Woman, Discharged Prematurely, Dies of Overdose From Pain Pump Refill

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A physician assistant, a physician and hospital personnel were found to be negligent and caused the premature death of a woman, Marie Heisey, after negligently placing pain medication through a pain pump, causing a deadly overdose.  Mrs. Heisey was a 57-year-old Michigan woman had a pain pump placed in her spine in 2006 after battling chronic pain from scoliosis for the past six years.

Her pain pump was battery powered and had a reservoir that held 20 milliliters. The pump could be programmed to deliver medication from the reservoir to the spine. A doctor could also use a device to read the œtelemetry from the pump. The device identified the patient, how much medication was left, and when the pump had to be refilled. From the date the pain pump was placed to the incident at issue, the woman had six refills and adjustments to the pump.

The pump was successful in controlling Mrs. Heisey’s pain and not impairing her daily activities.  Due to the success, she scheduled another refill of the pump at the hospital’s pain clinic.  During the procedure, a physician assistant (PA) attempted to refill Marie’s pump. He had  her lie down and took the pump’s telemetry, which verified her name and told him there were 13 milliliters of medicine in the pump. The PA took the template from the refill kit and felt the skin to make sure that the template fit over the pump. However, the PA could not match the template to the pump.  A  physician helped the PA. She oriented the template, which she was confident was properly oriented over the pump to access the center port. She then watched as the PA inserted the needle and aspirated 11.5 milliliters of fluid from the pump. After discarding the aspirated medicine, she saw the PA refill the reservoir with 20 milliliters of the new medicine.

When the PA removed the needle,  the PA and the physician saw some fluid come out from the injection site. The PA palpitated the area around the injection site and more fluid came out. Within one minute, Marie Heisey complained of feeling dizzy. She became unable to breathe for herself, her pupils became pinpoint, and she became somnolent, at which point the PA and physician got a crash cart.  They immediately placed the woman on oxygen and started an I.V. to administer Narcan, a medication used to reverse the effects of opioids. The physician retrieved another pain clinic physician, who obtained a new refill kit and immediately aspirated the pump. He withdrew about 19 milliliters of medicine. Subsequently, she was taken to the emergency room, intubated, placed on a ventilator, and given a Narcan drip. She was then transferred to the critical care unit.

The Narcan drip was discontinued about two days later. Within a couple hours, her condition deteriorated. The pain clinic physician got the critical care unit to restart the Narcan drip, which helped. Marie Heisey was on the Narcan drip the following day and appeared much improved. At some point before the morning of the fourth day after the overdose, she was taken off mechanical life support and had been weaned off Narcan. The critical care physician that took over her care on the fourth day found that she appeared to be showing clear improvement and had resolution of her illness. She no longer needed ventilation or Narcan and had even been taken off oxygen. Even though her husband testified that the critical care physician who discharged the woman never examined her, the critical care physician claimed Mrs. Heisey was  fully alert, knew where she was, and had normal vital signs. From this, he concluded that the Dilaudid’s toxicity had worn off. Accordingly, he discharged her from the hospital on that same morning.

After her discharge from the hospital, Mrs. Heisey’s cough became worse and she became progressively more tired. She was too tired to move from the couch. Two days after her discharge, she called to schedule an appointment with her doctor, but he could not see her until five days after her discharge.  Four days after her discharge, her husband left the house for just over an hour. When he got home, he found her on the sofa totally unresponsive. He called 911. Emergency personnel arrived but could not revive her. She died shortly thereafter.

Marie Heisey’s estate sued the pain clinic physician, the critical care physician who discharged her, and the hospital. The complaint alleged that the hospital’s staff negligently refilled her pain pump and caused an overdose of Dilaudid. It further alleged that the hospital’s staff negligently discharged her before the effects of her overdose had been resolved and that she ultimately died from that overdose.

The case proceeded to trial. Before trial, the parties stipulated that the pain pump was working properly. At trial the defense argued that only a small portion of Dilaudid had been injected into a pocket outside the pump.

The estate presented evidence that the PA injected the Dilaudid into the pain pump’s catheter access port. The estate’s expert testified that the pain pump had two ports: a center port used to refill the pump’s reservoir and a catheter access port that allowed direct access to the catheter. He stated that it was dangerous to inject medicine into the catheter access port because the medicine would go directly to the patient’s spine. In order to prevent such occurrences, the company that manufactures the pump has two separate access kits. The expert noted that after the PA injected the Dilaudid into what the PA and the physician stated was the pain pump’s reservoir, the woman immediately and quickly stopped breathing and became unresponsive. The fact that she responded to the injection immediately indicated that the injection went directly to her intrathecal space”into her spinal column”which could only have occurred if the PA injected the Dilaudid into the catheter access port. If only a small portion of Dilaudid had been injected into a pocket outside the pump, as claimed by the defense, it would have taken much longer for her to feel the effects.

The estate’s expert found it noteworthy that Mrs. Heisey had to be on Narcan for four days after her overdose. The  expert concluded that if the Dilaudid had not been injected directly into her intrathecal space, the effect would not have been immediate and it would not last more than four days.

The critical care medicine expert opined that the critical care physician violated the standard of care when he discharged Mrs. Heisey because he should have kept her for a prolonged period of observation after stopping the Narcan and should have performed further tests to ensure that she was ventilating properly. The medical records showed that Marie Heisey had a drop in blood pressure on the day of the overdose and then again in the intensive care unit the day before she was discharged and on the morning of her discharge. She was also on Narcan for a prolonged period of time. According to the estate’s expert, this evidence should have caused the critical care physician to realize that this was not a normal overdose.

The jury found that the pain clinic physician was professionally negligent in the placement of the template or instruction on the injection site or supervision. It also found that the critical care physician was professionally negligent in the discharge of the woman from the hospital. Finally, it found that the  pain clinic physician and the critical care physician’s negligence caused the woman’s death.

The trial court entered judgment against the new pain clinic physician, the critical care physician who discharged the woman, and the hospital. The total amount of the judgment with costs and sanctions was $1,014,097.40.   The defendants appealed the verdict.

The Court of Appeals of Michigan affirmed.

See: Estate of Heisey v. Kafi Yovino, 2014 WL 2619519 (Mich.App., June 12, 2014) (not designated for publication).http://statecasefiles.justia.com/documents/michigan/court-of-appeals-unpublished/2014-310159.pdf?ts=1402661594

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