Their final act of service: Autopsies of fallen soldiers

Colonel Howard Harcke, a U.S. Army pathologist, noticed something peculiar in late 2005. The emergency treatment for a soldier's collapsed lung involves inserting a needle and tube into the chest cavity to relieve pressure and allow the lung to reinflate. But in one case, Colonel Harcke could see from a scan of an autopsied soldier that the tube had been too short to reach the chest cavity. Then he saw another case, and another, and half a dozen more. A collapsed lung can be life-threatening, so proper treatment is essential.

He pulled 100 CT scans of autopsied soldiers from the archives and calculated the average thickness of the chest wall in the American troops. He found that the standard tubing, five centimeters long, was too short for half the soldiers. If the tube were eight centimeters long, it would have been long enough for 99% of them.

The findings were presented to the Army Surgeon General, who ordered in August 2006 that the kits given to combat medics should be changed to include only the longer tubing. This allows for more effective emergency treatment of collapsed lungs.

Advice: Autopsies can teach doctors how to change medical practice to save people's lives. These fallen soldiers had a final act of service to others.

Read another story about the life-saving use of autopsies.

Thanks to Denise Grady for the source article in yesterday's New York Times.

40th Birthday in the Kingdom: A fatal misdiagnosis by an EMT

Gina's story [the names are changed]:
My older sister was 39, almost 40, and lived in Beaufort, South Carolina, on St. Helena's Island. My kids called her Aunt Mell. One day, we had to call for emergency help for her. The firemen came first, then two EMTs (emergency medical technicians).

The emergency medical technicians (EMTs) tried to help her up, but couldn't. At that time, at 5:34 am, her pulse was 126, which was regular; she just needed oxygen. They decided not to treat her until she got up herself. One guy thought she was faking it. With a lack of oxygen, you act a little funny…But they said, If you don't get up, I'm going to call the policeman! They wouldn't let me intervene.

So they didn't treat her for some time – for 18 minutes. I was praying for everything to be all right. I was in shock. She was my big sister, and she depended on me to come through for her. That morning, when she really needed me, I felt so helpless. I tried to help her by letting them help her.

He had his boots on her arm to help her stay down, or whatever.

She went into cardiac arrest. The one EMT guy just flipped out, called her by name, and then he knew she was gone. The EMT guy tried to work on her. "We have no time to waste," he said. They tried to revive her for 15-20 minutes, but I knew she was gone already. So instead of having her 40th birthday party with us, she had it in the Kingdom [of God].

I wanted an autopsy. The nurse said, "We have to do an autopsy; who do you want to take the body? I have to talk to a family member." But they acted like there was a mix-up, like one of my other siblings had told them something different. They went ahead and had a funeral service director pick her up, so there was no autopsy.

But their mistake was in the record anyway, so we were able to find out the truth. Most people thought she had died from an asthma attack, but I saw, and I knew better. I never thought I'd witness a medical team that didn't give help. It was such a nightmare – I thought I was dreaming.

I went through all of this in a deposition with a lawyer. The EMT guy was really mean; he had anger management issues. My attorney picked up on that, and said, He's a very angry man! But nothing happened to that man.

My mom was devastated by this. She spoke at the deposition, and poured her heart out. That brought her peace. She knew the truth, but was in too much pain to talk about it. The stress from all that shortened her life.

I haven't told anyone about this for ten years, until now.

Gina's Advice: If the EMTs don't seem to be helping your family member in an emergency, call 911 again, or call the police. Act right away!

Read another story of a 911 call gone awry.

Thanks to Gina for telling her story over the phone. A fuller account can be found in the October 2004 issue of the Journal of Emergency Medical Services, in Volume 29.

