A pediatric surgery expert witness discusses a puncture to a patient’s pulmonary artery during surgery. This case involves a pediatric patient born to a diabetic mother. The patient had a past medical history significant for intrauterine growth restriction, prematurity and VATER association. VATER association is a non-random collection of coinciding congenital defects which include vertebral, anal, tracheoesophageal and renal pathology. The patient underwent surgery to repair a tracheoesophageal fistula and sustained a major complication during the procedure. An endoclose needle was inadvertently pushed through the esophagus at the inferior aspect and punctured the pulmonary artery on the way out. The patient desaturated quickly and the decision was made to perform an emergency thoracotomy to control the bleeding. The patient was eventually stabilized and returned to the pediatric ICU. In the post-operative period a CT scan of the patient’s head was performed which revealed a right frontal acute subdural hemorrhage. The patient was left with severe brain damage as a result of extensive brain hypoxia encountered during the code.