My story is about the failure of professional caregivers to properly treat a patient with Addison’s Disease (a rare disease.) It is a disease so dangerous that doctors (and the National Institute of Health) advise sufferers to always carry identification stating their condition in case of an emergency and when traveling, to carry a needle, syringe, and an inject-able form of cortisol for emergencies. It affects 1 to four of every 100,000 persons.
Addison’s disease occurs when the adrenal glands (of the kidney) do not produce enough of the hormone cortisol. Cortisol is essential to the body’s functions. It maintains blood pressure and cardiovascular function, maintains levels of glucose in the blood, slows the immune systems inflammatory response and regulates the metabolism of proteins, carbohydrates and fats. With the right balance of daily cortisol medication, most people are able to live a normal life.
When under stress such as infection, bodily damage, surgery etc, the body requires supplemental cortisol. A life threatening acute adrenal insufficiency crisis or Acute Addisonian crisis can occur due to lack of the cortisol. Signs of an acute Addisonian crisis in a sedated patient in the OR would likely be : Shaking Chills, Rapid Heart or Respiratory Rate, Low Blood Pressure………. Attempted Vomiting………Blood Chemistry (Low blood glucose and sodium, High blood potassium and calcium). All authorities require that prior to surgery patients known to have Addison’s Disease receive a presurgery dose of hydrocortisone.
My wife Mary Elizabeth Fox was hospitalized on October 2, 2008 in ValleyMedicalCenter on October 27, 2008. She died October 27, 2008.
Mary was hospitalized because she broke her femur. Surgery was required to repair the break. I was told that during the operation and afterward her blood pressure dropped sharply and drastically. The next day, she was put in critical care. This was on or about October4, 2008. I was given no further details, I remember asking my doctor if this had been an Addison Crisis. Mary was known to have Addison’s disease and this event should have been a blazing red warning flag. A severe drop in blood pressure is probably the leading symptom of an Addisonian Crisis. It usually causes severe kidney damage. Everyone denied that it could have been.
I remember that while I was comforting my wife, prior to that first surgery when the orderlies came to take my wife to the operating room I heard one of them say “She was supposed to take this half an hour before surgery, too late now…..”. Oh how I wish I had realized what that might have been about! Available hospital records and post death investigation findings indicate that my wife did not receive vital presurgery medication (although it was ordered). On October 6, my wife was examined by a nephrologist because her urine output had, since the surgery, decreased to dangerous levels, and her blood sodium was very low. The nephrologist report stated acute renal failure, due probably to acute tubular necrosis, and intervascular volume depletion. Her kidney dysfunction continued until her death.
In November 2008 I wrote the CEO of Valley Hospital relating the above and stating that I believed that (caregiver) personnel had been ignorant and not informed of the precautions necessary in treating those who have Addison’s Disease. I clearly identified my concern that my wife had not received presurgery hydrocortisone medication. Department of Health opened an investigation of my complaint December 1, 2008.
The initial Nursing Care Quality Investigation report, by a Jill Stevens, RN, totally ignored the complaint. There was no investigation to verify, or deny contradictory records concerning presurgery medication. The case was treated as a typical broken leg patient care incident! Contradictions in patient records were ignored. There is no record that any caregiver personnel were interviewed -either nurses or OR personnel. A false statement concerning the availability of hydrocortisone in OR “crash carts” was included as part of the report. This “breezy” investigation of my concerns derailed the entire complaint investigation. The nursing care case was closed and remained closed despite my many protests.
As a result of a revision in State law the case (Nursing Care Quality) was reopened two years later. Certified testimony was obtained from involved caregivers. Due to the elapse of two years, none of her nursing caregivers remembered anything about presurgery medication. A contradiction between “ Scheduled Medications records (no record of presurgery medication administered) and a patients chart (Order sheet) entry by an OR nurse was further emphasized when the OR nurse gave certified
testimony that she did not administer the medication but “saw” it in a nursing handoff report (she did not remember by whom or where. There was no such record in my copy of hospital records), I had been with my wife most of the morning and accompanied her until her gurney was wheeled into the OR. and did not witness any act of medication. The OR anesthesiologist certified that he had asked (in the OR) why the patient (my wife) had not received perioperative medication. The only record of a Medical investigation recorded an informal meeting with the Valley Hospital Risk Assessment Team. This team misinformed the Medical investigator by asserting that presurgery medication had been administered in the OR.
Despite these new inputs Department investigators failed to act. There was certified testimony that patient behavior in the OR caused a participant to question presurgery medication, patient’s blood pressure reacted negatively and no medical personnel bothered to test for an Acute Addisonian Crisis at the time. The OR records do not show that any hydrocortisone was available in, or administered, in the OR. The records show only administration of vascular constrictors, I questioned that in my protests because it was contrary to conventional treatment during an Acute Addisonian crisis.
Department of Health investigators demonstrated profound ignorance concerning Addison’s disease to the point that they asked nurses to describe how they would recognize Addison’s Disease instead of asking about symptoms of an emergency Addisonian Crisis. The initial investigation by nurse Stevens showed that there was no understanding of who to ask or what to look for.
Harry Fox
