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News: A 4-year-old girl was admitted to a hospital for a colonic motility study to determine the cause of her acute constipation. In preparation for the study, the child underwent a bowel-cleaning procedure and was kept without food or fluids overnight. The next morning, the procedure was performed. Afterward, the child began to vomit profusely and she lost consciousness. Her physician had left the hospital, and the nursing staff failed to closely monitor her . She had seizures and went into cardiac arrest. Although she was transferred to a children’s hospital, she was declared brain dead and taken off life support.
The hospital and physicians settled prior to trial for a combined $4.5 million.
Background: The plaintiffs’ 4-year-old daughter was admitted to the hospital for a colonic motility study. Because she suffered from severe constipation, the child’s pediatrician had recommended that the diagnostic procedure be performed. In preparation for the test, the child underwent a bowel cleaning procedure and was not allowed to have food or liquids overnight. The next morning, she was given Versed and Fentanyl to sedate her during the procedure. During the procedure, an unknown quantity of plain water — water that contained no electrolytes — was flushed through her system.
Immediately following the test, the child began exhibiting signs of electrolyte imbalance and vomited repeatedly. The electrolyte imbalance was neither diagnosed nor treated. At the time, her physician believed that she had overreacted to the sedative, Versed. However, hours after the effects of the sedating drugs should have worn off, the child remained somnolent and the working diagnosis continuted to be overreaction to Versed. During recovery, the physician left the hospital, and although he was called with updates on her condition, he did not return to the hospital to examine to the child. Further, the staff nurse in charge of the child’s first six hours of recovery took vital signs only for the first hour of her stay and failed to measure fluid intake and output.
Throughout the rest of the afternoon and evening, the child became less and less responsive. The staff caring for her felt that she was only experiencing an unusual reaction to Versed. Blood tests were not performed until late that evening. The tests revealed that the patient’s sodium level (an essential electrolyte) was low and that she was in metabolic acidosis. But despite these adverse results, the medical staff on duty continued with a working diagnosis of Versed sensitivity.
The child never regained full consciousness. She eventually began to experience seizures and, shortly after 11 p.m., she went into cardiac arrest. During resuscitation, the transport team from the neighboring children’s hospital arrived and determined that the child’s low sodium level was the cause of her life-threatening condition. She was transferred immediately to the children’s hospital where two days later, in the early morning hours, she was declared brain dead and taken off life support.
The plaintiffs claimed that the two defendant nurses and four defendant physicians were negligent when they failed to properly measure and monitor and child’s fluid status and vital signs. The plaintiffs also averred that the health care professionals’ failure to recognize that the child’s depressed level of consciousness was due to an electrolyte imbalance (not an overreaction to sedating drugs) and failure to properly respond to the need to modify her low serum sodium level were clear breaches of the standard of care.
The plaintiffs also claimed that when the physicians and nurses failed to order brain-imaging studies after the child started seizing, they were again negligent. The plaintiffs contended that proper monitoring, diagnostic testing, and treatment would have corrected the electrolyte imbalance and avoided the child’s death.
This wrongful death case settled prior to going to trial for $4.5 million with all providers contributing.
What this means to you: The medical care and treatment needs of pediatric patients are often very different than that of adults. Once the presumption was made that this child was simply reacting to the Versed, either the physician or nursing staff did not utilize physical findings and data to properly diagnose or re-evaluate the problem. As a result, far too much time elapsed before this pediatric patient’s electrolytes were assessed, and even once assessed it seems that it was too late to do anything about it. This begs the question of whether the staff of this facility was trained to handle the needs of a young pediatric patient, says Cheryl A. Whiteman, RN, MSN, CPHRM, a risk manager for Cigna Healthcare of Florida Inc. in Tampa, who says her opinions do not necessarily reflect Cigna’s.
A bowel prep for any diagnostic procedure causes the loss of body fluid and the flushing of electrolytes. While adult are susceptible to dehydration and electrolyte imbalance, a small child runs a much higher risk of this type of systemic assault rendered by a bowel cleansing, in this case, for a motility study. An unknown quantity of plain water was flushed through the child’s system during the procedure.
Staff should have noted the amount of fluid that was infused, along with the amount that was returned. Not only does water contain no electrolytes; in all likelihood, it literally flushed electrolytes from the child’s system. Following the procedure, the pediatric patient’s fluid and electrolyte balance was further endangered by the vomiting that she experienced. Certainly at this point, the physician and the nursing staff should have recognized the extent to which her fluid and electrolyte status had been compromised, and blood work should have been urgently drawn and reported. In situations such as this where the child remained somnolent, the physician should have ordered that vital signs and neurological assessment be done on a frequent basis.
Even though the physician didn’t explicitly order this type of monitoring, the charge nurse should have recognized the need for frequent vital signs and neurological checks on a child who was not responding appropriately. To obtain one set of vital signs on a child, who is somnolent over a six-hour period post-procedure, is indefensible. While it was reported that the physician was called with updates, it would appear that the information must have been cursory, if not even updated vital signs were made available to him. He, too, should have been asking for more at this point. Further, it would have been reasonable to provide imaging studies in the face of the child’s seizures. However, once the child had reached that stage, damage to her brain may have been too advanced to reverse, notes Whiteman.
In conducting a post-event investigation, the risk manager would need to determine whether the facility and its staff were capable of caring for their pediatric population. Since this was not a pediatric facility per se, particular attention to ongoing education would be necessary as would proficiency assessments of staff members caring for the small pediatric population, especially in relation to the services provided, adds Whiteman.
Bottom line: The young patient in this case was denied proper monitoring, diagnostic testing, and treatment. In the face of such poor care, there is no defense. Settlement was the only option for these providers. It would be hoped that this case was settled quickly and quietly and resulted in systemic changes in the way in which the facility handled pediatric cases, states Whiteman.