Michael Radetsky MD CM
`Pediatrics • Infectious Disease
`PO Box 22040 • Albuquerque, NM 87154 • Tel 505.292.3035 • E -Fax 866.851.2537 • msradetsky@gmail.com
`
`
`
`Randall Hanson Esq.
`Camrud Madddock Olson & Larson
`401 DeMers Ave.
`Suite 500
`PO
`
`Box 5849
`Grand Fork ND 58206-5849
`
`March 12, 2018
`
`Re: Moreno v Jamestown Regional Medical Center (File No. 5834)
`
`Dear Mr. Hanson:
`
`I am a licensed physician in the States of New Mexico, California, and Colorado. I am
`currently board certified in Pediatrics and Pediatric Infectious Disease and formerly in
`Pediatric Critical Care. I have practiced these specialties for over 35 years. In addition, I
`was Medical Director of Newborn Medicine at the Lovelace Medical Center in
`Albuquerque NM from 1993-2002. I practice Pediatric Infectious Disease at Presbyterian
`Hospital in Albuquerque New Mexico. Presbyterian Hospital has approximately 6000
`deliveries yearly and supports that delivery service with a 60 bed Neonatal Intensive Care
`Unit. I am the only Pediatric Infectious Disease Consultant for these Obstetrical,
`Perinatal, and Neonatal services.
`
`I am currently a Consultant in Pediatric Infectious Disease and Consultant in Pediatric
`Infection Control in Albuquerque New Mexico. I am the sole Pediatric Infectious
`Disease Consultant for the Presbyterian Health System, the largest in the state. I lecture
`on Pediatric Infectious Disease topics at the University of New Mexico School of
`Medicine as well as at medical conferences throughout the United States. I teach
`pediatricians, family physicians, emergency department physicians, and nurse
`practitioners. I am familiar with the medical science and the standards of care in all of
`these disciplines as well as with the subject matter of this lawsuit, and I am qualified to
`render opinions in this area.
`
`At your request, I send to you this expert report based on my review of the following
`documents in connection with the care and treatment of Sarina Bonno and
`
`:
`
`•
`
`
`Medical Records of Sarina Bonno
`o
`
`
`Prenatal record
`o
`
`
`Jamestown Regional Medial Center
`§
`
`
`5/18/14 Admission
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 1 of 34
`
`
`
`
`
`
`
` 2
`§ Fetal Heart Tracing (included as exhibit in deposition of Tracy
`Neva RN)
`o
`
`
`Other assorted medical records
`•
`
`
`Medical Records of
`o
`
`
`Jamestown Regional Medical Center
`§
`
`
`
` Birth and nursery records
`o
`
`
`Sanford Medical Center
`§
`
`
`
` Admission (2467 pp)
`o
`
`
`Banner Health
`§
`
`
`Neurology and Neurosurgery Clinics
`o
`
`
`Sun Life Family Health Center
`•
`
`
`Plaintiff’s Expert Reports
`o
`
`
`Elizabeth Alford RN
`o
`
`
`Garrett Burris MD
`o
`
`
`Brian Carter MD
`o
`
`
`Stan Smith
`o
`
`
`Michael Horgan MD
`o
`
`
`Brian Carter MD
`o
`
`
`Red Duboe MD
`o
`
`
`Genevieve Reid MD
`o
`
`
`Gordon Sze MD
`o
`
`
`John Mukand MD
`o
`
`
`Karlsson Roth PhD
`o
`
`
`Rodney Isom PhD
`o
`
`
`Susan Crawford MD
`o
`
`
`Michelle Murray RN
`•
`
`
`Defense Expert Reports
`o
`
`
`Carolyn Salafia MD
`o
`
`
`Marvin Nelson MD
`o
`
`
`Harry Chugani MD
`•
`
`
`Discovery Deposition Transcripts with Exhibits
`o
`
`
`Marco Moser CRNA
`o
`
`
`Tracy Neva RN
`o
`
`
`Kacie Pahl RN
`o
`
`
`Sarah Schatz MD
`o
`
`
`Jessica Timm RN
`o
`
`
`Maria Wegner LPN
`
`
`The facts of the case are as follows:
`
`
`Medical Records of Sarina Bonno
`
`Sanford Medical Center Fargo
`
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 2 of 34
`
`
`
`
`
`
`
` 3
`Prenatal Record (PCP: Sarah Schatz MD)
`• 18 year old, single female.
`• Gravida 1, Para 0.
`• EDC 5/24/14
`• Prior GYN History
`o Chlamydia infection.
`• Laboratory Results
`o Blood type = O negative. Antibody screen = negative.
`o HBsAg = negative.
`o HIV = non-reactive.
`o RPR = negative.
`o Rubella = immune.
`o GC/CT = negative/negative.
`o GBS = negative.
`
`4/24/14
`• Clinic Visit
`o 35.5 weeks GA.
