The 5-year-old's eyes widen and his mouth waters whenever he gets a whiff of oranges or pudding.

His parents believe that's their son's way of signaling his fondness for those smells. But they'll never know for certain.

Izzy Peterson can't tell them what he likes. He can't speak. He can't color with crayons. He can't even eat or breathe on his own.

As the 4-foot-tall, 60-pound youngster marked his fifth birthday Thursday at his home in San Antonio, Texas, Izzy remained in a largely vegetative state, hooked to medical devices that are his constant companions. Those devices keep him alive.

On Jan. 14, 2005, Izzy suffered severe and permanent brain damage when he was mistakenly given carbon dioxide instead of oxygen for nearly an hour after his caesarian-section birth at Tripler Army Medical Center.

Even though at least nine medical personnel, including three neonatologists, were in the operating room at one point as Izzy was essentially being suffocated by the carbon dioxide, the resuscitation gas mix-up wasn't discovered for about 50 minutes.

By the time someone realized that the mask being used on Izzy had mistakenly been connected to a portable carbon dioxide tank, not an oxygen one, his brain was so damaged that he was robbed of any hope of leading a normal life.

Five years later, the impact from what happened that Friday morning in operating room No. 10 reaches beyond the tragedy inflicted upon a little boy and his family.

U.S. military medical facilities worldwide were directed by the Department of Defense to take immediate steps to minimize the risk of a similar gas mix-up happening again.

At Tripler, the Army eliminated the use of portable oxygen tanks in all operating rooms, according to a spokeswoman. Instead, the hospital installed wall units for piped-in oxygen for resuscitation treatments, precluding the possibility of mix-ups in portable tank connections.

Tripler also began performing all C-sections in a dedicated labor-and-deli-very operating room, instead of doing them in general ORs, the policy in place at the time of Izzy's birth.

In addition, Tripler implemented more training for staff.

The changes were part of an action plan designed to reduce or eliminate the potential of a reoccurrence, Tripler said in a statement to The Advertiser. The plan was approved by the Joint Commission, the organization that accredits hospitals nationwide.

"Patient safety is at the heart of everything we do," the hospital said.

$16M SETTLEMENT

The Petersons sued the federal government over what happened to Izzy. The government admitted liability, and a federal judge in 2006 awarded the family more than $16 million — believed to be the largest personal-injury judgment for an individual in Hawai'i and the largest payout involving a malpractice case at Tripler.

Dr. Danielle Bird, the Army physician who treated Izzy and unknowingly administered the wrong gas, was not sanctioned by the Army for her role in the tragedy, according to her Honolulu attorney, Ken Robbins.

Bird was not the one who connected the mask tubing to the carbon dioxide tank. But the Army has declined to say, even by position, who made the errant connection or whether anyone was sanctioned, citing confidentiality regulations.

Bird, a pediatrician training to be a neonatologist at the time of Izzy's birth, also was not sanctioned by Hawai'i's medical licensing board, which originally issued her a license in 2003. State investigators in June determined there was insufficient evidence to conclude that Bird committed hazardous negligence in treating Izzy.

Hazardous negligence is a legal threshold used in such licensing investigations. It is a standard higher than simple negligence and requires the showing of egregious conduct resulting in bodily injury.

Robbins said Bird, who was very distraught and shaken by what happened, was not sanctioned by the Army or the state because she was not negligent but the victim of circumstances that led to the tragedy.

Before the delivery, Bird did a series of equipment checks, including making sure the tubing was connected to the gas source — there was only one tank in the operating room that day — and that the volume of gas, as indicated on the tank gauge, was sufficient, Robbins said in disclosing the first public details of the case from Bird's perspective.

Bird could only see the top portion of the tank, and it appeared worn, with the coloring rubbed off, and she didn't recall seeing any label indicating the tank's content, Robbins said.

But the person who brought it into the operating room believed it was an oxygen tank, Robbins said, adding that there was no reason to suspect otherwise.