An hour after being discharged from the Emergency Room: A family physician's conflict of interest

Question for the Ethicist:
I am a family physician. A patient I'd not seen in months passed away about an hour after being discharged from an emergency room. Her mother, also my patient, asked me to review the records and autopsy to see if she should bring a malpractice suit against the E.R. physician and the hospital. I am friends with the physician and on the hospital's board. Ought I to comply with this request?
-J.R., Connecticut

Answer:
You should not. Indeed, you cannot – not properly, not without risking charges of bias. Your attachment to your friend and your position on the hospital’s board create – or may seem to create – divided loyalties. You should recuse yourself from this task, explain to the patient's mother why you are doing so and refer her to a disinterested physician with the expertise to review the records and advise her how best to proceed.

Update:
J.R. met with the family but did not offer a medical opinion, explaining that the records offered insufficient information for him to do so. He said he believed that they would not be satisfied unless the matter were investigated further and so suggested they speak to a lawyer who would have a neutral expert review the case.

Read about another ethical issue.

Thanks to Randy Cohen for the source story in the Ethicist column in the New York Times Magazine of May 25.

An hour after being discharged from the Emergency Room: Conflict of interest on a potential malpractice suit

Dr. J.R.'s question:
I am a family physician. A patient I'd not seen in months passed away about an hour after being discharged from an emergency room. Her mother, also my patient, asked me to review the records and autopsy to see if she should bring a malpractice suit against the E.R. physician and the hospital. I am friends with the physician and on the hospital's board. Ought I comply with this request?


Ethicist Randy Cohen's answer:
You should not. Indeed, you cannot – not properly, not without risking charges of bias. Your attachment to your friend and your position on the hospital's board create – or may seem to create – divided loyalties. You should recuse yourself from this task, explain to the patient's mother why you are doing so and refer her to a disinterested physician with the expertise to review the records and advise her how best to proceed.

Update: J.R. met with the family but did not offer a medical opinion, explaining that the records provided insufficient information for him to do so. He said he believed that they would not be satisfied unless the matter were investigated further and so suggested they speak to a lawyer who would have a neutral expert review the case.


Advice to family members considering a lawsuit for a medical error: Consult a doctor or nurse who was not involved.


Thanks to Randy Cohen for the source article in the Ethicist column of the New York Times Magazine of May 25.

We now have a perfect little girl: Rare genetic disorders

Jenny Badner Falcon's story:
I carried two severely deformed, unviable pregnancies that were diagnosed in the second-trimester anatomical sonogram and would have likely led to stillbirth or death soon after birth.

It was only after a second detailed autopsy was performed by a dedicated and caring pathologist at Columbia University that a team of geneticists was able to give us a diagnosis. My husband and I are carriers of an extremely rare genetic disorder. But thanks to the autopsy and the diagnosis, we were able to have our third fetus tested during the first trimester and we now have a perfect little girl.

Advice to couples who have had more than one miscarriage: Jane Brody is correct to emphasize the importance of autopsies in recurrent pregnancy loss.

Read another rare genetic disorder story.

Thanks to Jenny Falcon for her letter to the editor, published in the NY Times of April 9, and to Jane Brody for her article in the Times on April 1.

She was the inspiration for "Hey Mama:" A death after cosmetic surgery

Donda West, mother of hip-hop mogul Kanye West, may have died because of complications from surgery, the Los Angeles County Coroner's office said Monday.

An autopsy may make clear the cause of death. West's publicist, Patricia Green, told CNN earlier Monday that West died after undergoing a cosmetic surgery procedure.

Publicist Jo-Ann Geffen said West contacted the surgeon again two weeks ago to say she was ready to go forward, but the surgeon said he needed a medical clearance before he would perform the surgery.

"I always insist on a medical clearance for women over 40, and in this instance it was particularly important because of a condition she had that I felt could have led to a heart attack," the surgeon said, according to Geffen's statement.

Geffen said she was scheduled to see an internist for the appropriate tests, but never made the appointment.

Donda West was a major influence on her son's life, as the music producer-singer-songwriter has often said -- including in lyrics to some of his songs. She regularly attended her son's concerts, and was at his performance at the MTV Video Music Awards in September.

