Province of British Columbia

Office of the Chief Coroner
Metrotower 11
Suite 2035 - 4720 Kingsway
Burnaby, BC V5H 41\12
Phone: 604 660-7745
Facsimile: 604 660-7766
Ministry of Public Safety and Solicitor General
BC CORONERS SERVICE
Case No.: 2002:586:0056
Police File: N/A
Police Department: N/A

I, T.E. Chico Newell, a Coroner in the Province of British Columbia, have inquired into the death of the above named, which was waived to me on the 30th day of September, 2002, and as a result of such inquiry have determined the following facts:

Gender: male
Native: no
Age: 1 month, 1 day
Premise/Place of Death: B.C. Children's Hospital, Vancouver, B.C.
Estimated Date of Death: 22 August 2002
Estimated Time of Death: 0440 hours
Date and Time of Injury: 20 August 2002, 0825 hours
Township of Injury/Illness: Penticton, B.C.
Injury/Illness Premise: Hospital
Identification method: Visual (parents)
Body released to: Summerland Funeral home, Summerland, B.C.
Post mortem examination: Full
Conducted by: Dr. G.P. Taylor, Pathologist, B.C. Children's Hospital, Vancouver, B.C.

(1) Immediate cause of death: a) Multi-organ ischemia, due to or as a consequence of b) exsangination [loss of blood], due to or as a consequence of c) circumcision
(2) Other significant conditions contributing to death: Post-surgical exsanguination

Classification of the event: Accidental
Date signed: 19 January 2004
T.E. Chico Newell, Coroner

On August 20, 2002, Ryleigh underwent a circumcision at Penticton Regional Hospital (PRH). The physician informed Ryleigh's parents that circumcision was an elective procedure and infection and bleeding were possible complications.

He asked if Ryleigh had any bleeding problems. [He was one month old!] Mrs. McWillis noted that his foot had to be squeezed at birth to get a blood specimen.

Ryleigh arrived at the hospital at 0750 and the procedure was completed at 0825. Prior to the procedure, Mrs. McWillis told the physician that her husband would be changing Ryleigh's diapers and dressings. The physician informed Ryleigh's father to come to the Emergency Room or contact him if extra bleeding occurred.

After the procedure, Ryleigh was diaphoretic [perspiring] and distressed, but settled by 0850.

During a post-operative assessment at 0855, the assisting nurse noted a moderate amount of oozing from his penis. Ryleigh's mother stated the gauze dressing was soaked with blood but the diaper was not. [Modern disposable diapers contain a gelling agent that conceals the volume of fluid retained.] The nurse changed the dressing and administered Tylenol 40 mg at 0915. The physician was notified of the oozing and instructed Ryleigh's mother to come by his office to have the circumcision checked. The nurse advised the parents that, if further bleeding occurred, they were to contact the physician or return to the hospital.

On examination, the physician saw a slightly blood stained 4x4 gauze dressing. He noted there had been only a small amount of bleeding; the blood looked dry; there were no clots present: and there was no active bleeding. He thought excessive movement due to his pain may have caused Ryleigh's bleeding and he placed a clean 4x4 around the circumcision site. Throughout that day, Ryleigh fed poorly and was irritable. During the early evening his mother changed his diaper and found it to be completely soaked with blood. During the night, Ryleigh continued to feed poorly and was irritable.

At 0400 the next morning, (August 22, 2002), his parents gave him Tylenol. At approximately 0530, his father, changed the diaper, found it to be soaked with blood, and noted blood clots. Ryleigh's lips were cool and pale. His parents took him to Penticton Regional (PRH) Emergency Department where he was admitted at 0606 hours for hypovolemia [not enough blood]. He was transferred to the Intensive Care Nursery where he was admitted at 0630. A pediatrician was called in, arrived within minutes, and assumed his care.

