The gravol injection administered to toddler Nicholas Cox couldn’t have caused him to stop breathing, according to the doctor’s report given to Georgetown Public Hospital Corporation (GPHC), which is being accused of overdosing him and causing him brain damage.
On Thursday, the hospital released the doctor’s report on Cox, which confirmed that he has sustained diffuse hypoxic ischemic brain injury, which occurs after prolonged reduced oxygen supply induces neuronal cell death. The report does not, however, state conclusively what caused the child’s cardiopulmonary arrest (the combination of cardiac arrest and respiratory arrest) or what caused subsequent gastrointestinal bleeding for almost two weeks after he was admitted as a patient.
Cox, who was discharged from the hospital on Tuesday after more than a month as a patient, was resuscitated after his heart stopped beating and he stopped breathing sometime after the drugs were administered to him in the hospital’s Accident and Emergency (A&E) unit on May 30th.
Debra Archer, the child’s mother, has been claiming that her then 16-month-old son was given an overdose of gravol by a nurse at the hospital and collapsed immediately after the drug was administered to him. Archer, who has been calling for a probe of her son’s treatment, also said that her son’s doctor has told her that the buy sustained brain damage during the time the child had stopped breathing.
“A head CT scan confirmed diffuse hypoxic ischemic injury,” the doctor’s report said, while later adding that, “It must be noted that the injection of gravol at the onset of treatment of the infant could not have caused him to stop breathing.”
Medical resources seen by Stabroek News, however, suggest that the brain injury could have resulted if Archer’s allegation is true.
Hypoxic-ischemic brain injury most often results from bodily injury, irritation or trauma such as cardiac arrest, vascular catastrophe, poisoning (such as carbon monoxide intoxication or drug overdose), or head trauma, according to UpToDate, which is an online physician-authored clinical decision support resource.
Further, www.rxmed.com says gravol is a dimenhydrinate, a drug used to prevent nausea and motion sickness and its clinical side effects include drowsiness but convulsions, coma and respiratory depression may occur with massive overdose.
In addition, according to the Alberta Health Services website, which can be accessed at www.albertahealthservices.ca/addictionssubstanceabuse/hi-asa-abcs-gravol.pdf, overdose of the drug can result in confusion, irrational behaviour, loss of muscle co-ordination, high fever and convulsions. Serious heart and breathing problems and coma can also follow.
Treatment
According to the doctor’s report, the child was taken to A&E department by his mother, who complained he was suffering from vomiting and diarrhea over the preceding five days. Cox was also experiencing “a low grade intermittent fever and increasing fussiness and irritability over last two days. He was being seen previously at Woodlands Hospital and was being administered suspension kaolin, liquid gravol and daily injections of the antibiotic rocephin,” the report added.
It said that on triage at A&E, Cox was noted to be “fussy and irritable, febrile and moderately to severely dehydrated.” At 11:15 hrs, he was seen by the A&E doctor on duty, who ordered three boluses (the administration of a medication, drug or other compound that is given to raise its concentration in blood to an effective level) of normal saline 180 mls each, injection flagyl (an antibiotic) 250 mg and injection gravol 3 mg iv, which were administered.
After this, doctors at A&E were alerted at 12:50 hrs by Archer that her son had suddenly “stiffened out and stopped breathing.” Cox was in cardiopulmonary arrest with pulseless electrical activity, the report said, while adding that an emergency response was activated by the doctor after unresponsiveness was confirmed and full resuscitation actions commenced. “Advanced CPR, six rounds of epinephrine (known as adrenaline and used as a drug to treat cardiac arrest) and one dose of sodium bicarbonate (baking soda) were administered before a perfusing rhythm was achieved at 13:20 hrs, some 30 minutes later. By this time patient was intubated, with blood-tinged secretions evident, nasal gastric tube was passed with blood-tinged returns and foleys (catheter) were passed with blood-tinged urine returned,” the report noted.
Cox subsequently developed “a generalised tonic clonic seizure” (a seizure involving the entire body) during return of systemic circulation and was reviewed by Intensive Care Unit (ICU) and paediatric staff who recommended admission to ICU, the report said. He was then transferred to the ICU in a critical state with “a working diagnosis of post arrest from severe dehydration secondary to gastroenteritis (inflammation of the gastrointestinal track and small intestine) to rule out hemolytic uremic syndrome (a disease characterized by hemolytic anemia—anemia caused by destruction of red blood cells—acute kidney failure and a low platelet count) and neurosepsis.”
While in the ICU, the child was on ventilator support for six days, during which time his condition remained critical but with slow guarded improvement. “Feeds were slowly initiated and stools were initially diarrheal in nature but on day four post admission, had signs of digested blood (melena) and a further complication of upper gastrointestinal bleeding was added to the list of Baby Cox’s issues,” the report said, while adding that lab tests were also done but the results returned within fairly normal ranges including negative blood, urine and stool cultures, normal coagulation (process in which blood clot is formed), along with negative dengue and typhoid serologies.
The child was also assessed by a pediatric surgeon to assess the causes of the upper gastrointestinal bleeding and imaging studies including x-rays, ultrasounds and CT scans were done on him but none identified definitively the cause of the bleeding. The toddler experienced gastrointestinal bleeding of unknown cause for almost two weeks.
An endoscopic examination (used to look into the interior of a canal or large organ) was also done but it produced no conclusive source of the bleeding. However, with medical supportive care, the bleeding subsided.
The report said the tubes were then removed from Cox’s body on day seven and on the tenth day he was transferred to the Paediatric Ward “still very ill with ongoing internal bleeding of varying amounts each day,” and was noted to be “poorly responsive and spastic (change in muscle movement).”
His recovery continued with the sporadic giving of blood, antibiotics and other supportive care and physiotherapy was also started to address the spasticity and the long term bed stay.
An ophthalmology review was also done after concerns were raised about the child’s sight and the results concluded that a follow-up was needed to produce a conclusive diagnosis but stated that the visual apparatus was not affected at the time.
The child was discharged from the hospital on Tuesday and “is tolerating oral liquid to soft diet,” the report further said, while noting that he is also defecating normal.
Cox is also off of all antibiotics and fever free but continues to have deficits and regressions in motor (a nerve or muscle that produce motion), speech and social interaction.
According to the report, Archer was kept abreast with all the developments and possible eventualities throughout her child’s stay at the hospital and “no effort was spared” in accommodating her queries and concerns at all times. “She fully understands Nicholas’ evolution in hospital and has committed to his ongoing rehabilitation and care. He will be followed up by paediatric medicine, physiotherapy and ophthalmology,” it added.
But Archer is claiming that the hospital is responsible for the current condition of her child. Archer, who has been calling for an investigation into the treatment of her son and the dismissal of the nurse responsible for administering the gravol injection, had told Stabroek News that his condition has not changed much. He is still unable to say more than “mama” and “papa” and cannot move any part of his body other than his right hand, where a little movement is seen, she had said.
