VMC TOXIC HOSPITAL ACQUIRED BACTERIA

It’s in the medical records that another patient acquired the same bacteria after my son did - a whistleblower has also come forward because instruments were not being sterilized properly (and the records were falsified). Another Ex-VMC employee who was working in Housekeeping came forward and told me about the supervisors changing and operating room cleaning (between patient surgeries) was put on a schedule of 8 minutes - without any concern of the prior patient condition and the risk of infection for the next patient. If the VMC Infection Control Surveillance System was in place and working as required by the Federal Government why didn’t the Department of Health (DOH) acknowledge the records I found and forwarded to them?

Maybe they (the DOH and VMC) don’t want the public to know…

What should VMC and the DOH tell all patients hospitalized at VMC (and publish in the VMC ICU brochure): “ALL VMC SURGICAL EQUIPMENT AND SURFACES ARE COLONIZED WITH “SEVERAL” TYPES OF BACTERIA – YOU WILL MOST LIKELY GET THEM.” 

VMC’s hospital acquired bacteria was confirmed in Mark within hours/days of VMC performing hospital procedures.  I’ll let you judge for yourself by the sequence of what happened below.

I have been in contact with the “whistleblowers” lawyer.

SEQUENCE OF EVENTS: (Note that Mark is supposed to be NPO - nothing by mouth)

November 9              Mark goes to the VMC ER with pain by his gallbladder.

                                    He tells the nurse he feels nauseous.

November 10            CT scan: Oral contrast is seen; suggestive of gastroesophageal reflux disease.

November 11            Nasogastric (NG) tube – confirmation.

November 11            Mark is going through medication withdrawal and is delirious – he is saying things that don’t make sense. Mark also receives toxic drugs contraindicated with MAO inhibitors; I ask Dr. Fatime Goda if Mark is having a toxic reaction to the Dilaudid. Mark is saying things that don’t make sense. By 3:00 pm Mark says “there is a cat under his bed” 8:00 pm Mark thinks his name is “Calvin” and for us (Wayne and I) too “cut him loose and he will tell us where she is” and “I need to run to the forest it’s the only place I’m safe.”  We should have listened and cut him loose and taken him to Swedish that second.

November 12            VMC heavily sedates Mark because of delirium (from drug withdrawal); Intubated by Dr. Ichiro Otsu. By November 14 MRSA and Enterobacter are now in Mark’s lungs.

November 12            OGT placement verified – Gastroview administered. WAS THE OGT PLACED PROPERLY OR WAS IT PLACED IN MARK’S LUNG LIKE THE TEMPERATURE PROBE WAS – TWICE.

November 13            CT scan: Aspiration of oral contrast is mentioned within Mark’s lung. Nasogastric tube tip overlies the distal stomach. Generous extension into Mark’s stomach. Why was oral contrast not given intravenously? Was suction available and used after aspiration occurred (if Mark had vomited)? What do the records say? THERE ARE NO RECORDS OF WHAT HAPPENED.

Note 1:                       Symptoms of aspiration: fever, cough, tachypnea (rapid breathing). Side effects: hypoxic (low oxygen to body, aspiration pneumonitis).

Note 2:                       There is no record in Mark’s VMC file that shows which doctor ordered the CT scan. Which doctors were in “command:” Dr. Amy Morris and Dr. Ayesha Haq.

November 14            Sputum culture taken ~ MRSA and Enterobacter present. Nasal probe is in place.

November 15            CT scan: Aspiration of oral contrast mentioned again.

November 17            Nasal probe inserted.

November 18            NG tube coiled inside of Mark’s neck - repositioned. Mark is started on nutrition today.

November 19            NG tube – placement (I am told nothing about this) – Mark vomits nutrition while intubated (and he is NPO).

November 19            Respirator tubing fails at bedside. Mark is then paralyzed for 20 minutes and reintubated by Dr. Stefanie Nunez at bedside. By November 21 Burkholderia is identified in Mark’s lungs.

November 20            NG tube – could not be advanced beyond stomach body.

November 21            NG tube insertion (“Initial attempts at placing the tube via the orogastric route were unsuccessful”).  Confirmation of placement.

November 21            Tracheal aspirate grows out the MRSA and Burkholderia cepacia

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

November 24            OG tube – placement – OG tube is looped in the stomach. Mark vomits bile.

