VMC

VMC
VMC Renton, Washington: where death happens and no one seems to care

EXPECT PROCEDURE ERRORS / EQUIPMENT FAILURES

Expect multiple procedure errors and equipment failures

What should be the most alarming to any patient is that if you search the State of Washington Department of Health (DOH) website for Adverse Event Reports you would think that you would actually see the errors being reported (i.e. contaminated devices [hospital acquired infections], device function or use, medication errors, wrong blood product, hyperbillirubinemia, pressure ulcers, restraints, etc.) but the only thing VMC reported while Mark was hospitalized there was a pressure ulcer - and this may not have been Mark. If VMC isn’t reporting anything – I can only imagine how damaged the healthcare system is in King County.

Check it out for yourself:
DOH Adverse Event Reporting

According to Mark’s medical records, procedures had to be repeated OFTEN; it appears they are not done right the first time. A lot of these “repeat” procedures were not discussed with me. I wonder what happens when a patient goes to sleep at night and there is no family around to ask questions and supervise the VMC staff?

Aspiration of Oral Contrast

In talking to one of my friends, who is a doctor, I am told that a patient aspirating oral contrast is a very, very bad thing. When this happens, it is very toxic to the lungs and they usually suggest to the family that the patient is moved to “comfort care" (ending their life) immediately because there is nothing they can do to help the patient at this point.

We were never told that Mark had aspirated oral contrast and this is documented in the CT scans and numerous Focus Notes. How did I find out? I read the medical records.

Note: Mark’s autopsy discovered a dried yellowish substance in his lungs.

When you have pancreatitis all nutrition, etc. is intravenous or an NG tube must be placed lower in the duodenal part of the intestine otherwise it aggravates the pancreatitis and you could vomit ~ just as Mark did. The oral contrast ended up going into Mark’s lungs (November 13) because Mark was heavily sedated, intubated and nauseous from the pancreatitis. I should have stayed at the hospital 24 hours a day to watch the VMC staff.

Significant Findings:

Warning: You should not receive Isovue 300 (Iopamidol) if you have any type of active infection - the VMC bill says he received this - but the nursing note says MD Gastroview. Isovue 300 is to be injected in the spine - the nurse said she administered this via gastro tube. Did VMC bill wrong again?

Mark receives VMC’s Hospital Acquired Bacterial Infections (MRSA and Enterobacter on November 14; Burkholderia on November 21 and Pseudomonas on December 2) literally throughout his hospitalization.

Risks: Mark had three commonly accepted indicators for being at greater than normal risk for aspiration: Heavy sedation from narcotics, severely ill (medication withdrawal, toxic drug interactions, gallstones and pancreatitis), and confinement in the supine position – arms and legs restrained to the bed. 

Per the internet: Where there is an inherent risk for aspiration, non-ionic iso-osmolar contrast (Visipaque) is preferred.

Isovue (or Iopamidol) is an injectable (the internet says injected by the spinal column). Isovue is used to help diagnose certain disorders of the heart, brain, blood vessels, and nervous system.

Gastroview is taken orally or rectally depending on body part being imaged.

The VMC hospital bill only shows Isovue being given to Mark - never for MD Gastroview – even though the nurse documented this. Per the hospital bill, Mark receives:

11/10 (150 ML) Isovue 300
11/13 (100 ML) Isovue 300 (Focus note says Gastroview) - Aspiration
11/15 (150 ML) Isovue 300
11/19 (150 ML) Isovue 300
11/22 (100 ML) Isovue 300 – Aspiration – 2 tubes in place
11/28 (150 ML) Isovue 300
12/5 (100 ML) Isovue 300
12/13 (150 ML) Isovue 300
12/28 (1 unit) Isovue 370

The Nurse Focus notes say she gives Mark Gastroview (via the OG tube she places) on November 13 – the same day Aspiration of contrast is noted in Mark’s lungs. Read below for the side effects of aspirating Gastroview.

November 10: Mark gets a CT Scan: Oral contrast is noted - suggestive of gastroesophageal reflux disease. Mark is coherent this day. The VMC bill shows the CT was done on November 9, not the 10th; no Focus Note exists detailing what was given to Mark; CT Scan stamp says done at 23:00.

