A healthy baby was given the wrong gas at birth, and now the 6-1/2 week old boy lies comatose in Tripler Hospital. It's meant heartbreak for a family of five awaiting a new member. Dad is in the Army and was home from Afghanistan for the birth.
Dwight and Shalay Peterson wanted a fourth child. After seven years of trying and more than one in-vitro procedure, she became pregnant.
Baby Izzy was born healthy at Tripler Hospital on Jan. 14, but one minute into his life, a nurse placed a mask over the baby's face to administer oxygen. At least it was supposed to be oxygen. It turned out to be carbon dioxide.
"I watched him deteriorate from the screaming and crying to a little less screaming," Dwight said. "The second time she pulled it off, and then she put it back on, and then I watched him deteriorate until it was done, until he was finished. There was no more movement. There was no crying. There was nothing."
Forty-two minutes went by before it was realized that a mistake was being made. The petersons say tripler officials have apologized and said the mistake won't happen again.
"I wouldn't want anybody else to go through what we went through," Shalay said. "But it's too late for my baby."
Izzy needs help to breath and will need 24-hour nursing care his entire life.
The Petersons have hired a lawyer and a claim has been made with the federal government.
Exactly. CO2 is used in the OR to insufflate the abdomen for laparoscopic surgery. It is used because it does not promote combustion, the way O2 or room air would. However, it comes in a gray cannister, and supposedly O2 tank fittings cannot be attached to CO2 because of the pin index system. Either someone bypassed the pin index system and ignored tank color, or an O2 tank was filled with CO2. Either way, someone went out of their way to put CO2 in absolutely the wrong place.
Kevin McHugh
Our OR is used for all our surgeries, including cesareans. We do lots of laps.
I don't work in any of the other surgeries though. .. I'm going to specifically look for that CO2 tank . . . .
We still have the question of O2 by mask on a screaming baby. . . . I too will be interested in the details.
The whole thing is awful. We have green o2 tanks on the back of our warmer. We use them in the OR or to transport the baby. We can also plug into the wall suplly of O2 through the green outlet in the OR. Very weird and very sad for the family.
Maybe the baby was screaming but not pink yet and the nurse chose to hurry it along by placing some CPAP? I know it's not NRP, but sometimes NRP isn't followed exactly...
Maybe the baby was screaming but not pink yet and the nurse chose to hurry it along by placing some CPAP? I know it's not NRP, but sometimes NRP isn't followed exactly...
Well, if she did that it was not good nursing care. A crying baby is the best way to pink up.
Even if the nurse had a good reason for administering O2, he / she should have done something besides O2 when the baby didn't respond. If the gas company filled the bottle with the wrong gas, certainly it is not the nurse's fault...the last thing I would even think about is that it was not oxygen in my bottle...and yes, the pin index safey system should prevent the bottle from being filled with anything but oxygen (if a bottle were used...who knows...maybe the CO2 came from a wall unit). If the baby were deteriorating as badly as it sounds like he was, one would think the nurse would have asked for help and taken the simple mask off and started venitalting...sigh.
I would really like to see this case published when it is all said and done!
My question: Doesn't this hospital have a NICU, special care nursery or anything. They worked on this baby for 45 minutes and it was never moved from that particular "O2" source. Where I work that baby would have been moved to the NICU. And then hooked up to wall O2. Surely not from a canister that entire time.
My husband is in the military stationed in HI...I just recently graduated nursing school and had a clinical or two at this hospital, as was my father an inpatient. Let me tell everything about Tripler...in the Army they are regarded as one of the best hospitals...this is far from the truth!! There are many sad stories that come out of this hopsital but this is by far the worst I've heard of. Tripler, or crippler as it is known on the island has a reputation for being a place you do not want to have any procedures done.
I have not only seen these things first hand, I have been affected by them also (my father went into anaphylactic shock and subsequent renal failure after being giveen a new antibiotic iv and not being reassessed for over an hour or two after. By this time his blood pressure was down around the 50's systolic). Although I do understand that mistakes happen this hopsital should be shut down after so many incidents like this. Hopefully the media attention will bring JCAHO in to reevaluate this place. Come on, with so many people in the room with something of this nature going on, and nobody realized until they put up a new tank?? Why was the mask even attached to a CO2 tank anyway?? :angryfire
By the way tripler does have a level 2-3 nicu but they also do not have the staffing to meet their needs nor is the nicu a "palace". It has been a very sad few days in Hawaii since this report came out...everyone is talking about how something of this nature could happen. I hope the family pursues it to every extent possible although nothing or no amount of $ will ever get rid of the pain or hurt that will be with them the rest of their lives. So sad.
Here is a link to a full article...http://the.honoluluadvertiser.com/article/2005/Mar/03/ln/ln07p.html
Spidey's mom, ADN, BSN, RN
11,305 Posts
Our OR is used for all our surgeries, including cesareans. We do lots of laps.
I don't work in any of the other surgeries though. .. I'm going to specifically look for that CO2 tank . . . .
We still have the question of O2 by mask on a screaming baby. . . . I too will be interested in the details.
steph