26

26 1 DR. SIMMER: Thank you. Are there any 2 questions? 3 Thank you very much. 4 The Commission welcomes our third 5 participant, Alison.I'm sorry. 6 MS. BROWN HEIMSATH: It's a hard one. 7 Heimsath. 8 DR. SIMMER: Thank you. 9 MS. BROWN HEIMSATH: Thank you for allowing 10 me to be here. My name is Alison Brown Heimsath. I'm 11 a registered nurse, although I'm not here in that 12 capacity today. 13 My mother, who is sitting next to me, Lynette 14 Brown, testified on November 15th in Lansing in 15 regards to my dad's death, which occurred June 9th, 16 1999, in a Royal Oak hospital. I just kind of wanted 17 to give you a summary of what it was that led to his 18 death. 19 He, on May 15th, went to the emergency room 20 and complained of shortness of breath and difficulty 21 breathing. He also complained of decreased colostomy 22 output and abdominal pain. He had a past medical 23 history of, let's see, emphysema, as well as colon 24 cancer and lung cancer, although he wasn't in 25 remission as far as his cancers went. He was status 27 1 post chemo and radiation. And he had only one working 2 lung, as he had had radiation therapy to the chest 3 area. He was oxygen-dependent at home, at evenings 4 only, but he was still employed full-time in two 5 courts, District Courts, as a magistrate. 6 Basically, he went to the emergency room and 7 was treated there. He had labs and chest x-ray, 8 abdominal x-ray, and then was admitted as an inpatient 9 to a general medical floor with a diagnosis of 10 abdominal pain, possible pneumonia, and treated for a 11 fecal impaction. 12 Was it about 24 hours later? He had an 13 incident on the general medical floor on the 17th at 14 1:40 in the morning -- 15 MS. BROWN: On the Monday morning, a.m. 16 MS. BROWN HEIMSATH: Right -- where he 17 vomited times one, and was given IV Compazine and 18 morphine as well for his abdominal pain. So at that 19 point, the four siderails were up on the bed as well. 20 MS. BROWN: And they were all the time he was 21 in the hospital room. 22 MS. BROWN HEIMSATH: Right, right. And then 23 a few minutes after four he was found by a nurse's 24 aide, and she stated that she found him after he had 25 tried to get out of bed, that he had been vomiting, 28 1 that he had aspirated and was not breathing when she 2 discovered him. 3 MS. BROWN: His heart never -- 4 MS. BROWN HEIMSATH: Right. She actually 5 made a point of saying that he had a pulse but that he 6 was in respiratory arrest. 7 So at that point a code was called. Narciam 8 [phonetic] was given to try to reverse the effects 9 that he had from the narcotics. He was intubated. 10 During the intubation period, and I'm not 11 criticizing the physician for this, but during the 12 intubation period his dentures that he had in his 13 mouth were broken and they were assumed to have been 14 aspirated, as well -- his broken dentures were assumed 15 to have been aspirated as well as that he had 16 aspirated on the vomit, since he had been vomiting. 17 As far as the aspirated teeth, that was 18 interesting because I discovered it later by looking 19 at the chart. They never mentioned that to us nor did 20 they do a bronchoscopy on him. A bronchoscopy was 21 done one week later, at our own insistence, but not 22 done -- my impression was that they were trying to -- 23 MS. BROWN: Cover up. 24 MS. BROWN HEIMSATH: -- make sure that we 25 didn't know, you know, some of the details on it. But 29 1 basically at that point he obviously was transferred 2 to the ICU unit, and that was in the early hours of 3 that morning. 4 And then by 6:30 on that morning he was fully 5 alert and conscious, was following commands and was of 6 normal mental status. Obviously, he continued to be 7 intubated and was on a respirator. However, 18 hours 8 later he, because of his agitation, was put on an IV 9 of Ativan, Ativan drip, and then also Norcuron, which 10 is a paralytic drip. Agitation -- and then, you know, 11 after that his mental status obviously was changed. 12 But then basically over the next three weeks 13 his condition deteriorated. Each -- they were doing 14 chest x-rays on him every few hours, and each one 15 looked a little worse until basically his only lung 16 that he had that was in use, his right lung, was no 17 longer, you know, functioning or working as well. 18 And then also during that three-week period 19 that he was in ICU he developed ARDS, which is Adult 20 Respiratory Distress Syndrome; DIC, which is a 21 blood-clotting type of disorder; and a cerebral 22 hemorrhage from the GIC that he had developed, and 23 then he passed away on June 9th, 1999. 24 So I thought for me when I think it over, I 25 think it's unfortunate. He did have some health 30 1 problems but certainly he went into the hospital in 2 the emergency room in good shape. He was still 3 employed full-time. He drove himself to the emergency 4 room and -- 5 MS. BROWN: I was visiting -- 6 MS. BROWN HEIMSATH: -- basically, then, he 7 left the emergency -- you know, left the hospital 8 three weeks later in a body bag type of thing. 9 And I felt really that the main cause of it 10 was a couple of things that happened but basically 11 that he was heavily medicated on both a narcotic and a 12 sedative. That he -- this was his second vomiting 13 episode. He was a patient that was at high risk for 14 aspiration because of the fact that he only had one 15 functioning lung. 16 So I think the fact that he was heavily 17 medicated, that the siderails were all up on the bed, 18 and I would guess that he was probably trying to get 19 out of bed to go into the bathroom, you know, and that 20 that was how this happened. So I think it had to do 21 with the medications. 