Memorable CLNC® Cases

Nothing Replaces a CLNC® Consultant for Uncovering the Key Factor in a Chilling Case

by Janet Lane, RN, CLNC

About a year ago a plaintiff attorney who was also a physician called me in on a baby case involving an accidental tear or cut to the renal vein during surgery. This case was memorable because it taught me that nothing can replace the knowledge, training and experience a Certified Legal Nurse Consultant brings to a medical-related case.

After the surgeon repaired the renal vein, a Doppler-flow study revealed blood flow through the vein, although somewhat decreased. The infant was then transferred to the pediatric surgical ICU at shift change.

In all the depositions given by the nurses and doctors, no one addressed the fact that the baby was extremely cold. Even my attorney-client who was also a physician did not pick up on that important point

After the report was completed at 7:30pm, the oncoming nurse did her assessment of the patient. Although she could not see anything specific out of the ordinary, she noted that something didn’t seem right.

One of the post-op orders was for blood work, including a potassium level. The blood had been drawn earlier and sent to the lab. About 8:00pm – one hour into the new shift and the second hour post-op for the baby – the lab called and reported that the potassium level was high. This is not unusual in infants because obtaining a blood specimen often involves doing a heel stick. This can damage the blood cells, causing hemolysis and giving a false high potassium level. However, because the level could truly have been high, the potassium test was ordered again “stat” with a venous stick, not a heel stick.

I could visualize the mild chaos occurring at this time. The nurses now needed to re-draw the blood, and since the baby’s diaper was still dry, they also had orders to insert a Foley catheter. Several nurses were trying to draw blood while others were trying to insert the Foley. Finally, they called a nurse from the neonatal ICU, and she successfully inserted the Foley. But at 9:00pm when the surgeon arrived at the bedside, the nurses were still trying to obtain the blood for the second potassium test.

At this time they were unable to get a true blood pressure reading on the baby. His heart rate was 158 and respirations were 33 (both in normal range), but his temp was 35.1°C (95.2°F). The surgeon talked with the parents, then told the nurse she planned to talk with the intensivist physician covering the SICU. Meanwhile, the charge nurse obtained a heat lamp to put over the baby to warm him up.

By 10:00pm both doctors were at the bedside. After many attempts to draw blood, the nurses were still unsuccessful. The baby’s vital signs were:

Heart rate – 177 (increased). Oxygen saturation – The pulse oxygen monitor, which had been at 100%, was not giving any reading, most likely because the baby was not being oxygenated well enough for the monitor to pick up the O2 properly. Blood pressure – 98/83, either inaccurate or very poor. Temperature – 35.2°C (95.4°F).

By 10:35pm the baby had started to go into shock, and a code situation was developing. The baby’s blood pH was down to 7.1, so he was given 5mEq of bicarb for this initial acidosis.

At 11:00pm he remained mottled with his heart rate elevated, extremities cool and no BP reading obtainable. At 11:30pm he received bicarb and Atropine, and at 11:40pm he was placed on a ventilator and given Versed for pain.

By 1:00am he was finally stabilized and remained so for the rest of the night. Unfortunately, this was only the beginning. A series of surgeries was to follow before his demise some months later.

My Nursing and CLNC Experience Made the Difference in My Analysis

Now you know the story as I read about it in the nurses’ notes. I also read the depositions given by the intensivist, the surgeon, the baby’s ICU nurse and the charge nurse that night. My legal nurse consultant job was to be ready to give an opinion based on all this information. What my attorney-client wanted me to find was that the nurses had deviated from the standard of care by taking too long to notify the intensivist physician of the baby’s condition. This doctor was angry because he wasn’t notified until around 9:00pm. He felt that if he had been notified at 8:00pm, the code situation might not have occurred.

I read the notes two more times and could not feel comfortable stating that the nurses had waited too long to contact the doctors. This was especially true when I noticed a conflict between what the nurses said and what the surgeon said. The surgeon had arrived in the room before 9:00pm and told the nurses she was going to contact the intensivist. The nurses felt she did this because they were busy trying to get blood from the baby.

What should I tell my attorney-client? I slept on it that night. The next day I decided to create a timeline of the events, as I’d learned in my CLNC Certification Program, to see if I could uncover what really happened. Could the crisis have been avoided if the surgeon and intensivist had been called at the beginning of the shift? How would they have responded if the nurse had called at 8:00pm merely to say there was nothing specifically wrong “except he just doesn’t look right.” Would they have come running, or would they have said they’d come when they could?

As I questioned myself about what had caused the baby’s crisis, it hit me!

In working with infants, NICU nurses learn from the beginning that the patient’s temperature is the most important element necessary to maintain homeostasis. Right at birth, one of the first things providers do is quickly dry the baby to ensure that none, or as little as possible, of the body heat is lost. Infants cannot shiver to conserve body heat when they are cold. Because of this, keeping them warm is vital, and this can be a big challenge for NICU nurses. For example, a baby who just came from the OR, which is always cool, should be covered with warm blankets.

I reexamined this baby’s temperatures as recorded by the nurses in the medical records and created a different timeline.

Time Temperature
(°C)
CLNC® Consultant’s Comments
06:10pm 36.0 Baby just came from the OR, which is always cool.
06:25 36.4 Almost normal.
06:40 36.3
06:58 36.2 7:00pm – shift change.
08:00 35.7 Unacceptable.
09:00 35.1 Baby is extremely cold. Charge nurse brings heat lamp.
10:00 35.2
11:00 36.0 This reading is questionable.
12:00am 35.3
01:00 36.0
02:00 36.8 Temperature maintained for remainder of night.

What was the problem here? All indications point to the most essential vital sign in infants – their temperature. This baby was cold, which caused the blood vessels to constrict. As a result, the baby had poor perfusion and the nurses could not get any blood from him. As they continued to try, the baby got colder and colder, making their efforts to draw blood almost impossible.

To make matters worse, the vein that had been torn or cut during surgery was now severely constricted. Remember that when the flow was checked after surgery, the vein was shown to be working, but with a decreased blood flow. The fact that the infant remained cold after surgery for an alarming seven hours most certainly affected the blood flow through that renal vein.

Needless to say, after that horrible night the patient’s next surgery was to open him back up and repair a necrotic area that occurred because no blood, i.e., no oxygen, was flowing to the area.

In all the depositions given by the nurses and doctors, no one addressed the fact that the baby was extremely cold. Even my attorney-client who was also a physician did not pick up on that important point.

After I wrote my report and talked with my attorney-client, my scheduled deposition was cancelled. Three days later he called to tell me that the defendants agreed to a large settlement for the parents of this poor infant.

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