November 11: Nasogastric (NG) tube – confirmation (I am told nothing about this – and was there with Mark and didn’t see any nasogastric tubes). WAS THIS PLACED CORRECTLY AND WHEN WAS THIS DONE? IS THIS A BILLING ERROR AGAIN? Mark is delirious from the medication withdrawal. Mark now has lost both fistulas.

November 12: VMC heavily sedates Mark because of delirium; Doctors have to intubate Mark because his blood pressure dropped precipitously low (per
Dr. Richard Wall). This is when the toxic drug interactions occurred with the opiods/opiates/benzos and MAO inhibitors – Mark is also going through medication withdrawal. Mark receives Fresh Frozen Plasma 2 units today.

November 12 – November 13 Nursing Focus Note: says the nurse uses Gastroview and not Isovue as billed. This nurse also places an OG tube for the oral contrast.

November 13: NG tube – placement (I am told nothing about this). Notes state: Generous extension into Mark’s stomach. Mark gets another CT scan - Aspiration of oral contrast mentioned within the lung. No CT Scan stamp is in the records.

November 15: Possible pneumonia mentioned.

November 22: Aspiration of oral contrast is mentioned again; “2 nasogastric tubes are in place (1 in stomach, 1 in third portion of duodenal).” Why 2 tubes???

WHO WAS IN CHARGE?

Date
Description
Hospitalist
Intensivist
GI
November 10
3rd Floor at VMC – CT scan
n/a
n/a
November 11
3rd floor, ICU transfer – Mark is delirious from medication withdrawal
No records
November 12
Mark is intubated and heavily sedated; CT head/brain w/o dye
November 13
CT abdomen w/dye;  Aspiration first noted in lungs
November 15
CT neck / head / thorax w/dye
November 19
CT abdomen w/dye
No records
November 22
CT abdomen w/dye; Aspiration of oral contrast mentioned again
No records

Side effects from aspirating Gastroview:

Aspiration of MD-GASTROVIEW into the trachea and airways may result in serious pulmonary complications including, pulmonary edema, pneumonitis or death. Bronchial entry of any orally administered contrast medium causes a copious osmotic effusion. Therefore, avoid use of MD-GASTROVIEW in patients with esophagotracheal fistula and minimize risks for pulmonary aspiration in all patients. Symptoms of aspiration: fever, cough, tachypnea (rapid breathing). Side effects: hypoxic (low oxygen to body, aspiration pneumonitis).

GASTROVIEW WARNINGS

(Mark had no fluids since November 9 – Mark was NPO):

Dehydration: Administration of hypertonic MD-GASTROVIEW solutions may lead to hypovolemia and hypotension due to fluid loss from the intestine. In young or debilitated children and in elderly cachectic persons, the loss of plasma fluid may be sufficient to cause a shock-like state. If MD-GASTROVIEW is used in infants and children (under 10 kg) or in dehydrated or debilitated patients, the solution must be prepared using the specific dilutions. In debilitated patients and in patients with electrolyte imbalances, post-procedural monitoring of hydration, serum osmolarity, electrolytes and clinical status is essential. In pediatric or severely debilitated patients, the maintenance of an open intravenous fluid line for rehydration may be advisable should hypotension or shock supervene. Electrolyte disturbances must be corrected prior to the administration of any hypertonic MD-GASTROVIEW solutions.

Hypovolemia: is a state of decreased blood volume; more specifically, decrease in volume of blood plasma.

Hypotension: abnormally low blood pressure

For very young (under 10 kg) and debilitated children the dose should be diluted: 1 part MD-GASTROVIEW (Diatrizoate Meglumine and Diatrizoate Sodium Solution) in 3 parts water is recommended.

There are no records that actually say what happened after contrast administration and the CT scans (when Mark vomits and aspirates) or even what doses were given. Because of Mark’s risk indicators VMC staff should have considered an alternative contrast, had cameras in place to watch Mark, been present when this started to occur (vomiting), had emergency equipment available for suction, and being trained in what all this means.

Based on VMC’s poor performance placing nasal probes into Mark’s lungs and VMC not placing the nasogastric tubes correctly (see below) – how do we know that the nurse didn’t put the OG tube into Mark’s lung? Is this why the records are missing? Maybe no one was watching Mark and had no idea it happened (when they are required to) until the CT scan results were available?

