A fresh perspective untangles a baby's incomplete recovery.
By Kurt Newman, M.D.
Kurt Newman greets a patient at Children’s National.
Baby Jessica continued to vomit green. Over and over again, my surgical colleagues expressed disbelief and frustration. Despite being born with an intestinal blockage caused by a rare double intestinal atresia, she should have been thriving. A procedure to rebuild her intestine by reconnecting the gaps was, by all appearances, a success.
Instead, months after surgery, she required intravenous nutrition, vomited green bile and remained hospitalized. Several exploratory operations had been performed, and no obstructions were found. It wasn't my case, but it was a hot topic across the Division of General Surgery at Children's National.
I was familiar with the background before my mentor, Judson Randolph, M.D., the first full-time pediatric surgeon in Washington, D.C., handed me Jessica's files. He demanded, "Take a fresh look. Pretend no one has ever looked at this child. Sometimes new eyes are the best eyes."
An intimidating charge given how many surgeons and specialists, including Randolph, had studied this case. Who was I, a young pediatric surgeon, to question these impressive brains? But when the boss asks, you listen.
I interviewed everyone who was involved in the case, read every note and studied every chart. I visualized what her surgeons did as they sewed her intestine together in two places. I examined Jessica again and again, looking for a clue.
One morning as I stood in front of her in the NICU, practically begging for an answer, I pictured the surgeons' hands unwrapping her intestine. It suddenly occurred to me. At about the 10-week mark of pregnancy, the intestine exits the fetus, grows, and then rotates as it returns to the abdomen to adhere in its natural alignment. What if the surgery neglected to account for that rotation?
The detached section may not have made the necessary move with the rest of the developing organ. It would mean since the surgery, the segment of the baby's bowel between the two atresia repairs had been functioning in reverse.
Solving a seemingly intractable case requires questioning the original diagnosis and all subsequent diagnoses.
I worked with a radiologist to test my theory by inserting contrast rectally via enema. We watched the screen as the contrast reached the problematic section of her intestine. Sure enough, the reattached section propelled the contrast toward her stomach. Unbelievable! It was a very simple error—the bowel segment had been sewed together in reverse.
The NICU paged me after the corrective procedure was completed. Jessica had her first—green—bowel movement. I arrived to find her parents clutching her tiny diaper as if it contained a sacred object. "I am going to bronze this stool!" her mother said, hugging a NICU nurse.
Randolph shook his head. "Never trust the notes," he said. "Never trust the damn notes." He told Jessica's parents he was kicking himself for failing to realize what happened.
Solving a seemingly intractable case requires questioning the original diagnosis and all subsequent diagnoses. That includes questioning your judgments and those of everyone around you. Collaborative interrogation—respectful distrust—was the golden rule on Randolph's team, and parents were seen as critical questioners, too.
"Never trust the notes," I would say to myself during surgical cases and to every resident and fellow who crossed my path. Even today as a CEO, I've found when a challenge seems insurmountable, new eyes can often be "the best eyes" to solve it.
Kurt Newman, M.D., is president and CEO of Children's National Health System in Washington, D.C. This column was excerpted from Healing Children: A Surgeon's Stories from the Frontiers of Pediatric Medicine.
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