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My son Parker was very aware of others and how to help them. He often got teased himself because of his height, large 16 size feet and his big smile. He would walk with the kids that he had noticed being bullied down the halls of his high school to help them feel safe. Parker had grown up with 3 older brothers and 4 younger siblings and was not afraid of anyone or anything. He loved life and everyone in it. Parker had a tradition of buying a few dozen roses on Valentine’s day and handing them out to the girls at school that didn’t have someone to give them a valentine. At his funeral, many people told me of how he had helped them, from changing a tire in a snowstorm to sitting up with someone all night after they had told him about their desire to end their own life.
Parker’s hugs were legendary. He would always greet you with a big hug by wrapping his long arms around you and pick you up off the ground. Those hugs would melt away the day’s troubles because you knew someone loved and cared about you. (Especially for a mom with a lot of teenagers, hugs from your kids are the best!)
On that fateful day, I was sitting in church and my daughter leaned over and said, “Mom, look at your phone.” I got it out of my bag and saw a message from my daughter-in-law to call her. I texted her and asked her if I could call her in a few minutes, but as I was sending the text, she called me. I got up and left the meeting and answered the call. The first thing she said over her sobs was, “Parker is not breathing.” She said the ambulance was already there. I rushed back in and got my family and we drove the mile to their home. As we approached the house an EMT came up and told me it was too late. “What???” Too late for what? What happened to my son??? The police tried to tell me it was an overdose. “Really? That is what you are going to tell a grieving mother, this was an overdose??? Not my Parker, I told them”. He hated taking Tylenol or any medication to treat pain. He would often tell me when he had a headache that he was going to go lay down for a bit, or drink some water, instead of taking a pain killer. He was only taking this prescription because the doctor told him that a tonsillectomy surgery as an adult would be more painful and that he needed to stay on top of the pain so that he didn’t have any complications.” Parker would not have taken too many pills!
It was a bitter cold December morning as we stood in front of Parker and Madi’s home trying to make sense of what happened. We were being told that his death was a “rare occurrence, a firestorm of events that came together and caused his death.”
I asked myself over and over how could a healthy 21-year-old male could just go to sleep and not wake up? How does that happen? No one had any answers for me. I was devastated, I was not prepared, nor did I want, to bury my child.
Parker and Madi had come to our house the night before around 6 pm and delivered a Christmas gift for us. I was thinking how on top of things this new couple was, they had been married only three short months. We were able to visit for a few minutes and then they were off making the rest of their deliveries. This was the last great big bear hug that I received from my son.
Madi, Parker’s wife described to me later what happened on their last night together. They had spent the day putting up their first Christmas tree. It looked beautiful. When they arrived home that evening, Parker wrapped his gifts to Madi and put them under the tree and told her that he was feeling tired, so he was going to lay down in the bedroom. This was around 8 pm. She finished taking care of the decorations and then went to bed. Parker woke up around 1 am and she went into the kitchen to get him a pain pill. Madi was very meticulous about recording what time Parker took his medication and how much. This helped us later as the Coroner proved that Parker had only taken half of the prescribed dose of his medication. They laid in bed that night talking for an hour before they both drifted back to sleep. They spent the time talking about their future, what they wanted to name their children and the exciting events they had planned for the holidays. No one knew that we would spend that Christmas with broken hearts burying her beloved husband, son, brother, grandson, nephew and friend.
Madi was up early the next morning and let Parker sleep to help him recover more quickly. She went in to wake him up for church at noon and could not get him to respond. She tried doing CPR but was told when the EMT’s arrived that he had been gone too long and that they could not revive him.
Only a few days later, a good friend of mine told me that this same thing had happened to a 3-year-old neighbor that she knew. I called and spoke to the mother. She told me her heart wrenching story. This got me thinking that this was not a “Firestorm of events” after all… How does a 3-year-old female and a 21-year-old male, both tonsillectomy patients, die the same way, a few days after the surgery, both found dead in bed? Within a year of each other? I started researching online and found many other stories about this happening to at least 5 in our valley within the last two years and many across the United States.