`o GBS collected.
`o US for position.
`o Cervix is very high.
`
`5/1/14
`• Clinic Visit
`o Subjective
`§ Patient complains of painful rash in her groin that started 2 days
`ago. Noticed several bumps on the labia. No discharge. No
`history of herpes in her or her significant other.
`o Objective
`§ Vulva: Multiple small ulcerated lesions. HSV culture obtained.
`§ Ultrasound conforms vertex position.
`o Vaginal lesions, ? herpes.
`o Valtrex ordered.
`o Laboratory Results
`§ HSV Nucleic Acid Detection
`• HSV 1 = detected.
`• HSV 2 = not detected.
`§ Urinalysis
`• NIT = negative.
`• LE = large.
`• WBC = 6-10.
`• Bacteria = moderate.
`o Prescriptions
`§ Valtrex.
`§ Cephalexin #30.
`
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 3 of 34
`
`
`
`
`
`
`
` 4
`5/9/14
`• Clinic Visit
`o On Valtrex.
`o Lesions are gone, per Sarina.
`
`5/11/14
`• Clinic Visit
`o Sarina is doing well. GBS results were negative. Reviewed her recent
`tests for herpes, and she tested positive for HSV. Lesions are gone now
`after starting Valtrex.
`
`5/15/14
`• GA 38.5 weeks.
`• Some contractions. Nauseated. Lesion healing. Cervix is closed.
`• Genital herpes resolved.
`
`
`Jamestown Regional Medical Center
`
`5/18/14
`• Admission H&P (Sarah Schatz MD)
`o HPI
`§ This is an 18 year-old female, who presents for routine prenatal
`care at 37 6/7 weeks. She is feeling fine, denies that she is having
`any contractions, has had good fetal movement. Last week she had
`some vaginal lesions, which have cleared up. Her HSV-1 test did
`come back positive. She is on Valtrex. She denies any vaginal
`bleeding or leakage of fluid. Her last menstrual period was
`8/17/13 and her EDC is 5/25/14. She is GBS negative and her
`blood type is O negative. She did have RhoGAM at 28 weeks.
`o Physical Examination
`§ VS: T 98.8, BP 128/78.
`§ FHT are in the 130s.
`o Assessment
`§ Primiparous at 37 6/7 weeks gestation.
`§ Teen pregnancy.
`§ HSV-1 genital herpes during pregnancy.
`§ GBS negative.
`o Plan
`§ Mange expectantly.
`§ Continue on Valtrex and prenatal vitamins.
`• Admit Report
`o EDC 5/24/14. GA = 39 1/7 weeks.
`o Weight = 194 lbs.
`o Contractions = 4 minutes. Duration 10-15 seconds. Intensity = mild to
`moderate.
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 4 of 34
`
`
`
`
`
`
`
` 5
`o Membranes = intact. Dilation = fingertip. Effacement = thick.
`o FHT
`§ Rate = 145. Moderate variability. Accels present. Decels absent.
`• Laboratory Results
`o UA (midstream)
`§ NIT = negative. LE = 500. Blood = 250.
`• Detail Notes Log (RN)
`o [Summary of FHT reports from 5/18/14 @ 1330 to 5/19/14 @ 1010]
`§ Reports were recorded approximately twice per hour.
`§ FHR baseline varied between 140 and 155 bpm.
`§ Variability was moderate during the entire interval, except at 0145
`it was minimal.
`§ Accelerations were present on every reading.
`§ Decelerations were primarily absent but with a period of variable
`decelerations reported from 0745 to delivery @ 1010. There was
`one early deceleration reported at 0615 on 5/19/14.
`o 1951
`§ SROM. Meconium thick. Moderate amount.
`o 2148
`§ Epidural catheter placed.
`
`
`• Detail Notes Log (RN)
`o 0757
`§ Patient noted to have area of blisters on right upper buttocks.
`o 0900
`§ SVE: Complete/100%/-1.
`o 1010
`§ Sterile vaginal delivery.
`• Delivery Report
`o Labor Summary
`§ Admit: 5/18/14 @ 1500.
`§ ROM: 5/18/14 @ 1951.
`§ Labor onset stage 1: 5/17/14 @ 2200.
`§ Labor onset stage 2: @ 0900.
`§ Delivery: @ 1010.
`§ Rupture type: SROM; thick meconium.
`§ Times
`• Duration ROM = 14 h 19 m.
`• Stage 1 = 35 h.
`• Stage 2 = 1 h 10 m.
`§ Oxytocin augmentation.
`o Newborn
`§ Male.
`§ BW = 3103 grams.
`§ Apgar: 2 (2 HR), 2 (2 HR), 6 (2 HR, 1 R, 1 M, 1 R, 1 C)
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 5 of 34
`
`
`
`
`
`
`
` 6
`• Placenta Pathology
`o Patchy mild acute chorioamnionitis.