On observation, Ryleigh was found to be in shock, breathing spontaneously but with an expiratory grunt; not perspiring; very pale; cold to touch; and had reduced muscle tone. At that time, no further bleeding was noted. His temperature was 34.40 C; pulse 120 bpm; respirations 33; and pupils equal and reacting to light. His oxygen saturation (02 sats) was between 72-80% (normal is 97%) and his blood gases indicated he was acidotic. He was administered oxygen by mask at five litres per minute. His blood pressure was 45/30. An intravenous was started in his left scalp vein. As Ryleigh was volume depleted, this required numerous attempts and took over an hour to complete. A Normal Saline solution was administered intravenously. At 0720, blood was drawn through a femoral vein for blood work (i.e. hematological testing and cross matching). This revealed Ryleigh had a low hematocrit (0.14 N=0.39-0.63) and red blood cell count (1.23 N=3.3-5.3) and an extremely low hemoglobin level (43 N= 102-182), all of which indicated hemorrhage. The blood was thick and difficult to extract. Ryleigh was administered Ampicillin and Gentamicin (antibiotics) intravenously through his scalp vein. [Why? He was not suffering from infection.]

During the next hour, Ryleigh's condition was critical and unstable. His blood pressure ranged from 63/52 to 39/19. His heart rate was in the 95 beats per minute (bpm) range, and at one point dropped to 57. His 02 sats increased from 68% on 3 litres of oxygen to 95% to 98% on five litres of oxygen. A respiratory technician commenced assisted controlled ventilation with 100% oxygen; a 3.5 endotrachial (ET) tube was inserted with good air entry to both lung fields; a 3.5 orogastric tube was inserted and thirty- five mls. of curdled milk was aspirated. This tube was left open for further drainage. An intra-osseous line (an intravenous line inserted directly into the marrow of a long bone) was established in his right tibia and Normal Saline infused through this at 80 ml/hr. Ten percent Dextrose (D10) was administered through his scalp vein intravenous line at 20 ml/hr. At this time Ryleigh's blood glucose was 25 (N=3.6-6.7). Ryleigh's femoral pulse was thready and his pupils were equal, but non-reactive. At 0850, a British Columbia Children's Hospital (BCCH) emergency physician who had been notified regarding Ryleigh's condition, advised the pediatrician to give four mls. 50% Dextrose by push then replace the 010 with Normal Saline so that the intravenous and intraosseous lines were infusing a total of 100 mljkg of Normal Saline. The pediatrician, not noticing what Ryleigh's blood glucose was at the time, gave the 50% Dextrose. Arrangements were made to transfer Ryleigh by air ambulance to BCCH.

At 0900, Ryleigh's blood work revealed his platelets were normal. His physician gave him fifty-five mls. of packed cells by intravenous push at 0905 hours. Blood gases revealed that Ryleigh was extremely acidotic (pH 6.419) and his blood glucose was 15.6. His physician noted his prognosis was grim. At 1000, he had slight bleeding from his penis and an ice pack was applied. At 1020, his physician began giving him 80 mls of fresh frozen plasma by intravenous push. After this, Ryleigh's colour improved; some peripheral pulses were palpable; and his pupils were marginally reactive at about 3 mm dilatation. Continuous Positive Airway Pressure (CPAP) was commenced. [He was put on a respirator.] The transport team arrived at around 1040 hours. They continued the infusion of plasma. Ryleigh's pupils were responding slowly and he tried to move his hands. A BCCH emergency physician recommended Ryleigh be paralyzed and sedated with Pavulon (relaxes skeletal muscles) and Versed (a sedative) and started on Dopamine (a vasoconstrictor). These infusions commenced at 1100. The infusion of fresh frozen plasma continued. A number 3.5 feeding tube was inserted into Ryleigh's bladder but there was no urine drainage. His orogastric tube drained bloody bile returns and there was a large amount of bloody oozing from his penis.

At 1223, five mEq of Bicarbonate (4.2%) was administered by intravenous push. Ryleigh was transferred to the transport incubator at 1235 and at 1250 the transport team transferred him to BCCH. His parents were notified of the seriousness of his situation. The transport team noted that Ryleigh was very pale with mottled skin and that he was cool to touch. He had a seven cm. fresh blood-stain on his diaper with no clots. A new dressing was applied. Ryleigh was observed to have good expiration and was diaphoretic, with clavicular indrawing. The following were noted: tachycardia [racing heart] with poor perfusion; thready brachial pulses; and femoral pulses were not palpable. Ryleigh's abdomen was distended but soft and bowel sounds were present. No urine output was noted since admission to PRH and a small amount of mucousy stool was passed. Muscle tone was limp; his eyes occasionally opened and he was fighting his ventilated breaths. Pupils were three mm. in size and slow to respond.