Three weeks after my son’s death, my daughter-in-law told me of a 15-year-old girl that lived less than a mile from my home that was saved because Dr. Catten (Parker’s doctor) had given her a pulse-oximeter to take home with her to monitor her oxygen levels. We went and visited with Amanda and cried right along with her as she told us her story. Her parents had been watching the monitor closely, but it was a model that did not alarm when her blood oxygen levels dropped below a safe level. After two long days of recovery and everyone was exhausted, her parents decided to have her sleep between them. At 3:45am her mother last talked to her and she seemed to be doing fine, at 4:00 am her mother suddenly awoke to find her daughter not breathing and not responding to any stimulation. They immediately began CPR and called for an ambulance, she started breathing and regained a pulse 2 times and then she would be gone again. Finally, the EMT’s revived her with 4 doses of Narcan on the way to the hospital and more upon arrival. She spent several days in the hospital recovering from the effects caused from going without oxygen. We learned from her experience that this kind of death can happen so quickly, but your body gives you signs plenty of time in advance if you use a pulse-oximeter or proper monitoring.
I learned of another near-death story of a woman in her 30’s that had had a tonsillectomy and was living in Idaho at the time. This had occurred 3 months before my son’s death. A couple days after the surgery, she laid down on the couch to rest and later was found unresponsive by her daughter who called the EMT’s and they were able to save her mother. She was treated at the hospital for pneumonia, she was told that she must have had it before she had her tonsils out, she said that she did not.
A young mother with 4 small children here in Vernal, Utah is lucky to be alive after taking pain medication for her tonsillectomy. Her husband had set a timer for every 4 hours to give her the dose prescribed by her doctor. At 5 am when he went to give her the medication, he was unable to wake her up and an ambulance was called, and thanks to the swift action of the ambulance crew, she is still with us.
Another tragic story was told to me by the father that lived it. He was at home on a Sunday night watching Sunday night football with his son. He was a football coach who had coach his son in football through all his growing up years and now loved watching his 21-year-old son excel at playing football for Portland State. His son AJ had had his tonsils removed a couple of days prior and was still recovering. His son had taken his pain medication and sat down in the chair next to him to enjoy the game and then dosed off, so he just let him sleep. He noticed his son’s breathing becoming labored and then his son stopped breathing. He shook his son trying to get a response and then put him on the floor, began CPR and called an ambulance. His son died and the EMT’s were unable to resuscitate him. His mother and sister arrived home too late that evening to tell their brother and son goodbye. Another family devastated because we had no idea of the serious side-effects from these drugs that we are given to reduce pain.
In my research of the pain killer – Percocet (that is what Parker had been prescribed), the very first 2 side-effects listed were Respiratory Depression and Death. The drug label warning went on for another 15 pages listing out all the other side-effects in small print that have occurred and could occur if you take this product, so why was this not stressed when this was given to my son and daughter?
Yes, Parker and his sister Sadie had their tonsils removed the same day. She was at home on that fate-filled Sunday recovering and texting my other daughter telling me to call Madi, Parker’s wife. Sadie had been prescribed the same dose of Percocet as Parker. Sadie is 5’9” 130 pounds, Parker was 6’5” weighing in at 230 pounds. They both had been prescribed a small dose. This had not affected her in the same way, but she had been unable to sleep much at all because of the pain. The medication took the edge off, but that was all.
It took 6 months from the day we buried Parker to get the final autopsy report. That is when I found out that Parker’s cause of death was listed as Pneumonia. Again, I was so confused. Parker had been at my home the night before, looking good, he had no difficulty breathing, no problems at all. You would not have guessed that he just had his tonsils and adenoids removed and his sinuses stretched. He was laughing and teasing his sister Sadie that was still lying on the couch complaining of all the pain that she was still in.
In the beginning, I was relieved to hear of the stories of those that had been saved by Parker’s doctor taking measures into his own hands and making changes at the local hospitals, but as time went on, I was hearing more and more tragic stories about others that were still dying unnecessarily.
Dr. Catten was given so much grief because he wanted to change the protocols at our local hospitals immediately before someone else died. For the others that had died this way, their deaths had been rationalized as some other cause, for example: poor health, possible other drug problems, sleep apnea, overdoses, surgical complications, but many of the autopsy’s had the same cause of death listed as Pneumonia.
