#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.

----

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.

----

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

Srirupa (00:01.07)

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 she did her medical school at the Medical College of Wisconsin and went to do her pediatric residency at Indiana University and is currently almost about to graduate, I would say. Would you agree, Isabella?

Isabella Eiler (00:27.869)

Yes, very close.

Srirupa (00:29.814)

Yes, 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 NeuroNICU because it seems like when I read your profile, I saw that that was your primary highlight. 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 (00:51.7)

Yeah. So it actually stems back to college days where I actually shadowed at Children's Wisconsin, which is our children's hospital that's affiliated with the medical college of Wisconsin. And I had seen a baby that was actually flown in for therapeutic hypothermia and watched the team work in such an acute fashion, all the synchrony that has to go into all the different things that need to happen prior to starting the cooling process. And 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.

Srirupa (01:34.018)

Yeah, no, I always feel like being in college and medical school is like 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 kind of get a little bit more information about your project. So you did this amazing study where you looked at missed opportunities for neonatal assessments for umbilical cord sampling. And I would love to understand and know more about this project because I think as neonatologists, we face this so much that, you know, we know that this 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 that we may still have cord gas data, but we actually may not have done a Sarnat exam. So I would love to hear what you found and how this project came about happening.

Isabella Eiler (02:31.262)

Yeah, so it was great. actually, so in medical school, I met Susan Cohen, who's my current mentor as in the fellowship program. And when I had matched at the medical college of Wisconsin during the last parts of my residency, I started to attend their twice monthly neuro NICU meetings that the team was doing. And I got to hear about the projects that they were trying to improve documentation as well as evaluation of infants who were affected by HIE had poor, poor for cord gases. And then I wanted to take it a step further and look at how we could actually increase the N of our cord gases that were being done because our institution is not one that does universal cord gas sampling. I know some institutions do that and some have more strict guidelines about which infants should have an umbilical cord blood gastron and ours is more up from a provider discretion perspective. And so I wanted to look at if in high risk deliveries, we're actually obtaining cord gases for infants that would benefit from that added evaluation with a Sarnet exam. And so ultimately, I did a retrospective cohort review of the years 2019 and 2020 and saw that of our over 6,000 deliveries, we had around 11 % that would have qualified for high risk deliveries, which as a team, we came up with having umbilical cord prolapse, placental abruption, shoulder dystocia, if the delivery was expedited from a cesarean or instrumentation perspective, or ultimately if the infant was depressed at the time of delivery. So if their five-minute apgar was less than or equal to five. And based on that criteria, 11 % qualified. And then we wanted to look at how many actually had an umbilical cord blood gas attempted at the time of delivery, as well as which ones had an arterial sample result. I wanted to look at attempted in general to see what our institutions interest was in actually getting the sample because obviously sometimes a lab could be either clotted or just doesn't make it to the lab for some reason it got lost in the tube system and want to do account for that as well. so ultimately we had 61 % of our high risk deliveries have umbilical cord blood gases attempted and of those all 11 % of the high risk deliveries we actually had 50 % have an arterial sample result. And so, based on that, we made the assumption that without these strict guidelines in place, there is inconsistencies in deliveries that are getting umbilical cord blood gases attempted. And so we looked at what intrapartum factors would be more likely to have a cord gas drawn. And we saw that category three fetal heart tones, if there was meconium stained at the time of delivery, if there was an emergency C-section that was being performed and then ultimately if instrumentation was used and actually more likely vacuum over forceps delivery. And so working on that and seeing those intrapartum factors, we now want to work with our OB team to enroll a more QI project perspective and seeing how we can actually improve this and have a more strict guideline in place for our teams to be able to act upon.

Srirupa (05:47.764)

That's fantastic. And I'm sure that that took a lot of effort to like dive into all of the retrospective data and, you know, clarify details on this. And that's amazing. What do you envision your protocol to do with the current practice?

Isabella Eiler (06:05.812)

I think trying to have more of those factors that we can determine prior to the delivery actually taking place, because obviously if Nikki's present at a delivery, we're trying to also improve that as if we're there, there should be a cord gas drawn so that we can assess the infant more appropriately in that first moments of life, as well as if there is concerning tracing that has been happening over the past few hours, not necessarily category three, but having more of a concerning tracing and leading us to get an umbilical cord blood gas sample drawn.

