A woman who was pronounced brain dead by doctors unexpectedly woke up just as her organs were about to be removed for transplant.
Doctors at St. Joseph's Hospital Health Center were called on the carpet by the state Health Department for not properly determining if Colleen S. Burns was actually dead before they sought permission from her family to harvest her organs and scheduled the procedure.
Burns, 41, of Syracuse, New York, was taken to hospital in October 2009 after a drug overdose.
Doctors believed she had suffered irreversible brain damage and was on the point of death, but it later came to light that she was in fact in a deep drug-induced coma.
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The Health Department's investigation uncovered a series of mistakes and miscommunications that culminated in a situation that was saved only because Burns opened her eyes on the operating table.
According to a report on the case, the state Health Department found that doctors ignored a nurse's observations indicating Burns was not dead and her condition was improving, and that not enough brain scans were performed to confirm the often-contested diagnosis of brain death.
Moreover, Health Department investigators found that staff skipped a recommended treatment to prevent the drugs the patient took from being absorbed by her digestive system, and that not enough testing was done to see if she was free of all drugs before her organs were taken.
The report said that the day before her organs were to be removed, Burns responded to a reflex test. Her toes curled downward when a nurse scraped the bottom of her foot with her finger.
A nurse said she saw Burns' nostrils flare on the way to the operating room, indicating that she was breathing independently of the respirator she was attached to, and that her lips and tongue were moving.
According to hospital records, twenty minutes after those observations were made a nurse gave Burns an injection of the sedative Ativan. The doctors' notes, however, make no mention of the sedative or give any indication they were aware of the nurse's observations.
Dr. David Mayer, general and vascular surgeon and an associate professor of clinical surgery at New York Medical College, also reviewed the records and found the use of a sedative perplexing.
"It would sedate her to the point that she would be non-reactive," Mayer told the Post-Standard. "If you have to sedate them or give them pain medication, they're not brain dead and you shouldn't be harvesting their organs."
The Health Department's report said that Burns "did not suffer a cardiopulmonary arrest and did not have irreversible brain damage," as St. Joseph's doctors had determined.
"The hospital did not undertake an intensive and critical review of the near catastrophic event in this case," the report said, and hospital officials did not "identify the inadequate physician evaluations of (Burns) that occurred when nursing staff questioned possible signs of improving neurological function."
Tragically, it was reported that Burns committed suicide 16 months after her sojourn in the hospital. Her mother, Lucille Kuss, told the Syracuse Post-Standard that the family did not pursue an investigation of the incident or sue the hospital because her daughter had been severely depressed before the incident and afterwards was not concerned that doctors almost took her life.
The state Health Department fined St. Joseph's Hospital Health Center $6,000 for mishandling the Burns case and for not properly investigating the cause of the incident. The hospital was also ordered to review its quality assurance program, and to hire a consulting neurologist to provide instruction on how to accurately diagnose brain death.
This is not the first time that a potential organ donor has woken up literally on the operating table, moments before they were opened up.
In 2008, a 45-year-old Frenchman revived on the operating table as doctors prepared to “harvest” his organs for donation, following cardiac arrest. In the subsequent investigation by the hospital’s ethics committee, a number of doctors admitted that such cases, while rare, were well known to them.
That same year, a “brain dead” 21-year-old American, Zack Dunlap, was about to have his organs harvested when his two sisters, both nurses, decided to test the hospital’s theory that his brain was no longer functioning. Family members poked his feet with a knife and dug their fingernails under his nails, provoking strong reactions by Dunlap and proving he was conscious. He recovered completely. He later related that he was conscious and aware as doctors discussed harvesting his organs in his presence.
The term “brain death” was invented in 1968 to accommodate the need to acquire vital organs in their “freshest” state from a donor who some argue is still very much alive.
While death had previously been defined as lack of respiration and heart activity, “brain death” was judged as compatible with an otherwise living patient. “Brain death” has never been rigorously defined, and there are no standardized tests to determine if the condition exists.
The report by the U.S. Centers for Medicare and Medicaid Services on the Burns case at St. Joseph's Hospital Health Center is available here.