The medical examiner was baffled by Parker’s autopsy and we discussed her findings a few times before she submitted her final report. Everything showed Parker as an extremely healthy young man. An elevated white blood cell count along with fluid in the lungs are what she based her conclusion of Pneumonia on. I later learned that this is very typical symptom of respiratory depression caused by taking an opioid based drug for pain. There are many studies out there, but for some reason this is continuing to happen.
The day I received this report, I came across a medical article written by a Dr. Andrea Rubinstein. It was titled, ‘Opioids linked to hospital pneumonia’. This tied in some of the puzzle pieces that I was missing to help me find out what happened to my son. Maybe the opioids had caused the pneumonia symptom???
During the time that this was all going on, Madi and I and my husband had met with Dr. Catten a few times to try and figure this problem out. Dr. Catten suggested trying to get the word out by taking this to the Utah Legislature. We set up an appointment with Senator Van Tassell and he got the ball rolling from there. The attorney that was drafting the bill sent us a few rough drafts to read over. After it was all said and done and ready to go before the legislative committees, we went before the committees and told our story. They seemed shocked! They had never heard of people dying this way. They had only heard of people overdosing from opioids, but people dying taking their prescribed amounts was unheard of. This was a side to the opioid problem that had never been looked at. Were people dying unnecessarily? Could this be prevented by monitoring that was already available? Could lives be saved as quickly as we could get the word out? Was it low cost? Yes, to all these questions.
Senator Van Tassell and his team were very wise to ask for the medical professionals help in solving this problem. Medical professionals are on the front lines every day and they have encountered these cases numerous times, but they had not been informed with the knowledge that the opioids could be causing the problem. Kim Bennion with Intermountain Health Care Hospitals has been working on finding a solution to this problem since 2008. She realized the connection when her 30-year-old brother-in-law was found dead in bed after taking opioids for pain after a bunion surgery, leaving her sister to raise 4 children under the age of 10 all by herself.
I have said many times, that I wish someone would have done something sooner so my son would still be alive, enjoying being married and possibly a father by now, but here I am. I learned from a wise grandmother growing up that when the question is asked, “Why didn’t somebody do something? She told me that I needed to remember that I was somebody. I am hoping that we can get the word out along with all the other things that the medical community is learning, to prevent these unnecessary deaths, so we can enjoy more time with our loved ones.
My husband, Roger, was admitted to a South Carolina hospital with pneumonia and an embolism. He began to improve and after a week in the hospital we were told he was ready for discharge.
Then the hospitalist shared with us that Roger had gotten too much blood thinner and said he was stopping his Lovenox shots immediately. But before he entered this important change into the medical record, a nurse came into the room with an injection. We told her the doctor had stopped injections and instead of checking with him, she proceeded to give another overdose, stating, “This will be the last one.” She was correct. It was the last one and it nearly cost my husband’s life.
Later that evening, Roger complained of side pain. The nurse did not come to the room but told her aide by phone that it was gas. When he complained later that the pain had gone to the other side, I heard her tell the aide on the phone to say the gas had moved to the other side. To make a diagnosis with second-hand information over the phone to an aide is not acceptable.
When we finally did see the nurse, we asked about pain medication. She said he could have either Tylenol or morphine. We both said out loud, “No morphine!” A few hours later she came into the room and gave him a shot. When I asked what it was she said, “Morphine,” and added, “That’s how we do things around here.” If the nurse had checked, she would have seen that Roger had severe bruising across his entire stomach and sides, a telltale sign of internal bleeding, especially with pain present. She did not check with or report his condition to the attending physician.
Roger was in a stupor for about 15 hours bleeding to death with no rescue in sight. The physical therapy team tried to get him on his feet the next afternoon and both times he collapsed backward onto the bed with eyes rolling. They also did not call the attending physician. As I watched his blood pressure plummet downward to a critically dangerous level, I finally screamed to get a doctor. The doctor came in and immediately rushed him to the critical care unit.
