Alleged Patient Exposure to HIV/Hepatitis After Drug Diversion

I want to start this post by saying "Oops, it happened again." The problem is, I shouldn't have to blog about this topic considering how serious it is and the potential risk to patients.

I live in Colorado. In February, 2016, it hit the news that one of the Denver areas largest hospital, Swedish Medical Center, was testing close to three thousand patients for possible exposure to HIV and Hepatitis after a surgical tech was suspected of diverting drugs.

What is drug diversion? Drug diversion is using a narcotic for anything other than its intended use. The most mildest form is not wasting drugs properly. It requires two licensed personnel to waste a drug and sometimes you just can't find another person at that moment and then you forget. Not excusable but understandable. The most serious form is healthcare workers using the drug themselves and not giving them to the patient or using the "waste" or overage for themselves.

The problem is, a relatively similar scenario happened at another Colorado hospital in 2008 and 2009. This was the case of Kristen Parker, a surgical tech who is currently serving a thirty year prison term for infecting three dozen patients with Hepatitis C. She was stealing unlocked Fentanyl set aside for surgery, injecting it into herself, and then drawing up saline into the same syringe where then an unsuspecting provider injected it into the patient causing transmission of the virus.

In fact, one of the anesthesiologists involved in this case went public and even wrote a novel based upon her experience. This wasn't a quiet news story.

In this blog piece from The Daily Beast in February, 2013, Gorman states:

“At that time, we didn’t think about locking drawers,” she says. “No one ever told me I was doing anything wrong. If there were rules to enforce locking the drugs up, they were not enforced.” Rose has said it sent memos to its anesthesiologists in 2001 and again after Parker’s crime, warning them “never leave controlled substances unlocked or unattended.”

In light of this incidence, it is unbelievable to me that a case of suspected drug diversion involving a surgical tech could happen again in this state and it makes me wonder if potentially the same process of drug diversion was used as Kristen Parker employed-- unsecured narcotics awaiting injection for surgical procedures.

The tech, Rocky Allen, has been arrested and has pleaded not guilty. Thus far, it appears two patients have tested positive for Hepatitis B.-- although the hospital currently denies they transmitted the virus as part of this case.

So please, hospital OR's everywhere, can we please develop a system where narcotics can be dispensed safely to surgical patients?

Author Question: Surgical Spleen Removal

Amanda Asks:

I have a character who was shot in the side, not life threatening, but he had to have surgery to remove his spleen as well as the bullet because some rib fragments damaged his spleen.

My question is how long would he be in the hospital after surgery? I'm sure when he first comes home he'll be getting around in a wheelchair or something while he heals and gets his strength back. When could I plausibly have him on his feet slowly walking around? I don't want any dramatic complications with his injury or anything. He's going to heal up great and be perfectly fine afterward.

Jordyn Says:

I ran this question by some of my nursing cohorts who focus in adult surgery.

Having your spleen removed would require a couple days stay in an intensive care unit. This would be due to risk of post-surgical bleeding and concern for infection.

The surgical nurse I spoke to said these patients are up and walking by the time they come to the floor so there would be no need for the character to use a wheelchair.

Once research point that is helpful with this question is that you can Google search for discharge instructions regarding many kinds of operations. For this one, I searched for Home Care Instructions after Spleen Removal. This document gives excellent information that can be translated into your novel.

For instance-- how long the patient should expect to have pain. Driving and lifting restrictions which can help determine what they would physically be capable of in your novel.

FYI-- patients who have had their spleens removed are at more risk of serious infection. Your spleen is part of your immune system. So some infections that would normally not be a big deal for the general population can be life threatening to those who have had their spleen removed.

Author Question: TB and Lung Surgery

What happens when a surgeon takes out the wrong lung?

This writer's question came from Lana and actually brings up several interesting points of discussion for her novel. First of all, the question stems from a family incident in 1954 which would really be considered historical as far as medicine is concerned.

Let's dive into Lana's question.