`o Acute funisitis.
`o 498 grams weight.
`o Focal infarct involving less than 5-10%.
`
`5/20/14
`• Discharge Dictation (Dr. Schatz)
`o Final Diagnosis
`§ Status post normal spontaneous vaginal delivery.
`§ GBS negative, teen pregnancy, history of HSV on Valtrex.
`§ Infant with respiratory distress requiring transfer.
`§ Second degree burn due to heating pad.
`o Hospital Course
`§ She delivered a viable male infant by normal spontaneous vaginal
`delivery. She did have about 500 cc of bleeding post-delivery.
`She is asymptomatic. She has a normal exam on the day of
`discharge.
`§ Her infant was transferred to Fargo due to respiratory distress.
`§ She slept on a heating pad while she was in the hospital and
`developed a blistered burn on her right hip.
`
`
`Medical Records of
`
`Jamestown Regional Medical Center
`
`
`• 1010
`o Delivery
`• Newborn Report
`o Labor Summary
`§ Admit: 5/18/14 @ 1500.
`§ ROM: 5/18/14 @ 1951.
`§ Labor onset stage 1: 5/17/14 @ 2200.
`§ Labor onset stage 2: @ 0900.
`§ Delivery: @ 1010.
`§ Rupture type: SROM; thick meconium.
`§ Times
`• Duration ROM = 14 h 19 m.
`• Stage 1 = 35 h.
`• Stage 2 = 1 h 10 m.
`§ Oxytocin augmentation.
`o Newborn
`§ Male.
`§ BW = 3103 grams (AGA; 29%)
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 6 of 34
`
`
`
`
`
`
`
` 7
`§ Apgar: 21 (2 HR), 25 (2 HR), 610 (2 HR, 1 R, 1 M, 1 R, 1 C)
`o 1011
`§ DeLee suction of thick meconium from nose and mouth.
`o 1012
`§ HR = 60.
`§ Cyanotic. No respiratory effort
`§ Positive pressure ventilation initiated.
`§ Chest compressions started for 20 seconds.
`o Intubation
`§ 3.5 cuffed ETT.
`§ First attempt.
`o UVC line.
`§ Single lumen.
`• Clinical Documentation Report
`o Apgar at 10 minutes = 6.
`o Apgar at 15 minutes = 6.
`o Apgar at 20 minutes = 8.
`• [Resuscitation Summary
`o 1011: Age 1 minute: HR 120.
`o 1012: Age 2 minutes: HR 60. Positive pressure ventilation. Chest
`compressions for 20 seconds. Suction bulb and DeLee.
`o 1015: Age 5 minutes: HR > 100.
`o 1018: Age 8 minutes: Apneic and cyanotic. Tracheal suction.
`o 1020: Age 10 minutes: HR > 120.
`o 1021: Age 11 minutes: Call to pediatrician because of apnea
`o 1026: Age 16 minutes: Intubation.
`o 1100: Age 50 minutes: ABG (right brachial artery) = 7.05/54/68/14.4/-
`16.3.]
`• Newborn Examination Summary
`o Poor tone.
`o Meconium stained skin.
`o Appears small. No subcutaneous fat.
`o No effort to breathe.
`• 1144
`o Anesthesia Note
`§ Called for Code Blue with non-responsive newborn. Patient was
`intubated with 3.5 mm cuffed ETT. 24 gauge IV placed in the
`right antecubital fossa. 1.5 ml blood drawn for lab. Patient
`receiving 3 ml/kg/hr of dextrose 10%. Ventilating at 30% O2 at 30
`bpm with max pressure of 20.
`• 1238
`o Ampicillin 317.5 mg given.
`• 1256
`o Gentamicin 12.7 mg given.
`• Admission H&P (Sarah Schatz MD)
`o HPI
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 7 of 34
`
`
`
`
`
`
`
` 8
`§ This is a term male infant born by spontaneous vaginal delivery to
`a G1, now P 1 mom, who has had an unremarkable prenatal course
`with the exception of primary episode of genital herpes, HSV-1, at
`about 37 weeks. On Valtrex. GBS negative. She had
`spontaneous rupture of membranes and had thick meconium
`several hours before delivery. Infant delivered spontaneously, and
`cord was doubly clamped, cut, and infant taken to the warmer to be
`suctioned. No spontaneous cry at delivery. Thick mucus and
`meconium was suctioned by the nurse. The infant failed to
`respond to stimulation after suction. Heart rate dropped. He
`required resuscitation with positive pressure airway ventilation and
`chest compressions. His heart rate picked up and ranged from
`120s-160s. We continued to resuscitate. He did not really show
`any effort to cry or breathe on his own. I did suction the trachea
`prior to the code being called and did not get any mucus. He
`continued to be limp. Code was called and Anesthesia arrive and
`intubated the infant. Apgars were 2—2. See the note from
`Anesthesia regarding ventilation. Chest x-ray was obtained, and
`tube was pulled back due placement near the carina. Repeat chest
`x-ray was performed and placement was acceptable. Arterial
`blood gases obtained: 7.05/54/68/14.4/-16.3. WBC is 35,800 (16%
`segs, 13% bands, 59% lymphs). Hgb = 7.5. PC = 152,000. Dr.
