Hypoxic Ischemic Encephalopathy

[squishO90]

What is the name of your state? RI

Hi,
I'm reposting this message because I must have locked out my previous post and I don't know how to unlock it Also how does one get a hold of a moderator here? Any suggestions would be helpful. Thanks Anywhere here goes my message again:

Hi,
I wanted to get you all's opinion on whether you think I might have a case, so here goes.
Back in July of 2006 I had a spinal fusion performed. The required stay in the hospital is 4 days. Well everyhting was going well until the morning I was supposed to go home I was found unresponsive. My O2 sat's were in the 40,s although at the time my blood pressure was ok. I was being treated with 80 mg of Oxycontin throughout this whole process.. Anyway 10 minutes after finding me they called a code blue and my blood pressure went down as low as 40/p. I was given NARCAN to try to reverse the effects of the Oxycontin but to no effect. I was intubated at approximately 7:30 ( the code blue was called at 7:00 am.). I had apparently aspirated and it went into my lungs and I also had a large pulmonary embolism in the right something or other of my lung. I ended up with a case of Hypoxic Ischemic Encephalopathy, which has profoundly changed my life. After reading the records from the night before my event, my wife noticed that at midnight the nurse took my blood pressure which was kind of high, 178/88 I think. 15 minutes later, she took it agin and it was 138/72. Then she says in her notes that she checked on me frequently through the nigh, and saw me repositioning myself. She doesn't note what time she saw me repositioning myself or any of the times she "frequently" checked on me, but that's what the records say. I could have been puking for all she knew. There is no notation in the chart that she checked my blood pressure again all evening. Doesn't it seem strange that she was concerned enough about my blood pressure at midnight to take it again 15 minutes later and then didn't take it again until 6:50 in the morning? Thank goodness for me that at shift change they came in and checked and that's when they found me unresponsive in respiratory arrest. They called my wife immediately and told her to get down to the hospital right away because something
"bad" had happened to me. When she got there she was told I had severe brain damage and would probably never recover. Damage to the brain stem they said and I had negative "doll's eye" response. They really put her through hell. My MRI showed damage to the brain stem and in the globus pallidus bilaterally with a tiny infarct in the left frontal lobe above the vertex, and in the basal ganglia. Anyway as you can see by my writing this, that I am alive and well enough to write this note to you all. My question is, did the nurse screw up by not checking my vital signs at sometime during the evening? It says in the records that the night before that they checked it at 4:55 in the morning, so why didn't they check it again at that time of the morning? And as far as frequently checking on me, doesn't it sound a little suspicious that she would write that, considering she hadn't noticed that my condition was deteriorating? I'm sure I just didn't get into this state in a few minutes, I think it probably took a while. And according to the medical literature I read, primary attention should be taken to secure ventilation for a patient who is in respiratory arrest while waiting for NARCAN. They didn't intubate me until a half hour after the code was called. Also with respect to the Oxycontin, don't you think 80 mg's is a bit high to start an opioid naive patient like me on? All the literature I've read says that 80 and 160 mg of Oxycontin should not be used on opioid naive patients and Oxycontin should be titrated up to a dose that kills the patients pain. Also it was a standing order for the 80 mg's, no real attention paid by my doctor. I also (according to the records) refused percosets on the evening of my event, and I was also very nauseous all 3 days while in the hospital so i was given Zofran, an anti-emetic, which is a centrally acting drug, which means it can also cause respiratory depression. The literature that I,ve read syas that when another centrally depressing drug is used Oxycontin should be given at 1/2 to 1/3 of the dose normally given. So in summary, I think the nurse screwed up by not checking on me properly, and by giving me 80 mg's of Oxycontin when I had a pain rating of 2 out of 10 or 3 out of 10. I think the doctor screwed up by starting me on a dose of 80 mg's of Oxycontin and then especially ordering Zofran to help with my nausea, and I think the team on the code blue screwed up by not intubating me immediately instead of waiting a half hour. My deficits are basically getting me fired from my job as an Air Traffic Contoller, I have to go out on disability because I can't see lines on the radar scope the same way I used to, I have problems initiating things ( my wife is making me write this) I have debilitating fatigue, I feel like I have to take a nap every early afternoon, I have a flat affect,and I have had a couple of seizures, which I am on 150 mg of Lamictal for. I also take wellbutrin to help with my mood and Provigil to help me try to stay awake during the day. All of these medications disqualify me from being an air traffic contoller. In fact the regional flight surgeon told me last week he was going to permanantly medically disqualify me because of the notes I've gotten from my doctors and neuropsychologists and the drugs I will be taking indefinitely. I will be losing $2 million worth of pay because i won't be able to work til I'm 65. Anyway. what do you all think. Case or not?

