CodeBlueBlog: CSI MEDBLOGS: QUESTIONS AND THEORIES: THE MYSTERY OF MARY MCCLINTON'S DEATH DEEPENS

April 2005

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On November 4th, 2004, Mary McClinton was placed on the procedure table in the radiology department of Virginia Mason Medical Center (VMMC) in Seattle, for the nonsurgical treatment of a cerebral aneurysm. This is a recognized procedure (info here) with a good safety profile.

Who, What, When, Where, and How?

Something went wrong during the procedure and two and a half weeks later, Ms. McClinton was dead. According to many published accounts:

At the end of Mary McClinton's recent operation, a technician was supposed to inject a harmless marker dye used for X-rays into a leg artery. Instead, the syringe was filled with chlorhexidine, a toxic antiseptic used to clean the skin

CodeBlueBlog has previously raised questions regarding the proposed chronolgy of this mishap (here and here). Two additional physicians have added to the comment sections of these posts, raising further issues.

Here are the questions:

1. Why was the leg artery injected at the end of a brain procedure?

2. Why was a technologist performing the injection?

3. Was a mechanical injector used or was this a hand injection (a "syringe filled with chlorhexidine" implies a hand injection).

4. How much chlorhexidine was injected?

5. Is it being proposed that the chlorhexidine was directly responsible for all the damage that ensued (including reported kidney failure and a cerebral infarction), or was the leg primarily damaged with the remaining problems resulting as complications of leg necrosis, compartment syndrome, gangrene and the ensuing medical and surgical interventions?

These Puzzle Pieces Don't Interlock

According to the Journal of Toxicology, the lowest possible lethal intravenous dose of chlorhexidine is 13mg/kg. If Ms. McClinton were approximately 60kg and the chlorhexidine disinfectant solutions generally available range in concentration from 0.5% to 2.0%, it is hard to imagine a volume less than 50cc causing death.

Besides, The Journal states the organ of injury as the lung with pulmonary toxicity and pulmonary edema developing. This was not mentioned as a complication in Ms. McClinton's case; however, there are, presumably, different sequelae between intravenous and intraarterial administration. There just isn't any literature on arterial misadministrations.

The hospital reports that a technologist injected the chlorhexidine, drawing it from a bowl on the procedures table. The largest hand injections done this way are usually no more than 10-20cc. In addition, since patients are awake during these procedures, I would imagine that the pain induced upon injecting this substance into Ms. McClinton's leg would have ellicited a scream of pain. It is therefore doubly difficult to imagine that a large amount of this substance was pushed through a syringe into her femoral artery.

So we have an off-procedure event (injecting the femoral artery during a cerebral angiogram), puportedly done by a technologist (is that standard at VMMC?), using an amount of material that would seem not voluminous enough to be the primary and direct cause of all the damage ascribed (leg necrosis, kidney failure, cerebral infarct) and then leading to a protracted death, drawn out over 21/2 weeks. The hospital's own memo calls the chlorhexidine "highly toxic" and they make the effects of this injection seem quite severe and systemic. By the words of spokesman Dr. Caplan:

The cleansing solution basically acted as a poison, which caused widespread damage to the organs of her body

Well, if this were such a toxic poison, and the effects of it's injection were so catastrophic and widespread -- why did it take her 2 1/2 weeks to die?

For Once, I Hope I am Wrong

I believe that the catheter or sheath (a tube that holds the catheter in the groin/femoral artery) was injected with a small-to-moderate amount of chlorhexidine disinfectant preparation. Of note, most chlorhexidine preparations that I could find were based in alcohol. Alcohol is a potent sclerosing agent -- in fact we used to occasionally use alcohol to sclerose renal cysts.

It is more likely that the combination of chlorhexidine and alcohol caused obliteration of the vascular supply to Ms. McClinton's lower extremity. She then could have developed a severe, unretractable compartment syndrome (a pdf on it here) with ensuing gangrene necessitating an amputation. Her death, therefore, from systemic complications surrounding this event, would NOT be due to the chlorhexidine injection per se; rather, it would be secondary to the complications of lower extremity gangrene, the treatments required for this condition, as well as the timeliness and appropriateness of those treatments.

This raises a new large set of questions for VMMC regarding their treatment of Ms. McClinton following the damage done to her leg. I will not speculate here without giving the hospital a chance to reply.

I sincerely hope my scenario is untrue. Because if it IS true, then VMMC's whole act of contrition is called into question as well as the type, nature, and timeliness of Mary McClinton's care after the misadministration.

I think the hospital needs to release another memo. This time to the public. There's explaining to do.

We'll wait to see if we hear from the VMMC.

Stay Tuned.

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health care also health·care (hlthkâr) n. :efforts made to maintain or restore health especially by trained and licensed professionals -- usually hyphenated when used attributively

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