Lana asks:

I am a new writer and have some questions regarding a medical incident that occurred in my family in approximately 1954, but today the details are sketchy. Dr. Mabry (thanks Richard!) gave me your name.

The story: My uncle was told he had TB and must have his diseased lung removed. He had surgery, but the wrong lung was taken out.

Question #1: Would they have planned to remove the lung because of TB and would a doctor have actually taken out a whole lung or would it have been one lobe?

Question #2: Would the doctor have been able to see his mistake immediately after surgery? I'm not sure how the mistake was made or discovered.

Question #3: After removing the wrong lung (or lobe), how long would it have taken to reschedule another surgery?

Jordyn says:

One-- I have to thank a physician coworker for her help on these-- thanks, Liz!

Question #1: It depends on how diseased the lung was. Back then-- there weren't antibiotics to treat TB like there is now so this was considered treatment. However, since it didn't cure the infection like antibiotics would-- I'm not sure how beneficial it was for the patient. If on x-ray it looked like the whole lung was involved then they would have taken the whole thing out. If it looked like just part was involved-- then perhaps just a lobe.

Question #2: The doctor would not have known about his mistake until the pathology report came back. The doctor I spoke to said on the outside-- the lung might be very normal appearing (which perhaps played into the wrong lung being removed) but all removed biological things go to pathology to confirm a diagnosis. The wrong something being taken out or off is rare but does happen and lots of things play into these surgical errors. I'm going to provide some links below that talk about how these happen in some other situations.

Question #3: Reschedule surgery? Obviously-- if they took out the whole lung he could not go back for another surgery to remove a whole other lung-- because then he'd have nothing to do oxygen exchange and would therefore die. I guess they could remove part of the remaining lung but I'm not sure how much lung tissue you need to survive. This could be an area for you do some reading on. I couldn't find a quick answer for you. It looks like the first successful lung transplant was in 1963 and it would have taken time for these procedures to become commonplace. If they did take him back-- perhaps they'd wait for him to recover from the first surgery which might be a good 2-4 weeks I'm guessing.

Here are some links to this particular kind of surgery error:

http://www.nytimes.com/1995/09/17/us/doctor-who-cut-off-wrong-leg-is-defended-by-colleagues.html

http://www.cnn.com/2010/HEALTH/10/18/health.surgery.mixups.common/

http://www.lasvegassun.com/news/2011/jan/29/double-ouch-doctor-operates-wrong-knee/

Has anyone had this experience or known someone this has happened to? Did the hospital disclose why the error happened?

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I’m Lana Kruse—last name pronounced Kruzey, rhymes with doozie! I’m one of the original baby boomers—you know, before we became a whole generation. It’s been fun to have been well-known, watched and written about since birth! I’m a wife, mother of two, grandmother of five (aka Mimi), and friend. I hope you will join me in that last category via my blog. I love people, words, laughter and eating out. Put all of these things together, and I’m in heaven!

Safe Surgeries Not Without Risk

Not only am I a pediatric nurse, but I'm a mother of two girls age 9 and 11. I tend to worry. Not about the little every day illness and injuries-- like say my daughter's broken arm that I didn't have evaluated for 24 hours. Hey, it wasn't deformed and she had good blood flow. Perfectly okay to see if rest and Ibuprofen made a difference.

What I do worry about is those zebras in the forest. This phrase is typically used for those diagnoses that happen but are a rare occurrence. Like your child with a nose bleed probably (99.5% of the time) doesn't have cancer.

But-- this is what I worry about out. Every headache is a brain tumor. I probably palpate lymph nodes more than I should which got me into an anxious worry cycle when my youngest was around three-years-old.

I looked at her one day and she has a lymph node bulging from her neck. She was otherwise fine-- which was actually more worrisome, because she didn't have a reason for the lymph node to be so prominent. No ear pain, sore throat, fever, scratch . . . etc.