RickWhat is the name of your state?RI

 

[squishO90]

Hi, I first posted this on October 2nd, does anyone have an opinion???

Thanks,

Rick

 

[lealea1005]

First, let me say that your post was very hard to read all the way through because of the lack of paragraphs, but I'll give it a shot.

The nurse appropriately took your blood pressure 15 minutes after the first reading of 178/88, and it was normal. What were your BP reading before that time? A blood pressure of 178/88 is not alarmingly high, so it wouldn't necessarily warrant checking repeatedly throughout the night, especially when a follow up BP of 132/72. She checked in on your periodically and saw you repositioning yourself. You were asleep, so I don't see how you could know how far she stuck her head into your room or how long she observed you. I don't have to wake the patient to observe whether they're breathing normally, or that they're not in distress.

Yes, you could "get to this state" in a very short period of time, even only a few minutes. You, yourself, said everything was going well until the morning you were supposed to be discharged.

The PE is a risk of surgery. The PE caused the repiratory depression, aspiration, and the infarct; not the nurse, not the Physician, and not the code blue team.

Perhaps one of the other medical people will be by to add information. In the meantime, the only other thing I could suggest is to seek the advice of a med/mal attorney who will obtain your medical records and have them reviewed by an expert. Good luck.

 

[squishO90]

lealea1005

First, let me say that your post was very hard to read all the way through because of the lack of paragraphs, but I'll give it a shot.

sorry about that, I'll try to do better next time.

The nurse appropriately took your blood pressure 15 minutes after the first reading of 178/88, and it was normal. What were your BP reading before that time?

They were all normal, although I do have a history of hypertension, for which I was taking Atenalol.


A blood pressure of 178/88 is not alarmingly high, so it wouldn't necessarily warrant checking repeatedly throughout the night, especially when a follow up BP of 132/72. She checked in on your periodically and saw you repositioning yourself. You were asleep, so I don't see how you could know how far she stuck her head into your room or how long she observed you. I don't have to wake the patient to observe whether they're breathing normally, or that they're not in distress.

Wouldn't she put it in her notes at what times she looked at me? And they also monitored my blood pressure at 4:40 the previous morning, so why wouldn't they do that again? Also how can you tell when someone who is hypoxic that they're not in distress. Wouldn't they just look like a normal sleeping person?

Yes, you could "get to this state" in a very short period of time, even only a few minutes. You, yourself, said everything was going well until the morning you were supposed to be discharged.

I was told by a medical professional that this could have happened over a long period of time, but your point is well taken. And when I said everyhting was going fine until the morning of the discharge, I was quoting from the medical records. I personally don't remember any of it. (probably a good thing)

The PE is a risk of surgery. The PE caused the repiratory depression, aspiration, and the infarct; not the nurse, not the Physician, and not the code blue team.

Once again, not according to the dcotors. They all said that my aspiration was caused by overmedication with Oxycontin. Everyone of them said that, it's even in the records. Even the physician who prescribed the Oxycontin noted "aspiration because of over medication with Oxycontin." And I don't know if I mentioned this in my previous post I was nauseous almost from tjhe moment I started taking the Oxycontin. He then proceeded to put down my weight which at the time was 230 lbs, which is his way of justifying the amount of Oxycontin I was given, I guess

Perhaps one of the other medical people will be by to add information. In the meantime, the only other thing I could suggest is to seek the advice of a med/mal attorney who will obtain your medical records and have them reviewed by an expert. Good luck.

Thank you very much for your time and sorry again about the non-paragraphed writing. I really do appreciate your input, thanks for taking the time to respond to me. And also I'm not being adversarial, I just want to know if someone was negligent in my care, because this incident has really affected me and my wife Your input has helped a lot in that regard. Thanks again

Rick

 

[LAWMED]

A few thoughts...

