13 Embolic Events

Embolic events contribute significantly to patient morbidity and mortality, with VTE specifically being the second most common medical complication in the US. Many signs and symptoms can mimic those of deep vein thrombosis or pulmonary embolism, or, as in the case of air embolism, incidence is relatively rare but has significant consequences.

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.

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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

Related APSS

13A Air Embolism

13B Venous Thromboembolism

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Michael Skolnik

Patient Stories

Michael Skolnik

The last normal day of Michael’s life began like any other. He was sitting on the couch playing with the family’s new puppy. Suddenly, he inexplicably passed out. When Michael regained consciousness, the 22-year-old EMT and nursing student knew he had to get to the emergency room right away.

At the time, a doctor suggested that Michael had probably had a seizure, a side effect of Wellbutrin, an antidepressant he had been taking for smoking cessation. But a CT scan later revealed a three-millimeter dot in his brain. The Skolnik’s believe that the neurosurgeon made a quick and deadly rush to judgment. He had warned that Michael was lucky to have survived his initial seizure and that he needed surgery immediately.

“He said, it’s a very simple operation,” Patty recalls the doctor saying. “You don’t even go in the brain. All I do is go in and excise the cyst.” The Skolnik’s say the doctor claimed to have performed many such surgeries, but he later admitted in a legal deposition that Michael’s procedure had only been his second.

Whatever the case, no cyst was removed or revealed. An exhausting three-hour operation ended six hours later, and Michael was never the same again. Other physicians have since told the Skolnik’s that at most, a shunt should have been placed in Michael’s brain and that the elusive dot was likely benign. The seizure, some doctors say, was likely a bad reaction to the Wellbutrin.

The neurosurgeon, who would later establish a […now closed…] medical practice at Western Plains Neurosurgery in Scottsbluff, Nebraska, has been unavailable for comment to the press. He reportedly still lives in the Denver area and plans to open a new practice in Glenwood Springs, according to a Western Plains receptionist.

The Skolnik’s become visibly angry when they describe the way the neurosurgeon announced Michael’s prognosis after the ill-fated surgery. “He pulled back his hat and says ‘I’ve had the worst year,’” David recalls angrily. “We were a family that made decisions together. This changed who we are. It was our life forever with Michael. Now, it’s still our life, but without Michael.”

The family’s 32-month nightmare included multiple surgeries, systemic infections, deep vein thrombosis, pulmonary embolism, DIC and sepsis. Michael suffered from paralysis, psychosis, respiratory arrest and an endocrine-system failure that caused him to gain more than 100 pounds. He was partially blinded and unable to speak. He was fed through a tube in his stomach.

On June 4, 2004, Michael looked into his father’s eyes, mouthed “I love you” and died.

It’s April 1, 1986. Seven-year old Michael Skolnik is up to his usual tricks, but this time, he is armed with a convenient little alibi called April Fool’s Day. The mischievous child is slowly creeping up behind his unsuspecting mother… when all of a sudden, crack! A perfect shot, over and easy. A broken egg scrambled on Patty’s face.

“He just thought that was the funniest thing he had ever done,” Patty recalls, as a glow quickly covers the same face. “My first reaction was, ‘What have you done?’ But then, you had to laugh because Michael just made you laugh. He was such a character.” The laughs come as easy as the tears when Patty talks about her only child. “Your life is forever changed and you hope there is something after death so you can believe you will see your child again,” Patty says. She remembers Michael’s realization, at 13, that he did not believe in God.

“What if you die and you find out there is a God, what do you think God will feel?” Patty quizzed her son at the time. “Well, if God is supposed to be all forgiving, he’ll forgive me for not believing in him,” the young teen retorted.

The exchange has resonated with Patty for more than a decade. “I thought that was pretty profound for a 13-year-old,”she says smiling.“Somehow, some way, I feel Michael is right there behind me pushing me along.”