Expect Respirator Equipment Failure

November 19: At 3:08 pm (Jane is at lunch) Mark’s breathing is very labored and Mark is making a very strange sound with his breathing. I go out and get Jane’s back up and tell her the IV pump and respirator alarms are both going off, and something is wrong with Mark’s breathing. She comes in the room tries to suction out his lungs. I ask her to call the respiratory folks, she does then hangs up. I ask her if they are coming up, she says Dan is busy writing up a report with someone, I tell her to call him back or give me the number to call. The nurse yells at Mark “MARK! YOU ARE OVER REACTING!!” about 5 times, then zaps Mark with 2 bolus of sedatives. Of course the sound and labored breathing do not stop; Mark is NOW UNCONCIOUS from the sedatives. I tell her to call respiratory back, she does and Dan arrives. After inspection Dan finds out that there is a crack in one of the tubes and he puts tape on it. I ask why Mark is out of it; the nurse says that the first bolus of sedatives she gave him didn’t work, so she gave him another.

A little while later, Mark starts struggling again. This time I go down the hall to see if I can find Dan versus getting the back-up nurse involved. I see Jane coming back from lunch and ask her to “PLEASE COME, SOMETHING IS VERY WRONG WITH MARK AND HIS BREATHING.” She does. Jane calls Dan; he arrives and does another inspection. I leave the room, go around the corner because I am very shaken and by the time I get back to Mark’s room
Dr. Stefanie Nunez and 4 or 5 other people are with Mark getting ready to pull out the respirator and place a new one. Apparently the balloon type of device that holds it in place and keeps air from seeping out has failed. They have to paralyze Mark for about 20 minutes to get it placed. I tell Dr. Stefanie Nunez that I told the nurse something was wrong, she yelled at Mark to stop over-reacting ~ zapped him with sedatives. Dr. Stefanie Nunez tells me “well, I wasn’t there” and I tell Dr. Stefanie Nunez “I WAS.” The back-up nurse comes by and stands by me and I tell her “YOU were wrong.” She tells me “I didn’t know.” I tell her “I’m not in the health care business and I KNEW something was wrong by the sound. I sure hope you didn’t kill him.” The nurse does say she is “sorry” and walks off. Dr. Stefanie Nunez and I have a short discussion.

NONE OF THIS IS DOCUMENTED IN THE MEDICAL RECORD, IMAGINE THAT.

November 22: We learn that VMC was just getting ready to celebrate 13 months without respiratory assisted pneumonia,
Bob Chapman, Rn was talking about ordering food for the celebration ~ Mark is the first since this time. If Adverse Events and Infections are not being reporting to the Department of Health, why bother even mentioning this to me?

December 17: There is a tracheotomy leak or site leak because the cuff is not sealing. This is brought up in rounds -
Dr. Stefanie Nunez is the intensivist. Dr. C. Gabriel Alperovich comes by to take a look and says it looks ok. I go for a walk a little later, come back and Dr. C. Gabriel Alperovich is back and has replaced it with a different one and no one bothered to call me. A nurse confirms with me that this (the site leak) happened on Tuesday when Bev made an adjustment on the respirator (the other nurse was doing a bandage change).

Expect Nasal Probes to be placed in your lung

What happened to the temperature gauges that Swedish (and Overlake) hospitals use that swipe across your forehead to give an accurate temperature reading for the patient? VMC staff (respiratory and nurses) enjoy (a little too much) pushing a nasal probe through your nose and down your esophagus…when they miss, it goes into your lung…I wonder if this is even more of an alarm for more infectious disease probabilities.

December 14: A Nasal probe in Mark’s lung. Bev in respiratory makes an adjustment on the tracheotomy earlier in the day and you can hear instantly that something is wrong with the tracheotomy right after she does this. Now the alarms keep going off. By 8:50 pm the respirator is doing all the breathing for Mark because of sedation given to him. Respiratory “fixed” the tracheotomy when I drove home to pick up dinner. A Bronchoscopy is done a little later and
Dr. Wynne Chen finds that the nasal probe to measure Mark’s temp is actually positioned in his lung and is irritating the tracheotomy cuff.

December 16: Nasal probe falls out today (the nurse) and Bev (ungloved) try to place it back in ~ must have shoved it in around 20+ times and now I’m way beyond upset. It now sounds like the tracheotomy is having another cuff problem. I ask the nurse to have
Dr. Wynne Chen check it out via Bronchoscopy. He does and it’s ok.