From what you describe you need to consult with a malpractice attorney who in turn will have a medical expert review your chart and the events of that morning.

1. 80mg of Oxycontin is never appropriate for pain control as a first dose in someone not previously taking narcotics on a regular basis. It is far too high of a dose.

2. Hypoxic encephalopathy can occur within 4 minutes. The MRI findings you describe often leave an individual in a vegetative state. Frequently there is little improvement. in that sense you are lucky.

3. Pulmonary embolism vs. opiate overdose cannot be determined by the information presented. A review of the chart by an expert is needed.

4. The delay in intubation may or may not be contributory. Again a review of the notes in the chart during the 30 minutes is needed. The fact that the narcan did not produce an effect is not surprising since the insult to the brain described would have rendered you unconscious regardless of the narcotic effects.

5. I would not hang my hat on the frequency of the RN checking on you. Apparently you were a stable pt. getting ready to go home. The narcotic issue and the response after you were found should be investigated.

 

[lya]

I'll add a few facts about documentation and acceptable standards of patient observation/interaction.

Nurses no longer make individual entries for each action taken. There is not enough time to do so nor is there a valid reason for documenting routine actions.

Documenting 'frequent checks' is meaningless; therefore, it does not indicate a lack of proper observation or an over-abundance of observation.

What has meaning is the response by the nurse to events that occurred outside of the normal or expected patient response. As previously posted, the nurse properly documented a change in BP and the follow-up BP measurement.

You, the original poster, would have no reason to know that BP fluctuations often have more to do with patient position and measurement technique than with changes in patient condition. In other words, one abnormal or changed BP measurement is meaningless.

Obviously, you were not a monitored patient; you had no cardiac telemetry and pulse oximetry continuous monitoring. If you had been a monitored patient, it is possible you would have received earlier intervention following your PE. Whether the outcome would have been different is not possible for anyone to determine or to guarantee the outcome would have been better.

It is incorrect to assume that a rapid response team or a code team can immediately intubate and ventilate a patient.

Even if intubation is rapidly secured, ventilation remains a problem, especially in the presence of aspiration or pulmonary embolism. The team is working with lungs that cannot accept air being forced into them or circulation of oxygenated blood from the ungs. The immediate outcome is often death. Those who survive such a respiratory insult often have physical and cognitive deficits.

I think the outcome of a medical and nursing expert review of the records will most likely result in the opinions that the patient is lucky to be alive and the actions of the nurse, the rapid response team, and the code team are the only reasons the patient is alive.

Consultation with a medmal attorney is usually free; the process of a medmal lawsuit is lengthy and very expensive.

 

[squishO90]

A few thoughts...

--------------------------------------------------------------------------------

From what you describe you need to consult with a malpractice attorney who in turn will have a medical expert review your chart and the events of that morning.

1. 80mg of Oxycontin is never appropriate for pain control as a first dose in someone not previously taking narcotics on a regular basis. It is far too high of a dose.


That is what I read as well, and also that was 80 mg twice a day


2. Hypoxic encephalopathy can occur within 4 minutes. The MRI findings you describe often leave an individual in a vegetative state. Frequently there is little improvement. in that sense you are lucky.

Yes I realize I am lucky. I do have some pretty severe cognitive and emotional deficits as a result of this. I also have has seizures as a result, which are causing me to lose my job. In fact my wife was told I was going to be in a vegetative state. Beleive me I know I'm lucky!!

3. Pulmonary embolism vs. opiate overdose cannot be determined by the information presented. A review of the chart by an expert is needed.

From everything that my wife and the doctors told me it was aspiration, no one ever mentioned a pulmonary embolism. We saw it when we looked through the records. I will have to recheck to see if that's what they actually found or if that's what they were suspecting.

4. The delay in intubation may or may not be contributory. Again a review of the notes in the chart during the 30 minutes is needed. The fact that the narcan did not produce an effect is not surprising since the insult to the brain described would have rendered you unconscious regardless of the narcotic effects.

I will have to review to "code notes" and "event notes"

5. I would not hang my hat on the frequency of the RN checking on you. Apparently you were a stable pt. getting ready to go home. The narcotic issue and the response after you were found should be investigated.

