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Comments

BardParker

The preps my radiologists use are breakable ampuoles within a plastic tube that fills a brush so such things can be avoided.
I have two aditional questions:
Aren't such post-coil films done with a power injector? If it was then the "technologist injection" may not be implausable since the tech would load the injector and push the button to begin the digital subtraction and injection.
How toxic is chlorhexidine? It is in things that range from Peridex mouthwash to Surgilube. I'm sure that it's not smart to inject such thing but how much would be required to have the effect advertized?

CodeBlueBlogMD

First,let me apologize for how this post published. Typepad is driving me crazy today. This post published on first PREVIEW, before spellchecking, and missing several key items including info/literature on chlorhexidine; pics and routine re cerebral embo technique; studies regarding the appropriateness of embo Rx in nonruptured aneurysms, as well as which centers should be doing this procedure. Now I cannot edit the post and my only recourse is to delete it, which I won't do; so, I will update this weekend with those missing data, in a second slightly more coherent format.

There used to be a fear that sponges and plastic applicators could "microfragment" and then become implanted during the Seldinger stick of the CFA leading to foreign body granulomas, infections, etc. I think newer materials have eradicated that possibility and your guys are certainly using the right applicators; in fact VMMC is now using those same ampule-applicators.

I considered the whole chlorhexidine angle early on. I had the exact same thought as you do. It's hard to believe. I mean what did they do, inject a janitor's drum of that stuff in her?

There isn't much in the literature out there regarding intravenous administration of this stuff, so I didn't really have enough ammo to question this mechanism (I'll post my research on this over the weekend); and the couple of incidents regarding chlohexidine complications seemed pretty dramatic. I realize that I could be missing a HUGE story, but I let it slide for two reasons: 1. I was going to come off as over-conspirational and thus undermine my credibility; and, 2. I have enough evidence to prove what I want to prove: that VMMC is using the "PR" game in an immoral way that, in the end, is going to back-fire and hurt EVERYONE in the medical field.

Most newer-trained neuroradiologists will use the power injector. In a recent survey, only 5 of 70 or so Rads said they were still ONLY hand injecting. I considered the power injector scenario and it raised an interesting point. The injector (which, depending on the model -- single or double barrell -- holds 60-300cc's of contrast)would have been filled at the beginning of the procedure. Surely they had done several limited runs before this last incident; so, if they were using the injector then there was CONTRAST in the injector. Each CCA run is about 10-12cc's and an ICA run is about 7-8cc's...it's hard to imagine they didn't load enough contrast.

But if they did miscalculate the amount of contrast needed then someone would have had to dip the nose of the power injector down into the chlorhexidine and manually crank it backwards into the injector and then rehook-up the catheter for that last, fatal injection.

That may well have happened, but there was no mention of any of these machinations in any reports.

If we assume they are telling the truth about the chlorhexidine injection then I believe the most likely scenario is that someone grabbed a syringe, reached over and quickly sucked up fluid from the "wrong" bowl and injected it.

A hand injection can never be done by a technologist.

Even in the case of the power injector, the Doc is obligated to check the injector, and attach the tubing to the catheter himself before allowing the tech to operate the apparatus.

Question remains: how did they get the leg? Were they doing the leg on the way out to work up claudication? Did they screw up the line, pull the catheter and inject the sheath to see what's up?

One of the points I was heading to(until fouled by TypePad) was that I TOTALLY agree with the concept VMMC pays lip service to : coming clean. They should come clean and go from there. But, you see, they are not only NOT coming clean, they are, instead, putting on a dog and pony show concocted by their PR firm...and it is SO transparent it is insulting, and I don't think people will go for it for too long. Then, when the truth comes out, and it blows up into pieces it will engender MORE antipathy against physicians and fuel the litigating lions out there.

That's why my advice is for them to fess up and answer-up. In excruciating detail.

Maybe I'm too cynical (who me?) and VMMC is just REALLY bad at PR and didn't mean to present such a distracted, uncoordinated, illogical story to the public (after all, 160 consecutive media stories caught on to NONE of these contradictions)...because maybe those hospital administrators care less about their jobs then about the wide world of medical errors and patient safety. Maybe.

But it's also possible that the screw-up here is worse than "systems" failure and they are shuking oysters like mad hoping to bury us all in the shells...I know where I'd place MY bet. Thanks for your letter.

That was so much effort, I think I'll post it on the site, if you don't mind...

