Any person who traumatically or unexpectedly loses a loved one, especially a child, will tell you that the pain never goes away. Here at the Beasley Law Firm, we have witnessed the pain and suffering that many parents had to deal with after the unnecessary death of their infant, toddler, adolescent or teenager. Brian and Cindy Abbiehl are currently feeling that pain after losing their 18-year-old daughter Amanda.
Amanda was admitted to the hospital with a swollen, sore throat and dehydration due to a strep-like virus. To ease Amanda’s pain, she was placed on a patient controlled anesthesia (PCA) pain pump that was filled with the narcotic Dilaudid. Brian and Cindy stayed with Amanda all day and then kissed her goodnight. At the time, they did not know that would have been the last time they saw Amanda alive. On July 17, 2010, Amanda was found unresponsive in her hospital bed and was unable to be resuscitated. It appears that she died due to respiratory depression or respiratory failure, which is a common side effect of Dilaudid and other pain medications.
When Amanda was on the pain pump, she was not connected to a monitor that would have detected a drop in her oxygen level, increase in her carbon dioxide level or a decrease in her respiratory rate because it was not the current standard treatment or protocol. Mr. Abbiehl feels that one of the reasons it is not the standard of care is because it is expensive for hospitals to do. Even though there are pain pumps that are equipped to monitor breathing or shut off if a patient’s respirations become dangerously low, hospitals are not purchasing them due to their price tag.
Out of their loss, grief and anger, the Abbiehl’s started the foundation, “A Promise to Amanda” to raise awareness to the potential dangers of PCA pumps in hopes that something like this does not happen to any other patient or family. What the Abbiehl’s are doing is very similar to what Mary Ellen Mannix did after she lost her newborn son James to a series of medical errors. Mary Ellen wrote a book and also founded James’s Project to educate other parents so no one would have to go thru what she and her husband did.
In addition to Amanda’s Foundation, a class at The University of Notre Dame is also working on raising awareness after hearing about Amanda’s death. The class is helping to “design materials to convey their message to medical professionals as well as the general public.” To help with this project, the class invited the Physician-Patient Alliance for Health and Safety (PPAHS) and other healthcare experts to discuss PCA errors and how to improve patient safety. The class has the following two questions that they would like to find answers to:
1) Who are the patient safety champions who would lead the charge in implementing smart PCA pumps at hospitals (e.g., anesthesiologists, nurses, respiratory therapists)?
2) What information would these champions need to have to affect change in their organizations?
In addition to unrecognized respiratory depression caused by PCA pumps, patients have died from numerous other pain pump problems. Errors when programming the PCA pump seems to be the most common drug mistake and patients are inadvertently overdosed with the narcotic. Other problems such as PCA by proxy, which is when someone other than the patient activates the PCA button, frequently leads to more medication than the patient needs. Because it is common knowledge that these errors can occur when using a PCA pump, it is extremely important for nurses to constantly monitor their patients for any signs of breathing difficulties, over sedation or narcotic overdose.
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