14A In-Hospital Cardiac Arrest

Up to 80% of patients will show symptoms of a potential cardiac arrest up to 24 hours prior (Kim et al., 2015; Schein et al., 1990; Chon et al., 2013) and yet early detection and intervention mechanisms are absent or insufficient.

Our APSS outline actionable steps healthcare organizations should take to successfully implement and sustain behavior change for high reliability, shared understanding, thorough communication, and meaningful person-centered care across the organization.

Actionable steps include:

Executive Summary Checklist
Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
Performance improvement plan to follow if improvements are necessary
Clinical workflow for preoccupation with workflow for areas of improvement
How to educate patients and family members about the significance of their role throughout the continuum
Guidance on how to measure outcomes

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Mary Scarlata

Patient Stories

Mary Scarlata

As told by Mary's son, Marc Scarlata

March 1, 2015

One of the happiest days of Mary’s life was when she celebrated the birth on her second grandson, Logan. Eleven days later, she would die. She only got to see Logan that one time, the day he was born. Mary needed an aortic valve replacement. She had a severely calcified, bicuspid aortic valve that needed to be replaced. She was an otherwise, healthy 68-year-old with two young grandsons and plans to enjoy her retirement. Had the surgeon just stuck with the aortic valve replacement, she would be enjoying her grand kids today. Instead, the surgeon decided at the last minute to add on a completely unnecessary, very risky procedure called septal myectomy. He provided very vague information about the procedure and we learned after the fact that he himself had very little experience with septal myectomy. We also learned that the assisting surgeon apparently, had very little experience with the septal myectomy surgery as well. So there was absolutely no thought or pre-planning for the septal myectomy procedure. Not surprisingly, the surgeon botched the septal myectomy procedure, leaving a hole in Mary’s heart that could not be closed. In trying to fix his mistake he also cut a chord of the tricuspid valve and had to repair that as well. It seems that he was so in over his head in the O.R. with his mistakes that he had to call in another surgeon.

Unfortunately, due to all the mistakes and extended surgery time, Mary left the O.R. in poor condition which would continue to deteriorate in the ICU. Mary was put on a dialysis machine. She also suffered cardiac arrest in the ICU. Her potassium level spiked suddenly and stopped her heart. To this day, no one could explain why this happened. She was resuscitated but the damage during surgery and in the ICU was too much or her to take. We ended life support 3.5 days after surgery.

To this day, we struggle to understand why this doctor would choose to perform a very high risk procedure that he has limited experience with at the last minute in an attempt to fix an issue that he himself estimates was only 5% of Mary’s problem. When asked why he chose to do a very risky procedure to fix a minor problem, his answer was, “I was just trying to be perfect as a surgeon”. We interpret that as pure ego. The aortic valve replacement alone would have fixed the issue without the septal myectomy procedure.

No matter what the doctor shares about this case, before, during or after, surgery, nothing can take away from the fact that he botched a surgical procedure that he has limited experience with and that didn’t need to be done and this directly resulted in the very poor condition of Mary, post surgery. Also, after the fact, in speaking to a cardiologist we use, we learned that our cardiologist never refers patients to this specific doctor or medical group and this was the case before our family member died.

To make matters worse, the response from the hospital lacked any sympathy and was appalling and pathetic at best. But, finally after a year of trying to get more answers, they did send us a letter that following their own “internal investigation” they came to the conclusion that there “there may be opportunities for improving care” and that the doctor was up for peer review. To add injury to insult, we received a hand-written sympathy card from the hospital with the wrong name for Mary. When we called the number on the card, it was disconnected. This is the only thing the hospital did for us. The hospital and the surgeon clearly preferred to keep this event quiet as they knew it was a bad death so nothing was done about it in regard to us, Mary’s family.

We struggle to understand the thought process and clear lack of proper planning in an already risky surgery. For example….

Why wasn’t Mary provided specific details and risks associated the septal myectomy procedure ahead of time like the other procedures that were done? The doctor has very little experience with the septal myectomy procedure and the assisting surgeon has no experience with the procedure. Yet we know the senior partner surgeon in the group has experience with it so why wasn’t he the assisting surgeon on the case?

Most importantly of all, why is the doctor doing a procedure that is so risky to fix an issue that is 5% of the patient’s problem?

Why didn’t he come and talk to Mary in the pre-op holding area to discuss the procedure and answer any questions? Instead he sent a nurse to get her signature for the septal myectomy procedure. It’s our understanding that this is against the law.

Unfortunately, for more than a year after Mary’s death, we investigated and found out from several cardiologists and heart surgeons that the doctor has a reputation for taking unnecessary risks. The unbelievable grief and frustration and lack of caring haunts us to this day. Perhaps, being a part of your organization is a way to filter or extreme frustration into a positive cause to help educate people on what to ask physicians, how to vet them properly.

DJ Sterner

Patient Stories

DJ Sterner

As told by DJ’s wife, Karen Sterner.

On September 19, 2010, I suffered the greatest loss of my life. My husband, Donald James (DJ) Sterner died unexpectedly and needlessly due to a food poisoning infection he contracted while an inpatient at a Texas hospital. In short, his intestines were broken down by Clostridium perfringens bacteria and leaked into his bloodstream, causing organ failure and cardiac arrest. Medical staff dismissed his complaints of pain and failed to diagnose and treat his food poisoning infection and resulting septic shock. He died an excruciatingly painful death, which has compounded my grief. The horrific images of the last 24 hours of his life are forever burned into my mind.