In critical care, they found every organ in his body had failed. The physicians were lined up outside his room with specialties in liver, kidney, heart, lung, etc. They worked extremely hard to save his life. While there he bloated up and had to have his wedding ring cut from his finger. He endured so much pain and suffering among other things with veins collapsing and had to have surgery to put an IV in his neck.
My question is: How does a patient go from pending discharge to every organ in his body shutting down? There is a clear explanation. Roger was the victim of one of the most common causes of death/near death experiences in hospitals across the nation, namely blood thinner overdose and “failure to rescue.” This could have been prevented if the people assigned to care for him had paid attention to their patient.
My husband left the hospital a broken man. He had been an active, robust man working 50-70 hours a week at a power plant and walking around the plant and staircases on a regular basis. When he entered critical care they could no longer hold his job for him. He was our breadwinner and it broke his heart and spirit that he could no longer provide for us.
Roger only lived another year. The assault on his body ultimately proved to be too much. The world has lost a fine man. We missed our 50th wedding anniversary last June and he will not be here for the birth of his grandson. Roger deserved better. He should still be with us.
This is a picture of Richie’s last birthday. He told us it was his Golden Birthday because he turned 27 on the 27th (of January). He said his life would have good things ahead.
Richie was well educated, graduating from the University of Texas at Arlington with a degree in English and Journalism. He was funny, with a quick wit and always a smile. He was a loyal and loved friend to all who knew him. His passions were writing and music.
Richie also had an addiction to heroin which we learned of in 2005. He continued to work two jobs and maintained a loving and close relationship with our family. We had our boundaries and he respected them. We viewed Richie’s addiction as an illness, not a moral issue.
Monday July 19, 2010 I called Richie to meet for lunch. He said he wasn’t feeling well and was having a hard time breathing. I immediately went to see him. He was weak, pale, and cradling his left arm. His arm was swollen from his shoulder and chest to his hand. When I asked what happened, he said he had relapsed.
My decision to take him to Parkland Hospital in Dallas, Texas was my belief that they could take care of his drug issues and care for the possibility of an infection in his arm, along with generalized pain and discomfort. Richie was admitted to ED at 17:40 with a diagnosis of cellulitis left upper arm; history of IV drug abuse.
Throughout the night, I made several requests to his nurse for pain meds and meds for withdrawal. This is what he rec’d:
21:50 – morphine 4 mg IV
23:49 – morphine 4 mg IV
03:23 – Valium 5mg po
Richie never received relief from any of his symptoms. He was repeatedly short of breath and fainted at one point. I was at his bedside all night and his nurse never even observed his arm. Nurses showed little interest and never documented these events.
07:20 July 20th – Richie was finally given a bed on the surgical unit.
12:15 – Richie began to show a rapid decline. He fainted in the hallway and then returned to bed.
13:40 – Finally sleeping, Richie then vomited a large amount of coffee ground material. As I assisted Richie to the restroom to help him clean up, he had a seizure. After my call for help, it took three of us to get him back to bed. He was extremely short of breath, his body cold. He said he couldn’t breathe. I told the nurse he was septic and going into shock. Dynamap was unable to read a b/p or oxygen saturation. The charge nurse called Richie’s doctor who was in the OR. The doctor told the nurse to call the RAT Team (rapid response) or call the MD who was covering. She chose to call the covering MD. This is when the most precious moments were lost to save my son.
14:20 – MD came to bedside. As she left the room to write orders, Richie had another seizure with coffee grounds from his nose and mouth. Code Blue was called.
15:45 – Richie transferred unresponsive and on a vent to SICU. Accepting MD note: Pt coded on floor; probable aspiration thought to be related to narcotic withdrawal.
22:59 – Life support was removed and my son was gone.
I have been a registered nurse for 40 years. I have always loved my profession and the patients I cared for. I would treat my patients as I would want my own family treated.
As I left the hospital in the early morning hours of July 21, 2010, I swore I would do anything to be sure no one else ever suffered like this again.
On Monday, January 19, 2004, my husband Jerry Carswell entered the emergency room and was quickly diagnosed with a kidney stone. He was given multiple injections of morphine and Dilaudid to relieve the intense pain. Later that day, he was admitted for observation and further tests. The physician began an aggressive regimen of additional narcotics and Toradol by IV to control the pain.