Ryleigh was admitted to BCCH intensive care at 1430 hrs, August 21, 2002, with a diagnosis of shock due to severe blood loss. An abdominal ultrasound revealed: liver normal; kidneys enlarged and echogenic (reflecting ultrasonic waves) indicating renal problems; a hematoma to the spleen; and a small amount of free fluid in the abdomen. Ryleigh's abdomen was distended with gas and fluid. His bladder was empty. A cranial ultrasound revealed the ventricles to be normal and there was no brain hemorrhage or other abnormality. The attending physician ordered antibiotics intravenously; and assessed Ryleigh for acute problems. At 1452, Ryleigh suffered a cardiac arrest and was successfully resuscitated. At 1500, an atrial cannula was inserted into his right carotid artery and connected to extra corporal life support (ECLS), which acts as a temporary cardiopulmonary bypass and reproduces the functions of the heart and lungs. His physician wrote ECLS Parameters aiming for a neutral fluid balance. He ordered 10% Dextrose, Sodium Chloride, Morphine, Versed and Nipride (to relax blood vessels and optimize the strength of heart beats). Ryleigh's platelets were low at 60 (N= 140- 350). At 1725, his ECLS cannula was advanced further to position the tip in his right atrium as a full flow had not previously been achieved. The flow improved markedly after this repositioning. A chest X-ray noted he had pulmonary edema after his fluid resuscitation and ECLS re-cannulation.

At 1915, the physician documented Ryleigh had received massive volume resuscitation during the day since his arrival in Penticton and had excess fluid volume and failing cardiac output. He was placed on dialysis and his prognosis was noted as poor. Ryleigh's parents were informed of his condition. The physician noted that Ryleigh was severely coagulopathic (his blood was not clotting appropriately) and Ryleigh's prognosis was guarded. Blood oozed from the atrial catheter site throughout the evening. At 2100 hours, Ryleigh's right arm was cool and pulseless and his right leg was dusky and pulseless. His scalp was blanched near the intravenous site. His abdomen became more distended and he appeared quite flushed.

At 2200, a nurse noted there was less bleeding from the IV site since the catheter dressing was changed. His abdomen appeared even more distended and tense and increasing bruising on the skin was apparent. He remained aneuric (not producing urine). His parents were aware of all changes. At 2215, cardiac rhythm changes were noted. By 2400, bleeding increased. Cardiac rhythm changes continued. His legs were noted as being dusky and mottled.

At 2350, a surgeon saw Ryleigh in order to assess his increasing abdominal distension. His abdomen was tight with bluish discoloration and his lower extremities were warm and adequately perfused, although his right leg was congested, possibly secondary to his femoral line. Lactate level was increasing (which happens in shock and decreased blood to tissues) but stable, as was the bicarbonate level. The surgeon planned to stop the nasogastric tube feed and place the tube to suction. He ordered Ranitidine (decreases acid secretion) 8 mg. intravenously every eight hours.

The plan was to perform an exploratory laparotomy only as a last resort. At 0100 of August 22, 2002, a drain was inserted into Ryleigh's right lower abdomen and approximately 75 mls of sero-sanguinous fluid was drained. There was slight clinical improvement after this procedure; however, he was grossly edematous (swollen). At 0200, Ryleigh's physician noted he had progressively deteriorated over the night. The physician thought his bowel was probably dead. At 0230, his dialysis filter was noted to be clotting frequently and he required repeated Heparin boluses to prevent clots.

