’s something you learn as you go through medicine: when you're blocked by a challenge, don’t quit; figure out a way around that wall. That’s definitely one of the best things I’ve learned from her.

Srirupa

I feel like fellowship is that time when you kind of pick up the things you want to carry forward in your career, and that’s such a great lesson to take with you. That’s amazing. If you were to give some advice to future Neo fellows who might be interested in your line of work?

Isabella Eiler

I think it goes back to what I’ve learned from my mentor. If you hit challenges, talk through them with the multiple specialties that your work might affect. Talk to OB, talk to neurology, and say, “I have this data, I’m interested in this research, but I’ve hit a roadblock. How do you think I can move forward?” Asking for help is one of the biggest things I’ve learned during fellowship. Sometimes you think you should know everything by now, but you’re still in training. Knowing that it’s okay to ask for help is so important. So I’d say: ask for help, work with your colleagues, and build those connections. That’s the best way to get through the challenges.

Srirupa

Medicine is teamwork, and it’s important to collaborate and get all the help you need to bring your project to completion, which is great. Well, that’s wonderful. It sounds like your life is taking you back to Indiana, and I’m very excited about that. The place is going to be extremely lucky to have you with your very specific interests.

Thank you so much for joining us on our episode today. I'm very happy and delighted to highlight you. Thank you.

Isabella Eiler

Thank you so much for having me. I appreciate you taking the time.te you taking the time.