I took her to her pediatrician and he wasn't concerned. They did a CBC-- which is a blood test that looks at red and white blood cells. It can give an indication of cancer but is generally not considered definitive. Even after the CBC came back normal, my mind wasn't completely at ease so I scheduled to take her to the ENT. They, too, were nonplussed but could see how worried I was and so the physician says-- "I don't think it will show anything to biopsy this node but I will take it out if it will make you feel better."

And that's when my nursing brain kicked in and began to override my mommy brain. I was risking surgery to ease my anxiety. I was going to give her a scar so I could sleep at night when this trained and well-respected physician and given me reassurance. I asked him what would be the most conservative bridge between surgery and easing my worrying and he offered to track it by exam every three months for a year.

Done deal.

Not too long after that we cared for a patient that got an infection after this type of surgery. Post-operative infection is a known complication of ANY surgery and doesn't imply that there was negligence.

My concern is this-- many parents are choosing surgery as first line defense when, perhaps, problems could be managed another way. Doctors are deferring to parents, at times, against their medical gut to cover themselves from potential lawsuits-- such as a parent insisting on a CT for head injury. This isn't always in the best interest of anyone. 

Next post I'll be analyzing the case of Jahi McMath-- who is the girl who suffered a surgical complication that led to brain death. Do I think, from what's been written about the case, that the hospital could be responsible for her death?

Tonsillectomy: Useful But Not Without Risk

I've been fascinated by the case of Jahi McMath, who is the girl who suffered surgical complications after a tonsillectomy and has been left brain dead. I'll be discussing other aspects of this case next week but I thought I'd invite fellow medical musketeer and ENT physician, Dr. Richard Mabry, by to discuss the risks/benefits of this procedure.

I happily endorsed Richard's forthcoming novel Critical Condition. It's a great story and gives insight into that elusive area of the hospital-- the OR. I hope you'll check it out when it's released in April.

Welcome back, Richard!

Any resident physician in otolaryngology (ear, nose and throat) can tell you that tonsillectomy is not a benign procedure. It’s very useful when indicated, but strict criteria for its consideration have been developed.  These include recurrent documented infections as well as sleep-disordered breathing. Attention to these criteria is important before tonsillectomy is considered.

Prior to the procedure, parents should feel free to ask questions or seek clarification of any points they don’t understand. Most physicians have instruction sheets that are given to help prepare families for the procedure.

The procedure itself is typically short—30 to 60 minutes—after which the child is observed in the recovery room until they are fully awake and stable. The child may be discharged later that day if they’re doing well, but sometimes complications necessitate an overnight stay.

The risk associated with a general anesthetic administered by competent personnel is tiny. Probably equally or more important is the possibility of complications occurring after the procedure. 

Undoubtedly, the number one risk is post-operative bleeding. If the child expectorates clots or large amounts of bright blood, parents should seek medical attention immediately. They are also warned to watch for and report fever, persistent vomiting, or difficulty breathing.

The tonsils receive their blood supply from branches of five different arteries, so bleeding—at surgery and afterward—can be a problem. To deal with this possibility, various methods—primarily application of caustic chemicals, use of ligatures, or various types of cauterization—have been traditionally been used. In recent years, surgical methods other than sharp dissection have become more popular. These include partial tonsillectomy and use of lasers to remove tonsil tissue. Thus far, the perfect solution hasn’t been found.

What are the risks associated with tonsillectomy? According to a recent journal article, the risk of dying from the operation ranges from 1 in 10,000 to 1 in 35,000 cases. Although mortality (i.e., dying) is rare, morbidity (i.e., complications) still occur. The most important, of course, is bleeding after the surgery. In one study, the incidence of bleeding was reported at from 2% to 3% of cases. The two most common times for post-tonsillectomy bleeding to occur are immediately after the surgery and after about a week, when scabs separate.

Does that mean that all parents should shy away from a tonsillectomy for their child? Not at all. It’s a very beneficial procedure when indicated and performed by a competent physician. But it behooves every parent to ask questions, learn what to watch for, and participate in the care of their child while they recover from the surgery.