Charles Bates II

Patient Stories

Charles Bates II

As told by Vonda Vaden Bates

Yogiraj Charles Bates died from a hospital acquired venous thromboembolism (HA-VTE), the most common cause of hospital-related death in the United States. He was and continues to be revered for his extraordinary mind and loving nature by people around the world. His contributions as an author, entrepreneur, father, sage, master trainer and an unrelenting advocate for the human spirit will have a positive influence for many generations to come. Yogiraj’s story begins with a fall from his meditation seat. We laughed at this odd occurrence, that is, once we felt assured he was unaffected by the impact. Several weeks later we learned otherwise. The fall was serious. I can still remember the moment the on-call neurosurgeon gave us this news. He swiftly pulled back the ED curtain with his backpack still tightly affixed to his shoulders. Out of breath, from what I imagined was a hurried bike ride, the neurosurgeon expressed his surprise that Yogiraj appeared well. He turned our attention to an image, pointed to Yogiraj’s head and stated, “Your head is half full of blood. In cases such as these, I would typically rush a patient into surgery, but you appear well enough to hold off until morning.” Although, rather in shock by this alarming news, we felt comforted by his confident assurance. The neurosurgeon confidently acknowledged his team handled cases such as Yogiraj’s every day and despite our unfamiliarity with Subdural Hematoma surgery, we remained optimistic it would bear a successful outcome. At first, the operation appeared to go well. Yogiraj emerged from the recovery room as I marveled at his tenacity to regard everything as a learning opportunity. I reported to our community that Yogiraj, although extremely parched due to a long surgery, was musing over the many benefits of liquid. This was a telling sign my husband’s cognitive function was sound. What appeared to be progress and standard recovery quickly shifted to incessant issues and pain. The day following surgery, we expressed our concerns, but were told his symptoms were normal. Our uneasiness continued as Yogiraj was phased from ICU to the hospital’s residential rehabilitation center. Each transfer, eight locations in the span of thirteen days, we would reiterate to each new care team his mounting issues. These symptoms included shortness of breath, chest pain, spells of uncharacteristic anxiety, low pulse oximetry, weakness on the left side, and pain in his lower left leg. Although we attentively made sure each team was familiar with his various symptoms, a diagnosis was never discussed. The hospital staff was kind and also attentive. We assumed they were doing their best. We were particularly grateful for the first physical therapist, who provided us with a strap so that I could walk alongside him. I still smile when I think back and remember my 5’4 frame steadying his 6’2 stature. Side by side, 24/7, 100% of our attention was focused on Yogiraj’s rehabilitation. Everything else remained on pause. He was determined to leave the hospital better than he had arrived. Family and friends would visit and bring food, while people around the world followed his efforts towards recovery. Unfortunately, his positive attitude and continued perseverance weren’t enough to avert the underlying issues. His symptoms had escalated. On Father’s Day, the 12^th day following his initial surgery, the first code blue was called. That morning I woke up to my husband in the middle of a tonic clonic seizure. He was rushed from Rehab to the ED, and several hours later admitted to a Cardiac unit. The next morning we would see several physicians come and go. After a couple of tests it was decided, he would either return to Rehab or be discharged and return home. We remained hopeful and took their words to heart. Yet we continued to be hyper-attentive. We knew something was not right. The second and last code blue was called when Yogiraj underwent an ordered EKG test. His son Ananda had just visited for lunch and although Yogiraj still needed oxygen his spirit was light. It always was when he was with family. During the EKG, he suddenly looked over at me with widening eyes and said, “It’s happening again.” I knew exactly what this meant. I cried for help and the formerly silent room instantly shifted into manic chaos. A chaplain arrived at our side before they could even rush Yogiraj to the ICU. I can still remember the initial strike of panic when the clergyman introduced himself to me. Naively, I convinced myself his presence was nothing more than a kind gesture to provide assistance. I proceeded to give him my phone and asked if he would contact our son Evan, who was waiting nearby. I ran alongside Yogiraj as he was rushed to ICU. This is when I first heard the words Pulmonary Embolism. These words, completely foreign to me at the time, were quickly overshadowed by the following eight words. The doctor and overseer of his resuscitation efforts said, “This doesn’t usually go well. He could die.” A mere thirty minutes later, I watched Yogiraj Charles