Jerry’s hospital stay was prolonged by an elevated creatinine level, which his physician thought was discontinued. Jerry continued to receive other pain medication. His pain was moderate and he was scheduled to go home Thursday if lab results tests showed that his creatinine levels were returning to normal. But Jerry never left the hospital.
I received a call around 6:00 Thursday morning: “Your husband had an emergency. Can you come to the hospital?” When I asked for details, the nurse simply asked how long it would take for me to get there.
When I arrived, a nurse guided me to an empty patient room. With her was a young woman I had not seen before. She looked at me and said, “Your husband is dead.” The nurse added, “He died peacefully in his sleep. You can take comfort in that.”
My shock was so complete that I could not process their words. I turned and ran to Jerry’s room – I tried to wake him – tried shaking him – and finally collapsed in screams and sobs. The nurse stood in the doorway: “Doesn’t he look like he is just sleeping? He looks so peaceful, doesn’t he?”
I got no answers to my questions. The young woman who had announced Jerry’s death was gone. I later learned that she was the new, inexperienced on-call physician for the urology group. The charge nurse would not supply any information or details. She just kept saying Jerry had died “peacefully.”
After Jerry’s funeral, I ordered his medical records and learned that he had been found lying “unresponsive” across the end of this bed by the phlebotomist who had come to draw blood at 5:15 a.m. The code team worked for 25 minutes and administered repeated doses of Narcan, a drug used to reverse drug overdose. These startling facts were in direct contrast to the “peaceful death” described to me by hospital employees.
We learned that at 3:30 a.m. Jerry had been give 75 mg of Demerol with 25 mg of Phenergan, injected intravenously all at once. No vital signs had been recorded in his chart before or after, and no one went back into his room to check his reaction after this concentrated dose of narcotics. The LVN who administered the drugs later stated she did not understand that Phenergan enhanced the effect of Demerol on the respiratory system. When she spoke with the on-call urologist at 3:30 a.m. she did not mention the pain medications Jerry already had in his system.
I asked for an autopsy by an independent pathologist or the county medical examiner. I was told that the on-call physician had requested a hospital autopsy that would be “the same” as one done by an independent pathologist. Too late I learned that, unlike a medical examiner or independent pathologist, a hospital pathologist does not investigate a possible drug overdose. The hospital pathologist did not determine a cause of death. In a sworn statement, he stated that as a hospital pathologist who had performed over 1000 autopsies, he had never done a drug panel to screen for possible medical errors. Three years later, we learned that Jerry’s heart had been retained by the hospital pathologist without my knowledge or consent. We are still attempting to gain possession so I can bury his heart and finally put my husband to rest.
At the emergency room, staff first thought the 69 year-old’s injuries were minor, but he died from internal bleeding about five hours later.
He was buried with full honors at Arlington National Cemetery. Following the death of her husband, Nancy co-founded the Community Emergency Healthcare Initiative, designed to measurably affect preventable injury and death now occurring in emergency departments.
Lewis Blackman was one of those children who just shines. For all his short life, he seemed to float effortlessly to the top no matter what he tried to do. He was a soccer player, a saxophone player, a writer, an actor in community theater, one of the top students in our state of South Carolina. We, his parents, thought he was the most brilliant boy in the world. We thought he would grow up to set the world on fire.
Two months after Lewis’s fifteenth birthday, we took him to a large teaching hospital for a minimally invasive operation to correct a defect of the chest wall, pectus excavatum. The surgery, as far as we know, went uneventfully. Afterward, Lewis was put on heavy doses of opioid pain medications, delivered through an epidural. He was also prescribed a full adult course of the IV painkiller Toradol, a regimen not now recommended for young teens. Even so, his pain was difficult to control. His opioid dose was continually increased. The Toradol, which had no discernable effect, was faithfully injected every six hours.
With so many painkillers, Lewis’s breathing was affected. He was monitored by pulse oximeter, and his oxygen saturation levels were never what they should have been. Because he had a history of asthma, the hospital staff did not seem to take this seriously. The day after surgery they moved the setting for the alarm from 90% saturation down to 85%, a very low level. They were concerned that the alarm would keep Lewis awake.
