In surgery, when something goes wrong, minutes become hours.
Minutes are the focus of a lawsuit filed by the family of a 29-year-old Seymour nurse who died in February 2015 after undergoing minor elective sinus surgery at the North Haven Surgery Center. The suit alleges that the center waited as long as 29 minutes to call an ambulance after Katherine O’Donnell’s blood pressure and pulse fell to critical levels on the operating table – and that doctors continued to proceed with surgery, even as their efforts to resuscitate her failed.
The case raises questions about how well equipped freestanding surgical centers are to handle emergencies, and what sanctions they face for alleged lapses in care. The lawsuit alleges that the center and Fairfield Anesthesia Associates, LLC, which handled anesthesia in the case, failed to properly respond by stopping the surgery immediately and calling a “Code Blue” emergency when O’Donnell’s blood pressure and oxygen levels plummeted.
Records show the state Department of Public Health investigated the incident in March 2015 and found that “the standard of care was met” for anesthesia and surgical services. The agency cited the center for two minor violations related to documentation, but did not raise concerns about the time that elapsed before an ambulance was called. No other state action is pending, a DPH spokesman said.
O’Donnell, known as Katie to her family and friends, was a dog lover and avid New York Yankees’ fan who worked as a licensed practical nurse at a visiting nurse agency in Stratford. She was in good health when she went in to the North Haven Surgery Center on Feb. 25 for elective sinus surgery, records show.
But within minutes of being put under general anesthesia shortly before 11 a.m., O’Donnell’s blood pressure began falling, according to court documents based on the surgery center’s medical records. By 11:11 a.m., her blood pressure was “unobtainable” and the pulse oximeter was “not reading,” documents show. According to anesthesia notes and the Code Blue emergency sheet, surgery was allowed to continue, even as cardiopulmonary resuscitation efforts were underway.
While the anesthesia notes say that CPR was started and an ambulance was called at 11:18 a.m., American Medical Response (AMR) records show no call was made until 11:40 a.m., reflecting “an approximate 29-minute delay in calling EMS despite a cardiac arrest situation,” according to a medical expert’s review included in the lawsuit.
O’Donnell arrived at Yale-New Haven Hospital at 12:22 p.m. Despite efforts to revive her, she was pronounced dead an hour later.
The lawsuit alleges that the surgery center and Dr. Barry D. Stein, an anesthesiologist employed by Fairfield Anesthesia Associates, LLC, failed to properly respond to the medical emergency, failed to keep proper records of the procedure, and failed to accompany O’Donnell to the hospital, among other lapses. O’Donnell’s father, John O’Donnell, is seeking unspecified damages in the case, which is pending in New Haven Superior Court. He referred comment to the family’s attorney, Josh Koskoff of Bridgeport.
Attorney Sally O. Hagerty of Stamford, representing Stein and Fairfield Anesthesia Associates, declined to comment on the case. An attorney for the North Haven Surgery Center did not return messages seeking comment.
Koskoff said O’Donnell’s family is seeking answers about what went wrong – not just for themselves, but for others who may turn to outpatient surgery centers as an alternative to hospitals. He cited another wrongful death case filed last year by the family of 53-year-old Michael A. Palmer of Stratford, who died after medical staff at an outpatient center in Trumbull allegedly gave him the wrong medication. Fairfield Anesthesia Associates is also a defendant in that case.
“We’re really in a dawn age with these surgery centers, and they really need to get their act together,” Koskoff said. “They’re fine when nothing goes wrong, but they don’t have those added layers of protection that hospitals do” in case of complications.
“It’s really important to Katie’s family not only that her case be brought to justice, but that it might help to prevent something like this from happening to any other family,” Koskoff said.
The Ambulatory Surgery Center Association says that the growing national network of outpatient centers is tightly regulated to ensure patient safety and quality.
Medical records in O’Donnell’s case offer conflicting accounts of how long Stein and the surgeon in the case, Dr. Craig S. Hecht, continued operating on O’Donnell after her blood pressure and oxygen levels began to fall. Hecht is mentioned in the lawsuit but is not named as a defendant.
The DPH report indicates that O’Donnell was given epinephrine, a heart stimulant, at 11:10 a.m., soon after surgery began. A Code Blue emergency was not initiated until 26 minutes later, at 11:36 a.m., when her pulse rate was recorded at just 42 beats per minute, the DPH report says.
An expert’s review of medical records, included in the lawsuit, cites conflicting accounts of what happened in the interim. The “anesthesia note” on the case says that all anesthetic medications were discontinued at 11:15 a.m., that surgery was stopped, and that CPR was started. Meanwhile, the Code Blue Emergency Chart says surgery was halted at 11:22, but then resumed at 11:30.
The surgeon’s operative report appears to support that surgery continued after O’Donnell’s vital signs failed. The report “documents completion of extensive surgery . . . far more extensive than could have been completed in the four minutes preceding Ms. O’Donnell’s circulatory collapse,” the expert’s review says.
In its report, the DPH cites several other discrepancies in the case. The agency notes that Stein, the anesthesiologist, originally had documented that he gave O’Donnell 300 mcg of epinephrine, but later “changed the amount to 500 mcg by writing over the initial entry.”
