Infant Injury Due to Failure to Properly Manage Medical Equipment – January 18, 2024
On January 18, 2024, WVFK&N attorneys Christopher Norman and Gregory Kirby filed a medical malpractice claim on behalf of a newborn who suffered an avoidable brain injury.
The complaint alleges that the child was born at the Greater Baltimore Medical Center (GBMC) on January 25, 2022, at 25 weeks gestation by spontaneous vaginal delivery. His APGAR scores were 7 and 8 at 1 and 5 minutes, respectively. The pregnancy was complicated by cervical incompetence, uterine fibroids, preterm labor, and preterm premature rupture of membranes. At birth, the child received brief positive pressure ventilation by face mask bagging. He was admitted to the GBMC NICU on noninvasive respiratory support and given surfactants, empiric antibiotics, and intravenous nutrition.
The first five months of the child’s NICU course were complicated by problems of prematurity, including chronic lung disease, mild pulmonary hypertension, and feeding/swallowing difficulties with severe gastroesophageal reflux disease (GERD). He required prolonged respiratory support with CPAP, steroids, diuretics, and nasogastric (NG) or orogastric (OG) tube feeding. Serial echocardiograms showed resolving pulmonary hypertension. Routine serial cranial ultrasounds on February 1, February 24, and April 12, 2022 were normal. The April 12 ultrasound report noted “no abnormalities can be seen” and indicated that the results were compared to the prior February 24 ultrasound, which also “had not demonstrated abnormalities” either. Overall, the child progressed in the NICU during the first 6 months of his life.
On July 19th, the child was taken to the operating room (OR) for laparoscopic placement of a more secure gastrostomy tube (GTT) so that his NG tube could be removed, as well as Nissen fundoplication to correct GERD. During the intubation process in the OR, the child’s respiratory status destabilized, and he became difficult to ventilate. The surgeon felt that he was unable to safely proceed with the procedure, and he decided to delay operative intervention with a plan to transfer the child to Johns Hopkins Hospital (JHH) for the GTT/Nissen procedure.
The child continued to receive the majority of his formula by NG tube, which, as an active 6-month-old, he frequently pulled out. For example, over the 48 hours between July 24th and 26th, he pulled out his NG tube three times. That and the child’s previous history of pulling out or dislodging his NG tube was known to the Defendant treating healthcare providers.
At about 7:00 PM on July 26, 2022, a nurse began her shift. The child’s first feeding, for which the nurse was responsible, was scheduled for about 8:00 PM. There is no indication in the record that the nurse auscultated the NG tube during the first feeding of her shift to ensure that it was in the correct place in the stomach. At 8:00 PM, the child took 28 ml of formula by bottle. The child’s neurological exam at this time showed that he was awake, active, and responsive to voice, environment, and light, with a tone appropriate for his age.
At 8:31 PM, the nurse responded to a bradycardia (low heart rate) alarm and saw the child “vomiting with the NG tube out of his nose.” At this point, he was in cardiac arrest. He was dusky and pale, was apneic (not breathing) with oxygen desaturation to 50%, and had an extremely low heart rate at 48 beats per minute. The nurse called out for assistance while suctioning the child. Respiratory Therapists and another nurse responded. The child remained bradycardic and hypoxemic, and although a code blue was called, no code sheet was created.
The duration of the child’s arrest, during which he was without blood flow and oxygen to his brain, was 32 minutes. During this time, before the child had return of spontaneous circulation, he received the following interventions: positive pressure ventilation by bag and face mask; chest compressions; intubation, which required multiple attempts; peripheral intravenous catheter; epinephrine, which was administered too late; and intraosseous line, which was established too late.
Post-arrest labs obtained at the conclusion of the code included an arterial blood gas that showed severe metabolic acidosis with pH 6.915, blood CO2 level 48.7 mmHg, blood oxygen level 331.7 mmHg, base excess -22.2, and serum glucose 257 mg/dL. There was no evidence of infection.
Before his arrest, the child’s brain imaging was normal, and there was no indication of a brain injury. On July 27, the day after his arrest, however, the child was noted to have hypoxic ischemic encephalopathy as a result of his cardiac arrest on July 26, 2022. In the early morning of July 27, several hours after his arrest, he developed signs and symptoms of seizures for which he received Ativan and Keppra. He remained nonresponsive to stimulation, was flaccid, and his pupils were fixed and constricted. He ultimately required critical care transport to the Johns Hopkins Hospital PICU, where he was placed on the post-cardiac arrest protocol. A continuous EEG was initiated and showed a severe diffuse cerebral disturbance.
On July 28th, Day 2 after his arrest, a Pediatric Intensivist noted that the child was severely ill with a poor neurologic exam – no eye opening, pupils moderate size and sluggishly reactive, absent corneal and cough reflexes, and slight right extremity movement to noxious stimulus and no movement on the left. The child’s acute respiratory failure was worsening and required full ventilator support with prolonged apneas. A Pediatric Neurologist noted that the etiology of his cardiac arrest was likely pulmonary.
On July 31, 2022, 5 days after the child’s arrest, his EEG remained markedly abnormal with diffusely slow background activity plus three electrographic seizures indicative of a severe diffuse or multifocal cerebral disturbance with a superimposed focal cerebral disturbance of the right hemisphere. A brain MRI showed areas of restricted diffusion bilaterally in the putamen, occipital lobes, and periorolandic regions. This pattern reflects acute global hypoxemic ischemic brain injury. Notably, there were no findings suggestive of pre-existing or chronic brain injury at this time. Further testing throughout August showed similar results.
On August 24th, 29 days after his arrest, physiatrists described the child as “having sustained a severe anoxic brain injury for which he will require lifelong rehabilitation and care. He remains ventilator-dependent and has a recently established tracheostomy as well as gastrostomy. He will benefit from transfer to inpatient rehab for intensive, multidisciplinary therapies, closely followed by respiratory therapy with caregiver training for trach/vent management, nutrition for continued enteral feeding optimization, and rehab physician oversight with titration of pharmacotherapy for hypertonicity management.” About one week later, a Pediatric Neurologist remarked, “his recovery may be quite limited with high risk for severe long-term disabilities. Ethan’s diagnoses included severe hypoxic-ischemic encephalopathy, seizures, chronic respiratory failure with hypercapnia (high PCO2) and ventilator dependence, tracheostomy dependent, GTT dependent, and spasticity.”
The child needed 12 days of inpatient rehabilitation at Mt. Washington Pediatric Hospital for intensive, multidisciplinary therapies before being discharged home, where he requires constant care.
Today, our child-client suffers from severe physical and intellectual disabilities, seizures, and cerebral palsy, and he is reliant on technology tracheostomy and gastrostomy tube to survive. He is and will be permanently dependent on others for his care.
The lawsuit alleges that the injuries were a result of the negligence of the Greater Baltimore Medical Center, Inc. d/b/a Greater Baltimore Medical Center and its employees in failing to properly manage our child-client’s nasogastric tube, failing to prevent our child-client from going into cardiac arrest, and failing to properly respond to our child-client going into cardiac arrest.
The action is pending in the Circuit Court for Baltimore County in Maryland.