At 0239, he went into ventricular tachycardia and was defibrillated [his heart went into functionless racing and electric shocks were given to restore it to normal speed] several times. At 0300, Ryleigh's colour was purple and mottled except for the left upper quadrant of his trunk and lower face. No pulses were palpable. There was dark sanguinous fluid around his nares and filling his orogastric tube. His abdomen drained dark, brown fluid; his nasogastric drainage was sanguinous; and his parents were aware of his deteriorating condition. Ryleigh's physician ordered Magnesium Sulphate 250 mg IV as an electrolyte replacement. At 0343, the dialysis filter clotted and dialysis was stopped. Ryleigh remained in a slow idioventricular (ventricles alone) rhythm with no pulses and no capillary refill peripherally. At 0420, Ryleigh's parent gave permission to discontinue treatment; his ECLS was discontinued; and at 0440, he was pronounced dead.

The physician who performed the circumcision related that Ryleigh's mother wanted him to be circumcised as a family member had experienced difficulty after a circumcision at a later age and they did not want him to go through a similar difficulty. [Solution: don't circumcise him now or later] The physician stated he told her a circumcision is traumatic for all involved and is an elective, non-medically indicated procedure.

[This seems like an attempt to blame the parents. Nobody was twising the doctor's arm.]

He examined Ryleigh and found no problems. He made arrangement to perform the procedure at PRH using a Gomko [Gomco] procedure. The physician reviewed the procedure with Ryleigh's mother; he asked about birth problems, bleeding problems, and Ryleigh's heel prick procedure to obtain blood after his birth. He assumed from her answers there were no bleeding problems. He wanted both parents at the procedure to talk to them about the risks and ascertain who would look after the child post circumcision.

On July 20, 2002, the physician met with both parents at PRH and talked with them for twenty to thirty minutes, discussing the risks of the procedure, particularly bleeding and infection. He told them it is normal for some bleeding to occur in the first hour or so and, for this reason, children are to stay at the hospital for this amount of time after the procedure. He told them it is abnormal if bleeding is ongoing and they should change the 4x4 dressing only, not the Jelonet dressing surrounding Ryleigh's penis. They [st]ated Ryleigh's father would be caring for him and changing the diapers.

While the physician was performing the circumcision, the only alteration in his normal procedure was that he used a medium sized Gomko, then decided it might be too small, tried a large size, found it to be too large, and then went back to the medium size. [The FDA has warned against mismatched clamp parts.] After the procedure, he did rounds at the hospital and went back to his Summerland office. At approximately 0930, he got a call from the pediatric nurse who had assisted him to inform him of some post procedure bleeding. She told him there was bleeding the size of a dime. At 1030, he saw Ryleigh in his office. The babe had good tone and was pink. His diaper was dry. The physician opened the diaper and saw only staining and some dried blood. There were no clots and Ryleigh's scrotum was dry. The physician noted there were approximately four to five mls. blood loss and bleeding appeared to have stopped. He told Ryleigh's mother that ongoing bleeding was not good. If the 4x4 dressing became stained or soaked, that could be considered extra bleeding and she should phone him or go to the hospital emergency department.

The pediatric nurse who assisted the physician with the circumcision procedure noted that the physician arrived early to discuss his routine with her. She heard him discussing the procedure and risks with the parents, but could not be specific regarding what was said. She stated there was not much bleeding during the procedure, which took the normal twenty minutes to complete. A Jelonet and 4x4 dressing were applied. After the procedure, Ryleigh was warm and diaphoretic (sweating), but, as he had been placed under a heat lamp, this was not notable. The physician spoke again with the parents for approximately five to ten minutes. The nurse noted that she told the parents that the Jelonet was to remain in place for forty-eight hours but the 4x4 could be changed as needed. At approximately 0850, the nurse examined Ryleigh and noted a one and one-half inch ('tooney') size amount of blood on the 4x4 dressing. She took the Jelonet off, cleansed the circumcision site, noted there was no more oozing, and put the dressing back on. As this was more bleeding than usual, she had Ryleigh and his mother stay for an extra half hour. She called the physician and gave the baby Tylenol. At 0930, Ryleigh was settling. At that time, there was about a one-half inch (dime) sized bleed on the 4x4. The physician returned her call at this time and asked Ryleigh's mother to bring him to his office. The nurse gave her the usual post operative instructions which were to check Ryleigh every hour for bleeding, call the physician if she had any concerns, and change his diaper when he urinated or when the 4x4 was wet. She informed her that Ryleigh should void within one to two hours and gave her 4x4 dressings to take home with her. Ryleigh's mother left with him at approximately 0945 hours.

