Down at the Courthouse: A Judge Wants to Know Why a Two-Month-Old Infant with MRSA Died

The Judicial Inquest into the MRSA-caused death of two-month-old Drianna Ross is taking place in courtroom 114 of the Law Courts Building in downtown Winnipeg. Presiding Judge Don Slough is nearing the end of his two-year investigation into Drianna’s death in November, 2011, in the northern Manitoba city of Thompson.

The Inquest was struck because Drianna’s mother and father, backed by community leaders, say that northern medical services are substandard and that’s why their child died.

Drianna Ross

Drianna Ross

The case began when they took Drianna, crying, coughing, and with difficulty breathing, to a local nursing station four times over two days. She was never referred to a doctor; instead, she was sent home with Tylenol. Finally, on her fourth visit to see the community nurse, Drianna was medevaced to Thompson General Hospital. The following day she died from a MRSA-induced septic shock.

The purpose of the Inquest is to examine the adequacy of healthcare in remote northern communities and, if that care is found wanting, to recommend changes in government healthcare practices so cases like Drianna’s don’t happen again. (Judicial Inquests, unlike trials, do not assign blame and do not have the authority to hold anyone legally responsible.)

On the stand yesterday afternoon was Dr. Stasa Veroukis, Pediatric Intensive Care Specialist at the Health Sciences Centre in Winnipeg. She wasn’t directly involved in the case but had reviewed the relevant medical documents in order to offer her expert opinion about the quality of Drianna’s medical care.

A half dozen lawyers from various health authorities questioned Dr. Verooukis, trying to pinpoint where it all went wrong after Drianna got to the hospital.

In Dr. Veroukis’s view the moment of truth was Drianna’s first night in the hospital. By 3:00 a.m. her heart rate had risen to 203 beats per minute, her temperature was a “very high” 39.3 degrees C and, most tellingly, when nursing staff poked Drianna to insert an IV she did not respond – which meant she was unconscious. Stunningly, that’s where it was left — no doctor was consulted to see what they should do next.

Those downward-spiraling vital signs meant that septic shock was setting in, said Veroukis, and as brain and heart cells begin to die off the process quickly becomes irreversible and death inevitable.

Dr. Veroukis was clear: “All the symptoms should have been put together by the nurse and [she should] have called the doctor.” Veroukis could only guess why that wasn’t done: a busy night perhaps, poor communication between nurse and doctor, inexperienced staff, and/or a lack of awareness about what the vital signs meant.

When asked how a two-month-old infant could possibly contract MRSA in the first place, Veroukis told the court there’s “More MRSA in the northern communities. The best option I can offer is the people around her have it.”

The research agrees with her, but with one important qualification: It’s not that MRSA frequents the north more than, say, the south, it’s that remote northern areas are home to First Nation communities and it is First Nation people who are disproportionately affected by MRSA.

For example, in a 7-year study ending in 2002, First Nation patients in Canada were found to be 6-fold more likely to have a Community Associated-MRSA infection than non-FN patients. (Community Associated means the patient picked up the MRSA before going to the hospital.)

And it might be getting worse: A U.S. study of Indigineous populations found that MRSA-associated hospitalizations increased from 4.6 per 100,000 American Indians/Alaska Natives in 1996 to 1998 to 50.6 per 100,000 in 2003 to 2005 – more than a 10-fold increase.

In other words, professional red flags have been waving about the increased prevalence of MRSA in First Nation communities for at least a decade.

Drianna’s death reminds us what happens when those warnings are ignored.

It’s Not the Crime it’s the Cover-Up: A MRSA lawsuit against the Tampa Bay Buccaneers illustrates the principle

In the Circuit Court of Broward County, Florida, this past Monday, former National Football League kicker Lawrence Tynes filed suit against his former team, the Tampa Bay Buccaneers.

TynesHe says he contracted a methicillin-resistant staphylococcus aureus (MRSA) infection from the Tampa Bay Buccaneers’ Training Facility, One Buccaneer Place, during the summer of 2013, which, among other things, caused him to: (1) have 3 surgeries to remove infected tissue (2) live under the threat that doctors were going to have to amputate his toe as the infection worsened (3) endure six weeks of intravenous antibiotic therapy which involved a central line catheter inserted into his arm and placed above his heart (photo) (4) live with persistent pain which he is reminded of every time he gets out of bed and his feet hit the ground, and (5) sustain permanent damage to his kicking foot thus ending his career which cost him over $20 million in expected future earnings.