CBBMD

jb

I'm not IntRad (I'm a General Surgeon), but, trying to put this together, this is what may have happened. It requires that an additional mistake was made, but otherwise explains what the article tried to describe. Most of these type procedures are done thru a sheath, a relatively short, slightly larger diameter device that allow the radiologist to insert longer catheters and manipulate them without multiple sticks into the femoral artery. These sheaths have a "side port" IV access to allow a slow drip of heparinized saline to prevent clots forming in the system. If the chlorhexidine had been injected thru this side port, it would be released into the iliac artery and do its worst damage in the leg, then possibly have done other damage systemically, including drops in blood pressure, renal damage, and a CVA as a result on a delayed basis.
My scenario makes perfect sense only if you posit that the additional mistake was made; i.e., that the injection was made thru the sheath and not the working catheter. Maybe they thought that it was heparinized saline. On second thought, keeping the heparinized saline flowing thru the side port may well be done by a tech, and the mistake may have been at that level. The doc may have had nothing to do with the mistake (the doc would have no need to double check that solution as he would the contrast, as you suggest).

CoeBlueBlogMD

I mention the sheath in the ensuing post. The heparinized saline is usually hanging in a bag attached by a tubing to the side port. However, if they had trouble with the cerebral catheter they may have pulled it out and injected the sheath to see what's up but again, a tech wouldn't do that.

The sheath may have clogged and the tech might have tried to flush it with chlorhexidine, I agree; however,VMMC made a pretty emphatic point about the chlorhexidine being confused with the contrast.

Of course, one of the major problems in trying to put this all together is that the reporters who write the articles get the facts second and third hand. 97% of the on-line news posts describe the embolization as a surgical procedure...

All the more why VMMC, if they REALLY wanted to expose what happened, discuss it and clear the matter up, they would have issued detailed information to EVRYONE. But they didn't.

I don't thin that is an accident.

My biggest issues in this case lie not with the concatenation of events that fell in line to create the catastrophe (although if they are hiding some sort of even WORSE issue by fessing up on the accidental mix-up I may change my mind); rather,it is the way VMMC has handled the PR and the spin (they admit a horrible error but don't really tell anyone exactly how it happened then they take a righteous position on "medical errors" like it's some type of problem they are actively fighting against...) which I believe is -- if they are doing it purposely -- immoral.

jb

Sorry I missed your reference to a possible sheath injection. I still think that it's the best explanation for the tragic sequence of events that followed (worst damage to the leg, then systemic problems leading to death).

Whatever happened, I think you may be reacting too harshly to VMMC's handling of the situation. They clearly are fessing up to causing an unnecessary death. When a disaster of this type occurs, the hospital's first responsibility is to minimize the damage to the patient, if possible (not possible in this case, where the patient died). The next thing is to make sure it doesn't happen again. In my hospital, EVERYTHING on EVERY sterile field is labeled. That should be an unbreakable law in every hospital in the country. If it was policy at VVMC, and a tech ignored policy, that tech should be dealt with in an appropriate manner. Keep in mind that hospitals are forced to entrust potentially life-threatening steps to $12-15/hr techs due to the way health care is funded in this country. It's amazing that these mistakes don't happen more often; there was an eerily similar incident in Miami 4 or 5 years ago where formalin found its way onto the sterile field and was injected intrathecally with a similar outcome. If a strict labeling policy is not in force at VVMC, it will be in the future.

The next step in this process goes under the category of risk management, or damage mitigation, or whatever other name you want to apply. Managemnt's next responsibility is to protect the institution, and to reassure the public that this freak tragic accident is just that, and that the institution will do its best to make the victim's family whole and make sure that this type of accident does not happen again. You and I have no idea what hospital management is doing behind the scenes, but you and I know what goes on in hospitals, and interpret the PR in that light. You and I are not the intended audience of Dr Caplan's PR. The general public is. You and I know that every word out of Caplan's mouth is vetted by the hospital's counsel, and polished by their PR department. After investigating, they may be in a position to announce that this tragedy was due to the fact that VVMC Employee #1234 failed to follow hsopital policy, did not label the syringe properly, and loaded the injector with the soap instead of the contrast agent. They may say that all policies were followed but there was no requirement to label everything at that atime, but there sure as hell is now, so this is unlikely to happen again. They may say that Dr. Nobrain grabbed a syringe, loaded it with the closest liquid he saw and ordered the tech to inject it, ignoring her protests. We don't know. What I do know is that it will be in everyone's interest for the hospital to reach a quiet settlement with the family, deal internally with systems problems and personnel problems, and get on with business, sadder, poorer, but wiser.

cardioNP

A thought as to why the chlorhexidine may have been injected into the leg: When completing arterial procedures there are devices called Angioseal and Vasoseal that "plug-up" the arterial puncture site. In the cardiac cath lab we routinely do an injection of the iliac artery prior to use of one of Angioseal to ensure that the insertion site is not at a bifurcation. (Placing the seal at the bifurcation can cause occulusion of the side branch.) Perhaps they were doing an injection at the end of the procedure to evaluate the sheath placement prior to using a vascular closure device?