The nurse stated that the information pamphlet normally given to parents was not given to Ryleigh's mother. The pamphlet was given only when a Plastibell circumcision procedure was performed. Ryleigh had a Gomko circumcision procedure. The Gomko procedure was rarely performed in PRH and instructions for it were not included in the pamphlet, therefore it was not offered to Ryleigh's parents. Verbal instructions were given instead.

A PRH pediatric nurse who received a call from Ryleigh's father at approximately 0520 hours said he told her that Ryleigh had a circumcision the previous day; asked "how much blood is too much blood"; and stated the 4x4 dressing was soaked with dark blood. He said the babe had last been changed when he was put to bed the evening before, was pale, and did not want to feed. The nurse told the father they should bring the baby to the emergency department.

The physician on call for the Emergency Department at PRH noted that he (the physician) was already in the emergency department after responding to another case. When Ryleigh came in he looked in shock and had grunting respirations. The physician stated they were doing many things all at the same time to help him and that they moved Ryleigh to the nursery as they had the supplies and equipment there to treat him. The pediatrician who was called for assistance was at the hospital within minutes and the emergency physician turned Ryleigh's care over to him. He related that Ryleigh's father told him the babe's mother had been up with him during the night, but had not checked his diaper. He also related that the pediatrician mentioned to him that if a baby's pH is below 7.2, death is inevitable. Ryleigh's was 6.4.

The pediatrician who cared for Ryleigh at PRH on admission to ER stated that he knew that the child was in deep shock but was not initially sure of the reason for it. He realized Ryleigh had a circumcision the day before, but, at the time, he was aware of the existence of only one bloody diaper, he was not sure if the shock was due to volume depletion, overwhelming sepsis, or some other cause. The diaper he examined had frank clots of blood, which he estimated to be fifty to one hundred mls. [A baby's body contains ~350ml of blood. 10% blood loss - 35ml, about two tablespoonsful - is considered dangerous.] with pale stool. One and one-half to two hours after his arrival to the emergency room, Ryleigh's father mentioned that the evening before, Ryleigh had fed poorly and had another clotted and bloody diaper. It was then that the pediatrician realized that Ryleigh had exsanguinated. The pediatrician established that Ryleigh was breathing spontaneously, (and therefore had a patent airway) and needed to be ventilated, but that circulation needed to be established immediately. The pediatrician made many attempts to initiate an intravenous line, first through Ryleigh's hands and then his scalp. Due to Ryleigh's volume depletion, venous access was extremely difficult, but after trying for an hour, the pediatrician established a scalp vein line and administered intravenous saline. Ryleigh was gasping for breath and he was then easily intubated and ventilated. On examination, he found all of Ryleigh's systems to be operating adequately. He called the BC Children's Hospital for medical assistance and to make arrangements to transfer him. The nursery nurse who assisted in caring for Ryleigh noted she was called to the emergency department at approximately 0615 and found Ryleigh to be white/gray in colour and that he was gasping. She put an oxygen mask on him. She said the emergency physician told her Ryleigh had a circumcision the previous day and had much bleeding. At the time, they also considered he may be in septic shock. She suggested they move him to the nursery. They began treating the baby and confirmed it took a long time to establish an intravenous line. When they did establish a line, they began to push fluids into him. They wanted to cross match him for blood, but he had very little blood in him to give for the cross match. They needed blood from the mother to do this. After blood was given to him, he began to ooze blood from his circumcision site and they questioned if he had developed a disseminated intravascular coagulopathy (DIC), which is a serious bleeding disorder characterized by exaggerated coagulation and profuse bleeding and is always secondary to another disease process, shock, or septicemia. His blood pressure was extremely labile. The evening nursing supervisor confirmed that for a long time, the health care team thought there was only one bloody diaper. The Nurse Manager in charge of the pediatric unit noted that her role was to obtain more nursing staff for the nursery.

In an interview with the coroner, Ryleigh's mother noted she understood, to prevent disturbing his incision, his diapers should be changed only if he defecated. Photographs of the first diaper reveal it to have been extremely bloody. The father reported there was a clot around Ryleigh's penis and there was another dot in his diaper that was two to three inches long and approximately one inch in diameter.

