Caring for Carter

When the pediatric GI arrived, he had a Sports Medicine fellow with him. The pediatric GI provider, who has decades of experience, instructed the Sports Medicine fellow to use hegar dilators on Carter to dilate the tract to 5mm. While dilating with the hegars, she was very rough and aggressive (really pocking and jabbing). *In a Medscape article that I read, it states “Aggressive probing should be avoided, as a false tract can be created.” (Schraga, 2018) Never force the tube! The GI provider in the room, who has over 30 years of experience didn’t say a word about how aggressive she was. After the fellow was done doing this to Carter, she was instructed to put in his new 14 Fr 2.5 cm Mic-Key balloon tube at bedside in the ER. The nurse asked the GI provider and fellow if they wanted to do contrast (a way to confirm the placement of the tube into the stomach) and they said, “No”. Carter’s discomfort after the procedure was noted and he was monitored for a few moments. After a few minutes, Carter was given ibuprofen for “discomfort” and sent home. Carter was happy, smiling, cooing, and doing well up until this day. When he passed away suddenly on Friday, June 1st, 2018 (a little over 24 hours after this procedure), our family knew something wasn’t right. An autopsy was performed and it found that Carter died due to the complications from a misplaced percutaneous endoscopic gastrostomy feeding tube as the tip of the PEG tube was present within the peritoneal cavity. The GI provider who instructed the fellow that day, overseeing the whole procedure, has called Carter’s mom several times apologizing for what happened and even stated, “when we tried to dilate, we must have made a false opening.” Carter would still be here today if it wasn’t for the negligence of these healthcare providers. PLEASE, PLEASE share this story with others so that this doesn’t happen to another child. It would have only taken minutes to make sure the g-tube was back in his stomach. Carter’s last hours were more than likely filled with severe pain and discomfort as associated with the misplaced PEG tube was acute peritonitis (Due to Carter being nonverbal, he was unable to verbally state how he was feeling) and they caused our family, friends, and others who cared for Carter immense pain, grief, and a void that will last forever as a result of the decisions they made that day. It is disturbing that the provider and fellow who were responsible for the death of Carter aren’t being held accountable. It is disturbing that this is supposed to be one of the best “teaching hospitals”, yet the fellow was TAUGHT to cut corners, that using excessive force to dilate a tract is OK, and that you don’t need to confirm the placement of a tube you just replaced. Since she has no idea what she did, I pray that she never replaces a g-tube again. It is disturbing that an experienced pediatric GI provider didn’t use his years of experience and do the right thing and that he will more than likely perform this same procedure on many other sweet and innocent children.
Schraga, E.D.(2018). Gastrostomy tube replacement technique. Medscape. Retrieved from: https://emedicine.medscape.com/article/149589-technique#c2