Imagine being prepped to have your organs removed for transplant, except… you are still alive!
In 2009, Colleen Burns, 40-year-old mother of three, was taken to St. Joseph’s Hospital Health Center in Syracuse, New York for a drug overdose.
One mistake after another almost killed her instead of saving her. The first mistake occurred shortly after Burns arrived in the Emergency Room when the recommended treatment of a charcoal-based substance, typically administered to prevent the stomach and intestines from absorbing the Xanax, muscle relaxants and Benadryl the patient took, was never given to Ms. Burns. Additionally, the hospital did not perform adequate testing to determine whether the patient was free of all drugs. Further, the patient did not undergo the proper amount of brain scans. But by far, the worst mistake made was that doctors ignored a nurse’s observation indicating that Burns was NOT dead and that her condition seemed to be improving.
The state Health Department found St. Joe’s care of Colleen Burns in 2009 unacceptable, and a federal agency criticized the hospital for not properly investigating the cause. The hospital’s mishandling of the case was part of the reason the state Health Department fined St. Joe’s $22,000 last September. This was the largest fine levied against a Central New York hospital since 2002.
St. Joe’s was fined $6,000 for the Burns case and $16,000 for leaving a patient unattended before that patient fell and injured her head in 2011.
After prodding by the state, an investigation was conducted by the hospital, which found that St. Joe’s had acceptable organ procurement policies and procedures. Except for one small problem…organs are not to be removed until the patient is dead. Colleen Burns was still alive.
Burns recovered from her overdose and was discharged from the hospital two weeks after the near fatality in the operating room. Unfortunately, 16 months later, January 2011, Colleen committed suicide, said her mother, Lucille Kuss.
Hospital spokeswoman, Kerri Howell said, “We’ve learned from this experience and have modified our policies to include the type of unusual circumstance presented in this case.”
St. Joe’s officials thought Burns suffered “cardiac death” in October 2009, according to documents obtained by The Post-Standard under the state’s Freedom of Information Law.
Colleen’s family agreed to allow doctors to withdraw life support and remove her organs after they were told she was dead.
Just one day before her organs were to be removed, a nurse performed a reflex test on Burns, scraping a finger on the bottom of her foot. Her toes curled downward, which is obviously not the reaction of someone who is supposed to be dead.
It was reported that Burns’ nostrils flared while being prepped for the operating room. In addition, it was reported that she seemed to be breathing independent from the respirator to which she was attached. Her lips and tongue moved. Twenty minutes after these observations were noted, a nurse administered an injection of the sedative, Ativan, according to medical records. However, the doctor’s notes make no mention of the sedative or any indication they were aware of her improving condition.
It is unbelievable that none of these signs were a ‘red flag’ and stopped the organ-harvesting process. It wasn’t until Colleen was wheeled into the operating room on October 20, 2009 and opened her eyes to see the lights above her that doctors finally called off the surgery.
The federal center for Medicare and Medicaid Services criticized St. Joe’s response to the incident.
In fact, it wasn’t until the day after the state made a surprise inspection that St. Joe’s did any investigation, the state report said. “The hospital did not undertake an intensive and critical review of the near catastrophic event in this case,” the federal agency’s report said. St. Joe’s officials did not “identify the inadequate physician evaluations of (Burns) that occurred when nursing staff questioned possible signs of improving neurological function.”
The state’s report said that Burns did not suffer a cardiopulmonary arrest and did not have irreversible brain damage, as St. Joe’s had determined. “The patient did not meet criteria for withdrawal of care,” the report said.
Hospital officials did not wait long enough or conduct enough tests to determine that all of the drugs were out of Burns’ system before deciding to take her off life support, as reported by the state.
Two medical experts reviewing the case for The Post-Standard found this case shocking, and questioned why St. Joe’s did not do more to ensure the safety of other patients. “Dead patients don’t curl their toes,” said Dr. Charles Wetli, a nationally-known forensic pathologist in N.J. “And they don’t fight against the respirator and want to breathe on their own.”
Dr. Wetli also questioned why, after seeing that Burns was alive, a nurse would give Burns a sedative.
Dr. David Mayer, a 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.”
Dr. Mayer added that the hospital erred four or five times. He called the case a gross deviation from all prevailing and accepted standards of care.
The state fined St. Joe’s $22,000 and ordered it to hire a consultant to review the hospital’s quality assurance program and implement the consultant’s recommendations. The hospital was also ordered to hire a consultant neurologist to teach staff how to accurately diagnose brain death.
It is unbelievable to think how close Colleen came to being killed by the doctors that were there to help her. It seems that her being an organ donor saved her from death. Not to mention the trauma her family had to endure when, for a full day, they believed their beloved Colleen Burns was dead, only to realize the doctors made a mistake.
What do you think about this horrific story? Feel free to comment on this blog post. You can contact one of our Gacovino Lake attorneys at 1-800-246-HURT (4878).