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Lewis Blackman, a
healthy, gifted 15-year-old, underwent
elective surgery at MUSC. In one of
the state's most
modern hospitals, he bled to death over 30 hours while those caring for
him missed signs that he was in grave peril.
Lewis
Blackman, a healthy, gifted 15-year-old, underwent
elective surgery at MUSC. In one of
the state's most
modern hospitals, he bled to death over 30 hours while those caring for
him missed signs that he was in grave peril.
How a
hospital failed a boy who didn't have to die
By JOHN MONK Staff Writer
Nothing indicated
15-year-old Lewis Wardlaw Blackman of Columbia had
four days to live when he entered the Medical University of
South
Carolina Children's Hospital in Charleston.
Without knowing
it, Lewis entered a little-known medical world where
doctors, nurses and hospitals make mistakes that kill people.
That day,
Thursday, Nov. 2, 2000, Lewis had the brightest of futures.
The weekend
before, Lewis' parents - Helen Haskell, 49, and LaBarre
"Bar" Blackman, 52 - had taken him and his sister, Eliza, 10, to North
Carolina. There, Lewis saw Duke University, which his parents had
attended.
Lewis was on
track to sail into Duke, one of the nation's hardest schools
to get into. He excelled in math, science, history and English. As a
seventh-grader,
he made the highest score in Richland County on a highly competitive
Duke
standardized test.
Ten days before
he entered MUSC, he took the preliminary college board
exam at his school, Hammond. After Lewis died, his parents learned he
had
scored the highest of any ninth-grader at the private school.
SPRITES
AND GOBLINS
"Lewis was truly
the most gifted student I've ever had - not that I
haven't had others. In second grade, he wrote a story of a butterfly
and
drew this amazing picture of a butterfly, with all the parts. The book
won first place in the school district visual literacy contest. He was
such a good all-around kid, too. I know he would have done something
great
with his life. Whenever I see a butterfly, I think of Lewis."
- Nancy Jarema,
teacher at A.C. Moore Elementary School for 27 years.
She taught Lewis in the second and fifth grades.
Lewis had a
"spark," says his mother, Helen Haskell.
At age 7, he was
chosen - out of hundreds of children - to be in a Sun-Drop
soda television commercial with NASCAR great Dale Earnhardt.
Ten months before
he died, Lewis played the mischievous boy Mamillius
in the S.C. Shakespeare Company's Finlay Park production of "The
Winter's
Tale."
In the play,
Mamillius says: "A sad tale's best for winter: I have one
of sprites and goblins."
A local reviewer
wrote Lewis was "wonderful. . . . This young performer
should go far."
In sixth grade at
Hand Middle School, Lewis' teacher Caren Hazelwood
told the students about a Columbia man who was trying to ban a book -
"Mick
Harte Was Here" - that the students loved. Lewis and his class wrote
letters
to the newspaper. The State published an excerpt from his letter.
"He who destroys
a good book, kills reason itself," wrote Lewis, quoting
17th-century poet John Milton.
'LIKE
GETTING BRACES'
"Lewis carried
mirth around with him. He had this little light in his
eyes, and he was very, very quick. As a teacher, I just wanted to work
harder for him. When he died, my students and I were terribly upset.
One
girl didn't recover for months."
- Jeanette Arvay,
Lewis' voice teacher, now at Dreher High School
Lewis was born
with a condition called pectus excavatum. It means a
crease in the chest cavity. About one in 500 people has it.
For years,
medicine believed the defect was cosmetic. But recent studies
have suggested it can cause respiratory problems if not corrected.
For years, Lewis'
parents debated having an operation to correct the
defect. But they decided it was too dangerous. The standard operation
took
as long as five hours. The whole chest was opened, and ribs and
cartilage
taken out. Then, a metal strut was put into the chest.
In 1999, Lewis'
parents saw an article about a new operation at MUSC
that supposedly was safer and quicker. In this operation, a metal bar
is
inserted through small incisions to prop up the breastbone.
The article,
first published in The (Charleston) Post and Courier and
reprinted in The State, was glowing. It described "a revolutionary type
of surgery at the Medical University of South Carolina" for patients
like
Lewis.
The article
quoted MUSC's Dr. Andre Hebra as saying he performed the
surgery in an hour through two small incisions. His patient would be
playing
basketball and swimming "in a month or two," Hebra said.
