In March of 2012, Glenn Clarkson was helping with a controlled grass burn in rural Kansas. Something went terribly wrong and he became surrounded by flames, so he dropped into a shallow pool of water. His clothes did not catch fire, but he did suffer thermal burns. His wife, Nancy Clarkson, took him to the emergency room of the nearest hospital. He was diagnosed with second degree burns over 30% of his body, mostly on his back. The emergency room physician told Nancy there was no need to transfer Glenn to a burn center, so he was sent to the ICU for the night.
His family later learned that the hospital’s protocol called for him to be intubated to ensure an open airway, given Lactated Ringers intravenous fluid at a rate according to the Parkland Burn formula, and transferred to a certified burn center. But none of that happened that night. Instead, Glenn was given an inappropriate fluid—first at a rate too high, and then at a rate far too slow. When his blood pressure dropped, he was given a medication to raise his blood pressure by constricting his blood vessels. This decreased blood flow to his burned skin, and also likely caused the failure of his kidneys.
The nursing staff knew that Glenn should have been immediately transferred to a burn center, but were unable to convince the emergency room physician or physician on call to order the transfer. Glenn spent the night in the ICU and received several inappropriate and ineffective medications.
At the shift change the next morning, a physician assistant came to see Glenn. He immediately ordered intubation, proper fluid, and a transfer to the burn center. Once Glenn was at the burn center the staff were able to reverse some of the effects of the treatment in the rural hospital, but Glenn remained in critical condition. He underwent skin graft surgery on his entire back, but his body was too damaged to recover. He died 13 days after being burned.
Glenn’s story is not only about the errors made in his care, it is also about the secrecy surrounding the errors. The rural hospital refused to discuss Glenn’s treatment with his family. It took three-and-a-half years—and a lawsuit—to learn what happened. Nancy and Melissa (Glenn’s daughter) are now advocates for the disclosure of medical errors. You can learn more about their experiences and work at disclosemedicalerrors.wordpress.com.