Commentary

This is a tricky case, with the majority of the paths leading to a baby with some long term learning difficulties. The best routes through the case involve identifying early that there is a serious duct-dependent cardiac defect and initiating a prostaglandin infusion. There are several ways to inadvertently delay this, and a drug error which all routes are subjected to also needs to be identified.

The purpose of this VP is to help trainees recognise a newborn with a critical duct dependent lesion, and to recognise that many errors that can contribute to adverse outcomes.

Choice 1: Poor triage, bravado

This initial step represents a fairly common scenario for a junior doctor during an overnight on-call. This initial decision is essentially one involving triage and identifying which job is the most urgent. There is also a failure in communication within the handover that fails to highlight the sickest children. Many hospitals will use a protocol for handover – and in this the SBAR tool is used. This stands for Situation, Background, Assessment and (expected) response. This is a technique of proven value, but is only as good as the information provided. There is enough in the handover to make a good choice, but it would have been easier if the doctor (player in the case) also knew that the infant was blue in air.

Even without this information, the sickest baby is likely to be the baby in respiratory distress. It is often the case that there is only limited clinical information provided when a doctor is asked to review a neonate – this hopefully will highlight the need to urgently review a tachypnoeic/grunting baby.

The child who needs a new cannula has mild dehydration and has already been on intravenous fluid for 24 hours. The clue for the jaundiced baby as a lower priority is the age. Jaundice under 24 hours of age is more likely to represent a serious pathology such as haemolytic disease of the newborn. Lack of knowledge of common infant disorders would hinder this assessment.

Choice 2: Knowledge, skills, fixation, playing the odds

This second step is the key decision point within the scenario. There is a lot of clinical information within the text, some more important that others, and picking up on these key points that will guide the player towards the correct decision (knowledge and skill). The baby is already on antibiotics and has had fluid resuscitation by the time this decision must be made, which are often the first interventions made in a sick infant.

The first choice of surfactant is made a possibility not by surfactant deficient lung disease associated with prematurity, but by the presence of meconium at birth, Both of these disorders are more common than cardiac defects as a cause of respiratory distress in a newborn, so those choosing surfactant may be playing the odds. The player may make this relatively timid choice, but have failed to address the strong possibility of a duct-dependent lesion. Also making this a poor choice is the clear chest radiograph and odd shape of the heart.

The second choice involves starting ibuprofen. The presence of a murmur may point the player towards treatment of a patent ductus arteriosus. Fixation on this as a cause could close the ductus completely leading to death.

Treating a duct dependent lesion is the best option as there are clues scattered throughout the text (early anomaly scan was delayed, no differential in pre/post ductal oxygen saturation, persistently low oxygen saturation in hyperoxia test, presence of a murmur and CXR shows boot shaped heart with oligaemic lung fields).

The baby is clearly very hypoxic, and in this instance waiting for an echocardiogram would not be appropriate.

Choice 3: System error, sloth, poor teamworking

The final stage is a drug prescription error (prostaCYCLIN vs prostaGLANDIN). The player is presented with a large amount of clinical information and has been given advice about what to do if baby’s condition does not improve by the cardiology team.

There is a system error in place by having two similarly named drugs that are both used in neonatal medicine, but one of the key skills in medicine is promptly recognising when a prescription error has been made. Here the player’s clinical supervisor has charted the drug, even though they have not been involved in the case. This is poor teamworking as it is not easy to prescribe well for a patient you have not been managing. It is also difficult for staff to identify errors that their supervisors have committed.

The easy choice is to call the consultant (sloth), and although this is not a wrong thing to do, there is a better option that reduces the delay in starting the correct drug. Missing the drug error and increasing the rate of the incorrect drug leads to further deterioration in baby’s condition, with much worse long term consequences.