Ryleigh's parents noted that on the day of the circumcision, Ryleigh's father was working the day shift at Penticton Regional Hospital. Ryleigh's father noted that before performing the circumcision, the physician discussed the elective nature and risks of the procedure, although "excessive bleeding was never a concern raised". Mr. McWillis was in the surgical waiting room before the procedure and returned at approximately 1000 hours, after the procedure. Ryleigh was given Tylenol at the hospital. There was bleeding on the 4x4 gauze. Mrs. McWillis noted the assisting nurse told her a "fair bit" of bleeding was normal after the procedure and that seeing the physician was "just routine".

Although Mrs. McWillis noted "a look of concern" on the nurse's face, she states she was never informed there was an excessive amount of bleeding on the diaper or of any other concern. Mrs. McWillis noted she was given no written or verbal instructions for Ryleigh's at-home care and that "at no time was (she) advised by the nurse that 'if further bleeding occurred, they were to contact the physician or return to the hospital' ". She has no recollection of being told to leave the Jelonet on for 48 hours after the procedure or to leave it alone. She took Ryleigh to the physician's office. He changed Ryleigh's diaper, which Mrs. McWillis noted to be "pinkish". Ryleigh's mother stated she did not question anything as she didn't know what questions to ask. She noted "at no time before or after the surgery were we made aware of the importance of monitoring the blood". Mrs. McWillis went to visit a friend in the afternoon. She left Ryleigh to sleep. Mr. McWillis came home after work and changed Ryleigh's diaper sometime between 1530 and 1800. At approximately 2100 hours, Mrs. McWillis changed Ryleigh's diaper. She noted that there seemed to be "a lot of blood" and a "good sized" clot and thought there was a combination of urine and blood in the diaper. She didn't know how much of each there was. Ryleigh's father saw the diaper and thought there was a "fair bit of blood". He didn't know how much blood was too much blood, but noted they were reassured with the information "that a fair bit of bleeding is normal". They noted they were never told "no blood is good". Ryleigh had good colour. He was fussy. Mr. McWillis thought if there was more bleeding, they would see the doctor in the morning. He stated they were aware that "bleeding was certainly a risk mentioned" but had never been "informed about the issue of excessive bleeding". Mrs. McWillis noted she was up in the middle of the night with Ryleigh. She was worried about his comfort; held and cuddled him for a considerable period of time; gave him Tylenol; and did not change his diaper during the night, as she had been "instructed to not disturb the area". At 0530, Mr. McWillis noticed Ryleigh was pale in colour and called the hospital. The nurse told him that as she could not examine Ryleigh, she could not assess the amount of bleeding or advise him about whether or not to bring him in to the hospital. She said that if Mr. McWillis was concerned, he should bring Ryleigh in to ER. Otherwise, Mr. McWillis could take him to see his physician during office hours. Mr. McWillis brought Ryleigh to PRH Emergency Department. Mr. McWillis stated he told the pediatrician in the nursery about the first bloody diaper and told someone else about the first diaper in the Emergency Department, but didn't recall who he told. Mr. McWillis noted that when he brought Ryleigh to PRH, he told the ER nurse that he was concerned about the amount of blood Ryleigh had lost and that he would likely "need an IV for fluid replacement".

In 1995, the Registered Nurses' Association of British Columbia (RNABC) wrote to the BC Council on Clinical Practice Guidelines, an advisory committee to the Medical Services Commission for developing medical services guidelines, asking the Council to consider developing practice guidelines for infant male circumcision. This was not developed as the Medical Services Commission develops guidelines only for procedures covered by the BC Medical Services Plan.