Thank you very much for your time in responding to me LAWMED, your input is valuable and appreciated

 

[squishO90]

I'll add a few facts about documentation and acceptable standards of patient observation/interaction.

Nurses no longer make individual entries for each action taken. There is not enough time to do so nor is there a valid reason for documenting routine actions.

Documenting 'frequent checks' is meaningless; therefore, it does not indicate a lack of proper observation or an over-abundance of observation.

Apparently you are correct.My daughter is a nurse and she says almost exactly the same thing

What has meaning is the response by the nurse to events that occurred outside of the normal or expected patient response. As previously posted, the nurse properly documented a change in BP and the follow-up BP measurement.

You, the original poster, would have no reason to know that BP fluctuations often have more to do with patient position and measurement technique than with changes in patient condition. In other words, one abnormal or changed BP measurement is meaningless.

After speaking further with my daughter, she says she thinks the nurse may bear some responsibility in administering me a dose of 80 mg of Oxycontin when my pain level was reported as 2 out of 10 or 3 out of 10.( and they were giving me percosets on top of that. Good thing I refused them the night before my event)

Obviously, you were not a monitored patient; you had no cardiac telemetry and pulse oximetry continuous monitoring. If you had been a monitored patient, it is possible you would have received earlier intervention following your PE. Whether the outcome would have been different is not possible for anyone to determine or to guarantee the outcome would have been better.
Fair enough

It is incorrect to assume that a rapid response team or a code team can immediately intubate and ventilate a patient.

Even if intubation is rapidly secured, ventilation remains a problem, especially in the presence of aspiration or pulmonary embolism. The team is working with lungs that cannot accept air being forced into them or circulation of oxygenated blood from the ungs. The immediate outcome is often death. Those who survive such a respiratory insult often have physical and cognitive deficits.

Of this I am well aware

I think the outcome of a medical and nursing expert review of the records will most likely result in the opinions that the patient is lucky to be alive and the actions of the nurse, the rapid response team, and the code team are the only reasons the patient is alive.

Yes you are probably correct. My question is how did I get to this state in the first place

Beleive me I am grateful for everything they did to save my life. I am very happy to be alive. I am not without differences however in my daily functioning and my ability to work. My relationship with my wife is not and will probably never been the same. I just want to know how something like this could have happened after such a routine procedure. And I was relatively healthy. From what I'm hearing from you guys, I should just deal with it and move on. Anyway thanks, lya, for your professional insight, it is very much appreciated

Consultation with a medmal attorney is usually free; the process of a medmal lawsuit is lengthy and very expensive.

 

[lealea1005]

A few thoughts...

--------------------------------------------------------------------------------

3. Pulmonary embolism vs. opiate overdose cannot be determined by the information presented. A review of the chart by an expert is needed.

From everything that my wife and the doctors told me it was aspiration, no one ever mentioned a pulmonary embolism. We saw it when we looked through the records. I will have to recheck to see if that's what they actually found or if that's what they were suspecting.

That's what you said in your first post: "I had apparently aspirated and it went into my lungs and I also had a large pulmonary embolism in the right something or other of my lung"

 

[squishO90]

That's what you said in your first post: "I had apparently aspirated and it went into my lungs and I also had a large pulmonary embolism in the right something or other of my lung"

Apparently I was incorrect. The records say " a pulmonary embolism ??"and it was confirmed this morning by the neurologist who first saw me in ther hospital that it was one of the causes that was suspected, but apparently they took a cat scan and it was negative for a pulmonary embolism. Please forgiveme for screwing this up. I guess I spoke without having an understanding fo the medical records. And just for the heck of it I asked the neurologist why he thinks I had this event and he said"pain medication and aspiration" And he also corrected me on what aspiration really means. I thought it meant just throwing up and having the vomit just sort of going down your throat, but apparently it means actually breathing in the vomit. I didn't know that. And he also confirmed what someone told me about hypoxic encephalopathy only taking 4 minutes. I know I sound like a rank amateur to you guys, (which I really am) but I'm really just trying to get to the bottom of why what happened to me happened to me and who might be responsible, if anyone. Thanks again for your reply lealea1005. I appreciate you taking the time to give me your advice and thoughts.

Rick

 

[LAWMED]

Final thoughts

You did just fine!