CodeBlueBlogMD

jb:

Thanks again for your thoughtful posts.

I used to feel the way you do. But things have changed, for me, in several ways.

Maybe the administrators at VMMC are wonderfully enlightened, professional, caring people with the best interests of all at heart. After all, it is yet a not-for-profit hospital and may be one of the last bastions of medical administrative nobility...but in my experience, hospital administrators have become a different breed. Mutants might be appropriate. Or body snatchers, who've come into our homes and taken over the minds and volitional actions of our relatives. I've been on the inside, involved in the way they talk about patients, doctors and employees and I've realized that the landscape has changed forever. I don't want to make this letter a screed, but, for now, suffice it to say that the motivations of hospital administrators are presumed, by me -- at all times -- not to be directed by physician or patient concerns. And they certainly don't care if techs/nurses/workers get eaten by the sharks or chopped up and used for chum, unless it affects the bottom line.

Your point about accidents is correct and astute, and I have no argument with making plain the freakish nature of these accidents. These are statistically unavoidable events and are amazingly rare, considering the actual number of decisions and events that occur every day with every patient and every case. This is actually part of my problem here...

You'll notice I mention the IOM study a few times--the study that indicted (mostly) physicians for making a ridiculous number of mistakes and causing a fantastic number of deaths each year. That study, in my opinion, was tendentious and bogus. It's for another time, but, suffice it to say that their error percentage was flawed by inferential conclusions (numerator) and undercounting total events (denominator). The idea that 98,000 patients die every year from medical errors is INSANE, yet we, as physicians, LET THEM DO THIS TO US! We let them just drop that hammer on our heads every time they have a itch to scratch.

Do you see where I'm going?

We are in a war for the survival of our profession, and we are flanked by lawyers and politicians. Hospital administrators -- on OUR side of the battlefield -- are firing bullets into our backs. We have lost most of the battles and our fronts have been pushed back relentlessly. I believe that this war can only be won, at this point, if we can win the battle for public opinion. Because right now, the public is ready to chuck the whole system away and go for a more nationalized version.

In order to win public opinion we have to clarify, educate, and be transparent. The admin at VMMC basically blame the SYSTEM and ALL the doctors and workers in it. This helps no one. As you agree, this is a freak accident that can be understood if we take the time to explain it carefully and explain it over and over again. I believe the public is very skeptical when they hear phony righteous babble, and their worst fears are confirmed when stories like VMMC fall apart. We've lost patients' trust, I believe, because of our own history of patronizing, even arrogant behavior; hospital administrators who sell us down the river to make a buck; and the tort lizards who USE the worst fears and misunderstandings of the public against us every day.

Every post I make has these factors underlying. When I first started this blog I tried to take on the issues of health care head first. That did not work. The enemies are too well prepared and basically, that's THEIR turf. Let them fight on OUR turf. The clinical battlefield.

I think we need to let the public know everything that's going on, in detail, and in the end that serves us better. No BS. No spin. If we can disable the invasion from Planet 9 (Tort lawyers) and work on educating the public honestly and transparently, with great repetition, we can win. That's my battle plan, and that's why I spend so much time working on this blog.

I also would like to extend an open invitation to all physicians who come across this blog and who agree with this adumbration of principles, to be guests on my site (you write a post and if it works I publish it and we discuss it or...whatever).

The idea is to publish clinically-oriented items that have a pull for the general public, and are either just intrinsically of intrerest, or illustrate (as almost any situation can) issues in health care (you know, the "crisis".

Just click on the "email me" button.

CodeBlueBlogMD

cardioNP:

Thanks. You know, I haven't actually done angios in a while, and the 2 interventionalists I consulted before writing this article did not mention the Vasoseal device to me.

You may be correct. My attention was focused on the first reports of the incident that specifically mentioned that the chlorhexidine was administered during an attempt to "observe the results" of their embolization, which, I presumed to represent the pullback-to-the-carotid.