Helen and LaBarre
discussed the procedure with Lewis and with their
Columbia doctor. They contacted MUSC doctors.
Everyone agreed
it was a good idea - and safe. Helen said she and her
husband were comforted by MUSC's reputation as the state's oldest and
largest
medical school.
"We thought it
was like getting braces," Helen said.
THURSDAY,
NOV. 2, THE FIRST DAY
"Lewis was really
funny. He would even make jokes about his chest -
that he could eat cereal out of it. He was also more mature. In seventh
grade, when we were all telling fart jokes, he was making fun of
political
things. One of his favorite songs was 'Typical Situation' from the Dave
Matthews Band. He said, no matter what mood he was in, that would make
him feel better. I think about him a lot."
- Michael Hood,
15, one of Lewis' best friends, now a junior at Dreher
High; the song "Typical Situation" is about protesting and accepting
life's
injustices
Lewis and his
family arrive at the hospital at 6 a.m. The night before,
the family - Helen, LaBarre, Lewis and sister Eliza - had driven to
Charleston.
Lewis chose where they ate, Poogan's Porch, a restaurant known for its
Lowcountry dishes.
Lewis brings the
book "Dune," the play "Julius Caesar" and a book on
the Israeli spy agency, the Mossaad.
He also has his
proudest possession: his new learner's permit to drive.
Since his 15th birthday, Sept. 6, he's taken it everywhere.
The operation is
set for 7:30 a.m.
Before the
surgery, Helen recalls, the nurses ask Lewis for his weight,
instead of actually weighing him.
That bothers
Helen, who's not a nurse. An archaeologist by training,
she nonetheless knows if drugs are to be administered, weight helps
determine
dosage.
"I insisted they
weigh him," she recalls.
The surgery is
supposed to last 45 minutes. It goes 2½ hours.
When lead surgeon
Dr. Edward Tagge emerges, he says he had to reposition
the metal bar in Lewis' chest four times to get it right. All in all,
he
says, Lewis did fine.
Lewis wakes in
the recovery room. He tells doctors that his pain is
about a "three" on a 1-10 scale.
At that time,
nurses and doctors note in Lewis' record that he isn't
producing urine.
This is crucial
because, after the operation, Lewis is given Toradol,
a powerful painkiller to soften his chest pain. Good urine flow helps
dilute
Toradol's side effects.
The Physicians
Desk Reference gives clear warnings about the drug's
side effects. Risks include perforated ulcers and internal bleeding. It
says Toradol's use should be monitored. Roche, Toradol's maker, also
notes
the drug's "administration carries many risks."
Doctors routinely
give medicines that carry risks. Usually, risks are
monitored.
One of the
failures in Lewis' case is that after the doctors prescribed
Toradol - with its clearly stated deadly risks - no one notices Lewis
is
having a fatal set of reactions, according to his medical record.
Lewis is taken to
Room 749 in the children's cancer ward. There's no
room in the surgery ward.
FRIDAY
AND SATURDAY, THE SECOND AND THIRD DAYS
"The things Lewis
said! Like, he had a 10-minute Santa Claus joke. ‘.‘.‘.
He could memorize things like anything. ‘.‘.‘. We had conversations
that
mesmerized me, talking about, 'What if the evil monkeys are still
here?'
after watching a television show that had evil monkeys coming from
alternate
dimensions. Six months after Lewis died, I fell asleep in class and
woke
up thinking he
was alive. Then I went, 'Oh, no.'"
- Alex Crawford,
16, one of Lewis' best friends, now a junior at Dreher
High
On Friday night,
Dr. Tagge, who operated on Lewis, leaves for the weekend.
At 9 a.m.
Saturday, surgeon Dr. Andre Hebra checks on Lewis.
"No evidence of
infection. Clear lungs," Hebra writes in Lewis' medical
record. "May sit up and consider getting out of bed."
Hebra is the last
veteran doctor to see Lewis for two days.
Instead, Lewis'
doctors will be apprentice doctors, called residents.
A resident has a physician's license but, because of limited
experience,
must work under a veteran doctor's supervision.
Saturday night,
Lewis begins to run a slight fever. His feet are cold
to the touch. He is still on Toradol, taking it by intravenous line.
SUNDAY,
THE FOURTH DAY
"On field trips,
Lewis would be one of the kids to point out a spider.
