State investigating care in baby's case

Honolulu Advertiser

Posted on: Monday, February 6, 2006

By Rob Perez Advertiser Staff Writer

The state has begun an investigation into the role a Tripler Army Medical Center physician allegedly played in the case of a newborn baby who suffered severe brain damage last year after being mistakenly treated with a wrong gas.

The Department of Commerce and Consumer Affairs, which oversees the state board that licenses physicians, is looking into whether the care provided to Izzy Peterson by Dr. Danielle Bird constituted a licensing violation.

Izzy was injured from inhaling carbon dioxide instead of oxygen for more than 40 minutes after his birth. The baby's mother, Shalay Peterson, and the family's attorney, Rick Fried, told The Advertiser that Bird administered the carbon dioxide to Izzy, thinking it was oxygen, and treated him throughout the ordeal.

By the time the mistake was discovered, Izzy's brain was so damaged that he is expected to be dependent on medical devices the rest of his life for such basic functions as eating and breathing.

News PhotoIzzy's parents have sued the federal government, alleging Tripler was negligent. Bird was not named as a defendant in the lawsuit. Federal law gives military doctors immunity from malpractice lawsuits.

In court documents, the government denied that Izzy's care was negligent, and the lawsuit is pending. Bird didn't respond to a detailed request for comment relayed through her mother.

The state's Regulated Industries Complaints Office, part of DCCA, began investigating the case after The Advertiser inquired about Bird's licensing status in December. The investigation is continuing, according to Jo Ann Uchida, RICO's complaints and enforcement officer. She declined to discuss details of the probe because it is ongoing.

News PhotoAmong the questions the state considers in licensing investigations is whether a doctor engaged in "hazardous negligence causing bodily injury to another."

If the state determines that a licensing violation occurred, the board can impose a variety of sanctions, ranging from a fine to license revocation.

Carrying her brain-damaged son, Shalay Peterson is careful not to disturb the breathing and feeding tubes that keep him alive. The boy, Izzy, was mistakenly given carbon dioxide instead of oxygen after he was born last year at Tripler Army Medical Center. Anita Baca

CHECKING ON YOUR DOCTOR

If a physician is licensed in Hawai'i, see the professional and vocational licensing search page of the state Department of Commerce and Consumer Affairs Web site for checking on any past complaints.

Bird's licensing record with the state is unblemished. As of Friday, it showed that no Another source for complaints have been lodged against her in the past, nor has any disciplinary action been physician information is the taken against her by the state, according to DCCA officials. American Medical Bird still works at Tripler. Association site. It requires selecting a state to do aIf the Army had taken any adverse action affecting Bird's practicing privileges as a result search.

of the Baby Izzy case, it would have been required to report that action to the state licensing board. As of Friday, DCCA had received no such notice.

The Army didn't respond to a written request for comment on whether Bird was sanctioned as a result of the gas mix-up.

Unlike civilian physicians, who must be licensed in the state where they practice, military doctors can be licensed in any U.S. state or territory. At Tripler, about 40 percent of the active-duty physicians are licensed in Hawai'i, according to the hospital. Bird is one of them.

BEGAN WITH C-SECTION

News PhotoOn Jan. 14, 2005, Shalay Peterson underwent what a U.S. Department of Defense document described as a routine cesarean section. It was a Friday morning. The scheduled C-section was the first of the day for operating room No. 10.

Army Sgt. Dwight Peterson, Izzy's father, even videotaped some of the procedure - until a problem became evident.

About a minute after Izzy was born at 8:10 a.m., a decision, now being questioned by the family, was made to give the infant oxygen to help him breathe. Fried, the family's attorney, said Izzy was doing fine at that point and didn't need oxygen.

Once the decision was made, though, a tiny mask with a connecting tube was placed near Izzy's face.

But because of a mix-up involving portable carbon dioxide and oxygen tanks, the tubing was connected to the carbon dioxide tank, according to a March 22 DOD safety alert on the incident.

