Syracuse, NY – A patient, thought to be brain dead, awoke as surgeons began the process of organ donation.
Doctors at St. Joseph’s Hospital Health Center were preparing to harvest organs from 41-year-old Colleen S. Burns on October 20, 2009 when she opened her eyes. To their shock, she was alive.
Leading up to the procedure, physicians had been under the impression the patient had been irreversibly brain dead, thus in a vegetative state. Instead, the woman had been in a deep coma – caused by a combination of drugs in her system at the time she’d been admitted to the ER for an overdose, reports The Post-Standard.
An investigation by the state’s health department, in March 2010, revealed how a series of mistakes in Burns’ care led to her waking in an operating room, narrowing avoiding involuntary organ donation.
Burns, who had arrived in the emergency room due to a drug overdose – having taken an excess of Xanax, Benadryl, and muscle relaxers – was mishandled by staff according to the state’s findings. It was assessed employees at the hospital skipped recommended treatment which would have prevented the drugs from being further absorbed by her stomach and intestines.
Limited tested were performed on Burns to see if she was later drug-free. An inadequate number of brain scans were done leading up to the brain dead diagnosis. And doctors ultimately ignored observations noted by a nurse, as she indicated the woman’s condition showed improvement.
Medical officials thought Burns had suffered from cardiac death. Based on the diagnosis, her family agreed to withdraw life support and opted for organ donation. But Burns did not suffer cardiopulmonary arrest and did not have irreversible brain damage.
The day before Burns’ organs were to be removed, a nurse, performing a reflex test, noted the patient responded in a way contrary to someone irreversibly brain dead – as Burns managed to curl her toes in response to having the bottom of her foot scraped.
It was also disclosed that just prior to entering the ER for organ donation, Burns was observed breathing independently without the aid of the respirator. Movement was also detected from her lips and tongue.
It wasn’t until Burns was wheeled into the OR and opened her eyes that doctors realized the woman had been in a deep coma.
The mother of three was discharged two weeks after the near catastrophic procedure, but in January 2011, she committed suicide.
Neither Burns nor any of her relatives sued the hospital following the ordeal.
Notably, the hospital failed to make its own independent review of the incident, at least not until the day after the state made a surprise inspection as part of theirs.
According to the federal report, “The hospital did not undertake an intensive and critical review of the near catastrophic event in this case. St. Joe’s officials did not identify the inadequate physician evaluations of (Burns) that occurred when nursing staff questioned possible signs of improving neurological function.”
Based on the findings, and other medical opinions injected into the probe, it was determined the hospital failed to meet adequate reasoning for withdrawing care and opting the patient for organ donation. As a result the hospital was subjected to a fine of $6,000, reports HNGN. Additionally, the state fined St. Joe’s $22,000 and ordered them to hire a consultant to review the hospital’s quality assurance program.
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