`Quanrud, pediatrics, was also called and placed a UVC, and Dr.
`Smith, neonatologist from Fargo, is consulting during this process,
`and the baby will be transferred to Fargo by Life Flight. After
`resuscitation, the infant is moving his legs and occasionally
`breathing above the ventilation.
`o Physical Examination
`§ Normal facies, caput.
`§ Appears small for age.
`§ Heart RRR.
`§ Lungs diminished but good chest rise.
`§ Abdomen normal.
`§ MS normal appearance.
`§ Opened his eyes spontaneously a few times and moves his legs.
`§ No visible skin lesions.
`o Assessment
`§ Term male infant with respiratory failure, likely meconium
`aspiration.
`o Plan
`§ Passive cooling at Dr. Smith’s recommendation, to keep temp at
`36.5. Infant was started on IV antibiotics: gentamicin and
`ampicillin. Transfer to NICU.
`• Consultation (Myra Quanrud MD)
`o I was called by the Nursery team to assist with resuscitation of a term
`infant delivered by normal spontaneous vaginal delivery with thick
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 8 of 34
`
`
`
`
`
`
`
` 9
`meconium. At the time of my arrival the baby had already been
`resuscitated. He was intubated with a 3.5 mm ET tube with adequate
`ventilation. A peripheral IV had been started. The baby appeared to have
`good peripheral perfusion. The team had already begun the process of
`passive cooling as recommended by Neonatology.
`o
`
`
`On my assessment it was noted that the baby was not dysmorphic. His
`anterior fontanel was soft and flat. He had good air entry to his lungs, and
`no crackles and wheezes were appreciated. The heart had a regular rate
`and rhythm without murmur or gallop. The abdomen appeared soft and
`nontender. Capillary refill was noted to be lass than two seconds.
`o
`
`
`A UVC was placed.
`o
`
`
`Laboratory samples had previously been obtained including blood culture,
`so ampicillin and gentamicin were begun.
`•
`
`
`Radiology
`o
`
`
`CXR #1
`§
`
`
`ETT with tip in the right mainstem bronchus.
`§
`
`
`Heart size is normal.
`§
`
`
`There is mild bilateral haziness in both lungs. No peripheral focal
`infiltrates are evident. No visible pneumothorax.
`o
`
`
`CXR #2
`§
`
`
`ETT in good position.
`§
`
`
`No other changes are evident.
`o
`
`
`CXR + AXR
`§
`
`
`Developing pulmonary infiltrates more prominent on the right than
`on the left. Air bronchograms are visible.
`§
`
`
`NG tube tip is in the stomach.
`§
`
`
`UVC with tip superimposed over the central liver.
`§
`
`
`UAC which is retroflexed with tip probably back in the umbilicus.
`•
`
`
`Laboratory Results
`o
`
`
`1042
`§
`
`
`CBC
`•
`
`
`WBC = 35,800 (16% segs, 13% bands, 59%lymphs).
`•
`
`
`I:T = 0.45.
`•
`
`
`H/H = 17.5/50.
`•
`
`
`PC = 152,000.
`§
`
`
`Blood Culture
`•
`
`
`No growth.
`o
`
`
`1100
`§
`
`
`ABG
`•
`
`
`7.05/54/68/14.4/-16.3.
`
`
`Sanford Medical Center, Fargo ND
`
`
`
`•
`
`
`2029
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 9 of 34
`
`
`
`
`
`
`
` 10
`o Admission H&P (Alison Becker PA-C, William Bellas DO)
`§ Admission Problems
`• Unspecified nutritional deficiency.
`• Need for observation and evaluation of newborn for sepsis.
`• Respiratory failure.
`• Meconium aspiration syndrome.
`• Term birth.
`• PPHN.
`• HIE.
`§ Physical Examination
`• VS: T 33.7, P 133, R HFOV, BP 94/67. Sat 79%.
`• Gen: Hypertonic. Mildly responsive with exam.
`• Head: Anterior fontanelle soft and flat.
`• Eyes: Pupils equal.
`• Neck: supple.
`• Lungs: Good wiggle on HFOV. Equal lung sounds.
`• Heart: RRR. No murmurs. +1 pulses. Capillary refill 3-4
`seconds.
`• Abdomen: 3 vessel cord. Abdomen flat. Bowels sounds
`absent. No organomegaly.
`• Neuro: Gross motor exam abnormal. Mental status quiet.