Srirupa (06:37.464)

Yeah, no, that's amazing. And I'm sure that that probably give you opportunities for a lot of multidisciplinary collaboration with the OB team. And I bring that point because one of the things that stood out when I was reading your bio was that you were awarded and received a grant by the current Institute of Wellbeing and Social Connection that was specifically to increase multidisciplinary relationship between Neo and MFM fellows. And that's fantastic. And I think that we all need someone to advocate for that relationship to get better because we work so closely with them. So tell me a little bit more about that and what you wish to do with the grant that you were awarded.

Isabella Eiler (07:18.644)

Yeah, so it was awesome. We had actually utilized it last year and the grant basically allowed us to have funds to one, have our programs support the fellows being gone for that one day so that we could all basically get together and get to know each other. So now when I go to a delivery that an MFM fellow is attending, I actually know their face. I know who they are and can have more of better relationship during that. And I feel like it just improves the care that you're able to provide for the patients in general when you have that more familiarity. And you're not concerned, you know, if I want to ask for a cord guess when we weren't originally going to get one, I now have a relationship with the person and they trust me and understand why I'm asking for it and not questioning the delivery process. But more, I want to make sure I'm evaluating this infant who I'm concerned about and knowing their risk of HIE in that time.

Srirupa (08:08.728)

Yeah, no, absolutely. And that's so great. And I feel like we should replicate that in pretty much every institution because we work so closely with them. feel like MFM and surgery are the two, ped surgery are the two areas that we as neo fellows work so, so closely and any support to help our relationship grow better and have options for collaboration would be fantastic. That's great. Tell me a little bit about, and I... Take this opportunity through this podcast to also help future neo fellows understand how their first year fellowship is going to look like. And for the most part, I think you would agree that the first year of neo fellowship is mostly figuring out who would be your good mentor and figuring out what area of medicine in neonatology within neonatology itself resonates to you, just like you found your niche to be neuro-nicu. So I have a question that's kind of twofold for you. One, how did you sort of find your mentor in a way and what would you have done if you didn't have someone who is not specific to NeuroNICU, which seemed to be an interest that you came in already. So help me understand that.

Isabella Eiler (09:28.288)

Yeah, and I got lucky because I actually met Susan Cohen when I was a medical student. So I knew her and wanted to work back with her when I had returned for fellowship. And so, you know, I, again, was lucky in that perspective and was able to start that relationship early, which I think is beneficial from that standpoint to actually talk with your program director for the institution that you do match at and say, hey, this is my interest. If there is a neonatologist that's specifically doing research in this area, can I start having conversations with them even before I get to campus? So that way, obviously in the first six months we’re trying to adjust clinically as well as pass our boards. So that definitely takes up a main portion of your experience in that first six months. But then having that relationship that you can start to build on and realize who you should partner with from a research perspective is something that's beneficial. And I think just being able to act early is helpful. And then again, if you don't have someone who is doing research in that area, if it's something like neuro NICU, finding a neurologist who does more neonatal research or someone else, if you're doing ID research or whatever subspecialty within the NICU, trying to reach out to those subspecialties at your institution. And maybe that could be someone that could pair with the neonatologist to give you that experience and allow you to still do the research in the area that you want to.

Srirupa (10:52.13)

Yeah, no, that's amazing. And I see that you have a couple of first-daughter publications. It seems like you've done some throughout your training in residency and fellowship, which is fantastic. I see that there was a specific article that I think recently got published on the impact of social determinants of health on follow-up neonates requiring neurocritical care. Tell me a little bit about your experience in doing that project because I do think that there are several aspects that can play a role in the most appropriate care, in this case, neurocritical care in our neonates.

Isabella Eiler (11:25.492)

Yeah, and I had the opportunity to do that research while I was in residency at the Indiana University School of Medicine. And I worked with Beatrice Stefanescu, who was my mentor during residency and still a great friend of mine. We looked at our neuro NICU had a specific follow-up clinic that we wanted to improve outcomes and obviously follow-up in general, and our institution has had a high reach of all throughout the state of Indiana, but the clinic follow-up was in central Indianapolis and trying to see what factors determined follow-up happening at that first clinic visit. And so we did find that insurance type public versus private having lower zip code associated income and living further from the clinic were risk factors that would result in worse attendance at the first follow up clinic. And so then they are working on improving the outcomes in reaching families while they're in the NICU to help try to prevent that from happening and have that follow up established more frequently afterwards.

Srirupa (12:31.724)

Yeah, no, that's amazing. looking at your record of doing first author publications, I am curious to know when your current project is going to get published. And I'm sure you're working on it being a third year fellow.

Isabella Eiler (12:42.998)

Yes, yes. In the current process of writing up the manuscript right now, we did add an additional year that hasn't fully been analyzed yet. So I want to add that data as well. But that is what we're currently in progress of doing.

