DAYTON LEE JACKSON, an infant, by his parents and Guardians Ad Litem, LISA M. ROMAN and DARIL L. JACKSON, and LISA M. ROMAN and DARIL L. JACKSON, Individually, in their own right, Plaintiffs-Appellants,
LEONARD GOLDSMITH, D.O., KIM MIRYE, M.D., MARYANN MCCLARNON, R.N. a/k/a KAREN MCCLARNON, R.N., JUDITH NELSON, R.N., ROSEMARIE MUSCI, R.N., PHILOMENA JOSEPH, R.N., VIRTUA HEALTH, VIRTUA WEST JERSEY HOSPITAL VOORHEES, Defendants, and JANE IERARDI, M.D., NEWBORN HEALTH ASSOCIATES, and DANIELLE GREENO, N.N.P., Defendants-Respondents
NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION
Argued April 30, 2013
On appeal from the Superior Court of New Jersey, Law Division, Camden County, Docket No. L-2110-07.
Joshua Van Naarden (Ross Feller Casey, LLP) argued the cause for appellants (Mr. Van Naarden and Robert Robert Ross, attorneys; Mr. Van Naarden and Mr. Ross, of counsel and on the brief).
Jay J. Blumberg argued the cause for respondent Jane Ierardi, M.D. (Law Offices of Jay J. Blumberg, attorneys; Mr. Blumberg, of counsel and on the brief; Christopher M. Wolk, on the brief).
Timothy P. O'Brien argued the cause for respondent Danielle Greeno, N.N.P. (Crammer, Bishop & O'Brien, attorneys; Mary Ann C. O'Brien, on the brief).
William G. Theroux argued the cause for respondent Newborn Health Associates (Buckley Theroux Kline & Petraske, LLC, attorneys; Mr. Theroux, of counsel; Karla M. Donovan, on the brief).
Before Judges Alvarez, Waugh and St. John.
On December 21, 2011, a jury returned a no cause of action verdict against defendants Jane Ierardi, M.D., Danielle Greeno, N.N.P., and Newborn Health Associates (Newborn Health). Plaintiffs are Dayton Lee Jackson, an infant, by his parents and guardians ad litem Lisa M. Roman and Daril L. Jackson, and Lisa M. Roman and Daril L. Jackson, individually. Dayton was born July 26, 2006, at twenty-seven weeks, weighing just under two pounds, and measuring twelve inches long. Plaintiffs appeal and we affirm.
Dayton was admitted to Virtua Hospital's neonatal intensive care unit (NICU) for preterm babies, after his birth on July 26, 2006. On August 3, 2006, two unsuccessful attempts were made to insert a PICC line. Such catheters, which are very thin and flexible, are inserted into the vein of the arm and then threaded through to a major vein near the heart. They provide prolonged access for the infusion of fluids, nutrients, and medications, in place of repeated intravenous injections.
During the early morning hours of August 4, 2006, Maryann McClarnon, R.N., also known as "Karen McClarnon, R.N., " inserted a PICC line in Dayton's left arm. Because she was not yet certified by the hospital to perform the procedure, she was supervised by Philomena Joseph, R.N.,  who had experience in the placement of PICC lines.
Greeno was also working in the NICU that night as the on-call neonatal nurse practitioner. Following insertion, she ordered a chest x-ray to confirm the proper placement of the PICC line. Greeno explained that in order to administer fluids, the x-ray she ordered had to show the tip in a central location. The x-ray would also reveal if the PICC line was "coiled or flipping up into the neck or making a hairpin turn and coming back out."
The chest x-ray, taken at 2:40 a.m. on August 4, 2006, revealed that the catheter tip was beyond the mid-clavicular point and over the innominate vein. Greeno therefore concluded that the PICC line was in proper position for use.
Between 7:30 and 8:00 a.m. the following morning, Greeno advised Leonard Goldsmith, D.O., the attending neonatologist on the overnight shift, of the placement of the PICC line and asked him to look at the x-ray taken at 2:40 a.m. Goldsmith reviewed the film and considered it unremarkable.
At 8:00 a.m. on August 4, 2006, Ierardi replaced Goldsmith as the attending neonatal physician. Ninetta Dickerson, N.N.P., came on duty as the nurse practitioner.
At 8:10 a.m. on August 4, 2006, a second x-ray was taken of Dayton's chest to address breathing issues. Dickerson subsequently examined Dayton and wrote in the chart that the PICC line had been inserted the previous night in the left arm and that the most recent x-ray showed the line at his shoulder. At that time there were no perfusion, or blood flow, problems.
Ierardi also examined Dayton, whom she described as an "acutely ill premature baby with very severe lung disease." She also checked the PICC line. Ierardi's training did not limit PICC line placement to the superior vena cava (SVC), the largest vessel with the best longevity.
At approximately 5:00 p.m., Rosemarie Musci, R.N., examined Dayton and noticed his left hand and forearm were blanched, and informed Ierardi without delay. Ierardi, in turn, immediately examined the child. Musci told her that the blanching had just occurred. Ierardi described Dayton's left arm as blanched and having poor perfusion. As soon as she suspected that there was an ischemia or occlusion or some type of interruption of the blood supply to the arm and believed an artery was compromised, she pulled the line.
Although the perfusion of Dayton's arm slowly improved, some areas remained blanched. Ierardi noticed blood flow at the site where the catheter had been removed, confirming her belief that the PICC line had been placed in an artery. She attempted to take remedial steps, but by 8:00 a.m. concluded that Dayton's arm had sustained some permanent damage despite improvement. Ierardi believed that McClarnon had mistakenly placed the catheter in an artery, not a vein.