`Tone overall increased. Pupillary responses equal and
`reactive. Gag reflex absent. Grasp reflex decreased. Moro
`absent. Plantar reflex decreased. Repetitive seizure like
`movements: lip smacking and tongue sucking. Normal
`pain response.
`• Skin: Warm and pink. No lesions.
`§ Medications
`• Dopamine, lorazepam, morphine, ampicillin, gentamicin,
`papaverine.
`§ Problems
`• Sepsis
`o Follow blood culture results. Send blood for HSV.
`• Respiratory
`o MAS. Concern for PPHN. HIE. Curosurf on
`transport. On HFOV.
`• Meconium Aspiration Syndrome
`• PPHN.
`• HIE
`o History of primary outbreak HSV in 3
`rd trimester.
`Meconium stained fluid. Appeared depressed at
`birth. No cord gases. Apgars 2.2.2. Passively
`cooled on transport. Neuro exam demonstrated
`high tone throughout/posturing, no blink, grimace
`with stimulation. CFM with low voltage-burst
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 10 of 34
`
`
`
`
`
`
`
` 11
`suppression pattern. Lactic acid 3.1 on admission
`No seizure activity at this time.
`• Laboratory Results
`o 1900
`§ CBC
`• WBC = 13,000 (18% segs, 37% bands, 33% lymphs).
`• I:T = 0.67.
`• H/H = 14.6/43.9.
`• PC = 114,000.
`§ Coagulation
`• PT = 15.6.PTT = 36.
`• INR = 1.5.
`
`5/20/14
`• Progress Note
`o Respiratory Failure
`§ MAS. Birth depression. PHN. Metabolic acidosis overnight, now
`corrected by increasing HFOV. Hypoxic respiratory failure. iNO
`started 5/19. FiO2 75%.
`§ Nitric oxide. Oscillator.
`o Hypotension
`§ Birth depression. Hypotension noted day of admission. On
`dopamine and dobutamine. Low cortisol level less than 5. Given
`hydrocortisone.
`o PPHN
`§ HFOV. iNO. Pressure support.
`o HIE
`§ Seizure activity noted within 12h.
`§ Continue hypothermia.
`o Sepsis
`§ Continue ampicillin and gentamicin. Hold acyclovir as no active
`lesions on mom and infant with renal impairment.
`o Neuro Exam
`§ Lethargic. Central tone decrease, peripheral increased. Reflexes:
`DTR absent, gag absent, grasp decreased, suck absent.
`• Laboratory Results
`o 0606
`§ CRP = 33 (normal < 8.0).
`§ BMP
`• 131/4.8/102/20/11/1.10.
`• (Creatinine normal = 0.80-1.30.)
`§ LFT
`• AST = 70 (normal < 35). ALT = 31 (normal < 55).
`o 0614
`§ CBC
`• WBC = 12,000.
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 11 of 34
`
`
`
`
`
`
`
` 12
`• H/H = 16.3/46.6.
`• PC = 102,000.
`
`5/21/14
`• Progress Note
`o Respiratory Failure
`§ MAS. Nitric oxide. Oscillator.
`o Seizures
`§ Secondary to HIE. Noted within 12h of life. Loaded with
`phenobarbital. Keppra load 5/20.
`o Hypotension
`§ Birth depression. Hypotension noted day of admission. On
`dopamine and dobutamine, hydrocortisone.
`o PPHN
`§ HFOV. iNO. Pressure support.
`§ Echo 5/20 with some elevated right side pressures, not supra
`systemic. Large PDA with bidirectional shunting. LA/So ration =
`1.33. Dilated RA and RV with normal function. Flattening of the
`ventricular septum suggesting elevated right side pressures.
`Moderate secundum ASD with left to right shunt.
`o HIE
`§ CFM with low voltage burst suppression pattern. Multiple CFM
`seizures.
`§ Continue hypothermia.
`o Sepsis
`§ Continue ampicillin and gentamicin.
`o Neuro Exam
`§ Lethargic. Central tone decrease, peripheral increased. Reflexes:
`DTR absent, gag absent, grasp decreased, suck absent.
`• Laboratory Results
`o 0507
`§ BMP
`• 135/4.4/100/19/14/0.9.
`o 0614
`§ CBC
`• WBC = 9,500 (35% segs, 29% bands, 26% lymphs)
`• I:T = 0.45.
`• H/H = 16.3/46.6.
`• PC = 102,000.
`• NRBC = 26.
`o 0710
`§ CRP = 57.3.
`o 0813
`§ HSV 1 & 2 Nasal PCR
`• DNA Not detected.
`§ HSV 1 & 2 Rectal PCR
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 12 of 34
`
`
`
`
`
`
`
` 13
`• DNA Not detected.
`§ HSV 1 & 2 Throat PCR
`• DNA Not detected.
`o 1710
`§ BMP
`• 140/4.2/102/18/16/0.8.