The mix-up happened even though the tanks were different colors and the content of each was clearly labeled, Fried said.

"What we had here was a system failure," he said. "A lot of people in the military dropped the ball."

Fried said he doesn't believe that Bird actually connected the tube to the incorrect tank but that she administered the gas, treated Izzy, and was the person primarily responsible for what happened to the infant.

If such a case had happened at a private hospital, the physician likely would be among the parties named as defendants, and a court would then decide whether the standard of care was breached, and which defendants shared in the liability.

Had Bird or other medical personnel in the operating room been more attentive, the tragedy could have been prevented with a quick look at where the tubing was connected, Fried said.

"That's all it would've required - just a glance before they started it up. It would've taken a second," he said.

At the time of the incident, Bird was a pediatrician training to become a neonatalogist (a physician who specializes in the treatment of newborns), according to Fried.

More than a year after the tragedy, Fried said he's surprised that Bird's state licensing record doesn't reflect her role in the incident.

6/24/2007 10:23 AM

Shalay Peterson celebrates the first birthday of her son, Izzy, last month at their Texas home.

"This was not something that took a great deal of time to determine what happened," he said.

The same day as the birth, the hospital acknowledged the mistake and apologized to the parents, according to Fried and Shalay Peterson. When the story hit the media in March, the hospital said publicly that immediate corrective action had been taken.

The government alerted its military hospitals through the March patient-safety notice, advising the institutions to take steps to prevent other gas mix-ups. The alert didn't mention Tripler by name, referring only to "one of our major military medical centers."

"The resultant assessment of the event found a number of knowledge, technical and process issues," the alert said. "While these issues have been addressed by the facility involved, it is essential that all military medical facilities take immediate steps to minimize the risk of similar events."

No other details were given about the issues uncovered. Tripler officials have declined to discuss the case because of the pending litigation.

Shalay Peterson said she recalled Tripler officials, including Bird, coming by her room to tell her what happened and to apologize.

"It's like this was something you see on television. I couldn't believe it was happening to me," she said.

Izzy remained at Tripler for about six months until the family moved to Texas in mid-July.

STATE PROCEDURE

If DCCA gets a notice that a military doctor has been disciplined, the state agency checks whether it has jurisdiction over that doctor's license and, if so, whether the underlying violation that prompted the discipline also constitutes a violation of Hawai'i's licensing regulations.

If so, that generally is grounds for discipline, and the board can impose a sanction, Uchida said.

Tripler officials, however, said they rarely have to report physicians to state licensing boards or the National Practitioner Data Bank, the government-run operation that keeps tabs on adverse actions against medical personnel. The officials said they do not keep statistics on such reports.

An Advertiser review of dozens of state disciplinary cases against medical personnel over the past five years found only two involving a military physician. It is difficult to know if there are more cases because some files don't say where a physician is employed.

One military case involved a doctor who was disciplined while working at a hospital on the Mainland. The physician didn't report that action on a timely basis, as required, to the Hawai'i board that issued his medical license. That physician's license was revoked in 2004.

The second case involved an Air Force physician who was disciplined by the military in October 2004 but failed to inform the Hawai'i board within the required 30 days. The records didn't indicate why the physician was disciplined. His case before the local board is pending.

Among the few Tripler doctors who have adverse reports with the national database, extenuating circumstances mitigate the reports, hospital officials said, without elaborating.

"Tripler validates every physician is trained, unimpaired, experienced and currently competent to hold delineated privileges before granting them," the officials said in an October statement responding to Advertiser questions. "Every physician's practice is continuously monitored by a senior physician and formally reviewed no less than every other year."

When Tripler determines a physician should not be practicing for a specific reason, such as lack of skill or knowledge, privileges are suspended and a thorough review is undertaken.

"Unlike civilian practices that tend to fire physicians when trouble first arises, military rules prevent the physician from moving on until a final ruling is made," the officials said.

"Unsafe physicians are identified rarely, but if found are not quietly released from service to possibly become some other organization's problem."