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The day Joy died

Article

When my patient died needlessly, part of me died, too.

It'll soon be the anniversary of my OB patient's death. Twenty years ago, I stood in the ICU, holding her limp hand. Her name, in stark contrast to her present condition, was Joy. Her mother was the only other person in the room.

The patient was brain dead, the result of an anesthesia catastrophe. In preparing her for her C-section, the nurse anesthetist had accidentally intubated the esophagus and failed to put a pulse oximeter alarm on her. She became severely anoxic during the operation, went into V fib, and was shocked back to sinus rhythm. The airway was corrected by an anesthesiologist who responded to the code, but it was far too late.

The patient was a beautiful, healthy 21-year old. She was well known locally as a singer. She and her husband had family all over the area. She came to me for her OB care because her mother had told her, "Go to Dr. Brandeland, he's always been so kind and polite when he gets his messages." Her mom worked at the telephone answering service I used.

Facing the family without any help

Everyone who'd been involved left the hospital. I looked out the window, and saw nurses who had been in the OR literally running to their cars to escape the horror of what had just happened. The senior OB who had performed the C-section disappeared. I was just the first assistant.

The family had been expecting to hear happy news. Instead, I had to tell them there'd been an accident. I answered some preliminary questions and agreed to meet with the family in a few hours so that all of them could be present.

Not surprisingly, no one from the hospital administration, the nursing staff, or the medical staff including the operating OB, wanted to join me. I was told by several people, "You're the family doctor, it's best if you speak to them." I walked in alone.

It was a regular-size conference room, standing room only, holding about 35 relatives. I gave a complete description using the chalkboard to illustrate. Without oxygen for that long, I could predict a grim outcome for the patient and her baby, who was now on the way to a hospital that specialized in neonatal care. I assumed my career was over and I thought that her five older brothers would probably kill me or at least beat me severely. I wasn't afraid. I was too numb to care and, subconsciously, probably hoped they would.

After a profound silence, there were questions; I stayed until the last one was answered. The meeting had started with soft-spoken voices; they gradually became heated, but to my surprise, remained nonviolent. I was so pathetically outnumbered, I think they took pity on me.

Initially, the patient still showed some brain activity on EEG. When I saw her CT scan, her brain was immensely swollen. After seven days, the consulting neurologist told me, "Take her off the ventilator." I unplugged the vent, and there weren't any spontaneous respirations. It took seven and a half minutes until she flat-lined. At that point, all I could say was, "It's over." I gave her mother a hug, asked if there was anything I could do, wrote a note in the chart, and left the hospital. I was in some kind of emotional shock.

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© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health