PE can be ruled out then since it sosunds like they dis a "Spiral CT" of your chest, a special cat scan ot detect PE's. That leaves us with narcotic overdose, respiratory depression and aspiration of vomitus. All of which go hand in hand. In point of fact, any introduction of vomit into the lungs is called aspiration. You do not have to be breathing to aspirate....you only have to have gravity working against you. Any significant aspiration most oftne leads to aspiration pneuomnia within 48-72 hours at most. It can be fatal. Another question to look into: Did you aspirate before or after the code team came? Intubation, bag mask ventialltion, if specific precaustions are not taken, can cause aspiration. It can be negligence in certain circumstances.

 

[squishO90]

This is going to LAWMED or any other professional who cares to answer



1. 80mg of Oxycontin is never appropriate for pain control as a first dose in someone not previously taking narcotics on a regular basis. It is far too high of a dose.

2. Hypoxic encephalopathy can occur within 4 minutes. The MRI findings you describe often leave an individual in a vegetative state. Frequently there is little improvement. in that sense you are lucky.

I have an additional question about the 4 minute time frame. It says in the records that I was found unresponsive at 6:50am, with O2 sats in the 40's. With blood pressure low, but not alarmingly so. The code was called at 7:00, by the attending physician. Shortly thereafter, the records say that my blood pressure rapidly decreased to as low as 40/p, requiring Levophed for support. Apparently, at or around 6:50, the nurse notified respiratory therapy and the attending physician, that I was found unresponsive and hypoxic. My question is, is it normal for a nurse to call a code blue when she finds someone who is in distess or hypoxic? And also since this Hypoxic Ischemic Encephalopathy could have happened to me within 4 minutes and I was unresponsive to the NARCAN(which suggests that the brain damage had already occured, and I was given the NARCAN at or after the code was called), could this all have been prevented if that 10 minute delay had not happened between when she found me and before the code was called ?
Thanks for your reply [/I][/U]

 

[lya]

This is going to LAWMED or any other professional who cares to answer



1. 80mg of Oxycontin is never appropriate for pain control as a first dose in someone not previously taking narcotics on a regular basis. It is far too high of a dose.

2. Hypoxic encephalopathy can occur within 4 minutes. The MRI findings you describe often leave an individual in a vegetative state. Frequently there is little improvement. in that sense you are lucky.

I have an additional question about the 4 minute time frame. It says in the records that I was found unresponsive at 6:50am, with O2 sats in the 40's. With blood pressure low, but not alarmingly so. The code was called at 7:00, by the attending physician. Shortly thereafter, the records say that my blood pressure rapidly decreased to as low as 40/p, requiring Levophed for support. Apparently, at or around 6:50, the nurse notified respiratory therapy and the attending physician, that I was found unresponsive and hypoxic. My question is, is it normal for a nurse to call a code blue when she finds someone who is in distess or hypoxic? And also since this Hypoxic Ischemic Encephalopathy could have happened to me within 4 minutes and I was unresponsive to the NARCAN(which suggests that the brain damage had already occured, and I was given the NARCAN at or after the code was called), could this all have been prevented if that 10 minute delay had not happened between when she found me and before the code was called ?
Thanks for your reply [/I][/U]

For your information, not only did "your" nurse take measures to protect your life during those 10 minutes, but so did most of the nurses on the unit/floor, and so did the respiratory therapist.

I get the impression you think the nurse stood around in a gape-mouthed stupor during those 10 minutes until the MD galloped in on his white steed and called a code.

I may be wrong about the arrival of the MD's being on a white steed; he could have appeared on a bolt of lightening. The point is, at a code, usually the MD is the one who answers "yes" when the nurse asks, while administering the needed medication, "don't you want to give "x medication?" After the code, the MD signs all of the verbal orders he/she gave.

Quit trying to find some reason to find fault with the nurse who saved your ungrateful rear-end. It appears from your ability to communicate, if "you" are indeed the author of "your" posts, that those who noticed and responded to your change in condition did everything right; if they had not done everything right, you wouldn't be able to communicate and/or reason at level displayed on this forum.

 

[LAWMED]

This is going to LAWMED or any other professional who cares to answer



1. 80mg of Oxycontin is never appropriate for pain control as a first dose in someone not previously taking narcotics on a regular basis. It is far too high of a dose.