Approximately 24 hours before his death, DJ displayed symptoms of food poisoning. He vomited three times in short succession and was complaining of severe stomach cramps near the bottom of his ribcage. He was not able to have a bowel movement and could not get comfortable. He was fidgeting every few seconds in his bed and was sweating profusely. His breathing had become so rapid he appeared to be panting like a dog. Despite being given morphine injections, his pain continued to increase throughout the day.

When DJ’s doctors came to his room during their normal round time, they dismissed his severe pain and difficulty breathing as anxiety and indigestion. Even the nurse told me DJ was just having anxiety. I had to argue with the nurse in the hallway outside his room that I had never seen my husband in this state before.

Both of DJ’s doctors failed to listen for bowel sounds and failed to take his vital signs, which would have alerted them to signs of septic shock. With the exception of an abdominal x-ray, they ordered no tests to try to ascertain the source of his pain. When one of the doctors palpated his abdomen and my husband cried out in pain, the doctor just made a startled face and walked out of the room. We never saw the doctor again.

As his condition deteriorated, DJ threw his hands up into the air and said, “That’s it. I want to be sedated.” He told me that he was scared and didn’t know what to do. These statements were very uncharacteristic of my strong-willed husband. Two resident doctors were then paged to come to his aid. However, with no explanation given to this day, neither of these resident doctors responded to the seven different pages of his nurse.

Every patient deserves proper medical care. I strongly believe that if a Patient Activated Rapid Response Team program had been in place, I would have called it and DJ would have received the medical attention he so desperately needed.

The leading cause of preventable deaths in U.S. hospitals is failure to rescue. This crucial patient safety measure will surely reduce these unnecessary deaths. Since patient-centered care is the goal of our medical care system, what better way to achieve that goal than to put the patient squarely at the helm?

Alex James

Patient Stories

Alex James

As told by John James

Nineteen-year-old Alex James, a Texas college student, collapsed while running on a university jogging path in the late August heat. He recovered and was taken by ambulance to the emergency room, where tests showed a low potassium level and an abnormal heart rhythm called a long QT interval.

Alex was seen by a cardiologist and by a consultant recommended a cardiac MRI. Alex thought one had been done since he was put through the procedure, but we later learned that the test had been aborted because the technicians at the hospital were not trained on new software. On the basis of this “inconclusive” MRI, Alex gave consent for a cardiac catheterization and an electrophysiology test, both invasive procedures. He spent four days in the hospital and a fifth day as an outpatient at a second hospital undergoing these procedures. He was never told that the cardiac MRI was not completed.

Alex’s heart catheterization and electrophysiology test showed no structural abnormalities. He did, however, meet the criteria for a diagnosis of long QT syndrome, a dangerous condition that can lead to sudden death. Inexplicably, this diagnosis was not made. One possible cause of long QT syndrome is low potassium, which can be brought on by strenuous exertion in a hot climate. The protocol in such cases is to replenish low potassium. Although we were told in the hospital that this would be done, it never was.

The doctor at the second hospital told Alex not to run and wrote this restriction in the medical record. However, the medical record also shows that Alex was given a second milligram of Versed, a drug known to cause loss of memory, just before being warned not to run. The total dose of Versed in Alex’s case was quite high for a 155-pound man. The only written instruction given to Alex when he was discharged a few hours later was not to drive for 24 hours. Alex was a good patient. He followed instructions and did not drive, but he apparently had no memory of the warning not to run.

Five days later Alex was seen by a family practice physician the cardiologists had recommended. This young doctor, still in her residency, lacked basic knowledge of cardiology. She did not know that Alex was supposed to be referred for genetic testing and gave him a clean bill of health.

Two and a half weeks later Alex was again running alone on the jogging trail. About a mile into his last run he collapsed and was found unresponsive by a passer-by. He died after three days in a coma. Pathology showed heart injury consistent with severe potassium depletion.

Lewis Blackman

Patient Stories

Lewis Blackman

As told by Lewis' mother, Helen Haskell

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.

Chris Salazar

Patient Stories

Chris Salazar

As told by Chris’s father, Ed Salazar.

By society’s standards, he wasn’t very significant. He wasn’t famous; he wasn’t a political figure; he wasn’t a scholar. In fact, he never graduated from college. He didn’t have a lot of material possessions. He worked as a cook and server in the restaurant industry. In other words, this young man was just another ordinary person. What he had that made him an amazing human being was a devotion to his two beautiful daughters whom adored him very much, a love for life and all the adventures it brought, and parents and family who loved and respected him as he did them. To his friends, he was a good-natured man you could count on, not only for help if it was within his power to do so, but also for a smile, a hug, and an attentive ear when they needed to vent or discuss whatever. On April 9th, the first tragedy happened: this young man needlessly lost his life. This young man died while in the care of highly trained critical care personnel at a Level III Trauma Center. Eighteen days after his devastating accident, his heart and lungs stopped working. At 27, there was nothing wrong with either organ. So why did this happen? Although the case for negligence seemed apparent to three different teams of lawyers, in the final analysis, we were told a little know healthcare law made it not “economically feasible” to pursue litigation. To me, that meant the lawyers found it wasn’t worth financially pursuing justice for this young man. This very significant 27-year-old man was my son, Christopher John Salazar.

Actionable Patient Safety Solutions (APSS)

<img src="https://psmf.org/wp-content/uploads/2020/12/Systematic-Prevention-and-Resuscitation-of-In-Hospital-Cardiac-Arrest.svg" alt="" /> 14A In-Hospital Cardiac Arrest

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Mary Scarlata

DJ Sterner

Alex James

Lewis Blackman

Chris Salazar

14A In-Hospital Cardiac Arrest