We had seen a newspaper article about a procedure for a condition called pectus excavatum, which Lewis had. It's a congenital condition that is fairly common, you know, 1 in 200 to 1 in 400. children have it. And the sternum doesn't grow straight so the chest has sort of a concave appearance. So it was a cosmetic condition for him. And we had seen this article saying that there was a new...
minimally invasive, very safe procedure to correct it. When he went into the hospital, he was slightly dehydrated. He was not producing urine. And after his surgery, he was prescribed a very low IV drip, something more appropriate for a small child than a 15-year-old boy, certainly not for a 15-year-old boy who was already low on fluids. And we couldn't do anything about it.
could not get those orders changed. Finally a pharmacist rounded and there happened to be a very receptive nurse who was a knowledgeable nurse. Most of them were very young and they were not going to challenge anyone.
But this was an older nurse who really knew what she was doing and she and the pharmacist got the orders changed. For his pain he had an epidural with hydromorphone and the Pivacaine and he had for an adjunct medication, IV, Cotorilac, Toradol, every six hours. The narcotics were up to, you know, very high levels, sort of dangerous levels for somebody who was opiate naive. And then the Cotorilac, which they kept giving, and it seemed to really have no effect on the pain. So he went in for surgery on Thursday.
It was Friday afternoon before we got the fluids regulated. Saturday he was still... you know he was sweating he was itching he was nauseated he didn't eat the whole time he was in the hospital at 6 30 sunday morning which was half an hour after a tordol injection he was suddenly just stricken with this excruciating pain in his upper abdomen you know quite a different place from his chest pain the nurse came running in she was just leaving the shift change and she was quite alarmed And she sort of ran out of the room and then a few minutes later she came bustling back in and said, oh it's nothing it's...
It's just constipation from the narcotics. That was the diagnosis that stuck. Through thick and thin, through every sort of evidence to the contrary, that was the diagnosis he had. Over the course of 30 hours, he continued to deteriorate.
He became septic. He exhibited signs of shock. And dehydration, it was, he was fairly obviously in bad shape and no one, no one did anything. Monday morning came and when they came around to take Lewis's vital signs he had no blood pressure. And there was just the assumption that...
That couldn't be right, because how could a healthy child in for elective blood surgery have no blood pressure? They took his blood pressure 12 times with seven different cuffs and machines. So they tried to take blood, and there wasn't much blood there.
They were trying to squeeze and wring his arm to get some blood out. While they were doing this, he... He looked over at me and he started saying something I couldn't understand because his words were slurred.
And he said, It's going black. And I said, What? And he repeated it with great difficulty. I just stared at him. I mean, I didn't know what to do about somebody saying something like that.
And then suddenly he just arced into cardiac arrest. And his body went at all angles and his eyes were staring. And he was dead. You know, one of the things that people don't talk about because it's so personal, is what happens afterwards. The effect on families.
My daughter's childhood ended that day. She was 10 years old. She lost her parents at the same time as she lost her brother. We had had one of those houses where all the kids came, all the teenagers came. Suddenly, our house was silent.
You know, and that's just part of it. It goes on and on. It echoes through the generations. Every time my daughter reached a milestone, it was a sad milestone. When she turned 18, we all cried because we knew who had not turned 18. I think that one of the big problems with what happened to Lewis was that people were following guidelines and protocols and were not looking at the patient.
All the way through, there was a plan, and the plan did not include a complication. Patients need... their caregivers to look at them as individuals, is the first thing. They need their caregivers to take their symptoms seriously, and they need their caregivers to research the medications that they're on.
It's not just to make assumptions. If someone is exhibiting a symptom, You need to find out the correlation of that symptom with their medications. To me, the overriding problem is just the lack of respect for the power of medications. People really don't, providers don't realize, and patients don't either, just how much harm a medication can do. Pain management is a pervasive issue in medication safety for several reasons.
First and foremost because the pain treatment systems are pretty complex because they have people issues, they have disease issues. We have dispensing and regulatory issues. And first and foremost, we have the patient compliance and people's reluctance to talk about pain and to manage pain well.
So we have a lot of... micro-systems intersecting. When we think about the management of medications in the hospital, it used to be a pharmacy responsibility.
But now the more we look at the medication use process, we have realized that it's more than just pharmacy responsibility. And it should involve all the health care professionals, medical staff, nursing staff, and others involved with the use of medications in the organization. The process starts with the planning phase when we plan on how we're going to address issues related to look-alike, son-alike medications and high-alert medications, followed by the process of selecting medications to add medications to the formulary, how we store medications across the organization, how we prescribe medications, prepare medications, dispense medications, to the administration of medications, monitoring of the effects of the medication, and last but not least, how we we evaluate the whole process to make sure that we identify the risk points of the process and implement mitigating strategies so we can prevent errors from happening.