Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 2)
© Copyright AAMI 2015. Single user license only. Copying, networking, and distribution prohibited.
Features
unable even to respond to our pleas for help.
I was stunned at the disorganization we had
witnessed, and felt that my son's death would
be meaningless if we did not do all we could
to change the situation."
Following Lewis's death, Haskell became
active in the patient safety movement. She
founded the group Mothers Against Medical
Error and helped create a coalition of South
Carolina health professionals and consumers to pass the Lewis Blackman Act, aimed
at addressing the conditions that led to
Lewis's death.
"These stories all involve people not
paying attention," says Haskell. "I believe
that continuous monitoring must be part of
a system for rescuing deteriorating
patients. Data must be trended, rolled up
into a score, and evaluated by a critical care
person who is not part of the original team.
Respiratory depression is the key measure,
and I believe that technology is the answer
to get around toxic relationships in the
hospital environment."
"Every patient deserves continuous monitoring," she says. "You never know what's
going to happen, particularly with postoperative patients. Lewis is a prime example. He
was a perfectly healthy child, which is why no
one could believe that anything was wrong
with him. You need an objective observer like
a monitor."
Leah Coufal: Chest Surgery
Risk Factors: None
In December 2002, Lenore Alexander's
daughter Leah Coufal, a healthy 11-year-old
girl, underwent elective chest surgery at a
major medical center in Los Angeles, CA, to
correct pectus carinatum, a deformity of the
chest. "A lot of things went wrong that day,"
says Alexander.
Leah came out of surgery successfully. She
was on an epidural with fentanyl for pain
control. When her pain was not relieved, they
increased her fentanyl dosing, ultimately to
the highest dose. When Leah's parents
insisted that they stop increasing her pain
medication dosing, they gave Leah ativan, an
anti-anxiety medication, instead. Leah was not
on any electronic monitors. Per hospital
policy, nurses checked on her every few hours.
Alexander stayed at her side that night but,
exhausted, finally dozed in a chair next to
Leah's bed. When she woke, Leah was dead, a
victim of undetected respiratory arrest. An
autopsy found that Leah's epidural had been
"These stories all involve people not paying attention.
I believe that continuous monitoring must be part of a
system for rescuing deteriorating patients."
- Helen Haskell, mother of son who died in the hospital
inserted in the wrong place, into the intrapleural space of her left lung rather than to the
epidural space in Leah's spine. This explained
why she was feeling so much pain.
"That night at the hospital, I didn't know I
needed to be ready to save Leah's life," says
Alexander. "I didn't know she needed
protection. But she did. This was so avoidable. Had she been on a monitor, they would
have detected that her breathing was deteriorating and something would have triggered
an alert. With no medical training, I could
have saved my child's life that night." Ten
years later, Alexander began speaking out
about Leah's experience, advocating for what
she calls Leah's Law: Continuous postoperative monitoring for patients on opioids.
"How many children will die this year
because they're not on a monitor after
surgery?" asks Alexander. "The way my
daughter died 10 years ago, she would die
today, just as likely. I think of all the families
that have been torn apart and broken by the
tragedy of losing a child, and it's because
most things have not changed. We're not
doing enough things differently. How many
families will be told, 'Your child died from
respiratory depression,' never understanding
Biomedical Instrumentation & Technology January/February 2015
41
Table of Contents for the Digital Edition of Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 1)
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 2)
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 3)
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 4)
Saving Lives, Saving Families: Continuous Monitoring For Patients on Opioids - (Page 5)
https://www.nxtbook.com/allen/bmit/january-february-2015-40
https://www.nxtbook.com/allen/bmit/november-december-2013-467
https://www.nxtbookmedia.com