THE WRONG VIAL, HUMAN ERRORS LEAD TO DEATH
Steve Sternberg, Knight-Ridder NewspapersCHICAGO TRIBUNE
When an eye doctor asked for a toxic chemical he had left in the operating room to preserve a patient`s cancerous eye tissue, the
anesthesiologist, Dr. Anthony Gyamfi, screamed, ''Oh, my God.''
Gyamfi realized instantly that an hour earlier he had injected the lethal chemical into the spine of veteran Miami Herald photographer Bob East during cancer surgery. Within minutes, he said, East`s blood pressure had dropped and his pulse rate slowed.
But until the eye doctor entered the room, Gyamfi had not known why. ''I was thinking of a million things, but not that,'' he said. ''Honest to God, I didn`t know.''
The lethal injection, which occurred last Friday, left East brain dead at Jackson Memorial Medical Center. Later tests showed no blood was reaching the brain. Brain scans disclosed no signs of life. Only one type of scan, an electroencephalograph, and other routine tests are needed to judge a patient dead under Florida law.
Wednesday, East was pronounced dead, shortly after his respirator was unplugged by Dr. Jeffrey Augenstein, the attending physician, said Zondra Thompkins, a hospital spokeswoman.
East, 64, had worked at the Miami Herald from 1951 until his illness forced him to retire this year. A malignant tumor had attacked his cheekbone and his right eye.
Surgeon James Ryan Chandler told East he would have to operate, and the operation itself was successful. But the lethal injection of the chemical glutaraldehyde was the final, fatal mistake in a series that doctors called
''bizarre, tragic and unique.''
The unmarked bottle of fluid was carried into the operating room by ophthalmology resident Allan Slomovic, who expected to use it to preserve East`s cancerous eye, which East was donating to research, Chandler said. Instead, Gyamfi injected it into East`s spine.
Gyamfi gave this account:
The anesthesiologist put East to sleep at about 9 a.m. Friday for the operation that would last all day. Then Chandler instructed him to insert a narrow tube in East`s back and drain 50 cubic centimeters of spinal fluid. The surgeon said spinal fluid is removed from patients in such operations and then reinjected after the procedure to check for leaks in protective brain covering, which is exposed during surgery.
The anesthesiologist left the task to Dr. Maimona Ghows, a resident in anesthesiology. Gyamfi left the room to attend to another case. Ghows drained the fluid and left it in a capped, labeled syringe.
At mid-day, nurse anesthetist Maria Harwood took over while Ghows took a break for lunch. That was when nurse Norma Anderson saw an unlabeled vial sitting on a table by the operating room door.
According to Harwood and Anderson, one of the surgeons who was bent over East told the nurse it contained spinal fluid, and told her to take it to the anesthesiologist. The vial was wrapped in a knotted rubber glove.
Harwood, remarking that it should have been labeled, pasted a label to the glove bearing East`s name and the words ''spinal fluid,'' Gyamfi said.
She placed the vial next to the syringe containing the spinal fluid. Gyamfi would later say that the knotted glove reassured him that this was indeed spinal fluid. He believed the vial had been inserted in the glove to keep the body fluid sterile. ''We work in a team,'' he said. ''You have to have trust.''
When Gyamfi was summoned to reinject the spinal fluid between 4:45 p.m. and 5:30 p.m., he emptied both the syringe and vial into East`s spine. Later, resident Slomovic came to pick up the cancerous eye tissue. He asked,
''Where`s my glutaraldehyde?''
Gyamfi recoiled with horror. He suddenly understood why East`s ''rock-stable'' blood pressure had dropped. ''At that moment I realized what had happened,'' he said, ''and I just screamed, `Oh my God, Oh my God.` I told Dr. Chandler something terrible had happened.''
Doctors said it was the first time a living human had ever been injected with the toxic substance, used to sterilize instruments and preserve tissues removed during surgery.
''A tragedy,'' said Chandler. ''It was preventable. It didn`t have to be. It was a tragic series of human errors.''
''I know nobody did this on purpose,'' said East`s wife of 39 years, Tina. ''It just fills me with such terrible rage. I think that people who take other people`s lives into their hands should be more careful.''
''It`s a terrible, tragic accident,'' said Fred Cowell, president of the Public Health Trust that runs Jackson Memorial Hospital. ''I`m just sick about it.''
East was admitted to Jackson Memorial late Thursday after spending the afternoon at Bascom Palmer Eye Institute undergoing laser tests on the diseased eye. It was his right eye, the camera eye, which doctors had tried for years to save.
The eye first had been jeopardized by diabetes diagnosed when East was 24, and then by benign facial tumors removed by Chandler eight years ago. In May, the tumors recurred and caused maddening headaches.
Chandler operated for the second time in January. He found a malignant cancer that had eaten away at East`s cheekbone and attacked the back of the eye. If left in place it would threaten the brain.
He told East he would have to operate. He would remove his eye, bone around the eye, the right cheekbone and the upper right jaw. Death was the alternative. ''It is an extensive operation and an unusual one,'' Chandler said.
Some doctors question whether spinal fluid should be reinjected at all. The body produces 0.3 to 0.5 cubic centimeters of spinal fluid per minute. By the time the anesthesiologist had reinjected the fluid, East`s body already had nearly replaced the amount that had been drawn, doctors said.
''It didn`t have to be put in, but we put it back in to check for leaks'' in the covering of the brain, Chandler said. ''It is routine in this procedure.''
Dr. Jorge Hernandez, a neurosurgeon, and Dr. Larry Page, vice chairman of neurosurgery, were called for help as soon as the error was discovered. Page ordered doctors to draw spinal fluid to try to drain as much of the glutaraldehyde as possible, but it was too late.
''The fact is that this stuff acts pretty quickly--within seconds or minutes rather than hours,'' the neurosurgeon said. ''This is a totally unique happening. A horrible event.''
(Hernandez`s notes record the time he was summoned as 6:30, and notes the reason for the emergency call: A ''possible chemical toxin'' had been injected into East 1 1/2 hours before.)
The brain and spine are literally bathed in spinal fluid. Within seconds of the injection, the preservative was traveling along the spinal column, destroying tissue. It traveled up to the brain, where spinal fluid is secreted in cavities called ventricles.
In those cavities is artery-laced tissue, called the choroid plexus. That tissue secretes the spinal fluid. It percolates through the brain and drips into the spine through a vent just above the bony opening known as the foramen magnum.
Then it returns to the brain, where it is drawn off again by pressure-sensitive veins.
The glutaraldehyde, traveling throughout the brain, breaks down proteins wherever it goes, Page said. The results are irreversible.
Chandler said the accident ''was not due to the human error of one man. It was due to the errors of many--doctors, myself included, who somehow bypassed all the safeguards to prevent such an occurrence. I accept full responsibility.''
Dr. Joseph Davis, the Dade County medical examiner, has declared jurisdiction over the case because it ''falls outside the realm of what is considered an acceptable risk of surgery.''