A Utah woman’s blood drained from her heart into a garbage can, killing her, according to lawsuit

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The family of a Vinyard woman is suing a Utah hospital, saying she died after surgery because doctors left an open tube from her heart that drained her blood into a garbage can.
Doctors at St. Mark’s Hospital in Millcreek performed heart surgery on Donnamay Brockbank in July 2018 to remove a medical device that was causing an allergic reaction, according to a complaint filed last week in Utah’s 3rd District Court.
The surgery required a cardiopulmonary bypass, with blood exiting Brockbank’s body through a large needle and tube near her neck going through a blood reservoir and re-entering through her femur.
After the surgery, when Brockbank’s heart was beating on its own again and the surgical wound was closed, the head surgeon left the operating room and a technician began to break down the bypass machine, the lawsuit states.
The tube and needle, or cannula, returning blood to Brockbank's femur was removed. But blood was still leaving Brockbank's body through the other cannula, which was left in her body, unclamped, the lawsuit states. The technician removed the blood reservoir from the bypass machine and put it in a medical waste garbage can as Brockbank's heart continued to pump blood into it, the suit alleges.
As Brockbank's blood pressure crashed, the surgeon, Dr. Shreekanth V. Karwande, returned to the operating room.
Over the course of 40 minutes, doctors performed plasma transfusions that added seven pints of blood to Brockbank’s veins, nearly doubling the amount of blood typically in a human body, said Rand Nolen, an attorney for her family.
But none of the medical professionals in the room addressed the tube piping blood out of Brockbank and into the garbage can, the lawsuit states.
"It boggles the mind, with how experienced this team was, that nobody would catch such a simple oversight," said Rhome D. Zabriskie, another of the family's attorneys.
Brockbank briefly stabilized with the transfusions, but as that blood also passed through the cannula, her heart began to give out, said Nolen, a Houston-based personal injury attorney. Eventually Karwande reopened Brockbank's chest and tried to manually manipulate her heart, Nolen said, but he could not revive her.
When Karwande left the operating room the first time, he told Brockbank’s family the surgery had gone well, Nolen said
"An hour and a half later, he tells the family this is on him, and that she has died," Nolen said.
In a meeting about two days later, hospital employees told Brockbank's family that the reservoir of blood had been found in the garbage can, Nolen said.
"We want to express our deepest condolences to Donnamay Brockbank’s family for their loss," said St. Mark's CEO Mark Robinson. "Unfortunately, we are unable to comment on any pending litigation. That said, we continuously seek to learn from every patient situation to improve the quality and safety of the care we provide in our operating rooms and throughout the hospital."
But Nolen and Zabriskie say they have largely had to piece together what happened with the help of outside medical experts and family recollections of their conversations with hospital staff — because, they said, the medical records from the surgery “fell well below any known standard of care in the United States of America.”
"The records relating to this surgery are as poor, if not poorer, than you would find in a third world country," the lawsuit states.
For example, Nolen said, the whereabouts of the assistant surgeon, Dr. David Affleck, are not documented after the initial surgery.
"The records are as poor as any I have seen in 27 years," Nolen said. "They're amazingly bad. Normally when a patient dies in a hospital, you get a discharge summary and an operative summary that will detail for you ... exactly what is happening throughout the procedure. Normally what you anticipate, particularly if a patient has passed away, is that you will get a step-by-step recitation from the surgeon as to what was happening in that operating suite. If those exist, they have not been provided to us."
Brockbank, 63, was survived by her husband, four children, five stepchildren, more than twenty grandchildren, as well as her parents and six siblings.
"Her family is devastated by this," Zabriskie said.
The lawsuit names as defendants St. Mark’s Hospital, Dr. Karwande, MountainStar Cardiovascular Surgery, SpecialtyCare Cardiovascular Resources, and Kyle Enslin, who was the anesthesiologist for the surgery.

Obviously one sided account but that’s a pretty devastating mistake to make with a cardiac bypass patient if the lawsuit’s allegations are true.

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Obviously one sided account but that’s a pretty devastating mistake to make with a cardiac bypass patient if the lawsuit’s allegations are true.

Horrible. Is it common practice for the technician to start breaking stuff down and remove canulas from patient without the surgeon present?
 
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Usually articles written by non-medical people are difficult to understand, but this one takes it to another level. I can't piece any of it together. What the F was going on here?

Which medical device would you have an allergic reaction to that would need a bypass run to remove? Something intracardiac? Why would you need to peripherally cannulate? Do they mean she was on ECMO, not CPB? What cardiac surgeon leaves the room with cannulas still in? Was there a resident/fellow there? Why would the perfusionist (I assume that's who they meant by "technician") start breaking down the pump with cannulas still in?

So confused...
 
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Nothing about this makes any sense.
 
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No clue what cardiac surgery she was having (maybe an allergy to an ASD closure device or something??), but it was likely minimally invasive via a mini-thoracotomy. Sounds like she bled out through the PA vent or the CS catheter, lines the anesthesiologist placed. I suppose it is also possible a venous cannula was placed in the RIJ but I assume the surgeon wouldn't have left before this line came out. I do a number of these cases and can see how this could happen if one wasn't paying close attention and a stopcock got turned.
 
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Usually articles written by non-medical people are difficult to understand, but this one takes it to another level. I can't piece any of it together. What the F was going on here?

Which medical device would you have an allergic reaction to that would need a bypass run to remove? Something intracardiac? Why would you need to peripherally cannulate? Do they mean she was on ECMO, not CPB? What cardiac surgeon leaves the room with cannulas still in? Was there a resident/fellow there? Why would the perfusionist (I assume that's who they meant by "technician") start breaking down the pump with cannulas still in?

So confused...
Agree. My best guess is an ecmo cannula came out while moving the pt.
 
I was also thinking maybe a lead extraction that they thought was going to go sideways? I can't imagine it was an actual allergic reaction to a device, had to have just been a device that was causing some sort of problem. IVC filter that got dislodged? Who knows. So many possibilities.
 
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No clue what cardiac surgery she was having (maybe an allergy to an ASD closure device or something??), but it was likely minimally invasive via a mini-thoracotomy. Sounds like she bled out through the PA vent or the CS catheter, lines the anesthesiologist placed. I suppose it is also possible a venous cannula was placed in the RIJ but I assume the surgeon wouldn't have left before this line came out. I do a number of these cases and can see how this could happen if one wasn't paying close attention and a stopcock got turned.

I also do a bunch of minimally invasive cardiac, so my $0.02.

The Nitinol alloy used in many intracardiac devices can cause irritation in patients with nickel allergies. Several patients have been referred for robotic ASD closure at our shop for this very reason. Doubtful the patient was on ECMO due to an allergic reaction, but I guess it’s possible...

If it was indeed a R sided procedure (i.e. ASD closure and device removal), any percutaneous R sided intracardiac catheter placement (CS cath, PA vent) would be unlikely due to the need for transseptal approach and bicaval cannulation, although your point about exsanguination through either of those catheters is totally possible if you’re not careful!

Sounds like somehow the SVC cannula wasn’t already removed when the surgeon left the room (possibly a larger Fr IJ/SVC line placed by the anesthesiologist, like in Heartport) and maybe through some awful stroke of bad luck a stopcock was opened while the perfusionist was taking down the bypass circuit...

Either way a terrible outcome, and a terribly written and researched article!
 
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Yikes. Sounds like a bad situation, although clearly we are missing some important details from that poorly written article.
 
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