We pediatric surgeons operate at the bedside not infrequently for several reasons. First, many are too unstable to transport, as was pointed out. Second, the child often gets very cold in transport and in the large OR. The NICU has radiant warmers built into most of the beds to mitigate this. Third, it's not uncommon for the child to be on an oscillator or jet vent and there often isn't time to "trial" the child back on a conventional vent, as would be needed for the anesthetic carts in the operating room. And so we bring the OR to the patient...
It is difficult to predict who will get "medical NEC" and need only bowel rest/antibiotics to recover and who will develop a rapid, fulminant NEC requiring surgery or leading to death. Peds surgeons often state its about 1/3 medical, 1/3 surgical, and 1/3 fatal. Early KUB's of NEC can be difficult in that pneumatosis and the "bubbly" look of neonatal poop are sometimes challenging. It gets more obvious with sequential imaging. While most of us repeat films every 6-8 hours on a patient with possible pneumatosis, that's based on common practice, not data. Additionally, surgery doesn't stop or "fix" NEC. We operate for the complications of NEC - full thickness perforation (or suspicion of it), severe deterioration despite optimal medical management (two pressors, acidosis, 100% fio2 and getting harder to ventilate), and abdominal compartment syndrome (as in this patient). It might have been good to call surgery to see them a little earlier. However, with portal venous gas on the first convincing film, the prognosis was already poor in this uber premature kiddo. I don't have an issue with use of fortifiers. I have a personal bias against 30 kcal formula in a micro-preemie (I max out at 27 kcal), but you can find data both for an against that.
If I was sitting on the panel, I'd offer $1 million to make the case go away. $5 million is a bit high for no clear error in care. Just my two cents, and I'm pretty new at the expert witness field.
Thanks for the insightful comment! Doesn't sound like there is any glaring negligence here, it will be interesting to see if the hospital will take this all the way to trial or not.
It is hard to judge without seeing the kub being referenced as early signs of NEC. It is plausible to also question why they waited 12 hrs for a repeat x-ray. that being said this baby was most likely not going to make it even if they had diagnosed him 6-12 hours prior. It seems absurd to put all blame on the medical team for this baby's misfortunes when it's clear the baby wouldn't have made it a day without all their hard work and extreme interventions. Mom trying to get rich from this after self sabotaging her own pregnancy is quite disturbing. I wonder how much lawyers are allowed to say regarding this.
I'm sure if they intend to take this to trial, there will be pre-trial arguments about discussing the mother's drug and alcohol use. Its a terribly tragic case and the jury will be sympathetic to the mom in some regards, but I would imagine most people on the jury would feel pretty upset that she engaged in these behaviors that harmed her child. I think its relatively unlikely the plaintiff would win.
As a former juror on a medical malpractice case, I have seen PMH of drug use brought up in similar circumstances (mitral valve vegetation/s. aureus infection in chronic heroin user). I don't think it will be possible for plaintiff to argue omission of PMH of polysubstance abuse.
You echo my thoughts precisely. My condolences for the tragic circumstances surrounding the mother, but in my view if you're going to smoke and drink during pregnancy and physicians can't perfectly manage the extremely fragile, razor-thin-margin-for-error care that results from a 26 week premature birth, you don't get to ask for $5 million on the back end.
My first reaction was also that you know stuff has hit the fan if there's a bedside ex-lap.
Also, people with externalizing ego defences will convert guilt into accusation. It's easier to blame the doctors than it is to accept your own involvement in your baby's demise.
Yep. Totally different ball of wax, but as an adult intensivist, I've had a handful of patients (maybe 5 or 6?) who needed a bedside x-lap ( they were requiring mega-doses of pressors and/or extremely hypoxic, and thus too unstable to physically leave their room to go to the OR). It probably won't shock anyone that not a single one of those patients ended up surviving to hospital discharge.
The mother was 34 at the time of the pregnancy. It was a complicated pregnancy from the get go before the smoking and alcohol use. Whatever the doctors and hospitals did or did not do, does not compare to the hand the child was dealt. I feel sorry for the plantiff for losing two child and a husband. But she is taking out her anger on the wrong entity and person.
NOT a neonatologist but twelve months of NICU under the supervision of the (literal) founder of modern neonatology (Louis Gluck, MD), four years of being a part-time neonatologist in the highest level NICU in my city, and forty years of experience as a pediatrician with many high-risk newborns as a result of my background...