The lungs showed severe hemorrhage and areas of hyaline membrane disease, which can arise from asphyxia, shock, and acidosis, and frank pulmonary infarction. There was no intrinsic abnormality of the penile tissues. [But there was considerable iatrogenic damage. What this does not answer is whether the frenular artery was cut.] The investigation neither supported nor excluded the possibility of Ryleigh having an unappreciated constitutional bleeding disorder. Factor VIII deficiency was not noted; however this test pertains to only about 50% of cases. The multiple blood transfusions that he received during resuscitation and the bleeding diathesis (predisposition to a disease) he developed as a consequence of his severe hypoxic/ischemic injury precluded other laboratory investigations for bleeding disorders. The cause of death was noted as multiorgan hypoxic/ischemic injury due to hypovolemic shock due to massive hemorrhage from the circumcision site.

The pathologist noted that clinical testing of the child's close relatives for inherited blood clotting disorders should be considered. [And this would achieve...?]

Ottem (1996) notes "circumcision of infant male children for non-medical reasons is generally not considered to be of sufficient risk to the infant to cause the parents' right to make decisions to be overridden." [It's time it was. And it's time "the parents' right to make decisions" to cut off one healthy part of their male babies - but only that part - was questioned.] The nurse's role is to ensure parents have enough information to make an informed decision about the procedure; to provide safe and effective nursing care including assisting in the procedure, giving direct physical care, and teaching parents about the infant's care needs after the procedure.

The Gomco clamp consists of three parts: a metal plate with a hole at one end, a round metal cap, and a screw device. The foreskin is first separated from the glans and cut lengthwise to expose the glans. Then the cap is placed over the glans. The foreskin is stretched up over the cap and tied securely to the cap handle. The hole at the end of the plate is placed over the cap and foreskin, and the flange on the handle is fitted into a groove in the screw device.

Turning the screw device forces the cap against the hole and squeezes the foreskin. This squeezing prevents bleeding. The foreskin is cut off. The clamp remains in place at least five minutes to allow for clotting before it is removed.

Since this incident, Penticton Regional Hospital has altered the information pamphlet given to parents regarding circumcision. The form states precisely when a parent should seek medical attention if postoperative bleeding occurs; how often the child should be voiding; and the directions for care for both Plastibell and Gomco procedures. They have also amended their policy to ensure parents are given written information regarding circumcision. PRH also has developed a follow up protocol in which parents are to telephone the pediatric unit after the surgery (at 1700 hours) and discuss their baby's feeding, wet diapers, amount of bleeding and swelling, and present any questions or concerns the parent may have. The information given and advice offered is to be documented.

[Since circumcision is not medially necessary, the question remains unanswered why the hospital - or any - continues to perform it.]

Ryleigh died from multiorgan failure from hypovolemic shock. Shock is a state in which adequate perfusion to sustain the physiologic needs of organ tissues is not present. Blood loss may produce shock or shock-like states. In hemorrhagic shock, blood loss exceeds the body's ability to compensate and provide adequate tissue perfusion and oxygenation. Most frequently, clinical hemorrhagic shock is caused by an acute bleeding episode with a discrete precipitating event, such as trauma or surgery. Without adequate, timely interventions hemorrhagic shock can lead to death.

According to Kolecki and Menckhoff (2001), the patient/s history is vital in determining the possible causes [The patient's history included circumcision: cause determined.] and in directing the care.

Emergency treatment of hemorrhagic shock consists of ensuring the person's airway is open, establishing that the person is breathing, and ascertaining that adequate circulation is provided. Three goals exist as follows: to maximize oxygen delivery by ensuring adequate ventilation, increasing oxygen saturation of the blood, and restoring blood flow; control of further blood loss; and fluid resuscitation. Two large bore IV lines should be started and, when this is accomplished, initial fluid of an isotonic crystalloid, such as lactated Ringer solution or normal saline should be initiated. If vital signs improve, blood should then be sent for cross-matching and typing. If vital sign improvement continues, type-specific blood should be administered. If vital signs do not return to normal, crystalloid infusion should contirliJe and type 0 blood should be given. If the patient is markedly hypotensive, both crystalloid and type 0 blood should be given. Proponents of colloid resuscitation, such as fresh frozen plasma, note that these substances reduce pulmonary edema. There has been some evidence that a combination of Dextran (glucose used as a volume expander) and hypertonic saline may improve cardiac contractility and circulation. Kolecki and Menckhoff (2001) also note "a common error in the management of hypovolemic shock is failure to recognize it early".