Earlier this year, she released a book she co-authored called "Raising Kanye: Life Lessons From the Mother of a Hip-Hop Superstar." She retired from her post as professor and chair of the English Department at Chicago State University in 2004 to become her son's manager, according to the Kanye West Foundation Web site. Donda West was the inspiration for the song "Hey Mama."

Advice to those thinking of cosmetic surgery: Be sure to consult your regular doctor first.

Read a very different elective surgery story, or read CNN's source story by Karen Bonsignore, K.J. Matthews and Lola Ogunnaike.

You don't have any questions for the pharmacist, do you?: A fatal methadone overdose

Terry Paul Smith, a 46-year-old roofer, suffered from a disorder of the peripheral nerves (neuropathy) in his back and legs, which kept him in chronic pain. He took Oxycontin and Neurontin, but he disliked the way it made him feel, e.g., making him sometimes "drop out" in the middle of a conversation. After he mentioned the pain meds' side effects, his doctor changed the prescription to methadone, a narcotic pain reliever. The doctor wrote a prescription for Terry to take four 10-milligram pills, twice a day.

Terry filled the prescription at a local Walgreen's pharmacy in Jacksonville, Florida. In handing over the pills, the pharmacy employee asked, "You don’t have any questions for the pharmacist, do you?" They didn’t.

Though Terry didn’t know it, the label on the medication vial was incorrect; it directed him to take four tablets "as needed for chronic pain," and did not mention any limits on the frequency. Terry took the pills for the first time on July 23-24, 2001.

Within 36 hours, he was dead. An autopsy that his widow insisted found toxic levels of methadone in his blood.

The pharmacist had mislabeled the pills as "take as needed" rather than take "twice a day."

Now Terry's widow, Pearl Smith, is pursuing a lawsuit against Walgreen's. Next week, the jury will begin considering the case.

A company spokesman says Walgreen's has spent $1 billion over the last decade on pharmacy safety systems, safety training and technology. Walgreen's filled more than half a billion prescriptions in the last fiscal year.

Advice: Read the doctor's prescription and check it carefully against the label, especially for a new medicine.

Read an informed consent story, or read more from the source article by Kevin McCoy in the USA Today of Nov. 2.

“Just a little sunbeam, very sweet”: Flu vaccine

Nichole Lang-Veru, a fourth-grader at Dale Mabry Elementary School in Tampa, Florida, died Dec. 27 after she became ill. An autopsy confirmed her death was flu-related, the Medical Examiner said. Doctors said Lang-Veru's death should serve as a warning to parents because the girl seemed to be healthy. "She was somewhat shy, very quiet, very respectful," said an adult classroom volunteer. "Just a little sunbeam, very sweet."

This isn’t a story about medical error, but since I have a daughter, it strikes close to home.

Advice to parents: Get your family vaccinated to protect them from the flu—it’s not too late.

Read another story of how parents can prevent tragedies, or read the newspaper story about Nichole by Abbie VanSickle or the story in Florida Today.

Our Hero: She Didn't Sue, Part 2: A drug error

Yesterday I described John Eric Kauffman's experience in taking Zyprexa. His mother, Millie Beik, is educating others about the dangers of Zyprexa, in the front-page article in the New York Times. By telling her story, she warns, teaches, and empowers others.

She performed another unusual and vital step: she asked for an autopsy. The doctor who performed it discovered that her son had died from an irregular heartbeat, which the autopsy report said had probably been caused by an enlarged heart caused by his high blood pressure. His high blood pressure had begun during his years on Zyprexa, when he had gained 100 pounds.

Autopsies are rarely performed nowadays, though doctors acknowledge that they provide critical and unique knowledge. They help doctors learn so they will not repeat the same mistakes. Personally, I greatly regret that we did not conduct an autopsy of a family member who almost certainly died from a surgical error.

Advice to family members and friends: If you suspect a death is due to a medical error, gently ask the surviving relative whether they would consider an autopsy, in the interest of saving someone else's life. If they say Yes, help make it happen.