He would pick up on things other kids might miss or I might miss. He
and
his Writing Spider T-shirt helped inspire our school's writing
excellence
program. Every class had a spider's web with writings on it. Lewis was
a great kid, very promising, and I often think, 'What if?' I'll never
forget
him."
- Darrell Weston,
retired science teacher, Hand Middle School
At 6:30 a.m., a
half-hour after another Toradol injection, Lewis gasps.
He has horrible pain in his upper abdomen.
"It's the worst
pain imaginable," Lewis says to his mother.
Helen summons the
nurse, who wants to know how intense the pain is.
Lewis says his
pain is "five on a scale of five."
He speaks in
wonder, almost as if amazed that a human pain could be
so bad, Helen recalls later.
That is the first
indication the Toradol is eating a hole in Lewis'
intestinal area. When this happens, blood and toxic material can leak
into
the abdominal cavity, a sterile place where some of the body's most
vital
organs are located. Toxic leakage and blood can kill.
Ordinarily,
Lewis' pain would be an indication to call a full-fledged,
veteran doctor, known as an "attending physician" or "attending," for
short,
said a medical expert who examined Lewis' case later.
Lewis is three
days out of surgery and should be getting better. And
this pain is in his stomach area - not in his chest, where he had the
operation.
The nurse tells
Lewis and Helen the pain is gas. "There's nothing I
can do for gas pain," she says, Helen recalls later.
In nurses' notes
that morning, a nurse writes, "gas pains ‘.‘.‘. pt.
(patient) needs to move around."
Another nurse
suggests a bath. She and Helen put Lewis in the tub and
sponge him off.
"Afterward, he
sits in the chair for a few minutes. This is a tremendous
expenditure of energy for him. He seems to be getting weaker and
weaker,"
Helen writes later in a diary that reconstructs Lewis' death.
Nurses insist
Helen walk Lewis. Lewis says his pain is getting worse.
Over Lewis'
feeble protests, mother and son lap the ward.
SUNDAY
AFTERNOON
"We didn't insist
Lewis have this surgery. It was his decision, but
he did it because he knew we thought it was a good idea. He was scared
to death to have surgery, and in that he was wiser than we were. When I
think of the four of us tooling down the highway to our doom, the day
after
Halloween, I just weep. When I unpacked the car days later, after it
was
all over, I found it full of candy wrappers and drink boxes and CDs.
Just
like a family vacation. Just like always. Except Lewis never came
home."
- Helen, Lewis'
mother
Lewis' belly
grows hard and distended, a sign of a possible intestinal
perforation and internal leakage.
His temperature
drops, his skin grows pale and he drips with a constant
cold sweat. His eyes are sunken. He's exhausted, in great pain.
All are signs of
what is called "acute abdomen" - a collection of potentially
life-threatening symptoms. Experts say that veteran doctors know to act
on seeing these symptoms. They assume the worst, acting quickly to
check
out a lethal condition - to rule it out, if nothing else.
Helen calls the
nurse a number of times.
"She seems
convinced that Lewis is simply lazy and not walking enough
to dissipate his 'gas pain,'" Helen writes in her diary.
Outside the room,
other nurses decorate the ward.
As Lewis grips
her hand in pain, "I could hear the nurses chattering
and laughing in the break room," Helen says later.
During Sunday,
Helen repeatedly asks for a doctor. By that, she means
a veteran doctor.
Instead, Helen
gets a beginning resident. She will later learn the resident
is four months out of osteopath college. Osteopaths are specialists in
bones and muscles.
As Helen repeats
her request, a nurse argues with her - offended Helen
doesn't consider the resident a real doctor.
The resident too
is upset at Helen's insistence on a veteran physician.
"She also is offended, and appears extremely downcast that I have
questioned
her judgment. ‘.‘.‘. I reiterate Lewis' alarming symptoms once again:
the
pallor, the dark circles, the cold sweat, the unremitting abdominal
pain,"
Helen writes later in her dairy.
"She stands at
the computer and nods glumly, but never says a word.
My impression is that she is too angry to speak.
"Somewhere along
the line, my request for an attending physician has
been quietly shelved. I do not know who made this decision."
At 6:26 p.m.,
Helen's insistence is such that a nurse writes in Lewis'
record: "Parent requesting upper level M.D."
At 8 p.m. Sunday,
the chief resident, Dr. Craig Murray, comes to Lewis'
room. A chief resident has more seniority than other residents but
still
is under the supervision of a veteran doctor.
