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Dialysis Mayhem

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A kidney patient is found dead in his car, a nurse is accused of gross incompetence, the Office of Inspector General (OIG) for health care is called to investigate. What went wrong? Our investigative blog will provide insights gathered from VA employees and experts, which are not widely known to the public.

On April 25, 2017, Salathiel M. Gaymon, Senior was found dead in his car that had been parked in the Wilmington VA Medical Center. We know his name from the fine reporting done by Jason Minto, in the News Journal. Mr. Gaymon had previously been treated for his chronic kidney disease in dialysis unit at the hospital.

Meanwhile, it was anonymously reported that a second dialysis patient was seen a week prior and at that time a nurse switched a valve in the wrong direction on the dialysis machine and then had to call a ‘Code Blue’ to resuscitate the patient. We won’t delve into this case. It’s sufficient to say that their dialysis unit was not wholly functional.

The OIG visited the facility a couple of months later and produced a report. They interviewed staff, checked the closed circuit footage on the remote cameras, and reviewed medical records.

Mr. Gaymon had a history of diabetes mellitus for the last 25 years and received treatment for this at the VA by a variety of specialists that included nutrition, social work, home health care, and endocrinology.

The OIG report states that the patient arrived for his appointment at 11 AM and because of being in a hurry, had not taken any meds. However, there is no mention of whether a medication reconciliation (med rec) was done. Now if a patient didn’t take his morning meds and was about to sit for a several hour session of dialysis, wouldn’t you want to know which meds that weren’t taken initially should still be given? Absolutely! And a med rec is the standard of care on every patient at every episode of care. 

Next, a fingerstick blood sugar was taken and found to be greater than 500, which is a critical value. For some reason a routine order, not an urgent or STAT order, was given to confirm the fingerstick with a serum or blood glucose.

An hour later, a nephrologist ordered 4 units of insulin and this reduced the patient’s sugar to 138. This is a very large decrease in a patient taking 36 units of insulin every day. And had someone reviewed the chart, they would have noticed that this patient was a so-called ‘brittle diabetic,’ prone to extreme highs and lows of blood sugar. The precipitous decline should have raised some red flags among the clinicians.

Similarly, he had severely elevated blood pressure at 200/94 and was given a single dose of an antihypertensive, clonidine. He was discharged and expected to drive home about fifteen minutes after the clonidine dose and an hour after the markedly lower fingerstick sugar.

Tragically, he was found dead in his car the next morning. An autopsy showed cardiopulmonary arrest probably from a fatal rhythm disturbance (arrhythmia).

On another note, the patient was given epogen during his dialysis. Epogen is a blood stimulating drug that is often given to dialysis patients afflicted with anemia. The medication can also cause very high elevations of blood pressure, such as this patient experienced.  However, this patient had his epogen rightfully discontinued by the pharmacist several weeks prior. Epogen does not offer benefits in patients with mild anemia and may be dangerous if given.

The OIG often takes a global view when patient tragedies occur and looks at ‘system’ mistakes. Here they examined waiting times of various intervals such as the time the patient received his first high fingerstick glucose to when it was confirmed in the blood. Also, the time of insulin and clonidine administration is dutifully noted.

However, our experts tell us this case reeks of gross malpractice by the treating nephrologist. He or she doesn’t understand the fundamentals of treating diabetes urgencies, gave a dangerous antihypertensive that can worsen the effects of low blood sugar, and continued using a blood stimulating agent that the FDA has deemed dangerous in patients with mild anemia.

There’s no system problem here — it’s a problem of competence. This is a flawed report that refuses to place the blame or hold the treating nephrologist accountable. Ultimately, someone is in charge of the care of patients in a dialysis unit and it isn’t the nurses.

Quite simply, the patient should have been sent to the VA ER for further monitoring after his dialysis. His blood pressure and sugar would have been checked regularly and within a few hours, he likely would have been discharged safely to his home.

Prof. Sam

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