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Richard Mabry is a retired physician, past Vice President of the American Christian Fiction Writers, and author of “medical suspense with heart.” His novels have been a semifinalist for International Thriller Writers’ debut novel, finalists for the Carol Award and Romantic Times’ Reader’s Choice Award, and winner of the Selah Award. You can follow Richard on his blog, on Twitter, and his Facebook fan page.

Hostages: Episode 8 Analysis 1/3

Seriously, medically speaking, the CBS drama Hostages is becoming that car accident I can't avert my eyes from. This episode had me doing some serious eye rolling-- one of my eyes may have actually rolled away from me at one point. I have since recovered it so don't worry.

During episode 7-- the husband is left alone with the primary hostage taker and his primary goal is to do him in. What remains in the house is the "colorless, non-traceable, fast-acting poison" that was contained in a lipstick holder for Ellen to give the President during surgery.

Hubby finds it, a needle and syringe and draws up the medication. At the end of this episode he manages to put it into his chest and pushes in a little of the medication.

Enter the hero doctor who is now convinced that he must live or all of her family will die.

She asks him, "What is the poison?"

He says, "A rapid-acting paralyzing agent."

At this point, I'm going to beg the producers of this show to either get a new medical consultant or hire one. Because, whoever is advising them doesn't know anything about WHY this wouldn't kill the president during his operation.

Paralyzing agents don't stop your heart from beating. I've blogged here before about the unique characteristics of heart cells. They have their own automaticity. Paralyzing agents work at the neuromuscular juction to stop the muscles from being able to contract. Your heart muscle is different from this system but your diaphragm is not which is the primary muscle used for breathing.

The reason a paralyzing agent will kill you is that it stops the contraction of your diaphragm muscle and therefore you stop breathing. Obviously, if you're not breathing you're going to die so to save your life we have to provide rescue breathing and preferably oxygen.

In surgery, especially the type of surgery the president is having which is a lung surgery, he is already going to be intubated and bagged with oxygen to keep him alive. The injection of a paralyzing agent (of which he may already have some on board to get him intubated) would have a net ZERO effect.

You can read more about neuromuscalur blocking agents here. 

So-- it is fiction people and someone in the military wants him gone. You can't invent an odorless, rapid-acting, undectable poison and give it a cool name?

Part II we'll continue with the good doctor's treatment.

Fall TV Medical Analysis: Hostages

Obviously, you know I'm a stickler for medical accuracy-- hence the mission of this blog.

Fall TV has started and given me some new shows to analyze. Don't worry, I'm sure I'll comment every now and then on a few of my TV staples like Grey's Anatomy.

Just remember-- what you see on TV is not likely accurate. Maybe not even close.

Hostages, which is airing on CBS, actually has a pretty genius medical set-up. The president needs surgery (some type of lung surgery) and wants to increase popularity points by using a "public" doctor who happens to also be a woman.

For some nefarious reason not yet discovered-- there are people who want the president deceased. So as a means to this end they hold the doctor and her family hostage until she offs the president during surgery.

Of course, each family member has a secret they're hiding (except maybe the doctor) which all spills out when they're in crisis.

The first couple of episodes deal with how the good doctor, played by Toni Collette, saves the president's life by giving him a complication that will postpone the surgery.

What it shows is her leaving a vial of saline at his bedside. It comes out later that the president was accidentally given Heparin (which is a blood thinner) by a nurse starting his IV and the doctor suspected this when he had some bleeding at his IV site.

And-- surgery postponed.

Medically, I have a couple of problems with the scene. The vial the doctor left on the bedside table was sealed-- it's plastic top in place. These can't be screwed on and off. Once they are popped off, any good nurse assumes that the vial has been used in some way. These can be multiple dose vials (meaning many doses drawn up for different patients) but these days most hospitals used pre-filled syringes or one vial/patient. That particular vial that she left couldn't have been tampered with because the top was still in place.