My take...
Way too long to post here...especially as the very pursuit of this case angers me to my corel
So some comments...
Danielle Saunders Walsh...Absolutely! An EXCELLENT comment. I have personally witnessed bedside surgical procedures for all of the reasons that you describe...not only by pediatric general surgeons by by pediatric cardiac surgeons as well.
Dan Milton...Agreed. The plaintiff's expert did, in fact, present a very detailed, well-documented, well-reasoned, if (in my opinion) completely wrong-headed argument in which he absolutely overstates and overestimates the outcome that could be expected in this patient. Regardless of how the patient had progressed to that point, there were many more months to come in which disaster could have eventuated and the patient could have died or been severely damaged at any given moment.
DJ...you have a good point about going back to TPN. The reason that it isn't done more often or more quickly is because of the increased risk of liver toxicity in a premature/LBW infant related to the long-term or repeated use of TPN in those patients. It is definitely not benign or risk-free.
All of you (including Med Mal Reviewer) who question the validity/appropriateness of this case...ABSOLUTELY! This is a clear money-grab orchestrated by a (unscrupulous) med mal attorney who has, in my opinion, victimized a vulnerable, grieving, multiply-distressed mother along with the medical providers and the legal system. SHAME on him/her!
And all of you who questioned the mother's choices and behavior during the pregnancy...I agree in principle, but am more sympathetic to her situation. I don't know and it was truly not well-defined what she used, how much, how often, and for how long...not to mention the trauma that she had already endured which could have led to it. Was her use habitual or situational? We don't know from what we have. What I do surmise, however, once again, is that the attorney in question has used it to his/her advantage to continue this case and what I do know is that if this case goes to court this woman will be utterly destroyed by the defense...and at what cost to her mental health and well-being?
Again, as too often happens in personal injury cases in general and med mal cases in particular, it is the attorney whom I hold responsible for this farce/debacle. And this from someone who has very good friends who are personal injury and med mal attorneys...all of whom I hold in high regard for their ethics and moral standards in which cases they accept and pursue.
Though I agree that this lawsuit is misguided and that the team was providing appropriate care, I was wondering about paragraph #13 in the Defense’s report. Is it truly inappropriate to hold (or maybe reduce) enteral feeds (and go back to TPN?) every time a premature neonate has abdominal distension or signs suggestive of feeding intolerance? It seems like the kind of resource-intensive and detail-oriented thing that a NICU could do. I don’t know, so I hit the web to try to learn more but didn’t get very far secondary to being inundated with advertisements for NEC Baby Formula lawsuits. The focus is on cow-based fortifiers and formula as risk factors for NEC in premature infants in the NICU. This seems recent and multi-state, and formula companies are being targeted. This will undoubtedly lead to increasing use of human rather than bovine products, or to the development of products that are safer and more physiologic. The cost will be high financially, but the benefits... maybe there's no price on that (unless you're an actuarial economist).
Its basically just luck in finding them... sometimes the attorneys don't put any interesting info in the court documents, and sometimes they include tons of records right from the beginning. I used to have to do a lot of digging, now I get a lot of tips of good cases.
Agree. I'm sorry to the mother for her situation but her time, effort, and money would be better spent pursuing drug and alcohol rehabilitation than attempting to ruin the careers of doctors who tried to save her complicated pregnancy.
Wow, for once I'm actually impressed by the plaintiff's expert witness opinion, very thorough and thoughtful. The part about $86,000 vs $1 million in life time earnings was interesting too, and almost veered into political territory.
It is unfortunate that this law suit took place. It sounds like the team taking care of the baby did their absolute best.
Yeah the economics experts sometimes really get into sensitive topics... putting a "value" on lifetime earnings is fraught with opportunity for bias. Sometimes things that are "true" in an actuarial sense can be very politically incorrect.
Am I alone in thinking this case sounds like a money grab? Even with only the limited information about the pregnancy, wondering if mother was even involved at the point that this happened? And envisioning the post discharge life for a very frail super-premie going to an unstable home environment, one has to wonder if the infant would have survived at all, outside of foster care.
We pediatric surgeons operate at the bedside not infrequently for several reasons. First, many are too unstable to transport, as was pointed out. Second, the child often gets very cold in transport and in the large OR. The NICU has radiant warmers built into most of the beds to mitigate this. Third, it's not uncommon for the child to be on an oscillator or jet vent and there often isn't time to "trial" the child back on a conventional vent, as would be needed for the anesthetic carts in the operating room. And so we bring the OR to the patient...