Goldsmith observed Dayton's ischemia and obtained a portable Doppler device to attempt to measure pulses. He could not identify any blood at the wrist or elbow. He reviewed the second x-ray, but did not consider the left axillary region in the shoulder area to be a central location. Goldsmith then called Sarah Jones, M.D., a pediatric surgeon, for a consult. Jones examined Dayton that morning, finding that his injury was significant. She did not review his chest x-rays. After taking additional ameliorative steps, Jones and Goldsmith decided to transfer the baby to NICU at Thomas Jefferson University Hospital, where Jones continued to treat him.
On September 11, 2006, Dayton was transferred to Children's Hospital of Philadelphia. Two days later, at the age of six weeks, surgeons amputated his left arm below the elbow.
Greeno, called by plaintiffs as an adverse witness in their case-in-chief, testified that the goal of any insertion was to place the PICC line in the SVC, one of the great vessels near the heart, as it provided the least resistance to the flow back to the heart of fluids, antibiotics, or blood itself. Greeno believed the PICC line could be placed in another vein, so long as it was centrally located. She had never encountered a situation where the PICC line was placed in an artery.
Greeno relied on the nurse who placed the PICC line to report problems, and had McClarnon expressed any concern regarding a possible arterial placement, she would have immediately removed it. McClarnon believed the PICC line had been successfully inserted into the SVC. Because the nursing staff did not report any difficulties, Greeno assumed the catheter had been placed in a vein, and did not order any further testing, which would have required an echocardiogram, arterial blood gas test, or ultrasound. Greeno did not recall discussing the x-ray with Goldsmith. She testified that the PICC line functioned throughout the night and she saw no indication of any perfusion problems with Dayton's arm.
Goldsmith, board certified in neonatal and perinatal medicine, also called by plaintiffs in their case-in-chief, understood proper insertion to mean placement of the PICC line in the SVC, but believed placement anywhere in the chest of a neonate was acceptable. He had placed approximately 400 PICC lines during his career, none in arteries. Goldsmith also relied on the person who inserted the PICC line to determine whether it was placed in an artery or a vein.
Ierardi explained that an x-ray would not reveal whether a PICC line had been placed in a vein or an artery. She too relied on the nurse who inserted the PICC line to place it into a vein. Prior to having Dayton as a patient, Ierardi had never encountered a case where a PICC line entered into an artery instead of a vein.
Based on her review of the x-rays, Ierardi believed that the PICC line was properly placed. Although she noted that in the first x-ray the tip sat in the area of the left innominate vein, a central location, in the second, the tip had migrated to the axillary area or armpit in the shoulder area. Movement was a known occurrence as a PICC line was often slippery for the first twenty-four hours and moved "in and out" all the time in babies. In Ierardi's view, the axillary vein was a central location appropriate for use. Nothing on the x-rays indicated that the PICC line should be removed. She commented that the line kept Dayton alive, two prior attempts at placement had failed, and there was no guarantee that a fourth would be more successful. Ierardi did not order other tests, because of the concern that an arterial gas test could ruin the lines, thereby increasing the jeopardy to which the baby was exposed, and the fact that during the night shift, an echocardiogram could take two to three hours to obtain. If she had suspected arterial placement, or that Dayton's arm was compromised in any way, she would have simply removed the catheter.
Jerrold S. Schlessel, M.D., was plaintiffs' expert in neonatal and perinatal medicine, having been employed for more than thirty years as a neonatologist in NICUs in the New York metropolitan region. Although he had, over his career, reviewed 300 to 400 x-rays to confirm proper PICC placement, he had never personally inserted a PICC line.
Schlessel opined, having reviewed both of Dayton's chest x-rays, that neither showed the PICC line in optimal placement. He believed optimal placement required placement of the catheter tip in the lower one-third of the SVC near the junction of the SVC and right atrium. Schlessel agreed, however, that it was also acceptable to place a PICC line in the chest area, including the innominate vein, although such placements carried a greater risk of complications such as pleural effusion.
Schlessel testified that the records showed no clinical evidence of perfusion problems in Dayton's left arm between the time the PICC line was inserted in Dayton's arm and the time Ierardi took over his care. He noted, however, that the first x-ray showed the catheter tip was over Dayton's clavicle, and that in the second x-ray the tip was outside the chest cavity in the shoulder or axillary region. Schlessel surmised that the tip had migrated peripherally as the blood flow in the artery pushed the catheter away from the heart.
Schlessel did not believe that a PICC line belonged in an artery, because of the high risk of an ischemic reaction. Since it was not possible to determine from an x-ray whether the PICC line was in a vein or artery, he believed the standard of care required a treating physician to order an echocardiogram or echovasculargram, or to obtain an arterial blood gas test through the PICC line. In his opinion, Greeno deviated from accepted standards of medical care by determining from only a chest x-ray that the PICC line was properly placed and appropriate for use. He believed Dayton would not have suffered the injury to his arm if Greeno had recognized the improper placement on the initial x-ray, and pulled the line between 2:40 to 3:00 a.m.
Schlessel also concluded that Ierardi deviated from accepted standards of care by failing to recognize from the x-rays that the catheter tip was improperly positioned, by failing to confirm that the PICC line was placed in a vein and not an artery through other tests, by continuing to infuse fluids and medicines through the catheter, and by failing to remove it in a timely manner. In his opinion, Ierardi's deviations contributed to the loss of Dayton's arm. Schlessel could not say to a reasonable degree of medical certainty, however, that ...