??/??/??                     When does VMC reposition the OG tube? Not in medical records.

November 27            OG tube – confirmation.

November 30            Dr. Richard Wall is the intensivist this week and says “Mark is not tolerating nasogastric tube feeding;” IMAGINE THAT DR. RICHARD WALL! Dr. Richard Wall feels this may be causing some issues with his pancreatitis. Feeding will now be done intravenously (TPN). What Dr. Richard Wall does not mention is that the tube is still not placed correctly because the nutrition is in Mark’s stomach and being suctioned out.

December 2              Dr. C. Gabriel Alperovich places tracheotomy and Peg tube for nutrition – CROSS CONTAMINIATION OCCURS (the surgeries happen in this order). By December 4 Pseudomonas is now found in Mark’s lungs; on December 14 Pseudomonas is identified in Mark’s stool. Dr. C. Gabriel Alperovich – you are a “surgeon” and your LACK OF PROPER PROCESS AND STERILE TECHNIQUE caused Pseudomonas to get in Mark’s lungs then you transferred the pseudomonas along with the Burkholderia (FROM MARK'S LUNGS) into Mark’s GI track. I wish you the same luck.

December 4              1+ gram positive (??) organism - unable to further isolate (Pseudomonas) on report.

December 7              Nasal probe inserted.

December 8              Aspiration of abdominal fluids mentioned in focus notes.

December 9              Culture taken today: Pseudomonas present on his tracheotomy.

December 11            Nasal probe inserted into Mark’s lung.

December 14            Nasal probe inserted into Mark’s lung.

December 14            Pseudomonas now in Mark’s stool (I’m not told about this – not in any Focus Notes).

December 16            Nasal probe shoved in 20+ times by Bev/nurse. At this point I am beyond mad and tell them to get someone in here that knows what they are doing. 

December 19            Lung secretions match the Peg tube suction output.

December 24            Foam coming out of his Peg tube output.

December 27            Dr. Wynne Chen receives a call from the lab that another patient has come down with Burkholderia and Pseudomonas. It's in the medical record.

January 4                  Dr. Mark Justus removes Peg tube replaced with G-tube – placement w/issues; then does a liver biopsy.

January 10                Swab culture taken of G-tube incision; positive for Pseudomonas (and Burkholderia which I’m not told about).

Other notes:

December 4: Dr. Lindy Klaff (intensivist from UW) discusses some of Mark’s doctors she knows from Swedish with me. I ask her about the autoimmune studies and she mentions that the Lupus came back negative. Dr. Lindy Klaff also mentions that a couple of days ago Mark’s sputum culture came back and he is now growing Burkholderia Cepacia. I’d like to know why Dr. Michael Hori or Dr. Richard Wall didn’t mention this yesterday. I tell Dr. Lindy Klaff I’ll research it on the web, she says don’t because it’s usually on found in cystic fibrosis (kids in their lungs). Dr. Lindy Klaff mentions that Burholderia may be a colonizer (I look this up and contact the CDC and State of Washington Epidemiology – no evidence exists for colonization other than having cystic fibrosis).

December 5: I discuss the Burkholderia with Dr. Lindy Klaff again and tell her I disagree that the Burkholderia was in Mark’s lungs prior to him coming to VMC. Mark had pneumonia back in 2009 and no bacteria showed up. Dr. Lindy Klaff says it is a colonizer again. I ask her why then wasn’t it discovered the same time of the MRSA and Enterobacter? She agrees with me.

December 15: Since Dr. Lindy Klaff mentioned that the Burkholderia in Mark’s lungs was something that was associated with cystic fibrosis (kids in their lungs) and research also shows that pseudomonas can also occur with cystic fibrosis I ask Dr. Wynne Chen if Mark has this (rule this out because cystic fibrosis can also affect the pancreas). Dr. Wynne Chen says “no, Mark doesn’t have cystic fibrosis” because he looked in Mark’s lungs via Bronchoscopy today.

I fly my sister Gina here from Florida to help me watch Mark in the evenings. Gina is a CNA that has worked with hospice patients. Gina notes the time (and individuals) that do not re-glove while cleaning Mark's trach then move onto another activity. Gina mentions the proper procedures to them, which they do not like being told what to do, the nurses in turn go to their supervisor (to complain about Gina) and avoid Mark's room now.