[Editor’s note: This article first appeared in The Doctor Weighs In. The team at Physician-Patient Alliance for Health & Safety thank Pat for her tremendous courage and working with us on this tragic story of what happened to her husband. We hope that in this retelling, hospitals will be encouraged to ensure that similar events become “never events”.]
By Patricia LaChance
After undergoing what most people would consider a routine surgery, my husband John, died. Just as heartbreaking as John’s passing was to me is the fact that his death was entirely preventable.
John died because his medical history was ignored and because he was not properly monitored after he was placed on a strong narcotic to ease the pain from his surgery to repair a torn rotator cuff in his shoulder.
That is the simple version of John’s story, but of course, there’s much more to it than that. Since he left us in March of 2007, I have come to learn a lot about what caused his death, and I want to share my experience so that other families, nurses, doctors and hospitals can prevent what happened to him.
John suffered from sleep apnea, which John and I thought at the time was merely a sleep issue. We had no idea it could also be a fatal issue.
John underwent two surgeries. His first was a same day surgery. After this first procedure, he experienced a great deal of trouble recovering from the anesthesia. He struggled for hours to wake up enough to be able to leave the hospital. He was very groggy, nauseated and dizzy.
During the months that followed, he struggled with similar side effects from several narcotics that were prescribed for his pain management. He had two severe episodes at work – one he was able to sleep off at home; the other required an ambulance ride to the emergency room.
Six months later, John’s shoulder injury required a second repair. Immediately following this second surgery, John — like millions of Americans who undergo surgery — was placed on patient-controlled analgesia (PCA), commonly known as a “pain pump” that intravenously delivered opioid medication to help him manage his pain. We were familiar with PCA, but unaware of the dangers associated with it.
Prior to and following John’s second shoulder surgery, I discussed his opioid-intolerance and sleep apnea with all of his caregivers, but he was nevertheless placed on PCA. Once again, his body rejected the medication and became extremely ill.
Observing John’s discomfort, a nurse disconnected him from the PCA pump and directly administered Dylaudid, a stronger opioid. With the removal of the PCA pump, the Pulse Oximetry and supplemental oxygen were also removed. Within minutes, he seemed to be comfortable – comfortable to the point that he did not move or speak to me again – he just stared at the ceiling. I was concerned about his condition, but the nurse was not.
Thinking John was finally going to get some much needed rest at the end of a trying day, I kissed him on the forehead, told him that I loved him, and promised to return first thing in the morning to take him home.
But that isn’t what happened. In the early hours of the morning, John passed away.
With all my heart, I wish I had known that night what I have come to understand today: Patients receiving opioids after surgery – especially those with sleep apnea – are at very real risk of fatal respiratory depression.
That’s exactly what happened with John. He fell into a deep sleep, and was not able to awake. Because he was not monitored, his caregivers had no idea that he was in trouble.
This did not need to happen. If the hospital had used technology such as capnography and pulse oximetry to continually monitor John’s respiratory status, he would still be with me today.
John meant the world to me, our children and his family, and many friends. Together, we sincerely hope that other families never have to go through what we did. For that to happen, I strongly believe that there are two critical patient safety issues that our nation’s hospitals must immediately address:
- In far too many instances, post-surgical patients are placed on opioid therapy with little or no consideration given to their medical histories, especially as they relate to medication tolerance. When I recently spoke to the Maryland Association of Nurse Anesthetists, one of the points I made was that each individual patient needs to be assessed for medication intolerance. Not all patients can tolerate the same medications. Yet, my observation is that far too often, opioids are automatically the medication of choice, and the patient’s medical history is not taken into consideration. My husband is a prime example.
- Continuous monitoring of all post-surgical patients receiving opioids should be a national standard of care. Recently, the Centers for Medicaid Centers for Medicare & Medicaid Services (CMS) issued guidance recommending that patients receiving opioids after surgery should be continuously monitored for signs of respiratory depression.
The CMS guidance perhaps summarizes this best when it states:
Each year, serious adverse events, including fatalities, associated with the use of IV opioid medications occur in hospitals. Opioid-induced respiratory depression has resulted in patient deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoring of the patient’s respiration rate, oxygen and sedation levels. Hospital patients on IV opioids may be placed in units where vital signs and other monitoring typically is not performed as frequently as in post-anesthesia recovery or intensive care units, increasing the risk that patients may develop respiratory compromise that is not immediately recognized and treated.