Helen believes
Murray is the veteran doctor she has been waiting for.
If Murray has identification on him to the contrary, she misses it.
Murray checks
Lewis. He writes in the record: "probable ileus." That
means: blocked intestine.
Murray orders a
suppository to ease the supposed blockage.
Murray also
writes that Lewis' heart rate is in the 80s, slightly above
normal but no cause for alarm.
However, at the
same time, a nurse notes in the record that Lewis' heart
is beating 126 times a minute - another sign something may be horribly
wrong. The nurse also records Murray has been made aware of Lewis'
sweating.
Murray has a
confident manner, Helen recalls. He says Lewis' sweating
and lowered temperature - 97.7 degrees, almost a full degree below
normal
- are "side effects" of the medicine because Lewis is so young.
Later Sunday
night, with Lewis' pain still enormous, Helen begins a
vigil. She stops trying to get a doctor. After all, the confident
Murray
came by. She believed he was a veteran physician.
"Neither Lewis or
I sleep at all Sunday night. I have given up on the
weekend staff and am waiting for morning when the regular staff and
doctors
will arrive."
That night,
Lewis' heart rate rockets. At midnight, it is 142 beats
per minute and his temperature is 95 degrees. At 4 a.m., his heart rate
is 140 and his temperature is 96.6.
MONDAY,
THE FIFTH DAY
"Lewis knew about
all kinds of things. If you introduced something to
the class, he wanted to tell all he knew about it, but he wasn't
obnoxious.
He was hungry to share his knowledge. In later years, even when he was
older, he would never forget to come by and give me a hug."
- Loraine
Lambert, Lewis' first-grade teacher at A.C. Moore Elementary
School
More residents
keep dropping by.
Sometime Monday
morning, Lewis' gut pain suddenly stops.
In cases like
Lewis', veteran doctors know sudden loss of pain can mean
impending death.
However, in
reaction to Lewis' loss of pain, a nurse says, "Oh, good,"
Helen writes later.
When Helen asks a
resident about Lewis' pale color - his lips are the
same shade as his skin - she recalls the resident says cheerily, "Oh,
that's
just that low blood pressure. It pulls the blood away from the
capillaries
to protect the vital organs."
An aide takes
Lewis' vital signs. She can't find any blood pressure.
>From 8:30
to about 10:15 a.m., Lewis' record reflects, others try and
fail to detect a blood pressure.
Lewis is bleeding
to death internally.
Instead of
summoning a veteran doctor, residents and nurses believe
the blood pressure devices are broken. They try various devices,
according
to Lewis' medical record.
Nurses' notes
say, "Unable to obtain B.P. (blood pressure). ‘.‘.‘. B.P.
attempts on arms and legs unsuccessful."
Helen recalls,
"The focus is entirely on the equipment. For two hours,
aides try blood pressure cuff after cuff with no result. They try to
take
his blood pressure about 12 times."
Nurses' notes
record Lewis' vital signs. At 8:30 a.m., his temperature
is 96.7 - almost two degrees below normal. At 10:45 a.m., his heart
rate
is 155 beats per minute - almost twice as fast as normal. Lewis' heart
is pumping so fast because he has lost so much blood internally; his
heart
is trying its best to pump what little blood is left.
Still, no one
calls a veteran doctor, according to Lewis' medical records.
About noon, two
technicians arrive to take a sample of Lewis' blood
for tests. They get just a small sample.
"Lewis is deathly
pale," Helen wrote. "As they take his blood, his speech
becomes slurred. He is trying to say something I can't understand. He
says
it again, very carefully and with great difficulty: 'Ish ... going ...
black.' "
It's going black.
Helen calls for
help. She thinks Lewis has had a seizure.
"Dr. Murray calls
loudly, 'Lewis! Lewis!' He stands there for two minutes,
then asks the parents and Eliza to leave the room," Helen writes later.
At that point, 30
hours after Lewis has shown signs of a potentially
fatal condition, hospital staff springs into action. Somebody issues a
full alert - a code. Surgeons rush in.
"We stand in the
hall in disbelief, watching this scene from a bad TV
movie. ... A pastor appears. I turn away in horror. He says, 'Don't
worry.
I come to all the codes,'" Helen writes.
Inside the room,
doctors - this time, veteran doctors - work on Lewis.
They do cardiopulmonary resuscitation. They shock his heart with
electrical
machines. They hook up intravenous lines, according to Lewis' medical
records.
