by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)
On July 23, 2007, 17-year old Logan died after successfully undergoing routine surgery to correct his sleep apnea.
In a podcast recently released by the Physician-Patient Alliance for Health & Safety, Pamela Parker, BSN, RN, CAPA describes her son, Logan, as âa red haired, fair skinned, seventeen year old fun big kid â¦ [who] was very silly and â¦ even embraced the term âgoofyâ.â
Logan had obstructive sleep apnea (OSA) with elements of central sleep apnea. He underwent surgery to have âhis tonsils and his uvula removed, septum and his turbinate repaired. Basically, opening up the airway by removing the tissue in the back of his airway.â
Below are some key excerpts from the interview with Ms. Parker:
On Loganâs Respiratory Assessment:
Logan received IV morphine. Two milligrams administered at 12:50, again at 12:53, and again at 13:10. His IV was removed eight minutes later and he was discharged at 13:25, just fifteen minutes after his last dose of morphineâ¦
Â There was not any scoring tool used to track his level of sedation during his recovery period. The surgery center only used the Alrdete Score during his anesthesia recovery period. And in reality Logan died in 2007 prior to the common use of the Pasero Opioid Induced Sedation Scale â¦
Based upon the [Pasero Opioid Induced Sedation] Scale Logan was probably a three. Changing the probe from one finger to another, it might have stopped the pulse oximeter alarm from going off, but it did not address the true problem. It can now be assumed that Logan was already having ventilation issues. According to that to the Pasero Opioid Induced Sedation Scale, Logan’s condition was unacceptable and this required a decreased opiate opioid dose – 25 to 50 percent – or notify the prescriber.
On the Need for Process Improvement:
We can do better.
Each health care provider needs to consider the risk of respiratory compromise in planning a patient’s care, and this includes all clinicians involved in creating and implementing a plan, including the surgeon, the anesthesiologist, and the nurses. And, it should entail frequency of respiratory assessment and the types of monitors being used. Capnography should be used on all patients who are at risk for increased carbon dioxide.
Other considerations include minimal usage of medications that increase respiratory depression, such as phenergan and benadryl. Additionally, the patient should receive full reversal medications by anesthesia at the end of surgery. Clinicians must create a better plan for the at-risk patient.
I am a recovery room nurse, and yet I did not have the tools and I could not save him. Â
After discharge, his deterioration was already rolling down too an accelerated path.
We must do better. Screen our patients for risk. Know the signs of deterioration in a timely manner with a thorough, a thorough nursing assessment and intervene earlier. I firmly believe that the appropriate monitors have been used – specifically capnography – and if he had received additional and longer monitoring in an un-stimulated environment, July 23rd of 2007 would have had a different endingâ¦
The recent guidelines for respiratory depression have come after his death. Unfortunately, it often takes a bad outcome to create a better process. Loganâs bad outcome was absolutely heart wrenching and devastating for our family. Now, now is a time for process improvement.
Do not just use capnography, use it and use it well. Understand it. Use it to become a better nurse in your assessment of your patients. Do not be a task oriented health care provider. Thoroughly assess your patientâs respiratory status. Look at the big picture.
Remember this story. Remember that if the seventeen year old boy could die from complications of sleep apnea, anyone can.Â
Ms. Parker has been a registered nurse for almost 25 years. She is a recovery room nurse and works in the ambulatory procedure unit at a hospital in Indiana. In addition to providing patient care, Pamela is a clinical educator and provides bereavement support. To help others with the loss of loved ones, she writes a blog âHope for Grieving Mothersâ (http://www.holeheartedmamas.com/).
For a pdf transcript of the interview, please click here.