October 20, 2006
The hospital error behind the record judgment prompted changes nationwide
By Leila Fujimori
A federal judge awarded nearly $16.5 million to the family of a child severely brain-damaged by a Tripler Army Medical Center doctor who mistakenly gave him carbon dioxide instead of oxygen right after his birth.
“It is the largest single verdict, to my knowledge, for any individual in the state of Hawaii,” attorney Rick Fried said yesterday. He represented the family of Izzy Peterson, who turns 2 in January.
But for parents Shalay and Dwight Peterson, an Army staff sergeant, “It doesn’t change a thing; we need to care for Izzy,” they told Fried. The couple, whose lives revolve around caring for their son, remained at their home in San Antonio and were not present for the decision.
The award is mostly to help pay for Izzy’s care for the rest of his life.
Tripler’s Maj. Gen. Carla Halwey-Bowland said in a news release: “Tripler Army Medical Center accepts responsibility for this tragic incident and respects the decision made by the Honorable David Ezra. Our command and well-trained staff are committed to doing whatever it takes to ensure an incident similar to this never happens again, such as improvements in medical gas safety — how they are labeled and handled and staff education.”
Tripler admitted in July it was at fault for the error that harmed the newborn.
“The one good thing” that resulted is that the error became a sentinel event. All U.S. military hospitals worldwide and all U.S. hospitals were alerted, Fried said. The mistake prompted taking steps to avoid such a problem, creating checklists and to eliminate the use of free-standing tanks.
A minute after Izzy was born healthy by elective Caesarian section Jan. 14, 2005, pediatrician Army Maj. Danielle Bird unknowingly administered the carbon dioxide. Not until the tank was nearly empty 42 minutes later did someone realize the mistake. Oxygen was substituted but his brain was damaged.
Fried said the operating room contained no other gas cylinder except the carbon dioxide, which is used for stomach surgeries, he said.
“Someone goofed up and put the wrong tank in the operating room,” he said. Fried also questioned why the doctor even intended to give Izzy oxygen.
Bird, a pediatrician doing a fellowship in neonatology, would have had to adjust the upright regulator of the free-standing cylinder clearly labeled carbon dioxide, different from the clocklike regulator attached to oxygen tanks, Fried said.
Early on, the government’s attorneys tried to show there was a problem with Izzy, until Fried showed home video of the birth of a normal baby, he said.
“You see him take his hand, trying to brush it (the carbon dioxide) away,” Fried said. “Even at birth he knew it wasn’t good for him.”
The Petersons chose to move to San Antonio so they could obtain the specialized care Izzy needs, Fried said. He will remain on feeding and breathing tubes for the rest of his life.
“They’re convinced he’s able to relate to them,” Fried said. He has self-awareness, recognizes his parents and responds to them, and his eyes track their movement. He can feel pain and kick a ball.