They work for 60
minutes.
Doctors
officially record Lewis' death at 1:23 p.m. Monday - 31 hours
after Lewis first said he was having horrible stomach pains.
At 2 p.m., Dr.
William Adamson, the lead doctor during the attempt to
save Lewis, writes in the record, "It is unclear why the patient
expired
at this time. We will pursue an autopsy."
"Someone comes to
get us," Helen writes in her diary later. "The doctors
want to talk to us. I am fearful they will tell us Lewis is
brain-damaged.
When we go into the room, there are five surgeons in green scrubs. One
introduces himself as Dr. Adamson. He is the doctor on call. We have
never
seen him before. Dr. Adamson says, 'We lost him.'
"This makes no
sense to me. He is speaking as though Lewis has lost
a battle with a long illness. He has to repeat it several times before
I understand. They say they have no idea what happened. "
Lewis' death is a
mystery, Adamson tells Helen and LaBarre. Chief resident
Murray found nothing wrong the night before, Adamson says.
Helen now
realizes that, despite her repeated requests Sunday for a
veteran doctor, the hospital sent a resident, Murray.
Adamson asks
Helen for permission to do an autopsy.
She says, "No."
Without knowing how, she feels the hospital killed Lewis.
The only thing she can think, she later recalls, is: They aren't going
to hurt my son any more.
Within hours,
Helen gets advice from relatives and friends with medical
backgrounds: Get an autopsy. She requests one.
The autopsy says
Lewis bled to death internally because of a perforated
ulcer. It shows his abdomen was filled with almost three liters of
blood
and digestive fluid.
A child Lewis'
size has 4 to 5 liters of blood. This means Lewis lost
most of his blood supply into his abdomen.
After the
autopsy, Dr. Tagge calls Helen to tell her of Lewis' perforated
ulcer and internal bleeding, Helen says.
A month later,
when Helen meets Tagge to discuss the autopsy, she tells
him how she had tried Sunday to summon a veteran doctor. He apologizes.
He says the residents should have called him, she says.
Later, medical
experts tell Helen that an experienced doctor, seeing
Lewis Sunday, would have known to order routine blood tests that would
have uncovered the problem.
Lewis should be
alive, the experts tell Helen.
'IT'S
HARD TO KILL A HEALTHY 15-YEAR-OLD'
"Lewis was always
laughing. From the time he was a tiny baby, we have
picture after picture of him exploding into peals of laughter. ‘.‘.‘. I
think the thing that so many people found shocking was that this could
happen to someone who was so full of life. He just brimmed with energy.
What they don't know - but I do - is how casual it all was. It was the
easiest thing in the world. They just filled him with toxic chemicals
and
let him die."
- Helen, Lewis'
mother
MUSC sent Helen
and LaBarre literature on how to go through the grieving
process.
Helen knew that
suing MUSC wouldn't bring Lewis back. But she felt she
had to do something. She looked for a lawyer.
She found Richard
Gergel, a Columbia lawyer who specializes in medical
negligence cases.
To Gergel, Lewis'
case was a clear case of "wrongful death." That's
the legal term for the death of a person caused by the negligence of
another.
Gergel had
medical experts study Lewis' records. Those records include
more than 100 pages of doctors', residents' and nurses' notes, made on
an almost hourly basis, as well as charts and the autopsy. Gergel said
the experts concluded that the medical residents and nurses should have
summoned a veteran doctor or - at the least - honored Helen's repeated
requests to call a veteran doctor.
"This is about a
boy who bled to death over 30 hours in a hospital with
modern technology and vast technical resources," said Gergel. "Our
experts'
main point was that Lewis wasn't properly monitored."
With Lewis'
symptoms, a veteran doctor would have known to order a routine
blood test - called a CBC - that probably would have shown Lewis was
bleeding
internally, Gergel said.
"The test costs
about $30," said Gergel. "Our experts couldn't understand
why it wasn't ordered. It's one of the most common tests in hospitals."
Gergel contacted
the hospital's insurer. Negotiations began.
Helen also sent
Lewis' medical record to an old friend, Dr. Gregg Korbon,
a veteran anesthesiologist and former assistant professor at both the
Duke
and University of Virginia medical schools. Korbon has participated in
thousands of operations, taught hundreds of medical students.
Korbon said he
was appalled by what he saw. "Even a Boy Scout could
have done better."
