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December 10, 2000
On Sunday, December 10, 2000, our 62-year-old
mother called us from her home to tell us that she was in severe
pain. We rushed her to the hospital where she was diagnosed with
gallstones. She was admitted and scheduled to undergo what was described
as "a simple laparoscopic procedure" to remove her gallbladder the
following morning.
The next morning, mom was taken into the operating
room. The surgeon explained that the procedure would take about
1 to 1-1/2 hours and that she would be able to go home that afternoon
or the following morning, at the latest. After about three hours,
the surgeon explained that the surgery had taken longer than expected,
but that Mom was doing fine. We were told that we could see her
after she was moved to her room.
About an hour later, the surgeon informed us
that mom was not awakening from the anesthesia as expected and that
anesthesia sometimes takes longer to clear from the systems of some
people. He also said that we needed to understand that he
did not have control over everything that occurs in the operating
room. He continued, telling us that she
was in a coma-like state and that we would have to give her more
time to regain consciousness.
After several more hours, we were finally allowed
to see her. What we saw was beyond belief. Mom's face was contorted,
and she was lunging and jerking in the bed. Her breathing was extremely
labored, and she appeared to be in terrible distress. We immediately
phoned the surgeon from the nurse's station. We told him we couldn't
believe what we were seeing was normal. His response was that he
"was not going to let us pin him to this." After hearing his response,
we thought we had inadvertently offended him. We felt we had to
calm ourselves and let him do his job because, after all, he was
the expert. Not wanting to offend further, we agreed that she was
simply struggling to awaken.
Throughout the next several days, our mom's condition
seemed to deteriorate rapidly. We watched in horror as she turned
into someone we did not recognize. She suffered convulsions, thrashed
about in pain, and at one point almost bit her tongue in half. Then,
after life support was finally removed, brown, frothy secretions
would erupt from her nose and mouth, filling her oxygen mask.
During the days before our mom's death, we tried
to find answers to what was happening—and why—from anyone we found
to be involved in mom's surgery and post-surgery care. Not one person
we spoke with revealed the terrifying events that we later learned
had occurred in the operating room. We were told by the surgeon
and anesthesiologist that they were
unable to determine what had happened to her,
and that she may have had a stroke or other apoxic event. We asked
if there were monitors during surgery that would have indicated
a problem. Their response was that while monitors are very good
tools they can't always be depended on for answers. We were also
told by the surgeon and anesthesiologist that we shouldn't expect
exact scientific answers because sometimes
things happen that are out of even a doctor's control.
Throughout the days following the surgery, the surgeon, anesthesiologists,
specialists, and even members of the hospital staff continued, what
we discovered later, a cover-up of extraordinary, almost criminal
negligence.
Not only did we feel completely deceived by the hospital
in general, but the successful attempt to conceal information made
our already agonizing experience a complete and total nightmare.
Following the surgery, we were faced with the painful decision to
either terminate life support or continue in hope of recovery. But,
because we did not know all the facts, our family elected to keep
her on life support, thinking she might pull through. Had we known
the whole truth, we would have been able to make the most caring
decision we possibly could, and not allow her cruel and lengthy
death.
What actually happened during the operation?
What actually occurred during surgery was finally
revealed only after we hired an attorney and filed a lawsuit. We
then learned that the anesthesiologist had turned off the ventilator
during mom's surgery for a cholangiogram, or intra-operative x-ray.
After the x-ray was complete, the
anesthesiologist failed to turn the ventilator back on.
The anesthesiologist said in a deposition that his
attention was diverted from monitoring mom's respiration because
his assistance was required to re-position her on the table after
the x-ray. He also said that the table used by the hospital during
surgery had manually operated gears that did not function properly
and slipped out of place. Further, the anesthesiologist said the
x-ray technician required his help to remove the x-ray cassette.
For a period of time after the x-ray—seven to ten
minutes, according to expert testimony—mom received no oxygen whatsoever!
When the anesthesiologist finally returned his
attention to mom and the monitor, he "discovered" that the ventilator
was off and that she had been deprived of oxygen completely, but
he did not reveal this information to anyone
until after the procedure was complete. The
original anesthesia and surgical records did not disclose what transpired,
no did the original death summary and autopsy report.
The anesthesiologist testified that he was unaware
that the alarm function on the anesthesia monitor was set in the
"Indefinite suspend" mode—disabled completely—so there
was no alarm to signal that mom was not receiving oxygen.
We know now that the hospital continually maintained
the alarm function of its anesthesia monitors in the "indefinite
suspend" mode.
