Hospital fined after overdose patient awakes just before surgeons harvest her organs
July 8, 2013, 4:39 pm
The Syracuse (NY) Post-Standard reports that St. Joseph’s Hospital Health Center has been fined $22,000 for a 2009 incident in which a patient declared brain dead and cleared for organ donation woke up in the operating room just before the harvesting procedure was to begin.
According to the report, the 41-year-old patient was brought to the emergency department comatose. Although staff at the hospital thought she had suffered a cardiac catastrophe, she was actually suffering from effects of an intentional overdose of drugs including Xanax, diphenhydramine, and a muscle relaxant. It is not clear from the newspaper report what drug levels were obtained, or the exact interval between the time the patient arrived at the hospital and when she was cleared for donation.
A review by the NY State Health Department listed mistakes they felt were made in this case:
*Not enough testing was done to see if she was free of all drugs.
*Not enough brain scans were performed
*Doctors ingnored a nurses observations indicating Burns was not dead and her condition was improving.
Apparently in the day before harvesting was scheduled, the patient had a downgoing plantar reflex. Just before being taken to the operating room, she seemed to be breathing around the ventilator. Before being taken into the OR, she was given an injection of Ativan.
None of those signs stopped the organ-harvesting process. I:t wasn’t until [the patient] was wheeled into the OR on Oct. 20, 2009, opened her eyes and looked at the lights above her that the doctors called it off.
As @ToxTalk pointed out in a tweet, Sullivan et al reported a similar case caused by baclofen overdose. That paper gives a good history of the changing definition of deathover the last several decades, and makes the following important points:
- Reversible causes of coma — such as overdose, hypothermia, and metabolic or endocrine disorders — must be ruled out.
- EEG can be used to determine that brain death is not present, but is an unreliable indicator that a patient is in fact brain dead.
- In massive overdose, elimination half-lives of drugs can be markedly prolonged compared to listed therapeutic values.
- Determination of brain death should made with caution, especially if there is no clear evidence of an irreversible CNS catastrophe.
The patient in Syracuse recovered and was discharged from hospital 2 weeks after almost becoming an organ donor. Tragically, she committed suicide 16 months later.
Tip o’ the hat to @Skepticscalpel and @napernurse, who brought this story to my attention.
Note: For an important update on this story, click here.