On Sunday morning, the third day after surgery, Lewis was suddenly stricken with an excruciating pain in the area of his stomach. This was very different form his surgical pain and much more sever: 5 on a scale of 1 to 5. Initially concerned, the nurses eventually decided he had an ileus, severe constipation caused by the epidural narcotics. That assessment stuck like a burr as Lewis’s condition spiraled downhill. His belly grew distended and bowel sounds ceased. He became paler and paler and his temperature dropped. His heart rate skyrocketed. He ceased to urinate. Because it was a Sunday, the only doctor we saw was an intern, five months out of osteopathic school. When we requested an attending physician, another resident came (and neglected to inform us of his status). All confirmed the diagnosis of constipation.
That night, Lewis’s oxygen saturation dropped so low that even the 85% pulse oximeter setting was too high to prevent the alarm from going off. The nurse turned the pulse oximeter off, again in the hope that Lewis could get some sleep. But in his state there was no sleep. We spent the night trying to manage his agonizing pain, nausea, and growing weakness. When the vital signs technician came the next morning, she could not find a blood pressure. In response, the intern and nurses spent 2 ¼ hours scouring the hospital , looking for a blood pressure machine or cuff that would register a reading. In all, they took his blood pressure 12 times with seven different instruments. The crisis was declared over when a second-year resident arrived from the operating room and, in a fit of wishful thinking, announced she had found a normal blood pressure. Just over an hour later, Lewis went into cardiac arrest and died. No attending physician had ever been called.
An autopsy the next morning showed a perforated duodenal ulcer, a well-known risk of the medication Toradol. From a known deadly side effect of a drug he was taking, Lewis had developed peritonitis and lost nearly three-fourths of his blood over the course of 30 hours, while his young caregiver assured us that nothing was seriously wrong.
What happened to Lewis was a result of a system that had no care for its patients. Residents and young nurses were left alone to perform jobs for which they were inadequately trained, with no ability to recognize a declining patient and no one to turn to when questions arose. Our family was also left completely isolated without a way to call for help. Trends in vital signs were not noted or even charted. The one objective monitor, the pulse oximeter, was first modified and then silenced. No one was there to speak for the patient.
Ten years ago, Lenore Alexander’s healthy, 11-year-old daughter, Leah Coufal, underwent elective surgery to correct pectus carinatum at a prestigious Southern California hospital.
Though the surgery went well, Lenore awoke at 2 a.m. on the second post-operative night to find Leah “dead in bed,” a victim of undetected respiratory arrest, caused by the narcotics that were intended to ease her pain. If Leah had been monitored continuously after the surgery, staff would have been alerted and Leah would probably have been rescued. But ten years later, knowing that the standard of care remains unchanged, Lenore works to make continuous postoperative monitoring the law (Leah’s Law) to help prevent other children suffering the same fate as Leah.
Visit http://leahslegacy.org/ to learn more.
John LaChance was a Christian who served His Savior at Tabernacle Baptist Church as a Sunday school teacher, youth leader, choir member, and trustee with faithfulness and joy for 14 years.
He was a well-liked and respected man at church, in the community, and at work. He had a great sense of humor and an infectious laugh. His life verse was, “A merry heart doeth good like a medicine.” Proverbs 17:22
John was a loving son and brother. He was my husband for 27 years and a wonderful father. He cared for our three children and me unselfishly and with loving devotion. He was the hero of our lives.
John was a patriot who served his country on land and at sea in the United States Navy with dedication and pride for 21 years. He quickly advanced through the enlisted ranks and onto becoming a naval officer. Upon retirement from active duty, he continued serving the Navy as a government contractor. He was truly an officer and gentleman. John was a selfless man who gave freely of himself in life and then in death through organ donation.