A crucial component of Mr. Tynes’s complaint against the Bucs is found in paragraph 23 of his 57 paragraph Statement of Claim which reads, in part: “… Defendants failed to disclose, and actively concealed, ongoing separate incidents of infection amongst individuals who used and visited One Buccaneer Place.” (My emphasis)

What, exactly, did they cover-up? It was the fact that 6 other members of the Bucs – 4 players, an assistant coach, and the head trainer – were also battling bacterial infections that summer. That these people “used the same hot and cold tubs, soak buckets, and other therapy devices, equipment, and surfaces used by Mr.Tynes.” And that as a result Lawrence Tynes contracted his life-threatening career-ending infection.

But why the cover-up? What reason would the Bucs have for keeping this critical information from him? The answer, according to Mr. Tynes, is the Bucs’ effort to gain advantage in the very competitive NFL marketplace in order to attract the best available players and coaches.

Lawrence Tynes, an integral part of the New York Giants 2007 and 2011 Super Bowl Championships, was a sought after free agent when he signed with the Bucs in the summer of 2013. What induced him to sign was the Bucs’ highly-touted superior medical and rehab facility, as laid out in para 9 of his Claim:

“Defendants represented to Bucs players, prospective Bucs players, including Mr.Tynes … that the Bucs Training Facility is a world-class facility at which ‘state-of-the-art’ physical training, medical care and treatment, and other rehabilitative services are provided … that the ‘gleaming new team headquarters,’ which it calls ‘One Buccaneer Palace,’ ‘is the largest facility in the NFL. Equipped with every modern tool to help produce a successful team on the field, the facility is also a major draw for potential free agents.’”

This had particular appeal to Tynes because as a kicker he has “a podiatrist perform a toe-nail procedure on his great kicking toe” in the summer before the start of each season. This requires a strict rehabilitation regimen; the use of “hot tubs, cold tubs, and a soak bucket for his toe, and included dressing changes to the open wound on his toe” – the functional equivalent of a quarterback’s arm.

Knowing this, the Bucs told Tynes’ agent that they had “the best of everything” and “procedures designed to prevent the spread of infection were in place … at the Bucs Training facility.” And that’s what Tynes relied on.

Now, Lawrence Tynes only feels betrayed: it’s not so much that he contracted MRSA; rather, it’s the cover-up that led to the infection that bothers him most. In a recent interview he told ESPN: “You expect this billion-dollar enterprise to protect you at all costs, and obviously, they didn’t do a lot of right things. I’m standing up for what I think is right, or what I know is right. I’m in this thing ’til the very end. I’m not going away.”

 

 

Greater Global Co-ordination is Needed to Address SSI Prevention and Antibiotic Resistance

SSISurgical Site Infections (SSI) are a significant risk factor for patients undergoing surgeries. In fact, 77% of deaths among patients with SSI are directly attributable to SSI. Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI. Each SSI is associated with approximately 7-10 additional postoperative hospital days, resulting in significant financial burdens to the healthcare system.  SSIs are classified as superficial incisional (involving only skin or subcutaneous tissue of the incision), deep incisional (involving fascia and/or muscular layers) and organ/space. 1 The cost of each SSIs ranges from $1,000 to $100,000. SSIs are believed to account for up to $10 billion annually in healthcare expenditures in the US, and up to $1billion in Canada…before including the cost impact on families and the economy.

Significant reductions in SSI rates have been realized due to adoption of protocols involving prophylactic use of potent systemic antibiotics like Vancomycin. Long term Vancomycin resistance generation resulting from more widespread use is the trade-off for these significant reductions in short term SSI rates. Vancomycin, long considered one of the potent “last resort” class of antibiotics, has become a prophylactic medical tool to keep surgical site infections in check. The challenge is that there are too few new classes of last resort antibiotics being developed to replace Vancomycin should significant resistance evolve, due to the $1-1.5 billion cost and over a decade required for new drug development.