22 MS. BROWN: They were -- when I was there the 23 Monday afternoon, they were very short of help in the 24 hospital, nursing help. He was the last room down 25 from the nurse's station. I'm assuming they were even 31 1 shorter, from the hospital records, during the wee 2 small hours when this happened to him. He was never 3 checked in the period between the first vomiting -- 4 MS. BROWN HEIMSATH: And the second. 5 MS. BROWN: -- and the one many hours later. 6 And no doctor saw him at any time after the first 7 vomiting. 8 I believe that the -- it would appear to me, 9 from having spent much time with the hospital records, 10 that the computer was down in the emergency room and 11 that much of the information that they obtained in the 12 emergency room did not travel with him to the hospital 13 room. 14 So they were unaware in the hospital room he 15 was functioning on just one lung. They did not know 16 who his internist was. They did not know the seven 17 oncologists that were taking care of him. In other 18 words, the communication was totally lacking between 19 his care in the emergency room and the information 20 that traveled -- that did not travel with him to the 21 hospital. 22 MS. BROWN HEIMSATH: I think there were a lot 23 of things that went wrong from beginning to end, but 24 for me I feel like the worst thing that happened was 25 the fact that he was so heavily -- was in a strange 32 1 environment, had all the siderails up, was very 2 heavily medicated on both a narcotic and Ativan as 3 well, and then basically was a high-risk patient due 4 to the fact that he had a compromised respiratory and, 5 basically aspirated. 6 MS. BROWN: And he was alone. 7 MS. BROWN HEIMSATH: And it wouldn't have 8 happened to him at home because he wouldn't have had 9 siderails up nor would he be on those medications. 10 MS. BROWN: And I would have called 911. 11 MS. BROWN HEIMSATH: Right. So I think the 12 whole thing was just very unfortunate. 13 MS. BROWN: And then there was a big cover-up 14 while he was still living. And, you know, I think -- 15 I don't know if there's any legal difference between a 16 cover-up when someone has died, but I felt there was a 17 great one between someone who was still living for 18 weeks, and particularly when I could not get them to 19 do the bronchoscope for the teeth that they believe 20 were aspirated from his dentures, for a week, because 21 they never told me about any of that. 22 MS. BROWN HEIMSATH: I just asked one day to 23 read the chart and -- 24 MS. BROWN: She read it. 25 MS. BROWN HEIMSATH: -- saw it on the chart 33 1 that that had happened to him in the code. And I 2 don't criticize the physician for breaking his 3 dentures because in an emergency situation you're 4 trying to -- 5 MS. BROWN: No, no, but I should have been 6 told immediately. 7 MS. BROWN HEIMSATH: So I don't know what can 8 be learned from it but I think it was a combination of 9 siderails being up, high risk -- 10 MS. BROWN: Yes. And when I testified at the 11 first hearing, the paper that -- I had not expected to 12 testify, and I certainly did not write what I filed as 13 part of the record, which is "Note from Lynette 14 Brown," and it's 10 typewritten pages, single spaced, 15 margins crowded, and it was done for the lawyers to 16 work their way through the folders of the records 17 after I had arranged the records, you know, in 18 chronological order, et cetera. So that was the note 19 that you got as part of your record. 20 MS. BROWN HEIMSATH: I guess basically that's 21 it. 22 DR. SIMMER: Okay. Thank you very much. I 23 think that is very illustrative. 24 MS. BROWN HEIMSATH: Thank you. 25 DR. SIMMER: And are there any questions 34 1 among members of the Commission? 2 MS. McDONALD: Only that the records did not 3 travel with him, that's what you're saying? The 4 records weren't coming -- 5 MS. BROWN HEIMSATH: That was part of it, 6 that the records didn't go from the ER up to the 7 floor. 8 MS. BROWN: The three-page emergency room 9 report was typed and transcribed three days later. 10 And, you know, but none of that -- what traveled with 11 him, for instance, on the chart, where it says 12 attending physician, it says none. And all of this 13 information was in the computer and, you know 14 Dr. Simpson had been his doctor for decades, and there 15 were just a number of things like that. 16 Now, for instance, on the information that 17 traveled with him, this wasn't important for him, but 18 the information that traveled with him said he had no 19 allergies. Actually, he had an allergy to the iodine 20 dye for CAT scan, which had been discovered about ten 21 years earlier at the hospital and which was 22 permanently on his record, you know how it appears. 23 And so the only explanation is that the computer was 24 down when he was in the ER. 25 MS. BROWN HEIMSATH: Basically, they weren't 35 1 fully aware that he was he was a respiratory risk 2 patient and that he could aspirate and -- 3 MS. BROWN: So this shows how important 4 communication is and that this information travels 5 with the patient. 6 MS. BROWN HEIMSATH: Thank you.

Source: http://www.mihealthandsafety.org/statecommission/barefoot/testimony/409O.pdf