Lewis probably
could have been saved up through Monday morning, Korbon
said. "It's hard to kill a healthy 15-year-old."
Eleven months
after Lewis died, and without a lawsuit being filed, MUSC's
insurer paid Lewis' estate $950,000. That's almost the $1.2 million
maximum
a state-operated hospital can pay under S.C. law that limits payouts.
Lewis' parents
say the money will go for scholarships and to work for
better patient safety. They are setting up a foundation.
"It's public
money," said Helen. "This is money we want to give back
to the state of South Carolina. It's Lewis' legacy."
In settlement
documents, Helen laid out her claim:
"Petitioner
‘.‘.‘. asserts that MUSC was negligent in failing to properly
prescribe and monitor the use of Toradol, monitor, assess and treat
postoperative
complications, provide adequate, experienced attending physicians to
monitor
assess and treat Lewis, and conduct a timely and appropriate
resuscitation
effort."
'OUR
SYSTEM BROKE DOWN'
"Lewis was just
one of those boys who would have made a real difference
in the world. He had this particular combination of intelligence and
enthusiasm
and essential goodness. People loved him."
- Mary Jeffcoat,
Lewis' longtime drama teacher
Since Lewis'
death, Helen has been to MUSC three times at her request
to speak with doctors and administrators. She wanted to speak to them
about
the dangers of Toradol and her perception that MUSC put too much
responsibility
on
inexperienced residents.
Helen also wanted
to speak to the medical residents about how Lewis
died.
The hospital
denied that request. However, MUSC said it has instituted
patient safety reforms since Lewis' death.
Nurses and
residents now must call a full-fledged doctor if a family
or patient requests it. Patients also will be given manuals explaining
their rights. The manual will have a phone number of the lead doctor on
their case.
Joe Good, MUSC's
general counsel, said he personally was shaken by Lewis'
case.
"Our system broke
down," said Good. "It shook this place to the core.
And, God knows, I hope we never see that again. ‘.‘.‘. This is the most
tragic case I can recall in my 16 years here. ‘.‘.‘. We've got to do
better."
Dr. Murray did
not return phone calls.
Dr. Tagge keeps a
picture of Lewis on his desk at MUSC.
"I can look
directly at him every day," he said. "I don't want his death
to have happened in vain."
In hundreds of
operations that he's performed over his 11 years at MUSC,
Lewis is the only child to have died unexpectedly, Tagge said.
Children's
Hospital doctors and nurses were - and are - devastated by
Lewis' death, he said. "It really sucks the life out of you."
Lewis' death has
brought changes, he said.
The children's
surgery unit has trimmed its use of Toradol. It also
now utilizes a pre-surgical procedure that cuts down on intestinal
blockages
after operations. Those blockages were common, Tagge said. That's one
reason
residents didn't take more action; they believed Lewis had a blockage,
Tagge said.
Although parents
and patients always had the right to call a veteran
doctor, that standard has been reinforced, Tagge said.
Tagge said he
accepts responsibility for what happened.
"As a surgeon, if
something happens to your patient, you always accept
responsibility. I'm the captain of the ship, and if something goes
wrong,
it's my responsibility. ‘.‘.‘. It's all under our watch. Absolutely, we
take responsibility. That's why we feel so deeply, and that is why we
have
changed."
Still, he said,
Lewis' case was not as simple as it might have looked.
"This was a one in a zillion case," he said.
Blood from a
bleeding ulcer of Lewis' type normally passes into the
gastro-intestinal tract, where it is vomited up or passed out the colon
- giving a clear sign that something bad is happening.
"He broke that
rule," Tagge said. "His blood went into his peritoneal
cavity and just sat there, which I've never seen before."
Perhaps, said
Tagge, a veteran doctor seeing Lewis Sunday would have
detected his serious condition.
But many doctors
- possibly including himself - would have missed it,
he said. "I can't say what I would have done if I were on the firing
line."
Lewis'
complication was "so unusual" it's understandable why it would
be missed, Tagge said. "I don't know if I can say much more than that."
'I
WONDER WHY'
After Lewis died,
Helen and LaBarre got his belongings from the hospital.
Lewis' proudest
possession - his new learner's permit to drive - was
missing.
It was never
found.
"I wonder why
people have to die."
- Lewis, from a
poem he wrote in the sixth grade
II
The Blackman family, October 1996
L to R: Helen, Eliza (age 6), LaBarre, Lewis (age 11)