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I lived every
parent's nightmare of losing a child and this is especially
difficult because our child should be alive today, but because of
medical
errors, she is not.
I went to
Washington because I believe The McConnel Amendment is unfair
to victims and their families.
Here are the
reasons why and you judge for yourself:
1)When our 13
month old daughter was brought into the emergency room
we were told that the shunt which was placed in her head at birth was
in
failure, her condition was "emergent", and that she required immediate
surgery. We were then told that since the "OR" was too busy and due to
the late hour and on the weekend, she was being bumped from surgery
that
evening and would have to wait until the next morning for surgery ( but
she did not make it until the morning).
2)Given her
clinical presentations at that time, it was grossly negligent
not to have done the surgery immediately.
3)To further
compound the problem, she was not even placed in an intensive
care unit, nor was she properly monitored while she awaited
surgery.
4)My daughter was
showing all of the signs of fatal intracranial pressure
which was totally ignored by the nursing staff and the attending
resident
neurosurgeon who failed to even check on my daughter at all after she
was
placed in the room.
5)Prior to being
placed in her room the resident neurosurgeon working
that evening at the hospital paged the attending neurosurgeon who was
suppose
to do the surgery and was on call that evening, however, the attending
neurosurgeon put his pager on vibrate and went to sleep and never came
in and did not answer the numerous pages, despite the fact he had
previously
given an order to the attending resident neurosurgeon to tap the shunt,
which the resident neurosurgeon did do, but the shunt was dry and no
fluid
was obtained, which was a dangerous condition.
6)After tapping
the shunt, the resident neurosurgeon repeatedly paged
the attending neurosurgeon to let him know that the shunt could not be
tapped, but as previously noted, the attending neurosurgeon had gone
into
the supermarket to do his shopping, and then he says he put his pager
on
vibrate as he went into the supermarket, and then went home and fell
asleep
never answering any of the pages from the resident neurosurgeon and
never
even bothering to inquire as to the results of the shunt tap or my
daughter's
condition.
7)The resident
neurosurgeon in question who rendered care to my daughter
that evening had a limited medical license, which had expired at the
time
he rendered such care, yet he was left in charge to call the
shots.
8)The resident
neurosurgeon also ordered blood tests which were taken
that evening, which showed that my daughter had critical carbon dioxide
levels, as well as abnormal potassium and sodium levels, but nobody,
including
the resident neurosurgeon, even bothered to inquired,acknowledged or
address
these abnormal results.
9)Although ICU
monitoring was needed my daughter was not placed in and
intensive care unit.
10)No doctor ever
examined my daughter from the time she was admitted
to the time she went into respiratory arrest. (12:20 am to 6:20
am)
11) The hospital
could have done a bedside procedure to relieve the
pressure on my daughter's brain but did not even attempt.
This is why I'm
fighting for patients rights and to prevent this senseless
tragedy to happen to another child or family.
Nurse disputes
events in death at Children's
By Anne Barnard, Globe Staff, 9/20/2003
Thirteen-month-old
Taylor McCormack waited all night at Children's Hospital
with excess fluid building up in her brain partly because no operating
room was available for surgery that might have saved her life, medical
residents directing her care told investigators in 2001.
Now, nearly three
years after the child's death, an operating room nurse
who was on duty that weekend night at Children's Hospital has said that
an operating room was available. If a senior neurosurgeon had come to
the
hospital, he could have performed surgery to relieve the swelling in
Taylor's
brain, according to the nurse's deposition in the McCormack family's
lawsuit
against the child's doctors. A copy of the deposition was provided this
week to the Globe.
But the residents
never reached the neurosurgeon responsible for Taylor
that night, Dr. Craig van Horne, nor did they call in an alternate
surgeon.
And van Horne's supporters now say the residents didn't try very hard
to
find him.
Van Horne's
lawyer and another person who knows him personally, interviewed
by the Globe, said he was home all night, but that the residents never
called him at home or on his cellphone. The residents tried only his
pager,
which van Horne has told investigators he did not hear because he muted
it while grocery shopping and never turned it back on.
The new documents
in the McCormack case suggest a chain of miscommunications
and finger-pointing that some observers say is similar to the problems
revealed in the death in May of a patient with epilepsy during seizure
monitoring at the world-renowned hospital.
The death of the
5-year-old with epilepsy has triggered a federal review
of the hospital's eligibility for Medicare and Medicaid funding after
investigators
found that numerous doctors and nurses failed to intervene to stop the
boy's severe seizure even though they were concerned that the treatment
wasn't aggressive enough. Most of the medical personnel failed to call
their supervisors to raise questions.