2. Hypoxic encephalopathy can occur within 4 minutes. The MRI findings you describe often leave an individual in a vegetative state. Frequently there is little improvement. in that sense you are lucky.

I have an additional question about the 4 minute time frame. It says in the records that I was found unresponsive at 6:50am, with O2 sats in the 40's. With blood pressure low, but not alarmingly so. The code was called at 7:00, by the attending physician. Shortly thereafter, the records say that my blood pressure rapidly decreased to as low as 40/p, requiring Levophed for support. Apparently, at or around 6:50, the nurse notified respiratory therapy and the attending physician, that I was found unresponsive and hypoxic. My question is, is it normal for a nurse to call a code blue when she finds someone who is in distess or hypoxic? And also since this Hypoxic Ischemic Encephalopathy could have happened to me within 4 minutes and I was unresponsive to the NARCAN(which suggests that the brain damage had already occured, and I was given the NARCAN at or after the code was called), could this all have been prevented if that 10 minute delay had not happened between when she found me and before the code was called ?
Thanks for your reply [/I][/U]

Without reviewing the medical record it is difficult to answer these questions with confidence. After finding you the nurse likely placed you on face mask oxygen and your oxygen saturation may have returned to noraml limits. Something influenced the nurse to choose calling resp. therapy and the physician, rather than a code team. Calling the code is much easier since you just push a button. Not every patient in distress or exhibiting hypoxia requires a code. However, the physician DID call the code presumably shortly after he arrived so I am suspicious of the nurses decision, though I cannot find fault with it. I am also wondering at your blood pressure of 40 systolic requiring Levophed. It is somewhat unusual and needs investigation. In a small % of patients Narcan can cause vascular collapse and pulmonary edema. Again, the timeline of events, the vital signs and the notes of the providers have to be evaluated in total by an expert to definitively answer these issues.

 

[squishO90]

For your information, not only did "your" nurse take measures to protect your life during those 10 minutes, but so did most of the nurses on the unit/floor, and so did the respiratory therapist.

I get the impression you think the nurse stood around in a gape-mouthed stupor during those 10 minutes until the MD galloped in on his white steed and called a code.

The question is, What exactly did she do or not do, and that is exactly why I am asking the question

I may be wrong about the arrival of the MD's being on a white steed; he could have appeared on a bolt of lightening. The point is, at a code, usually the MD is the one who answers "yes" when the nurse asks, while administering the needed medication, "don't you want to give "x medication?" After the code, the MD signs all of the verbal orders he/she gave.

Well I learned something new


Quit trying to find some reason to find fault with the nurse who saved your ungrateful rear-end. It appears from your ability to communicate, if "you" are indeed the author of "your" posts, that those who noticed and responded to your change in condition did everything right; if they had not done everything right, you wouldn't be able to communicate and/or reason at level displayed on this forum.

I'm just asking questions, and I'm certainly not ungrateful. And you should read the medical records and the reports from the Dr's. Things like "grave prognosis" and "little if any chance of recovery". That sure doesn't sound to me like they had much faith in the actions of whoever took care of me, at least in terms of preventing hypoxic damage. Beleive me I know it is a miracle that I am still here and able to communicate at all. And yes I am the author of these posts. And for your information, my wife is helping me write these posts and is the one who is going over the medical records. Not only that, I never said my ability to communicate was compromised. I said I have severe cognitive and emotional deficits. Would you like a list? And you have no idea how long it took me to make this reply to you. Not only that but I'm losing my job and in a few weeks I will be without a paycheck. Does it make you feel good to pick on someone who doesn't have the ability to defend himself? You sound awful defensive, as if Nurses are infallible or something. I know because of my brain injury, my daughter is a better nurse. For example, she actually checks on her patients during the night and doesn't take for granted that because they showed a little movement that they are ok. At least that what she tells us. And for your information, my daughter , and sister, who are both nurses can find plenty of fault with the way the nurse on duty acted, the neurosurgeon who prescribed the 80 mg of Oxycontin and the hospital acted and the record keeping in general. I appreciate your input however And don't worry. I don't think all nurses are bad, but just like any profession, they do make mistakes at least occasionally. Have a nice day