Bates take his last breath. Shock and disbelief pervasively continued to follow for months. The reality of his sudden death hit once I received the autopsy report. It was at that time Pulmonary Embolism (PE) became a term for me. This term, married with my husband’s medical records, became my meticulous (devoted) study for months. It was what prompted my future concerns. My husband’s symptoms had lined up to the most common U.S. preventable hospital death, HA-VTE. With the need for more answers, I contacted friends in the medical field and tried to piece together what delayed his diagnosis until it was too late. I knew that understanding what had gone wrong would not change the circumstances that followed. I would never again wake up to Yogiraj’s beams of love. However, maybe my comprehension and experience had the power and potential to prevent future deaths and could save other families from despair. After analyzing several peer-reviewed studies alongside my husband’s medical records, I contacted the hospital. My first conversation didn’t go well. At the start, I left a message at the patient representative’s office and received a call back from the manager. I said I wanted to know what questions the hospital was asking surrounding my husband’s experience. It felt important to express to the hospital staff member that I was solely seeking understanding, rather than pointing fingers to blame. The response back shocked me. The manager said, “People die in the hospital every day.” I could not hold back my immediate gut response and said, “Not like this, I hope. Not like this.” There was silence, followed by the manager’s agreement to vet for more details and call me back. That promised call never came. Months went by as my interest escalated and research continued. I wrote dozens of draft letters which introduced my desire to simply understand and transcend blame. It had become clear that HA-VTE was a systemic issue and my husband’s experience was happening in hospitals across the nation. Over a year later, I sent a letter and requested two meetings. One meeting with an officer of the hospital and the second with physicians. It gave me peace to finally feel closer to answers once my requested meetings had been set. I offered to send my questions ahead of time in support of any preparation they may need. Our family was eager to learn and share our experience and hoped our approach could benefit others. The first meeting was disheartening. The officer on the phone casually spoke, making attempts to be chatty rather than getting to the root purpose of the call. I am familiar with the cultural notion to start a serious conversation lightly. It’s a technique I’ve used myself. However, my husband had died and I couldn’t help but wonder why the administrator made no effort to set a tone that acknowledged this significance. In that same conversation, I was told the physicians were “busy saving lives,” so our in-person meeting could not include them. I pushed back, but their approach was the only avenue forward. Only administrators would be present. As promised, I sent my questions in the week before the meeting. Several days later, the meeting was canceled. The administrator responded by email and stated my questions had changed the agenda. I was confused by this statement, but my reply accepted the fact that our objectives were not aligned. The hospital hasn’t contacted me since. In my attempts to better understand the hospital perspective, I can imagine the associated challenges to manage the complexities and risks after an adverse event. Yet I cannot help but feel the moment my husband took his final breath as Yogiraj Charles Bates, II, he suddenly turned from being a cared-for patient to a managed risk. For those who knew him, nothing could change who this great man was. Like any another delayed diagnosis death resulting in a hospital-associated death, his deserved a robust investigation – one that included the observations of the family who cared for him alongside the medical team. The real risk for a hospital is not taking time to know the person after an adverse event. If this hospital administration had heard our experience, and that of the dozens of nurses, doctors, and other staff members who cared for him, it may have been more difficult to treat this person like a risk. Yogiraj was a master teacher. In telling his story, my hope is that his life and death will reach and teach as many individuals as possible about HA-VTE, and that his experience will ultimately improve patient safety.

As Told By

Vonda Vaden Bates

Vonda Vaden Bates is an alliance builder and leadership coach. For over 30 years Vonda has guided professionals to succeed […] Read More

Actionable Patient Safety Solutions (APSS)

<img src="https://psmf.org/wp-content/uploads/2020/12/Embolic-Events.svg" alt="" /> 13 Embolic Events

Related APSS

13A Air Embolism

13B Venous Thromboembolism

To gain access to a PDF of the APSS for download, please login/register below.

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Shared Learning Network

Michael Skolnik

Charles Bates II

13 Embolic Events