Beside Surgeries – Even more Infectious disease possibilities:

December 12: Mark is on dialysis, in his bed.
Dr. Oliver Aalami comes by and inserts femoral catheter. While dialysis is continuing, Dr. Oliver Aalami has the nurse move the lines to the new dialysis lines just inserted so he can remove the Quinton. When Dr. Oliver Aalami removes the Quinton he comments that the Velcro end that attaches to the skin had not attached, leaving an opening into the body (not protected).

December 17: There is a tracheotomy leak or site leak because the cuff is not sealing. This is brought up in rounds.
Dr. C. Gabriel Alperovich comes by to take a look and says it looks ok. I go for a walk a little later and Dr. C. Gabriel Alperovich is back and has replaced it with a different one and no one bothered to call me. A nurse confirms with me that this (the site leak) happened on Tuesday when Bev made an adjustment (this nurse was doing a bandage change) to Mark’s tracheotomy.

December 24:
Dr. Oliver Aalami came in today and inserts Mark’s dialysis catheter in Mark’s neck. I am at the bedside when this is done. I do express my concern about the location and proximity to the tracheotomy and the pseudomonas and Burkholderia infection. I also mention Mark’s ears being infected. Dr. Oliver Aalami goes to push the guide wire in and says it is getting stuck on something and doesn’t want to push/shove it in. I tell him not to, and why don’t they do this with x-ray (like Swedish) so they don’t puncture something. Victor goes out and gets a different guide wire; Dr. Oliver Aalami bends the end of it. Dr. Oliver Aalami then says it goes in easily. Later, Victor goes to use the new dialysis lines and they are not working. He is waiting for the dialysis nurse to come when I leave for dinner ~ 4:30pm. ALARMING: When I get back, Dr. Oliver Aalami had already come back to the room and had to re-do the dialysis line with a longer one (I find out why Christmas morning when I see Dr. Oliver Aalami ~ he said the other was too short because of where he had to place in Mark’s neck.

So, how come Dr. Oliver Aalami couldn’t figure out that having to move the access incision/line placement up 2 to 3” might mean it will be 2 to 3” shorter at the end of the line? Dr. Oliver Aalami, that is simple math. OMG, even my niece (who doesn't have her high school diploma yet) can figure that out and she's not a doctor.

December 28: New Picc line put on the right side today (Mark’s arm). An iv nurse comes in to do it; I voice my concern with all the other trouble the doctor had putting in the dialysis catheter. I ask for a doctor to do it.
Dr. Kenneth Reger comes in to place it. This line is place into Mark’s heart too far (and the 2 x-rays they did on Mark didn’t show the tip of it) causing the V-tec and heart rate indicators to go off every second (I told the nurse something was wrong). Instead of Dr. Kenneth Reger coming back to reposition it; he tells the nurse (Cindy) to pull it out a bit and she won’t. Cheryl comes in and pulls it out a bit. VMC now orders a third x-ray to confirm the placement.

December 29: Mark is now spitting foam balls (constantly). Mark wants to be suctioned all the time. This started on Monday night with the evening nurse. This seems to be related to having to move Mark for the Picc line placement and things not being the same afterwards.

Rectal tubes and lack of monitoring:

November 24: Mark has massive diarrhea this evening. Shelly has to insert a Rectal Tube/catheter to catch poop.

I note that the last Rectal Tube output recorded is December 11. I ask and none of the Rn’s are concerned.

December 12: Dr. Daniel O’Neil come in and looks at ~ 7 blue cards with patient data on them. He says the enzymes are about the same and that they are waiting on the test to come back from the paracentesis fluid, I tell him those came in days ago and they were negative.

I ask Dr. Daniel O’Neill if it is normal to have such a small amount of fecal output (which looks like nothing to me). I’m told that is average.

December 14: Debbie is the nurse today. Early in the day I ask about the rectal tube and output. Debbie is not concerned. I do mention that there hasn’t been any output recorded since December 11. While helping turn Mark I see poop between his legs and say “oh shit!” Debbie lifts Mark’s leg and looks - the rectal tube/balloon (fully inflated) pop out of Mark’s rectum and a huge pile of poop is now on the bed. It’s almost as if the balloon was blown out from the pressure – I can only imagine the pain Mark was in from this. WHY DIDN’T THE NURSES CHECK THIS OUT – I KEPT ASKING AND THEY TOLD ME THIS WAS OK.