Also, what size sheath are you using? The neuro catheters/sheaths are small ones; I'll check on exact diameters...thanks for your post

CodeBlueBlogMD

cardioNP:

Also: would a tech do that injection?

cardioNP

In the cardiac cath lab sheaths range from 4-7 Fr.
I have worked primarily in tertiary care teaching hospitals where there have been fellows available as the second pair of hands, so injections were done only by MDs. Occasionally the fellows were not available and the RN would scrub and might assist w/ dye injections. I personally have assisted during PCI and did some dye "puffs", but have not done direct cor injection.
It is not uncommon to have cath labs where CVTs do scrub and assist with the cases. I imagine that this is more common at community facilities that don't have residency or fellowship programs. Don't have as much experience with IR though. When I was an RN rotating thru radiology at a VA hospital only the IR attending and IR fellow were at the table.

rhonda

What about the person that placed the bowl on the procedure table during the procedure? The table is sterile and all materials needed should be dropped on the table, careful not to contaminate the sterile field.
Did this person find a bowl of fluid, pick it up and place it onto the sterile field?? Also, why is cleaning fluid kept in a bowl that is exactly like those used during procedures. Cleaning fluid should be kept in an enclosed container,not an open bowl. This institution might consider spiking the contrast bottle and withdrawning through tubing instead of pouring contrast into a bowl. Consideration might also be made to label all fluids in syringes.
I agree that it is possible that the injection may have been at the end of the case for angioseal placement.

Jennifer Quinto

I am not a doctor or professional, I am just someone that was lucky enough to have had the chance to be a part of Ms. Mary's life.

Her memorial was today, I was there to witness her family, sons, and friends grieving her loss. I know that my time with her was brief, but it was profound, as it was for all of those who were there for her service. After hearing everything that was said and all of the feelings that were displayed, the lines between family and friends was very fine. If you were lucky enough to befriend her, you were lucky enough to be treated like her family.

As well, her past co-workers talked of their experiences with her, and they too had the same to say. They knew they were cared for by her and her presence was far reaching. It was not just former employees that knew her determined and powerful ways, but everyone that came to know her.

Everyone, at some point, saw her working hard to battle injustice wether it was as the social worker pushing for a cause, a mother caring for her children, a woman going to bat for someone that was in trouble or alone, or as a teacher steering a student back to the right path, they all had seen her nature.

After reading these posts, I am even more in awe of the entire situation. I had only learned of her death after opening the paper, caught not by her name but the horrific headline. I was shocked by the article, then floored to know that it was such a wonderful woman, and a woman that was a part of my life.

The paper articles seemed to placate the offense. After reading these posts a whole different picture is painted.

I know that if this had happened to one of Ms. Mary's children or family she would be stirring up a great wind, fighting for the justification of her family. She would not slink back to the simple answer of a "system problem". Her voice would be heard and she would not give up.

If her sons and family do decide to pursue further action with this incident, I fully support them. These days many people have become lawsuit happy and thus we've come to know about such things as the "Stella Awards", where people sue for the most pathetic reasons.

I know that Ms. Mary would not pursue such an incident in a vendictive or petty nature. So I know that in this instance this is the very way her family ought to pursue this matter. I can only hope that such knowledgeable, and passionate people would be the ones to aid her family in their cause.

I'm glad to know that people are taking notice.

stan

It was a system error because the error occurred by highly trained competent personnel, and any number of similarly trained people in a similar situation could make the same error.
Blame and shame will never fix these problems. Americans must understand this fact.

Mark

Do you have an update to this case?

Davespart

Here is an update on Virginia Mason including events relating to Mry McClinton

Late last year, you had some excellent comment on the tragic death of Mary McClinton, a 69 year old woman, who was killed at Virginia Mason Hospital in Seattle when unlabeled chlorhexidine was purportedly confused with similarly clear radiological dye. (In fact, it was saline it was confused with not radiological dye as reported by the hospital). You accused the hospital of spin rather than meaningful action in the wake of her death.

Since then, many other damning facts about Virginia Mason have come to light. Virginia Mason were consulted by Martin Memorial Hospital, Florida, after a 7 year old boy died there in 1995, as a result of two unlabeled bowls of liquid in the operating theater. Yet Virginia Mason had portrayed itself as the paragon of patient safety. Sadly for Mrs McClinton and her family, 9 years later they were still putting unlabeled bowels of indistinguishable liquids in an operating theater. (Not to mention pouring chlorhexidine from a container into an unmarked bowl, as opposed to purchasing pre-filled applicators at a monumental 6 cents each.) Astonishingly, this week, an anonymous letter from current staff to the press revealed that five months after the death of Mrs McClinton, they are still doing this.