It is difficult to predict who will get "medical NEC" and need only bowel rest/antibiotics to recover and who will develop a rapid, fulminant NEC requiring surgery or leading to death. Peds surgeons often state its about 1/3 medical, 1/3 surgical, and 1/3 fatal. Early KUB's of NEC can be difficult in that pneumatosis and the "bubbly" look of neonatal poop are sometimes challenging. It gets more obvious with sequential imaging. While most of us repeat films every 6-8 hours on a patient with possible pneumatosis, that's based on common practice, not data. Additionally, surgery doesn't stop or "fix" NEC. We operate for the complications of NEC - full thickness perforation (or suspicion of it), severe deterioration despite optimal medical management (two pressors, acidosis, 100% fio2 and getting harder to ventilate), and abdominal compartment syndrome (as in this patient). It might have been good to call surgery to see them a little earlier. However, with portal venous gas on the first convincing film, the prognosis was already poor in this uber premature kiddo. I don't have an issue with use of fortifiers. I have a personal bias against 30 kcal formula in a micro-preemie (I max out at 27 kcal), but you can find data both for an against that.
If I was sitting on the panel, I'd offer $1 million to make the case go away. $5 million is a bit high for no clear error in care. Just my two cents, and I'm pretty new at the expert witness field.
Thanks for the insightful comment! Doesn't sound like there is any glaring negligence here, it will be interesting to see if the hospital will take this all the way to trial or not.
It is hard to judge without seeing the kub being referenced as early signs of NEC. It is plausible to also question why they waited 12 hrs for a repeat x-ray. that being said this baby was most likely not going to make it even if they had diagnosed him 6-12 hours prior. It seems absurd to put all blame on the medical team for this baby's misfortunes when it's clear the baby wouldn't have made it a day without all their hard work and extreme interventions. Mom trying to get rich from this after self sabotaging her own pregnancy is quite disturbing. I wonder how much lawyers are allowed to say regarding this.
I'm sure if they intend to take this to trial, there will be pre-trial arguments about discussing the mother's drug and alcohol use. Its a terribly tragic case and the jury will be sympathetic to the mom in some regards, but I would imagine most people on the jury would feel pretty upset that she engaged in these behaviors that harmed her child. I think its relatively unlikely the plaintiff would win.
As a former juror on a medical malpractice case, I have seen PMH of drug use brought up in similar circumstances (mitral valve vegetation/s. aureus infection in chronic heroin user). I don't think it will be possible for plaintiff to argue omission of PMH of polysubstance abuse.
I'd love to hear the story about your experience as juror some time!
You echo my thoughts precisely. My condolences for the tragic circumstances surrounding the mother, but in my view if you're going to smoke and drink during pregnancy and physicians can't perfectly manage the extremely fragile, razor-thin-margin-for-error care that results from a 26 week premature birth, you don't get to ask for $5 million on the back end.
My first reaction was also that you know stuff has hit the fan if there's a bedside ex-lap.
Also, people with externalizing ego defences will convert guilt into accusation. It's easier to blame the doctors than it is to accept your own involvement in your baby's demise.
Yep. Totally different ball of wax, but as an adult intensivist, I've had a handful of patients (maybe 5 or 6?) who needed a bedside x-lap ( they were requiring mega-doses of pressors and/or extremely hypoxic, and thus too unstable to physically leave their room to go to the OR). It probably won't shock anyone that not a single one of those patients ended up surviving to hospital discharge.
The mother was 34 at the time of the pregnancy. It was a complicated pregnancy from the get go before the smoking and alcohol use. Whatever the doctors and hospitals did or did not do, does not compare to the hand the child was dealt. I feel sorry for the plantiff for losing two child and a husband. But she is taking out her anger on the wrong entity and person.
My background...
NOT a neonatologist but twelve months of NICU under the supervision of the (literal) founder of modern neonatology (Louis Gluck, MD), four years of being a part-time neonatologist in the highest level NICU in my city, and forty years of experience as a pediatrician with many high-risk newborns as a result of my background...
My take...
Way too long to post here...especially as the very pursuit of this case angers me to my corel
So some comments...
