Posted on 03/03/2005 12:09:25 AM PST by BROKKANIC
An Aliamanu couple says a critical mix-up at an Oahu hospital has left their otherwise healthy newborn brain damaged and in a coma. It happened when the mother delivered the baby boy at Tripler Army Medical Center on Jan. 14.
Dwight and Shaley Peterson say the problem involved giving carbon dioxide instead of oxygen just after baby Izzy Peterson was born.
Switching oxygen with the wrong gas is a crucial mistake, one that has happened 22 times in the United States in the past 4 years.
The Petersons tried to have another baby for nearly 7 years. When it was time to deliver at Tripler, their dream became a reality.
"The epidural was perfect, the delivery was perfect, everything was perfect," said mother Shaley Peterson. "But... shortly right after birth, I remember lying there and the drape is there and you can't see what is gong on and I started hearing things."
Dear God! What an unthinkable catastrophe!
To the locals on O'ahu, Tripler Hospital has earned the dubious distinction of being called, "Tripler the Cripler." Their record speaks for itself.
Easy solution:
1. CO2 canisters get a mandatory obnoxious color change.
2. Infuse an unmistakable odor into CO2 akin to mercaptan in CNG/LPG.
My condolences to the family.
Now for the solution. You are right. We must learn from these tragic mistakes and every hospital should take note of possible solutions.
CO2 is very, very common. It's used all the time in fast food restaurants. I do think the tubes should be painted another color. That's what sharper restaurants do to distinguish which kind of syrup goes into which kind of drink slot. I really don't want to see the gov'ment imposing more laws at a faster rate. I think a simple 'word of advice' should be sent to all hospitals. It could also cost a fortune to put coloring in CO2, and that could ultimately be unneeded chemicals entering human bodies one way or another.
As for the legal side, the parents should sue that hospital for all this is worth. They will need every dime they can get to help their child. And an example should be made.
I am at loss as to WHY compressed CO2 would even be available in a clinical environment, particularly neonatal.
Any neonatal nurses out there to offer a suggestion as to how in the world a non-green CO2 bottle would end up in the mix?
Also, why weren't they monitoring blodd gasses? Something about this story is really wrong.
OK, a quick google check reveals hospitals do have a use for CO2, but it comes in a grey cylinder, not green.
Medical carbon dioxide is used:
*to increase depth of anaesthesia rapidly when volatile agents are being administered. It increases depth of respiration and helps to overcome breath-holding and
bronchial spasm.
* to facilitate blind intubation in anaesthetic practice.
*to facilitate vasodilatation and thus lessen the degree of metabolic acidosis during
the induction of hypothermia.
*to increase cerebral blood flow in arteriosclerotic patients undergoing surgery.
*to stimulate respiration after a period of apnoea.
*in chronic respiratory obstruction after it has been relieved.
*to prevent hypocapnia during hyperventilation.
*for clinical and physiological investigations.
*in gynaecological investigation for insufflation into fallopian tubes and abdominal
cavities.
Except perhaps for apnea, didn't see a neonatal protocol.
I am at a loss.
Good fix.
...and my question, was the tank located centrally and hooked up to the wrong system, or was the tank actually located where the child was born, and someone attending the birth, made a mistake.
I don't know how often this happens in civilian hospitals, but over the years I have heard more and more about birth injuries in military hospitals.
When I was stationed at Hawaii, we called TRIPLER...CRIPPLER hospital.
They once let a guy die from head injuries so they could harvest his organs for another patient in 1980 or 1981, huge scandal, guy was beaten with a hammer, had massive head injuries, came in there brain dead, they let him linger on life support with NO EFFORTS to stop the bleeding, they just kept him on IV long enough to get the needy patients prepared who needed his organs.
It was a sick read.
you'll know of similar stories from Crippler!
"...and my question, was the tank located centrally and hooked up to the wrong system, or was the tank actually located where the child was born, and someone attending the birth, made a mistake."
Or, was CO2 gas in an O2 tank from the supplier.
Cracker jack reporting by the press as ususal.
For industrial/laboratory cylinders, they are.
CGA 320 for CO2 service, .825"-14 NGO-RH-EXT (Flat Nipple):
CGA 540 for O2 service, .825"-14 NGO-RH-EXT:
The cylinder fittings are on the left, and the regulator fittings are on the right. The two are designed to be incompatible, and durned difficult to attach a cylinder of one gas to a system for another.
If they were E-cylinders they already have the Pin Index Safety System in place. Larger G and H size cylinders use the Diameter Index Safety System. Sounds like someone wasn't paying attention.
Didn't see your reply before I posted.
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