The letter also revealed that a patient had been set on fire because "his doctor was in too much of a hurry to wait for non-flammable skin cleaning solution to be brought into the OR." The patient died and a staff member is alleged to have commented 'He was going to die anyway'. Hospital Director of Medical Quality, Robert Caplan, called the care he received 'heroic'.

It further alleged that a convicted spousal abuser, John Mburu Karanja, had been hired, and worse still, in a separate incident, a felon on an Al Qaeda watch list had been working there. He had a felony conviction in California, had changed his name, and was only caught when the Seattle Post Intelligencer printed his name in an article regarding homeland security on November 19th, as Mary McClinton's lay struggling for her life in one of their beds. Virginia Mason managers then hurriedly removed the Seattle P-I from the mailboxes of staff over the weekend in an attempt to cover up this fact. According to the memo, Ahmad Abdul al Salaam as Sadiq, was arrested for weapons possession, a breach of his parole conditions. Strange that Virginia Mason never acted on his reputed tendency of taking colleagues to his car, and showing off his gun collection. Even more so given that he was in the habit of using this collection to intimidate those colleagues he believed to be homosexual in accordance with his outspoken homophobic beliefs.

The letter says that staff live in a climate of fear, whistleblowers have been fired, safety advice is routinely ignored, and it further accuses Virginia Mason of being more interested in spin and PR than safety, an accusation repeated by Gerald and Doug McClinton, two of Mary's sons and in the lawsuit filed by the attorney for the Estate of Mary McClinton. This fact is further borne out by the fact that Dr. Robert Caplan, ostensible Director of Medical Quality, is also VMMC’s chief spokesman. VMMC has blatantly confused good patient safety practices with good public relations.


There is far worse to come however. Gordy Holt in an article in the Seattle P-I on April 11th on Valley Medical printed a table of charitable healthcare spending in Seattle.(http://seattlepi.nwsource.com/local/219605_hospital11.html?searchpagefrom=1&searchdiff=2)

At the bottom of the table, measured as a percentage of charity care of total non-Medicare and Medicaid billing, Virginia Mason comes a woeful last place. My further research revealed that this is just the tip of the iceberg. Looking at Charity care, and even including Medicaid, Virginia Mason's record of providing healthcare to the poor people of Seattle is worse than disgraceful. They are not just the worst in Seattle, they are the worst in the entire state. In 3 of the last 4 years, they have been rock bottom in Washington State. In 2003 they gave about 1/5 of the Puget Sound Average, at 3.5% of Total Revenue. Harborview gave 42.19% and University of Washington 28%. What's more it seems to be a deliberate policy of the current management. In 1994, they gave 7.02%, still way below the average. By 2000, they had managed to slash that to 3.24%, at which point they sunk to 90th out of 90 hospitals in Washington State.

Meanwhile, their revenues rocketed from $374 million to $893 million in the same period. Perhaps this could explain why CEO Dr Gary Kaplan pocketed a cool $902,022 from the hospital, and President J Michael Rona $761,204 according to IRS Form 990. In fact Dr Kaplan gave himself a 40% increase in 2002.


But he must be very busy because a full 152 days after Mrs. McClinton's thoroughly avoidable death, he still hasn't found time to make an offer of settlement to her family.
In fact, VMMC’s lawyer asked the McClinton’s lawyer for an extension of time to respond to the McClinton’s settlement demand and then on the last day of that extended date they offered no money. They merely proposed mediation which is required by Washington law anyway. Hardly the stuff made of good faith. Compare that to Martin Memorial who made an offer the very day the results of the investigation were returned from the laboratory..

Did I forget to mention that Virginia Mason are also being sued by two of their patients for overcharging and for charging for services those patients never had? (http://seattletimes.nwsource.com/html/localnews/2002149490_toenail13m.html)

This morning Robert Caplan called for a ‘Cultural Change’ at Virginia Mason. Might I suggest that this could begin with him, President J Michael Rona and Gary Kaplan resigning from the hospital or being fired by the remaining Board of Directors?

For further information see Carol Ostrom’s article in the Seattle Times (http://seattletimes.nwsource.com/html/localnews/2002242105_virginiamason15m.html)
The leaked letter can be found at www.MaryMcClinton.org.


PS The death of the man who was set on fire prior to his heart operation is now the subject of a police investigation.

Desaree Jackson

Hi,
I am so greatful for sites such as this one. You help to shed light on the darkness of the lives of people who suffer from a mistake that could have and should have been avoided. Death by decimal is a careless mistake, sometimes I feel it may be intentional (my opinion), because if they would pay attention to vials that they are drawing up the meds from this could be totally avoided.

Tomeczek

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