WRONG GAS

Izzy had been delivered by another physician, then placed in the care of Bird, who placed the infant in a warmer.

About a minute after Izzy's birth, Bird determined the infant needed some oxygen — an assessment that the family has disputed — because of poor coloring, difficulty breathing and because he wasn't very active, according to Robbins.

At that point, Bird took the mask off the tank holder and proceeded to position it near — but not on — the infant's face to "pink up" the baby, Robbins said. The physician who delivered Izzy, two nurses and several other people besides Bird and Izzy's parents were in the operating room at the time, he said.

As Izzy's health continued to deteriorate , more medical personnel came into the operating room. At one point, at least nine were present, including the three staff neonatologists, two anesthesiologists, a neonatal intensive care nurse and several operating room nurses, Robbins said.

Once Izzy stopped breathing, an effort to resuscitate him began, and a hand-ventilating bag and the mask were used, the attorney said. At one point, Bird placed the mask directly on Izzy's face, attempting to increase the flow of pure oxygen to him, he said.

"It was not just Dr. Bird who was the primary person doing the resuscitation," Robbins said. "There was a gaggle of people in the room."

The resuscitation effort continued for about 50 minutes until someone — Robbins doesn't know who — discovered that the tubing was connected to a carbon dioxide tank, he said.

Throughout the ordeal, Bird did what any neonatologist would've done in caring for her patient, and to single Bird out for the gas mix-up would be unfair, Robbins said.

"Under these circumstances, Dr. Bird was as much a victim as the Peterson family was," Robbins said. "It was very, very upsetting to her."

Bird, an Army major who has done at least one tour in Iraq since the Peterson incident, still is assigned to Tripler, Robbins said, noting that the case has had no impact on her Army career.

Bird completed her training to become a neonatologist, a physician who specializes in caring for newborns.

"She is a valued member of the Army Medical Department and highly respected by patients and peers alike," Tripler said in its statement.

Rick Fried, the Petersons' attorney, said the family wasn't upset that Bird received no sanctions.

"Even though every minute of every day is consumed with caring for Izzy, they didn't feel it would help Izzy in any way to further punish Dr. Bird," Fried said.

'TOO LITTLE, TOO LATE'

Beyond the changes made at Tripler, military representatives could not say what system improvements were made at other medical facilities because of the Baby Izzy case.

Dr. Jeffrey Lee, a California anesthesiologist who specializes in obstetrics, said he was surprised that Tripler didn't have a dedicated labor-and-delivery operating room in 2005. Hospitals that did a lot of deliveries typically had such ORs at the time, he said.

"Having a dedicated OR for C-sections is a great idea," said Lee, a University of Southern California faculty member who spent a week at Tripler in 2003 to pursue a job possibility.

Shalay Peterson, Izzy's mother, said she appreciates the changes the military made to try to prevent a gas mix-up from happening again.

But the reforms, she said, are not enough to assuage the anger she still feels about what happened. "It's too little, too late."

Peterson said Izzy is doing as well as can be expected, showing small signs of progress through his physical growth and the fact that he has fewer seizures. He is able to move his head back and forth and slightly wiggle his fingers. But he continues to need nursing care around the clock. The court award pays for that care.

CELEBRATING IZZY

The family marked Izzy's birthday Thursday with a small celebration in his Island-themed bedroom, where the walls have ocean scenes as a tribute to the state where Izzy was born and a place to which the Petersons still feel a special connection.

Today, the Petersons will have a bigger party — as many as 50 people are expected — and Izzy will be brought into the living room to join the celebration.

But as yet another reminder of Izzy's condition, the Petersons have asked people with colds not to attend because their son's suppressed immune system makes him especially susceptible to getting sick.

The challenges of caring for someone like Izzy are numerous. But his mother said the family has benefited.

"It's brought us all closer together," Peterson said. "Everything we do pretty much focuses around Izzy."

"It was not just Dr. Bird who was the primary person doing the resuscitation. There was a gaggle of people in the room."