In light of this challenge, there should be a global coordinated effort to develop new classes of powerful replacement antibiotics as well as a global coordination of antibiotic rotation to preserves the ones that we do have. More emphasis should be taken on screening for at-risk individuals as well as health care workers, at times, the vectors of the spread of infection. Non-antibiotic antimicrobial therapies, such as Photodisinfection, Ultra-Violet Robotic Sterilization, etc. should be quickly advanced and integrated into healthcare associated infection prevention protocols. The superior patient outcomes would be well received around the world and the economics easily justified.

Reference: Infection Control Hospital Epidemiology/Volume 29/Supplement S1/ October 2008, pp S51-S61 http://journals.cambridge.org/action/displayJournal?jid=ICE

The CRE Infections: No One Warned the Patients

“I want to know what the hell is going on and I want to know right now,” Sheila Adamczyk said. “They had two deaths. They knew this had taken place.”

Sheila is talking about the endoscope-caused CRE, or carbapenem-resistant Enterobacteriaceae, superbug outbreak at the Ronald Reagan UCLA Medical Center this winter that killed 2 people, seriously infected 5 more, and put 179 other people on notice that they, too, might become infected.

informed consent 4Her worry is that her 16-year-old daughter, Bailee, whose recent cancer screening involved a scope similar to the ones involved in the outbreak at UCLA, is now at risk. The problem is, no one told her this could happen. Sheila learned about in news coverage and has been trying to reach her doctor ever since.

And this is the position approximately 500,000 people across the country find themselves in, the number of people who annually undergo the procedure.

But there’s an even deeper story. According to specialists like Dr. Andrew Ross, head of gastroenterology at Virginia Mason Medical Center in Seattle “You have to understand that this issue dates back to 2011 – 2012.”

For example, we saw the emergence of the CRE deadly pattern of illnesses in 2012 – 2013 at hospitals in Seattle (11 deaths, 32 infected), Chicago (38 infected) and Philadelphia (8 infected). In each case investigators identified the same source of transmission: a specialized endoscope, threaded down the throat of patients to treat GI tract illnesses.

The agency responsible for oversight of these outbreaks, the U.S. Food and Drug Administration, also knew about them. In a March 4 letter from Congress to the head of the agency, demanding answers, they write: “It appears that the FDA has known for at least two years that the design of [endoscopes] could result in CRE outbreaks.”

Remarkably, the knowledge trail is actually decades long. “We have known about this even as early as 1983 or 1984,” says John Allen, of the Yale School of Medicine. In 1987, Allen wrote in an academic journal about 10 of his patients in Minnesota mysteriously becoming infected with a bacteria that they traced to a single endoscope.

And in this case, knowledge is power. Because in hospitals where outbreaks occurred they immediately fixed the problem, preventing any further infections.

For example, at Seattle’s Virginia Mason Hospital they put used scopes in quarantine for 48 hours after disinfecting and then retested them to make sure no bacteria had regrown before reuse.

So what we have here is everybody knew – the hospitals, the Feds, and the scientists – everybody, that is, except the patients.

The National Law Review, commenting on the pending CRE lawsuits in California and Pennsylvania, issued a clear warning: “Health care personnel should … thoroughly explain associated risks to patients when using reprocessed endoscopic devices.” (My emphasis.)

This is not only how you avoid lawsuits, it’s also how you keep innocent people like Sheila, young Bailee, and others across the country from feeling they were sucker-punched by a “nightmare bacteria.”

So now – and only now – are we seeing places like Cedars-Sinai Medical Center in Los Angeles, also the scene of a recent outbreak, issuing directives that physicians will discuss with the patient “the current unresolved national questions regarding [endoscopes] and CRE.”

While that may be a start, Lisa McGiffert, consumer advocate and director of the Safe Patient Project at Consumers Union in Austin, Texas, says this comes too late for some patients: “It’s really horrific to know so many people underwent these procedures when they could have known the danger beforehand,” she said. “They went in trusting the system, and the system broke down.”

It came too late for Lori (a nurse) and Glenn Smith, the adoptive parents of 18-year-old high school student Aaron Young. Aaron has been in the UCLA hospital since January, bedridden, trying to overcome his CRE infection. We know how Sheila Adamczyk feels because she told us. Here’s a picture of Lori and Glenn taken at their home last month.

How do they feel?

aaron 7

 

 

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