I think what would have been more believable would be to show the doctor adding the medication to the vial, and leaving it opened at the bedside and then giving it to the nurse for the IV start versus just hoping the nurse uses it because it's there.

Also-- thinning blood based on one Heparin bolus isn't that easy to do. Generally a patient is given a bolus and then started on a drip for a period of time.

I do like the show and I'll keep watching. We'll see how the medical scenario plays out.

Medical Question: Surgical Timeline

I'm pleased to have Amitha Knight back who will be hosting a medical question today and tomorrow about surgeries. Today, she covers the general surgical timeline and what the patient's process is through the OR. On Friday, she'll cover more in depth about brain surgeries.

RB asks:

In the book my one lead character, a Brain surgeon, will be performing two major surgeries during the life of the book, one on (an animal), and the other she will be performing a radical operation on the male lead.

Could you, in as short as possible, give me an overview of what happens during such a surgery. The big picture and any suggestions you could give me that would make the scenes believable.

Even if you can point me at a website where I can read up about brain surgery – any videos would help as well, I am not squeamish about blood etc… so don’t worry about that side (more fascinated by the whole process).

Any help would seriously be appreciated.

Amitha says:

While I saw lots of surgeries during my 12-week surgery rotation in medical school, ranging from cholecystectomies (gall bladder removal) to liver transplants to cardiac surgeries to breast implants, I didn't see any brain surgeries. I especially didn't see any veterinary surgeries so I can't comment on that part of your question.

The reason I didn't see the brain surgeries was that the surgeons wanted you to be there for the entire surgery and brain surgeries can take a long time. For example, I heard of one brain tumor removal taking 6 hours. A quick search of the web reveals people who report their brain surgeries having taken more than 12 hours--not sure if they're counting recovery time. Performing and assisting surgeries for long periods of time requires stamina, dedication, and patience. Alas, our hospital didn't have a surgical theatre like on Grey's Anatomy where people could eat lunch, gossip, and come and go as they please while watching surgeries.

While I haven't seen a brain surgery, the very basic timeline of surgeries are generally the same:

• The patient is wheeled into the sterile operating room (OR) and transferred to the operating table. Everyone in the room (besides the patient) is required to wear a face mask, a hair covering of some kind, scrubs, and shoe covers.

• The anesthesiologist sedates the patient (sometimes this is started in the pre-op area). During some brain surgeries, the patient is kept awake for portions of the surgery (so they can monitor the patient's brain functions by having the patient do different things during surgery) while in others, the patient is intubated and kept under general anesthesia the entire time.

• The patient is positioned appropriately for the surgery. Parts of the body that aren't being operated on are covered up. The patient's head is shaved (or at the very least the part that they are operating on I should think).

• Meanwhile the surgical team "scrubs in" (i.e. they go to a separate room attached to the OR to thoroughly clean their hands/arms up to the elbows and then return to the OR where they are helped by surgical technicians and nurses into sterile gowns and gloves, all the while making sure not to touch anything that isn't sterile). Sterile coverings (which are usually all blue) are draped everywhere so that people who are "scrubbed in" don't accidentally touch non-sterile things. People who aren't "scrubbed in" aren't allowed to touch anything in the sterile field. Keeping things sterile and clean is key.

• The surgical area is "prepped" (i.e. cleaned).

• Surgeons and surgical techs do a "time out" and double check the patient's name and the procedure being done and the area being operated on.

• The first incision is made.

• The surgery is performed. Tools are all counted by the surgical tech. (During long surgeries, this may happen several times throughout.)

• The surgical site is "closed" i.e. stitches are put in, the wound is dressed.

• The patient is wheeled to the post-operative area ("post-op").

Have you ever written a scene that involved the operating room?

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Amitha Knight is a former pediatric resident turned writer of middle grade and young adult fiction. She’s also a blogger, a book lover, an identical twin, and a mom. Follow her on twitter @amithaknight or check out her website: http://www.amithaknight.com/.