DEPARTMENT OF INTERNAL MEDICINE
KING-DREW MEDICAL CENTER
CHARLES R. DREW UNIVERSITY OF MEDICINE
AND SCIENCE
April 8, 2005
Thomas Garthwaite, M.D.
Director, Department of Health Services
County of Los Angeles
313 N. Figueroa
Los Angeles, California 90012
RE: Death of 3 Cases Reported In L.A. Times April 6, 2005
Dear Dr. Garthwaite:
I am providing you with a summary of our Department of Internal Medicine Peer Review
conference on the three cases that were reported in the Los Angeles Times on April 6,
2005. The conference was held on April 7, 2005 and was attended by 12 faculty
members of our department.
I would like to state that the report in the L.A. Times was inaccurate and extremely
misleading in terms of the quality of care and appropriate supervision of trainees. As you
know, recently the Accreditation Council on Graduate Medical Education (ACGME)
fully accredited our residency program with NO CITATIONS and even gave us three
commendations. Our four subspecialty fellowship programs (endocrinology,
gastroenterology, geriatric medicine and infectious diseases) also were fully accredited
with no citations.
The case of the patient who allegedly died because of a “medical accident” due to “her
breathing tube which caused her lung to collapse” according to a coroner’s report is not
consistent with our review of the case. This patient had end-stage emphysema who had
required home oxygen and was brought in with respiratory failure. Because of the
severity of her lung problem, she had a tracheostomy performed. She was stable after the
tracheostomy but then complained about pain in the neck region. The patient was now
having some respiratory problems despite having a tracheostomy. ENT evaluated the
patient and elected to intubate the patient. At that time, it was noted that the patient had
subcutaneous emphysema round the neck and face (which is a sign of air linking from a
source into the neck region). Despite the intubation, the patient continued to deteriorate
and eventually had a cardiac arrest and died. The time period from symptoms to arrest
was approximately 30 minutes. A chest film 10 minutes prior to the arrest showed the
patient had a pneumothorax on the right chest and partially in the left chest.
Pneumothorax is a COMMON complication of patients with emphysema, especially
when they require ventilation due to high pressures of the ventilator that is necessary to
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sustain these patients. We suspect that the subcutaneous emphysema was most likely due
to the pneumothorax. Thus, it is our assessment that the patient died of a complication of
her underlying disease and NOT from a medical error. Despite the endotracheal tube
being in one of the main bronchus, this does not lead to pneumothorax and was not the
cause of her demise. Our faculty, however, did feel that the house staff should have
called his/her attending physician (who was in house at that time) at the time the
subcutaneous emphysema was first noted. This may have permitted an earlier diagnosis
of the pneumothorax (which is treatable by a chest tube), but may not have ultimately
changed the outcome, given the severity of this patient’s lung disease. We will counsel
the house officer on this matter.
The patient with HIV infection had severe AIDS. This patient was recently discharged
after being treated for cryptococcal meningitis, a common but life-threatening fungal
infection in AIDS patients. It is often NOT cured in this population. As you know
secondary infection is the most common mode of death for AIDS patients. This patient
had a CD4 count of 2, which is very low and indicates an extremely severe HIV
infection. The patient was admitted from the HIV clinic directly to our ward because of
dehydration. The patient was seen in a timely manner by the senior ward resident and an
attending physician note was written within 24 hours (according County policy). The
patient was seriously ill on admission but was stable. He was given fluids, packed red
blood cells and other medications. Approximately 3 days later, the patient appeared to
worsen despite initial treatment and the attending physician recommended the patient be
transferred to the intensive care unit while on morning rounds. It was felt the patient had
sepsis. While awaiting a critical care bed, the house staff was at the bedside managing
the patient (this is clearly documented in the nursing notes) until 1 hour before the
patient’s eventual transfer to the critical care unit (the patient was stable when the doctor
left the bedside to see another patient). The house officer was not notified when the
patient was transferred and thus during patient transport to the critical care unit, only the
nurse and nursing attendant accompanied the patient. While in the elevator, it was noted
that the patient’s oxygen saturation was declining and upon reaching the critical care unit,
the patient suffered a cardiac arrest. Our faculty felt that this patient was not abandoned
by a doctor during his acute deterioration. It was our opinion that even if a physician
accompanied the patient, the outcome would not have changed since his death was most
likely due to septic shock and this condition has a mortality rate exceeding 75%,
especially in such patients. In our critical review, the attending physician who
recommended transfer to the critical care unit did not document his findings on the chart
because he was called away to see another sick patient in the emergency room.
Nevertheless, we felt that a note in the chart must be recorded by the attending physician
according to hospital policy. The attending physician will be appropriately counseled by
the department chairman.
The third patient had end-stage liver disease due to chronic alcoholism. He was admitted
for gastrointestinal bleeding. An endoscopy revealed grade III esophageal varices, which
was banded, and gastritis. During his hospital course, he showed the complications of a
failed liver with ascites (requiring fluid removal on three occasions), kidney failure, and
pulmonary failure (pulmonary edema) due to retained fluid and low serum albumin. It
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was felt the patient had a poor prognosis. During this period he was hypotensive, which
was appropriately managed with dopamine, phenylephrine and later levophed. His
clinical condition deteriorated despite pressors and the patient suffered a cardiac arrest as
a terminal event of his multi-organ failure while in the critical care unit. At this time he
was already intubated. When a code blue was called, the critical care attending physician
was at the bedside managing the cardiac arrest. The anesthesiologist was informed by the
critical care attending that his/her presence was not necessary since the patient was
already intubated. Thus, it is incorrect to state the patient “may not have received the
appropriate medication at the right times for low blood pressure” as quoted in the L.A.
Times. Furthermore, the anesthesiologist did not respond to the code blue because the
critical care attending informed the anesthesiologist that his/her assistance was not
needed, given that the patient was already intubated (anesthesiologist role in code blue
situations is provide airway support by intubation).
In summary, it is clear that the LA Times head lines “3 King/Drew Deaths Blamed on
Lapses” and “Officials believe the March cases involved critical errors…” were blatantly
inaccurate, and the newspaper shamelessly attempted to characterize the quality of care
as poor. These patients did not die of lapses of care but of their underlying diseases!
Moreover, it is unconscionable that premature judgments are made on the quality of care
of such terminal patients BEFORE a thorough peer review is made. It is unclear to me
how the L.A. Times received this information prior to completion of an objective
investigation and evaluation. It is unethical and furthermore unfair to the doctors and
other health providers who provide quality and timely care at this institution. We would
welcome an independent review of these three cases to support our findings.
Sincerely,
Thomas T. Yoshikawa, M.D.
Chairman and Professor
Department of Internal Medicine
King-Drew Medical Center/Charles R. Drew University
Cc:
Roger Peeks, M.D., Medical Director, KDMC
Carole Black, M.D., Advisor to Medical Director, Navigant
Hank Wells, Interim CEO/Navigant-KDMC
Marcelle Willock, M.D., M.B.A., Dean, College of Medicine, Drew University
Harry Douglas, III, D.P.A., Interim President, Drew University
Bart Williams, Esq., Chair, Board of Trustees, Drew University
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