Children's has
vowed to make changes to address the problems. But John
McCormack, Taylor's father, says the latest case shows the hospital's
leaders
did not do enough after public health officials said systemic problems
with communication and monitoring at the hospital contributed to her
death.
Subsequently, the hospital also found that communications problems may
have contributed to two more deaths at the hospital in August 2002.
"It's just like
in my case," McCormack said yesterday. "They promised
the public changes after my daughter's case. Even after [the two August
2002 deaths], they were in the middle of changing policies, but it was
too late."
Department of
Public Health officials say the Taylor McCormack case
differs from the recent incidents. They ruled that van Horne and the
residents
all agreed that McCormack was stable enough to wait overnight, a
medical
judgment that in hindsight may have been wrong. And they said the
communication
problem was that a senior doctor was unreachable, not that he wasn't
called.
On the other hand, the state medical board issued the residents a
"letter
of concern" for not trying to reach another attending doctor -- as well
as giving van Horne a harsher warning for not answering the page.
Rosemary
Gibson, author of "Wall of Silence," a book on medical mistakes, said
that
the two deaths illustrate problems that arise when junior doctors are
not
in close enough contact with supervisors -- whether it is because they
are afraid to speak up when they doubt a plan of care, or because they
are overconfident and don't think they need advice.
After the
McCormack case, Children's Hospital canceled its practice
of having Brigham and Women's surgeons take responsibility for their
patients
on some nights to improve oversight of residents. Van Horne and Dr.
Adel
Malek, the senior resident, were Brigham doctors, specializing in
adult,
not pediatric, neurosurgery.
But at issue in
the McCormack case -- which is pending in Suffolk County
Superior Court -- is not just whether or not the residents could reach
a senior surgeon. To John McCormack, the key is that resident Dr. Tien
Nguyen told Taylor's mother that night that there was no operating room
available for Taylor until the next morning.
Nguyen wrote the
same thing to the state medical board: "I was informed
that the first available time for surgery was 8 a.m."
But in her
deposition, operating room nurse Bertha Terlecki says that
at around 11 p.m., when Nguyen first contacted her to ask for an
operating
room, she gave him two choices.
She said she told
Nguyen he could either have a definitely scheduled
room at 8 a.m., or put Taylor on the equivalent of an airline standby
list
-- the girl could go in for surgery during the next gap in scheduled
cases,
probably around 3 or 4 a.m.
When Nguyen
agreed to take the 8 a.m. time, Terlecki said in the pretrial
discovery, she "told him to call his attending [van Horne], make sure
that
was fine with him and call me back." Terlecki said didn't hear from
Nguyen,
but she beeped him again later, after midnight. An anesthesiologist and
a standby team of nurses would be available after their last case of
the
night, which ended at 1:19 a.m. Before letting them go home, she wanted
to make sure he was comfortable with the 8 a.m. time.
But Nguyen said
he would stick with the later time. Malek, the resident
above him in the hierarchy, has said he agreed with that decision. They
never consulted with van Horne or another senior physician. Around 6
a.m.,
Taylor stopped breathing. She never woke up.
McCormack
believes they put off the surgery either because van Horne
could not be reached or because they didn't want to bother another
senior
doctor.
"If [Nguyen] was
forthright with me and my wife that night, saying there's
nobody available, how many hospitals are around there? I would have
brought
her to one of them, maybe she would be alive today," said McCormack.
Nguyen's lawyer,
William J. Dailey Jr., said his client believed Taylor
was medically stable enough to wait, adding that he has "great
sympathy"
for the McCormacks.
In another case
of dueling accounts, attorney George Jabour -- whose
use of private eyes and phone records reflects his experience as a
Quincy
special prosecutor and filer of police brutality lawsuits -- has also
challenged
van Horne's version of events.
He argues in
court that phone records suggest van Horne was not at home
that night.
"He was at home,
it's as clear as day," responds van Horne's attorney,
Douglas Morgan. He noted in a statement that public health officials
found
"Taylor McCormack's surgery was not delayed by the unavailability of
Dr.
van Horne."
The other person
who knows van Horne said he is talented, cares about
his patients, and empathizes with the McCormacks, adding "This is
something
he lives with every day." Offering an explanation of a longstanding
mystery
in the case, this person revealed what van Horne says is the reason he
muted his pager in the grocery store: In Brookline, where he lives, so
many doctors are shopping that etiquette demands they keep their pagers
quiet in the vegetable aisles.