`
`5/22/14
`• Progress Note
`o Respiratory Failure
`§ Nitric oxide. Oscillator.
`o Seizures
`o Hypotension
`§ On dopamine and dobutamine, and hydrocortisone.
`o PPHN
`§ HFOV. iNO. Pressure support.
`o HIE
`§ Seizure activity noted within 12h.
`§ Continue hypothermia. Begin rewarming at 3 pm.
`o Sepsis
`§ Continue ampicillin and gentamicin.
`o Neuro Exam
`§ Lethargic. Central tone decrease, peripheral increased. Reflexes:
`DTR absent, gag absent, grasp decreased, suck absent. Some
`withdrawal to noxious stimulus.
`• Laboratory Results
`o CBC
`§ WBC = 10,000 (62% segs, 6% bands, 19% lymphs).
`§ I:T = 0.09.
`§ H/H = 13.2/37.4.
`§ PC = 118,000.
`§ NRBC = 20.
`o CRP = 39.8.
`o BMP
`§ 141/4.1/107/25/18/0.8.
`o LFT
`§ AST = 39. Alt = 31.
`o HSV 1 & 2 Blood PCR
`§ DNA Not detected.
`
`5/23/14
`• Progress Note
`o Respiratory Failure
`§ SIMV.
`o Seizures
`§ Last seizures noted 5/20.
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 13 of 34
`
`
`
`
`
`
`
` 14
`§ Phenobarbital and Keppra.
`o
`
`
`Hypotension
`§
`
`
`On hydrocortisone.
`o
`
`
`PPHN
`
`
`§
`
`
`On iNO 5/19 to 5/22.
`o
`
`
`HIE
`§
`
`
`Seizure activity noted within 12h.
`§
`
`
`Continue hypothermia. Begin rewarming at 3 pm.
`o
`
`
`Sepsis
`§
`
`
`Continue ampicillin and gentamicin 5 days total.
`o
`
`
`Neuro Exam
`§
`
`
`Lethargic. Central tone decrease, peripheral very increased.
`Reflexes: gag present, grasp decreased, suck absent. Stiff.
`•
`
`
`Pediatric Neurology Consultation (Christopher DeCock MD)
`o
`
`
`HPI
`
`
`§
`
`
`
` is a now day-old boy born at 39 2/7 weeks, who was born
`after rupture of membranes x 24 hours. Late 3rd trimester HS V
`initial outbreak. On Valtrex. Respiratory failure and HIE.
`§
`
`
`He was intubated after meconium aspiration syndrome. Apgars
`were 2—2—2. He was passively cooled on transport. He had high
`tone throughout with posturing. No blink, grimace, or stimulation.
`CSM showed a low-voltage burst suppression pattern. Later in
`evening he had a seizure. Loaded with phenobarbital. Ultimately
`CSM monitor returned to normal settings. He had no further
`seizure activity. He finished cooling last evening.
`o
`
`
`Physical Examination
`§
`
`
`Somewhat responsive to the examination. Withdraws to painful
`stimuli equally.
`§
`
`
`Pupils equal and reactive to light. Unclear if he responds to
`sounds. Positive gag. Positive corneal.
`§
`
`
`Normal strength in arms and legs.
`§
`
`
`No tremor.
`§
`
`
`2-3+ reflexes throughout. Palmar and plantar reflexes intact.
`o
`
`
`Impression
`§
`
`
`Possible HIE who has finished cooling.
`•
`
`
`Radiology
`o
`
`
`Brain MRI
`§
`
`
`History
`•
`
`
`Suspected HIE. Seizures.
`§
`
`
`Findings
`•
`
`
`On diffusion-weighted imaging, there are multiple areas of
`abnormal restricted diffusion affecting cortex and
`subcortical white matter in the left frontal and left parietal
`and left temporal regions. There is extensive involvement
`to the left insular cortex. There is additional abnormality
`on the right side affecting cortex and subcortical white
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 14 of 34
`
`
`
`
`
`
`
` 15
`matter in the right frontal and parietal regions, also
`extending towards the right insular cortex. The right
`temporal region is better preserved than the left side.
`• There is abnormality that is identified within the left
`caudate. There is restricted diffusion that is identified in
`the left caudate nucleus. There appears to be some mild
`restricted diffusion in the thalamic regions and basal
`ganglia regions, left greater than right.
`• There is no abnormal restricted diffusion that is related to
`either the brain stem or cerebellar hemispheres.
`• Corresponding T2 sequence demonstrates extensive
`abnormal increased T2 signal that affects the cortex and
`subcortical white matter in the frontal regions, left greater
`than right, as well as in the parietal regions, left greater
`than right, extending inferiorly into the insular regions and
`temporal regions. Left greater than right. There is
`abnormal hyperintense T2 signal that is identified within
`the left caudate nucleus.
`• There is slight effacement of the overlying sulci that is
`identified, especially in the frontal regions on the left side.