Wayne and I go and talk to Michele Bohl, VMC Social Worker, and tell her our concerns (again). I also tell her if this had happened to her kid, she would be pissed. Michele will get with some of the doctors and get back with us. We do talk to Tina, the nursing supervisor acting in Bob Chapman, Rn’s place and Dr. Wynne Chen.

Note for this same day: Pseudomonas is confirmed to be in Mark’s stool; of course no one tells me anything about this.

More rectal tubes and the lack of output:

December 31: 9:30 am and the nurses are here and have put in a rectal tube against my wishes. By 4:15 pm Mable says it appears that it isn’t working. I leave around 5:00 pm and the nurse is still looking for another nurse to help her with rotating Mark and checking the rectal tube.

January 2: Only a small amount of poop is in the rectal tube ~ TPN was stopped on last Thursday December 30th.

January 6: I ask why the rectal tube has no output; tube feeding is stopped. Rectal tube/stool is blocked for ~ 4 days (last recorded output was January 5).

January 7: The nurse said she tried to flush the rectal tube out today but only water came out.

January 8: The nurse said he flushed the rectal tube out today – no output.

January 9: I ask the nurse to take out the rectal tube because of no output. He says he flushed it and says it is working fine. After bronchoscopy today poop is now all over the bed.

January 10: Another rectal tube is inserted today and it isn’t working. I ask the nurse to take it out and she does.

January 10: Pseudomonas (and Burkholderia that I’m not told about) are now confirmed in Mark’s G-tube incision.

Fed Ex Doesn’t deliver??

December 16: During rounds today a gal mentions getting some type of (gastro) endo-tube that Valley doesn’t have. She mentions NJ, OJ and J tube.

December 31: Dr. Thomas stops by and says that Mark is getting better. He is going to go and look at the abdominal CT done on December 27.  He will be on call this weekend. Dr. Thomas is stopping TPN because he feels this is causing the liver enzymes to be elevated (never mind the drugs were causing the elevated enzymes); says that Mark will be fine without nutrition for a couple of days until they place the new naso/duodenal G-tube that will go into his stomach and past the pancreas (into the small intestine). THE WAY IT SHOULD HAVE BEEN PLACED THE FIRST TIME!

January 1: Attend rounds today with Dr. Krell. WBC are up a little. The naso/duodenal G-tube is still in route (via FedEx). Dr. Krell mentions that the abdominal CT is unchanged and Mark is still very swollen. Mark’s heart rate last night got into the 40’s. (Mark starts talking today!!!)

January 3: We are still waiting for the naso/duodenal G-tube to arrive. Apparently there is a problem with Fed Ex and the holiday schedule. Nutritionist to look into this today. Dr. Park said this is priority #1.

January 4: There appears to be a lot of issues with the feeding tube arriving via Fed Ex; VMC insists this is because of the holiday. THIS MAKES NO SENSE TO ME BECAUSE Fed Ex; OPERATES 24-7 AND I HAVE NEVER HAD A PROBLEM WITH Fed Ex. I WONDER IF VMC ACTUALLY ORDERED THIS BECAUSE DON’T WE ALL KNOW HOW TO USE TRACKING NUMBERS AND PICK UP THE PHONE WHEN OUR ORDER DOES NOT ARRIVE??

VMC says that since the special tube didn’t arrive they will use a different one. I talk to the radiologist, Dr. Mark Justus, and he tells me there will be one tube with two different tubes within it. I later try to explain this to the nurse (Mable) and she won’t listen. Finally, Mable realizes that she doesn’t have the proper equipment available at VMC to hook up the drainage bag to the new G-tube and has to “Jimmy-rig” it to work (with various parts from other products not related to G-tubes). Why did VMC (and Dr. Mark Justus) use a product (G-tube) that they didn’t have the proper parts in-house to make it work correctly??

Miscellaneous errors

December 7: The nurse puts the water blanket on Mark to reduce his fever. She forgets to turn it on. We go downstairs to get coffee and when we get back to the room, water is all over the floor and bed and Mark is sweating profusely. We pull off the plastic blankets and dry off Mark.