Srirupa (12:54.392)

That's awesome. That's really great. I would love to understand where you're taking your interest in neurocritical care from here on, because I feel like third year fellowship is such a wonderful phase where your life's going to take multiple directions, I would say. And the niche that you develop during fellowship is something that some of us want to carry forward. So how do you foresee that happening for you?

Isabella Eiler (13:21.258)

Yeah, I definitely am interested in staying in the neuro and acute focus for my research. And I actually will be at the Indiana University School of Medicine working at Riley is one of the major hospitals in the area with actually Beatrice Stefanisky, who was my mentor during residency. And so I'm hoping to expand, you know, looking at tools that we can add to our tool belt from assessing HIE from that standpoint, as well as again, doing more clinical and prospective research to help improve the outcomes of infants affected by HIE.

Srirupa (13:53.122)

No, that's fantastic. That's amazing. And it always, feels like your life came a whole circle. You're back to Indiana where you started your, I guess, pediatric journey. And that's fantastic. That's fantastic. I always feel like we all talk about the positives of research. And I think that I want this series to also be a place where we are honest about some of the challenges that we all face as trainees during our fellowship and doing research. So,  in that context, I would love for you to share what were your challenges in doing your current research and how did you tackle these challenges?

Isabella Eiler (14:31.766)

Yeah, I think one of the challenges is, when you think of a research project, you kind of think of it in your own silo and neonatology obviously is the silo that I currently am in. But expanding that to work with the MFM colleagues, OB colleagues in general, newborn nursery so that I wasn't just thinking of the problem from a NICU perspective and how can I get more numbers? Obviously we can always do universal umbilical cord blood gas sampling, but also working with our OB team to say, you know, from a cost perspective, from a technical standpoint, who's drawing the labs, figuring out how to best serve all three of the specialties that would be affected by increasing our umbilical cord blood gas sampling. And I think, you know, knowing early on that this was going to be a challenge to make sure that everybody had basically a place at the table, having them included in my research group was actually how I started to combat that and make sure that I'm talking to an OB team, the newborn nursery team and making sure it agrees with everybody else's efforts and how we can better serve our patients. And Dr. Brach-Plenasek actually came on to our team back in October of last year and has been really enthusiastic about also improving this project. And we're currently doing a survey at our institution to look at perspectives of umbilical cord blood gas sampling. And there's been results that are preliminary right now, but looking at what people have actually offered as barriers to getting the gastron and seeing if we can actually target those areas from a QI perspective.

Srirupa (16:04.408)

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

Isabella Eiler (16:28.754)

I've learned a lot of lessons from her, which has been great. And one of them is really learning how to pivot in your work. Because if you ever come up to a challenge, you shouldn't take it as we have to stop all the work that we've previously been doing. You should try to figure out how you can actually form it and pivot it into something that you can still move forward. And I feel like that's something that as you go through medicine, you learn instead of, you know, again, quitting if you become blocked by some challenge, figuring out a way around that wall is the way you need to work through it. So I think that is one of the best things that I've learned from her.

Srirupa (17:03.396)

Amazing. No, think we all feel like, I feel like fellowship is that time that you kind of like pick up on, on, on like things that you want to carry forward in your career. And that's such a great lesson to learn from your mentor. That's amazing. If you were to give one big advice to future neo fellows who might be interested in your line of work, your NICU, what would be some of the advices, I’m not going to go with one advice. Let's go with some of the advices.

Isabella Eiler (17:29.11)

I think it kind of stems also from what I've learned from my mentor. Again, if you come up with challenges, either talking through it with, again, multiple specialties that are being affected by what you're doing. So talking to the OB colleagues, talking to neurology, figuring out, okay, I have this data, I have this research that I'm interested in doing, I seem to hit this roadblock. How do you foresee me actually going through it? And asking for help is a main thing that I think is definitely helpful going through fellowship because, you know, you think you should know everything by now, but you're still in training. So learning that you should still ask for help when you can is really beneficial. So I think that and working with your colleagues is the best thing to do to help get through those challenges.

Srirupa (18:13.976)

Yeah, no, absolutely. And Golden Boards for sure, because I feel like it's teamwork, especially in fellowship, because you have to just, like you said, rightly collaborate and get all the help you need to get your project to completion, which is great. Well, that's wonderful. And seems like your life's taking you to Indiana, and I'm very excited about that. And 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 and I'm very happy and delighted to highlight you today. Thank you.

Isabella Eiler (18:44.886)

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