Woman opens eyes before organs are harvested.
Yesterday the Associated Press published a post in the Wall Street Journal, titled NY Hospital Nearly Took Organs from Living Woman.
SYRACUSE, N.Y. — Doctors at a central New York hospital nearly harvested organs from a woman in 2009 despite warning signs she wasn’t dead, and the hospital has been fined, according to state records.
Colleen Burns, 41, opened her eyes as she was being prepared for surgery by St. Joseph’s Hospital Health Center, the Syracuse Post-Standard reported Sunday (http://bit.ly/181voF3 ). Doctors had told her family she was dead after a drug overdose, and relatives agreed to take her off life support and allow the donation.
Records the newspaper obtained under state freedom of information laws document a series of missteps, including doctors ignoring nurses’ observations that Burns was responding to stimuli and trying to breathe on her own. The surgery was called off when she opened her eyes in the operating room.
The North Syracuse mother of three was released from the hospital after two weeks recovering from an overdose of Xanax, Benadryl and a muscle relaxant, but killed herself 16 months later, her mother, Lucille Kuss, told the newspaper.
“The hospital did not undertake an intensive and critical review of the near-catastrophic event in this case,” the federal agency said, and did not “identify the inadequate physician evaluations of (Burns) that occurred when nursing staff questioned possible signs of improving neurological function.”
The overdose had put Burns in a deep coma, but hospital staff interpreted that as irreversible brain damage without doing enough evaluation, the state health department found.
It said the hospital: skipped a recommended treatment to prevent the drugs the patient took from being absorbed by her stomach and intestines, failed to do enough testing to determine whether she was free of drugs, didn’t do enough brain scans and that doctors ignored a nurse’s view that Burns was alive and improving.
A day before surgery, Burns reacted to a reflex test performed by a nurse. Outside the operating room, staff reported her nostrils flared, she appeared to be breathing on her own despite being on a respirator, and her lips and tongue moved.
There’s no mention in doctors’ notes that they were aware she was improving, according to the report.
The organ-harvesting procedure continued until Burns opened her eyes under the operating room lights.
Doctors had told her family she was dead after a drug overdose, and relatives agreed to take her off life support and allow the donation.First of all one of the contraindications of a diagnosis of “brain death” is that if anyone is on a possible drug overdose they do not do an Apnea Test. The Apnea test shows if a person can breathe on their own over the ventilator;however when they are on any type of drugs it can repress that ability.
Contraindications include any depressant drugs, neuromuscular blockers, hypothermia or metabolic disturbances are responsible for the patient’s comatose state. The article in the WSJ clearly states she was in a coma due to drug overdose.
Under both federal laws all of this is completely laid out in the Uniform Determination of Death Act and the Uniform Anatomical Gift Act. There are multiple publications from physicians and every hospital has guidelines on what to do if a person is under the influence of drugs.NOT doing an Apnea Test or pronouncing someone dead are the protocols. The complaint linked below says they did not follow national medical standards. I find it hard to believe they didn’t know them. If you’ve been following my blog there are national standards but it is left to each hospital their own decisions on protocols.
In this case according to the WSJ article the relatives gave permission to take her off life support and donate her organs. However had Colleen Burns had a Organ Donation Card, they would not have had to get permission. It is situations like this why I advise people to get off the organ registry.
Analysis of what happened
Lisa McGiffert, director of Consumers Union Safe Patient Project, said there is no way of knowing how often near-catastrophes like the Burns case happen because there is no system in place to collect information from hospitals about medical errors.
“These sorts of things do happen,” McGiffert said. “It’s pretty disturbing.”
Her organization believes states should require hospitals to report all such incidents soon after they happen.
“That would require people to think about how to prevent it in the future,” she said. “If you don’t have to account for it, that doesn’t always happen.”
Two medical experts who reviewed the case for The Post-Standard found it shocking, and questioned why the hospital didn’t do more to ensure other patients aren’t put in the same position.
“Dead people don’t curl their toes,” said Dr. Charles Wetli, a nationally known forensic pathologist out of New Jersey. “And they don’t fight against the respirator and want to breathe on their own.”
Once those signs of life appeared, the organ-harvesting process should’ve stopped, Wetli said.
Wetli also wondered why, after seeing signs that Burns was alive, a nurse would give Burns a sedative. The toxicology report already showed she had
Dr. David Mayer, general and vascular surgeon and an associate professor of clinical surgery at New York Medical College, also reviewed the records and found the use of a sedative perplexing.
“It would sedate her to the point that she would be non-reactive,” Mayer said. “If you have to sedate them or give them pain medication, they’re not brain dead and you shouldn’t be harvesting their organs.”
The hospital erred four or five times, Mayer said. He called the case a gross deviation from all prevailing and accepted standards of care.
There is such an urgency to get organs and no accountability that this scene can happen every day in hospitals across the nation.
The entire complaint is here. Please take a few minutes to read. I honestly don’t know why the parents and herself did not sue. Perhaps like “most” people they didn’t understand brain death and that it was not true death.
She opened her eyes and they stopped. How many don’t? They are too sick to do so or too sedated.