`§ Impression
`• Extensive abnormal restricted diffusion affects the cerebral
`hemispheres, left greater than right. There is involvement
`to the left caudate nucleus. I think there is some mild
`patchy involvement to the basal ganglia and thalamic
`region on the left side. There is sparring of the brainstem
`and cerebellar hemispheres. I think that this represents a
`diffuse ischemic event. Patient will likely go on to develop
`extensive areas of encephalomalacia in the cerebral
`hemispheres.
`• Not described in the body of the report is that there is a
`small focus of abnormal susceptibility artifact that is
`identified in the high body of the right lateral ventricle.
`There may be some minimal blood products within the
`right lateral ventricle. This is relatively minor finding.
`• Laboratory Results
`o CBC
`§ WBC = 14,000 (64% segs, 7% bands, 16% lymphs)
`§ I:T = 0.10
`§ H/H = 12.0/35.2.
`§ PC = 108,000.
`o CRP = 20.3.
`o BMP
`§ 140/3.7/106/26/33/0.8.
`o LFT
`§ AST = 35. ALT = 26.
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 15 of 34
`
`
`
`
`
`
`
` 16
`
`5/24/14
`• Progress Note
`o Respiratory Failure
`§ SIMV.
`o Seizures
`§ Last seizures noted 5/20.
`§ Phenobarbital and Keppra.
`o Hypotension
`§ On hydrocortisone.
`o PPHN
`§ On iNO 5/19 to 5/22.
`o HIE
`§ Brain MRI done yesterday. Results pending.
`o Sepsis
`§ S/P 5 days of ampicillin and gentamicin.
`o Neuro Exam
`§ Lethargic. Central tone decrease, peripheral increased. Reflexes:
`gag present, grasp decreased, suck absent.
`• Laboratory Results
`o BMP
`§ 141/2.7/111/23/26/0.5.
`o LFT
`§ AST = 23. ALT = 19.
`
`5/25/14
`• Progress Note
`o Respiratory Failure
`§ SIMV.
`o Seizures
`§ Phenobarbital and Keppra.
`o Hypotension
`§ Wean hydrocortisone.
`o PPHN
`§ Repeat echocardiogram.
`o HIE
`o Neuro Exam
`§ Central tone decrease, peripheral very increased. Reflexes: gag
`present, grasp decreased, suck absent.
`• Laboratory Results
`o CBC
`§ WBC = 13,200 (43% segs, 16% bands, 29% lymphs)
`§ I:T = 0.27
`§ H/H = 12.7/37.2.
`§ PC = 188,000.
`o BMP
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 16 of 34
`
`
`
`
`
`
`
` 17
`§ 141/3.7/105/28/26/0.5.
`o LFT
`§ AST = 22. ALT = 21.
`
`5/26/14
`• Progress Note
`o Respiratory Failure
`§ SIMV.
`o Seizures
`§ Phenobarbital and Keppra.
`o Hypotension
`§ Wean hydrocortisone.
`o PPHN
`§ Repeat echocardiogram.
`o Neuro Exam
`§ Increase in spontaneous movements and eye opening. Muscle tone
`mildly increased in LL>UL. Suck is poor.
`• Laboratory Results
`o CRP = 22.4.
`o BMP
`§ 142/4.1/102/31/280.5.
`o LFT
`§ AST = 24, ALT = 23.
`
`5/27/14
`• Progress Note
`o Respiratory Failure
`§ CPAP.
`o Seizures
`§ Phenobarbital and Keppra.
`o Hypotension
`§ Wean hydrocortisone.
`o PPHN
`§ Repeat echocardiogram.
`o Neuro Exam
`§ Responsive to exam. Gross motor exam abnormal. Responsive.
`Tone improving. Gag fair. Grasp fair. Moro absent. Suck good.
`
`5/28/14
`• Progress Note
`o Respiratory Failure
`§ CPAP.
`o Seizures
`§ Phenobarbital and Keppra.
`o HIE
`§ Brain MRI with multiple bilateral areas of restricted diffusion.
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 17 of 34
`
`
`
`
`
`
`
` 18
`o Hypotension
`§
`
`
`Wean hydrocortisone.
`o
`
`
`PPHN
`
`
`§
`
`
`Repeat echocardiogram.
`o
`
`
`Neuro Exam
`§
`
`
`Responsive to exam. Gross motor exam abnormal. Responsive.
`Tone improving. Gag fair. Grasp fair. Moro absent. Suck good.
`
`6/21/14
`•
`
`
`Discharge and Hospital Summary
`o
`
`
`Final Diagnoses
`§
`
`
`Respiratory distress syndrome in newborn.
`§
`
`
`Persistent fetal circulation.
`§
`
`
`Convulsions in newborn.
`§
`
`
`Hypotension.
`§
`
`
`Acidosis of newborn.
`§
`
`
`Ostium secundum type atrial septal defect.
