Looking at the whole picture...

A seven-month-old infant was admitted to hospital with vomiting and abdominal distention. His past history revealed that he was born at term. There were difficulties establishing oral feedings. The infant was managed with total parenteral nutrition, and discharged home at nine days of age. At five months of age, the baby was seen with a history of intermittent vomiting of bile-stained fluid during the previous two to three weeks. An abdominal x-ray showed distended loops of bowel. A barium enema was performed to rule out intussusception. This investigation showed the cecum to be in a “high lying medial position”. Two days later, an upper gastrointestinal series showed a “spiral appearance to the proximal jejunum descending in the midline”. The radiologist expressed concern: “There was a malrotation at the mid gut. The radiological appearance suggested nonfixation of the mesentery and that the patient may be predisposed at some stage to a mid gut volvulus”. The infant was in hospital for four days and discharged. Over the next 44 days, the baby had repeated visits to doctors’ offices and to the emergency department with a complaint of recurrent vomiting of bile-stained fluid and, at times, constipation. During that time he was seen in consultation by three paediatricians, a general surgeon, a paediatric surgeon and three different family physicians. A repeat barium enema was performed in a facility outside the hospital and showed the same findings. On the final admission, the infant was admitted because of vomiting, constipation and lethargy. Over the next 8 h, his heart rate increased from 136 to 156 to 180 beats/min and, finally, to 200 beats/min 8 h after admission. Blood pressures were never recorded. The abdomen became increasingly distended, and the child was brought to the x-ray department for another barium enema to rule out intussusception. During the procedure, the baby regurgitated, aspirated and died. At autopsy, the infant was found to have a malrotation of the gut, with a volvulus and infarction of the entire small bowel. At the subsequent inquest, the jury expressed concern that each of the physicians who saw this child did not appear to have reviewed the entire record to get a total picture of the infant’s illness. Concern was also expressed that when x-rays are performed in two different settings, they should be compared. Expert testimony suggested that intermittent vomiting of bile in the neonatal period should be considered malrotation with volvulus until proven otherwise. This baby clearly had intermittent volvulus from which he recovered each time, except for the final admission. The baby’s vital signs clearly indicated an infant who was going into shock. Despite this, intravenous access was not established, and appropriate fluid resuscitation was not implemented. The jury recommended that physicians gain expertise in the insertion of intraosseous needles and maintain Pediatric Advanced Life Support certification. The failure to measure blood pressure, the failure to recognize increasing tachycardia and the failure to initiate appropriate fluid replacement are frequent themes observed by Ontario’s Paediatric Death Review Committee. The committee encourages physicians who assess children who have seen many other physicians to review comprehensively the children’s entire history – all assessments, consultations, and laboratory and x-ray reports.

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