On March 15, 2007, John underwent his second routine rotator cuff repair surgery. Due to numerous adverse reactions to several pain medications after his first surgery, his surgeon recommended John spend the night following the surgery for pain management. He was to come home the next morning. John also had a condition called sleep apnea, which when mixed with opioids, puts a patient at a much higher risk of respiratory depression. This condition was dismissed by all attending medical staff, and a CPAP machine was not ordered. Immediately following surgery, John seemed to be doing well. His pain had been managed with a shoulder block and patient-controlled morphine through a PCA pump. During the afternoon, John became very hot and uncomfortable but had no fever. The nurse dismissed this as a side effect to the morphine. By early evening, the shoulder block wore off. The morphine was not managing his pain but was causing extreme vomiting. John was removed from the PCA morphine, pulse oximeter, and supplemental oxygen as directed by the surgeon (this was the hospital’s standard of care), and was given an injection of Dilaudid for pain and an anti-nausea medication. This change was prescribed by an on-call doctor who was never informed of John’s sleep apnea. John was assured the Dilaudid would give greater relief as it could be given more often and at higher doses.
Within less than a half hour, he was what I can only describe as comatose. He never looked at me or spoke again. Because he had not been able to urinate, which the nurse also attributed to the morphine, he had to be catherized. A very private man, John normally would have been unnerved by this. John never flinched or blinked an eye. Motionless and staring at the ceiling, John did not respond. The nurse stated that male patients normally experience a fair amount of discomfort from the procedure and she was quite surprised at the lack of any response from John, but dismissed it. (Throughout the day and evening, his vital signs were giving indication of possible patient distress, but these were dismissed as well.) Shortly thereafter, John seemed to be sleeping well, so I went home for the night with the intent of taking him home the next morning.
Instead, I was awakened by that dreaded telephone call from the hospital around 5:30 the next morning. The head nurse from the orthopedic ward informed me that my husband had taken a turn for the worse and had been moved to ICU and was on life support; the doctor needed me there immediately. I was later told that a nurse making rounds around 4:20 a.m. found John unresponsive in his bed. The “crash team” worked on John for over 40 minutes. They were able to regain a heartbeat, but his brain had suffered a major brain hemorrhage due to anoxia – or lack of oxygen. John was brain dead. We lost him – he was gone from our lives. The nurses and doctors responsible for John’s care did not appreciate the dangers of the respiratory depressing effects of opioids upon patients with sleep apnea. We believe John’s death could have been prevented if his nurses and doctors had not simply dismissed his sleep apnea and if he had been placed on a CPAP machine and/or kept on the pulse oximeter throughout his overnight stay.
As parents of a teenage daughter, our worst fears were that our daughter would become pregnant, take drugs, or drink and drive. Never did we imagine that our daughter would go into a hospital with an infection, be hooked to a patient-controlled analgesia (PCA) pump to manage her pain, and never come out alive; but this is exactly what happened.
Our 18-year old daughter Amanda was admitted to a local hospital on Thursday, July 15, 2010. She was dehydrated, had lost at least 10 pounds, and had a virus that was causing a great deal of pain in her mouth and throat. Our family physician’s plan was to rehydrate her and put her on medications for both viral and bacterial infection. This was to help jumpstart her system and hopefully she would be back home with us in a couple days.
The rest of Thursday was a rough day for Amanda. The morphine that the hospital staff was giving her was not getting rid of the pain. Moreover, Amanda’s tonsils and uvula were extremely swollen. She was still not interested in eating; even drinking hurt. To help manage her pain, Amanda was put on a PCA pump that allowed her to control the pain medication used (hydromorphone).
The next morning, Amanda was found unresponsive and died.
We realize that we cannot get our daughter back, but we can raise awareness regarding respiratory depression, and in honor of our daughter we intend to make this our lifelong mission. We have started A Promise to Amanda Foundation to remind patients, their families, and their healthcare providers to always monitor PCA use with oximetry and capnography.
HealthGrades Quality Study. (2004, July). Patient safety in American hospitals. Retrieved from: http://www.providersedge.com/ehdocs/ehr_articles/Patient_Safety_in_American_Hospitals-2004.pdf
Johnston, M.J. et al. (2015, April). A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery, 157 (4), 752-763. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25794627
Susan Lorenz, DrNP, RN, NEC-BEC, EDAC, Vice President of Patient Care Services and Chief Nursing Officer, Princeton HealthCare System.
Reed and May, HealthGrades Patient Safety in American Hospitals Study, March 2011.