`§
`
`
`Other conditions.
`§
`
`
`Observation for suspected infectious condition not found.
`§
`
`
`Meconium aspiration with respiratory symptoms.
`§
`
`
`Umbilical hernia.
`§
`
`
`Neonatal bradycardia.
`§
`
`
`Allergic gastroenteritis an colitis.
`o
`
`
`Course in Hospital
`§
`
`
`On room air since 6/17.
`§
`
`
`No seizure on EEG 5/25.
`§
`
`
`Two diapers with bright red, though small blood in stool. Some
`skin irritation with excoriation. Most likely related to cow’s milk
`protein allergy.
`§
`
`
`Hearing test 6/19/14: pass/pass.
`o
`
`
`Discharge Examination
`§
`
`
`Responsive to exam. Alert and fussy. Muscle tone increased
`overall. Increased extension posturing preferred.
`
`
`Follow-Up Information
`
`4/21/15
`•
`
`
`Jordan Developmental Pediatrics – Phoenix AZ (Tim Jordan MD)
`o
`
`
`Developmental Pediatric Consultation
`§
`
`
`Nearly one year-old boy who was present at the evaluation with his
`parents and grandmother. He was referred because of concerns
`about his motor skills.
`§
`
`
`
` cannot sit by himself and seldom bears weight on his legs.
`He has difficulty feeding himself and refuses to use a spoon. He
`has had these problems since shortly after birth. He was born in
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 18 of 34
`
`
`
`
`
`
`
` 19
`North Dakota. He suffered meconium aspiration at birth and
`secondary hypoxia. He apparently experienced a seizure at that
`time and was placed on phenobarbital for three weeks. An EEG
`was negative. A hearing test was normal at birth. He has been
`seen by an ophthalmologist because “his eyes turn outward.”
`Patching ahs bee ineffective because tears the patch off. He
`is scheduled to see an ophthalmologist again soon. There were no
`other problems during the pregnancy, except that he had some type
`of “spasm” and seizure-like jerking activities sometime around the
`middle of the pregnancy.
`§
`
`
`
` weighed 22 pounds and was 27 inches tall. He was a sturdy
`and serious-looking boy. His facial feature were slightly
`dysmorphic. His neurological exam was remarkable for a right-
`sided stiffness and inflexibility in both his upper and lower
`extremities. He held his hand almost fisted on the right side and
`could not straighten out his right leg or arm. His deep tendon
`reflexes were approximately equal in both lower extremities. His
`toes were down-going bilaterally, and he had a normal range of
`motion in his ankles. His upper extremity strength was definitely
`less on the right side. He seemed to have difficulty holding
`himself in a sitting position and slumped forward slightly. He held
`his head slightly cocked to the left. The rest of his exam was
`unremarkable.
`§
`
`
`
` was administered the CAT Clams test of
`neurodevelopmental functions. This is a test of the language and
`problem solving skills of children up to three years of age. He
`achieved a language score of between 60 and 70. He orients
`toward a bell and he babbles. He does not see any words. In the
`problem solving section he achieved a score of less than 50. He
`pulled on a ring but could not transfer. He could not obtain a cube
`but could pick up a cup.
`§
`
`
`
` had difficulty holding himself upright in a sitting position
`and slumped over somewhat cocking his head a little to the left
`during the testing. He gave his best effort to pick up things with
`his left hand and partially succeeded. He would not use his right
`hand. His still right leg seemed to prevent him from bending over
`far enough to pick things up easily when they were in front of him.
`He seemed to bear little weight on his legs when he was on his
`father’s lap. His eye contact was always very good. He was not
`heard to make any sounds.
`§
`
`
`To summarize, is a friendly little boy who has a right sided
`stiffness or hemiplegia. He is also behind in his development.
`However, it is hard to say if his neurological problems are
`affecting his development and how much. For example, if he
`wasn’t so stiff he could probably pick up more objects and even
`Case 3:16-cv-00114-TLB-ARS Document 161-16 Filed 04/10/19 Page 19 of 34
`
`
`
`
`
`
`
` 20
`feed himself more effectively. He definitely cannot use his right
`side as well as his lift.
`§ Neurology referral
`
`5/13/15
`• Banner Health Pediatric Neurology (Daniel Crawford NP)
`o Assessment
`§ Spastic hemiplegia.
`
`5/21/15
`• Banner Desert Medical Center Radiology
`o MRI Brain with and without contrast
`§ Findings
`• The diffusion-weighted sequence is without signal
`alteration, militating against acute ischemia.
`• On T2 sequences, there is extensive volume loss and cystic
`encephalomalacia involving the left frontal lobe inclusive
`of the superior, middle, and inferior frontal gyri, as well as
`the left frontal operculum and ventral insula. The left
`supramarginal and ventral left cingulate gyri are also
`involved. Findings are consistent with a remote insult
`i