The DPH report also cites misleading documentation on the time O’Donnell was transferred to Yale-New Haven. The patient transfer form “incorrectly identified” that O’Donnell was transferred at 11:45 a.m., 10 to 15 minutes before EMTs actually took over her care.
A spokesman for the DPH, Christopher Stan, said there are no other actions pending against practitioners involved in the case. Stan confirmed that, in general, the DPH has authority to cite facilities for not following proper procedures in alerting emergency personnel. All outpatient surgical facilities are required to have guidelines for emergencies, as well as emergency equipment and drugs for resuscitation.
Stein is a managing partner of Fairfield Anesthesia Associates and is listed as medical director of the North Haven Surgery Center. He did not return messages.
The North Haven Surgery Center is part of a national for-profit chain of surgical centers owned by United Surgical Partners International and Tenet Healthcare, according to court filings. Dr. Mark Thimineur, director of the Comprehensive Pain & Headache Treatment Centers in Derby, is a principal of the North Haven center and was involved in its founding as the North Haven Pain Medicine Center, state records show.
Thimineur’s Derby pain center has been the subject of state and federal scrutiny in the past year. A nurse who was employed there, Heather Alfonso, was charged last summer with accepting kickbacks from a drug company in exchange for her prescribing of a powerful cancer drug. Thimineur was reprimanded and fined $7,500 in June by the Medical Examining Board for writing prescriptions without properly assessing patients.
I am very sorry to read of the tragic and completely preventable death of Katie O’Donnell. And I understand the anger and outrage of her family, better than anyone.
My 21 year-old son died in August, 2012, after what was supposed to be “simple” surgery on both of his feet at an outpatient surgery center owned by Orthopedic Associates of Hartford , to remove hardware that had been inserted in two painful surgeries five years earlier to create arches. The titanium implants had broken into sharp metal shards and required extraction. In recovery following the surgery, they were slow to effectively medicate and manage his post-op pain (it is well-known that redheads require higher doses of both anesthesia and pain medication). Instead of the typical one hour in recovery before discharge, he required two in order for his pain to be managed sufficiently to be discharged. This meant that they had another patient coming out of surgery, and they needed the bed, causing the nurse to rush his discharge, “Here are your instructions [single-spaced, densely-written, difficult to read], sign here, take two baby aspirin, elevate your legs above your heart, call us if there’s a problem.” Those were literally her words, and the sum total of discharge instructions he received while still woozy from anesthesia and post-op pain medication.
What she failed to do, what the surgeon or anyone in the surgery center failed to do, was review the list of medications that he had submitted prior to surgery, and say clearly to him, “Johnny see this list of meds that you regularly take? You will still have anesthesia in your system for several days, and we are giving your Percocet for pain. Those will suppress your respiratory system, so do NOT take the Xanax and Sonata you have listed here, that you normally take when you are going to sleep, for the next few nights.”
Outpatient surgery centers are owned by large practices and hospitals and run for profit, “in by 7, home by 12!” My son had too many red flags (weight of 350 lbs, mild sleep apnea, eight different prescription medications for anxiety and depression, which he fully disclosed) to be undergoing any procedure involving general anesthetic in an outpatient setting; had he been hospitalized and observed post-op overnight, he would not have been given his regular sleep meds, and any drop in his heart rate and O2 saturation would have been detected and addressed. In short, he would still be alive.
Instead, he did take the meds he regularly took at bedtime – no one told him not to. All he had were the difficult-to-read written discharge instructions with one brief phrase buried in the middle – “Do not take tranquilizers while taking the pain medication prescribed.” My son didn’t even know what “tranquilizers” WERE! That is an archaic word used in the 60s-70s, no longer part of common medical parlance. As far as he understood, he took “anti-anxiety” medications. Was a 21 year-old supposed to understand that when they said “tranquilizers,” they, in fact, meant his meds for anxiety?
Johnny went to sleep that night, taking his bedtime dose of Percocet, and the Xanax and Sonata (a mild short half-life sleep medication) that he took ever night. He never woke up. The combination of medications with the anesthesia remaining in his system suppressed his respiratory system too much, starving his brain and heart of oxygen, causing cardiac death. Deaths from accidental overdose due to the combination of Xanax ( a benzodiazepam) and Percocet (an opiate) have become epidemic, especially among young people, but are rarely mentioned in discussions about the dangers of opiate use.
Outpatient surgery centers are surgical assembly lines, designed for speed and profit. More and more procedures are being pushed out of hospitals to outpatient centers. Corners are cut, such as careful and thorough review of discharge instructions, or immediate and appropriate response to unexpected medical emergencies, putting patients are at far greater risk than they would be in hospital settings.
My heart goes out to the O’Donnell family, and I grieve for the beautiful young woman whose life was cut short due to egregious medical error. Her death, and my son’s death, were entirely preventable, had appropriate medical practices been followed. More and more outpatient surgery centers are being opened as physicians and hospitals seek to cut costs and protect profits. Our oversight and regulation of these centers needs to be far better; every death or negative outcome should be thoroughly investigated, beyond the Medical Examiner’s autopsy findings for cause of death. with a careful, independent review by the State of procedures, decisions and actions for adherence to best medical practices.
Am sorry to hear what happen but I just lost my dauther on 2/16/18 in a surgery center in fort lee new jersey still weighting on the medical report