Critical Condition

Another patient, another investigation for Presbyterian/St. Luke's.

After three years on the waiting list, Walter Andre finally got a kidney transplant at Presbyterian/St. Luke's Medical Center on January 27.

He came out of surgery quite well and was soon able to call his out-of-town friends and family to tell them he expected to be discharged in about a week. But on the morning of February 3, a staffer bringing in his breakfast tray found the 58-year-old diabetic in insulin shock, says Linda Andre, his wife of twenty years.

When she visited that afternoon, Andre says, "Walt was in the throes of an insulin reaction." Her formerly alert husband was disoriented and couldn't speak. He was also incontinent and vomiting frequently.

When she complained about his condition, Andre adds, she was told by medical staff that her husband was probably having a reaction to the immunosuppressive drugs he had to take after the transplant.

But after demanding to see her husband's medical records, Andre pieced together what she believes happened: For eleven hours, from 8:10 p.m. to 7:30 a.m., Walt's insulin levels hadn't been measured. "If that's an acceptable standard of care, then something needs to be changed," she says.

Walt was released from the hospital on February 8, but as a result of his treatment there, says Andre, her husband has been severely disabled.

The same day Walt's blood sugar crashed, a nurse in another ward at P/SL injected morphine into the bloodstream of 78-year-old Mary Catherine Heidenreich instead of into the patient's muscle as directed. Heidenreich, who was in the hospital for routine knee surgery, died from the incident.

In November 1997, 63-year-old Karl Shipman, who had been chief of medicine at Presbyterian Hospital from 1975 to 1977, died at P/SL after an undiagnosed staph infection resulting from surgery for a broken wrist moved into his spine ("Doctor's Orders," March 25).

On March 25 of this year, an 83-year-old male patient at P/SL died after he fell out of bed following surgery.

Spurred by these and other cases, the Colorado Department of Public Health and the Environment and the U.S. Health Care Financing Administration (HCFA), which oversees hospitals receiving federal Medicare funds, investigated P/SL earlier this year. They found that the hospital "failed to provide a basic competency program for every nurse" and "allowed nurses to work without competency testing," among other violations. They also said that some nurses' medication-competency tests had been mis-scored, allowing those nurses to be assigned to patient care even though they had performed poorly on the exams. One nurse worked with patients for six months before taking the competency test.

The hospital has drawn up a plan to address the concerns, and investigators will continue to monitor P/SL for the next few months. In the meantime, the health department has launched a new investigation into the Andre case, according to CDPHE spokeswoman Jackie Starr-Bocian.

Like 500,000 to one million Americans, Walt Andre has Type 1 diabetes, which he developed during adolescence. Such diabetics must inject insulin during the day to keep their blood-sugar levels in the healthy range of about 80 to 140 milligrams per deciliter (one-tenth of a liter of blood).

Patients whose blood-sugar levels drop between 20 and 40 milligrams per deciliter can have seizures; below 20, they are susceptible to coma. Either can result in brain damage.

Walt Andre's hospital chart shows that on the morning of February 3, his blood-sugar level had fallen to 39. "I had known [his blood sugar] was running low," says his wife. "I didn't know how low--and I didn't ask, which I will always regret. I trusted the nurses."

On February 5 a doctor noted in his chart that Walt Andre had been "very somnolent last 2 days [due to] low blood sugar which has, in all probability, contributed to his somnolent, confused state. Better today."

Hypoglycemia, or low blood sugar, occurs when a patient has too much insulin in the bloodstream, which can result from an irregular eating schedule. Type 1 diabetics usually follow a food plan, which includes three meals and two snacks a day. Andre says her husband, who is legally blind and needs very bright lights for assistance, was eating poorly in the hospital because he couldn't see his food. When she asked why he wasn't receiving help, Andre was told "that the nurses didn't have time to feed him," she says. At one point, Linda Andre, who uses an electric wheelchair and has limited mobility, brought the couple's live-in aide from their Lakewood home to the hospital so she could help out at dinner time.

While leafing through her husband's prescriptions, Andre discovered that Walt had been given erythromycin, an antibiotic that could have reacted with the Propulsid he was already taking. The drugs come with strict instructions not to mix them because of possible "cardiotoxicity"--which could result in a heart attack. Andre wonders how the hospital's in-house pharmacy overlooked the danger.

P/SL spokeswoman Jessica Anderson says that some of Andre's claims are false; however, she adds that the hospital cannot give out any other information because of patient confidentiality rules.

Last week, P/SL patient representative Patty Boyd sent a letter to Linda Andre insisting that Walt's "EKG irregularities are not a result of the medication combination...[but] your concern has resulted in changes in our pharmacy procedures as an improvement opportunity." The pharmacy has "flagged" the drug interaction on its computer system, Boyd wrote.

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