Danielle Saunders Walsh...Absolutely! An EXCELLENT comment. I have personally witnessed bedside surgical procedures for all of the reasons that you describe...not only by pediatric general surgeons by by pediatric cardiac surgeons as well.
Dan Milton...Agreed. The plaintiff's expert did, in fact, present a very detailed, well-documented, well-reasoned, if (in my opinion) completely wrong-headed argument in which he absolutely overstates and overestimates the outcome that could be expected in this patient. Regardless of how the patient had progressed to that point, there were many more months to come in which disaster could have eventuated and the patient could have died or been severely damaged at any given moment.
DJ...you have a good point about going back to TPN. The reason that it isn't done more often or more quickly is because of the increased risk of liver toxicity in a premature/LBW infant related to the long-term or repeated use of TPN in those patients. It is definitely not benign or risk-free.
All of you (including Med Mal Reviewer) who question the validity/appropriateness of this case...ABSOLUTELY! This is a clear money-grab orchestrated by a (unscrupulous) med mal attorney who has, in my opinion, victimized a vulnerable, grieving, multiply-distressed mother along with the medical providers and the legal system. SHAME on him/her!
And all of you who questioned the mother's choices and behavior during the pregnancy...I agree in principle, but am more sympathetic to her situation. I don't know and it was truly not well-defined what she used, how much, how often, and for how long...not to mention the trauma that she had already endured which could have led to it. Was her use habitual or situational? We don't know from what we have. What I do surmise, however, once again, is that the attorney in question has used it to his/her advantage to continue this case and what I do know is that if this case goes to court this woman will be utterly destroyed by the defense...and at what cost to her mental health and well-being?
Again, as too often happens in personal injury cases in general and med mal cases in particular, it is the attorney whom I hold responsible for this farce/debacle. And this from someone who has very good friends who are personal injury and med mal attorneys...all of whom I hold in high regard for their ethics and moral standards in which cases they accept and pursue.
Though I agree that this lawsuit is misguided and that the team was providing appropriate care, I was wondering about paragraph #13 in the Defense’s report. Is it truly inappropriate to hold (or maybe reduce) enteral feeds (and go back to TPN?) every time a premature neonate has abdominal distension or signs suggestive of feeding intolerance? It seems like the kind of resource-intensive and detail-oriented thing that a NICU could do. I don’t know, so I hit the web to try to learn more but didn’t get very far secondary to being inundated with advertisements for NEC Baby Formula lawsuits. The focus is on cow-based fortifiers and formula as risk factors for NEC in premature infants in the NICU. This seems recent and multi-state, and formula companies are being targeted. This will undoubtedly lead to increasing use of human rather than bovine products, or to the development of products that are safer and more physiologic. The cost will be high financially, but the benefits... maybe there's no price on that (unless you're an actuarial economist).
This is an amazing amount of information for a case that is still ongoing. How did you do that? Sorry if that is a naive question.
Its basically just luck in finding them... sometimes the attorneys don't put any interesting info in the court documents, and sometimes they include tons of records right from the beginning. I used to have to do a lot of digging, now I get a lot of tips of good cases.
You do fantastic work!
Thank you!
I thought so, too!
This looks like another way to win the lotto!!!
Agree. I'm sorry to the mother for her situation but her time, effort, and money would be better spent pursuing drug and alcohol rehabilitation than attempting to ruin the careers of doctors who tried to save her complicated pregnancy.
Wow, for once I'm actually impressed by the plaintiff's expert witness opinion, very thorough and thoughtful. The part about $86,000 vs $1 million in life time earnings was interesting too, and almost veered into political territory.
It is unfortunate that this law suit took place. It sounds like the team taking care of the baby did their absolute best.
Yeah the economics experts sometimes really get into sensitive topics... putting a "value" on lifetime earnings is fraught with opportunity for bias. Sometimes things that are "true" in an actuarial sense can be very politically incorrect.
despite doing everything to the best of their ability they were sued. shameful
Am I alone in thinking this case sounds like a money grab? Even with only the limited information about the pregnancy, wondering if mother was even involved at the point that this happened? And envisioning the post discharge life for a very frail super-premie going to an unstable home environment, one has to wonder if the infant would have survived at all, outside of foster care.
Lost income? That is bizarre.
Very common in most med mal cases to cite this, especially with younger patients or highly productive / high earning plaintiffs.