Our points of concern with the hospital
We have had ample time since mom's tragic death to
reflect on the events of that day. Many questions remain unanswered.
We feel strongly that the hospital bears a large part of the responsibility
for Mom's death and is not properly regulated. Our concerns are
as follows:
- Had the alarm on the monitor been set properly
in the "active" mode, it would have notified the surgical staff
that mom was being deprived of oxygen. The purpose of the alarm
is to notify the surgical staff when a patient is not receiving
sufficient oxygen or is in some state of distress. Why
would a hospital maintain it in suspended mode that, in essence,
circumvents its function? Is it not
the hospital's duty to maintain its equipment in proper working
order?
- In spite of the lack of alarms, we were shocked
to learn that no one in the operating
room noticed the flat line on the monitor's carbon dioxide graph,
which indicated a lack of ventilation. We
have seen photos of the operating room with the equipment positioned
as it was during Mom's surgery, and the monitor was visible clearly
to everyone in the room. During this critical time period, it
is unbelievable that no one in the operating room recognized that
the ventilator was turned off or even noticed mom's acute distress.
Any adequately trained hospital personnel should have noted its
lack of movement for a seven- to ten-minute time period.
- After surgery many people at the hospital,
including the risk manager, surgeon, neurologist and ICU physician,
became aware of the events that occurred during Mom's surgery.
No one told us the truth. It was a conspiracy
of silence. Is the system such that
a family is not entitled to know what happened to their loved
one for fear the hospital may be liable? Should a hospital not
be required to correct a patient's record when true events come
to light? Finally, should the hospital and the doctors not be
required to report these events to the patient's family, so they
can take appropriate action to see that no other patients are
harmed in the same way?
- At the time of Mom's death, peer review laws
designed to encourage healthcare professionals to report errors
causing death and injury to the hospital risk management team
conceal information regarding adverse events. Many specifics related
to the accident are not admissible in court or available to the
public in hopes that the medical staff can freely report errors
without fear of liable. The primary reason for reporting errors
without fear of retribution is that the facility will openly acknowledge
errors, alert the staff and make corrections to procedures and
circumstances that may have caused the accident. Throughout depositions
during Mom's case, time after time, nurses, technicians
and other staff members repeatedly said they were unaware of the
mishap and had learned nothing. Apparently
peer review laws created for the purpose of creating a blame free
environment did not have the desired effect in our case.
The actions our family took and the results:
Upon becoming aware of the cause of Mom's death, our
family contacted a dozen different regulatory, licensing and government
offices hoping that the incident would be investigated and the hazardous
conditions at the hospital would be cited and corrected. The results
from responding agencies and offices are as follows.
- Texas Board of Medical Examiners
- Our first two attempts to notify The Board
brought no response. Only after meeting a representative from
The Board at a House Committee hearing in Austin, were we able
to initiate an investigation. Disciplinary action against the
anesthesiologist was taken.
- Texas Department of Health -
After providing the department with a detailed account of events
during and after surgery, the department interviewed multiple
hospital personnel, thoroughly reviewed Mom's medical records
and were unable to determine what events may have contributed
to her death. The department is unable to take depositions under
oath. Next, we contacted the associate commissioner at the department,
provided the same detailed account and results of the department
investigation. He explained he would review the case and re-open
for further investigation if necessary. He found nothing compelling
to warrant re-opening the case.
- Joint Commission on Accreditation of
Healthcare Organizations - This organization
acknowledged receipt of our complaint, and explained there would
be an investigation. The results of the investigation were kept
confidential according to the Commission's charter.
- Governor Rick Perry's Office
- referred us to the Texas Department of Health,
which we had already contacted.
- United States Congressman Joe Barton
- The Congressman determined it would be inappropriate
for a Member of Congress to intervene because of the separation
of powers doctrine in the Constitution.
- Dallas District Attorney's Office
- Determined there was no criminal activity.
- State Representative Vicki Truitt
- Authored House Bill 1614 mandating hospitals
in Texas to submit an annual report to The Texas Department of
Health listing the number of medical error occurrences and to
establish a Patient Safety Program.
- 2003 Legislative Session -
Our family visited with multiple State Representatives and Senators
expressing our frustration with the lack of safety procedures
and oversights in hospitals. Additionally, we presented an account
of our experience at House and Senate Committee hearings. House
Bill 4, limiting damage for medical mal practice awards, passed,
amending the Civil Remedies Code.
- Over the course of the past few years,
The Joint Commission on accreditation
of Healthcare Organizations has adopted
policies regarding the use of alarms and notifying family members
in the event of medical error.
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