December 7: Mark is a dialysis patient: Before dialysis the nurse gets the patients weight and subtracts that from their “dry” weight to determine how much fluid to take off in dialysis. The Rn is asked what Mark’s weight is by the dialysis nurse; the Rn goes by Mark’s weight last night and is not concerned. The dialysis nurse and I have to calculate Mark’s weight.

December 8: I discuss the green / yellowish puss around the Quinton (dialysis catheter);
Dr. Frank Fung wants the Quinton changed. Dr. Frank Fung opens the Tegaderm bandage leaving the Quinton lines and biopatch exposed. This bandage is not changed until noon the next day (caught by the IV nurse).

December 9: IV nurse wants the left arm IV line unclotted (again) and finds the Quinton line bandage open, moisture seen under it. Apparently the dialysis nurse (last night/this morning) looked at the date only on the bandage and not the condition of it. Puss is found under the biopatch again. Dialysis last night went to 1:30 am today. Biopatch was found on top of the line and not around it like it’s supposed to be. Ann Marie (the dialysis nurse) tells
Dr. Frank Fung.

Naso-gastric tubes and placement

This section is an “add on” to the previous section for Aspiration of Oral Contrast that shows VMC continuously has issues placing the naso-gastric tubes – then blames it on the patient.
November 17:  Nasal probe inserted

November 18:  Naso-gastro tube inserted. Tube is coiled inside of Mark’s neck (I am told this is placed but not that it was coiled). Repositioned. Note: The NG tube was supposed to end in the duodenal section of Mark’s intestine. Nutrition is started today.

November 19:  NG tube – placement (I am told nothing about this). Valley has to reposition the NG tube (Mark vomits – nutrition is still going INTO HIS STOMACH).

November 19:  Respirator fails; emergency respirator/intubation done at bedside

November 20: NG tube – could not be advanced beyond stomach body (I am told nothing about this)

November 21: NG tube insertion (“Initial attempts at placing the tube via the orogastric route were unsuccessful”).  Mark pushes the NG tube out with his tongue. Confirmation of placement.

November 21: Tracheal aspirate on November 21 grew out the MRSA and Burkholderia cepacia, which is sensitive to Ceftazidime. Mark is not given Ceftazidime until January 12.

November 22: Aspiration of oral contrast is mentioned again; “2 nasogastric tubes are in place (1 in stomach, 1 in third portion of duodenal).” Why 2 tubes??? Is this a safe practice?

November 24: OG tube – placement – OG tube is looped in the stomach. (I am told nothing about this) Mark vomits bile.

November 24 there are no records saying this OG tube is repositioned until November 27.

November 27: OG tube – confirmation (I am told nothing about this)

November 30: Dr. Richard Wall is the intensivist this week. Mark is not tolerating nasogastro tube feeding.

IMAGINE THAT Dr. Richard Wall. They feel this may be causing some issues with his pancreatitis. Feeding will now be done intravenously (TPN). TPN is started. What Dr. Richard Wall does not mention is that the tube is still not placed correctly because the nutrition in Mark’s stomach and being suctioned out.

Does it appear that Valley has serious issues in placing NG and OG tubes correctly causing the patient severe complications? You bet is does.


2 comments:

  1. Anonymous10:01 AM

    Why didn't you Mark transferred? Remember, you have to be a bit of your own advocate.

    ReplyDelete
  2. If any one family was a patient advocate for their loved one, it was our family. I guess you didn't have a chance to read some of the other sections. Even VMC doctors and staff told us that no other family had asked so many questions and wanted to be a part of their families care like we were. I'm sure new processes were set up because of this. As far as your comment on trying to have Mark transferred to Swedish...we tried everything we could (calls to Swedish, discussions with the VMC staff, etc.). What you may not have seen are all the discussions (documented in a separate MS Word file) we had with the VMC staff, by date, on the transfer. When I was told that Swedish had denied the transfer I called the Swedish transfer center (and talked with 3 people there) to get more details and discuss further; Swedish wasn't going to make a profit. Swedish now says VMC never contacted them. I am still pulling med recs on this to hold Swedish's accountable to why Mark was not allowed to go there (his doctors were all at Swedish). My discussions with Swedish are now with the Chief Medical Officer (oh, he did say that Swedish is changing their processes now because of this).

    ReplyDelete