Monday, December 16, 2019

Blame Anderson Cooper

I jokingly blame Anderson Cooper for my ultimate selection of Vanderbilt Medical and Dental Clinic to do my reconstruction work as it is connected to him via his Mother's familial legacy. I doubt that Anderson has ever set foot on the campus or inside the medical facility that bears the name of his predecessors and as the University and Medical facility have long split and only share a name I see no reason why anyone would think this hospital is as elegant and as intellectually interesting as either he or his Mother were or are.

Vanderbilt is a medical behemoth in Nashville and largely responsible for some of the reimagining of everything from malls to neighborhoods thanks to their growth and ever expanding footprint in Nashville, a city dominated by many legacy medical landmarks, one tied to the Frist family, another said family with a storied legacy in America. Perhaps one recalls the former Senator from the state of Tennessee, William Harrison Frist; He is an American physician, businessman, and politician who began his career as a heart and lung transplant surgeon. He later served two terms as a Republican United States Senator representing Tennessee. He was the Senate Majority Leader from 2003 to 2007 and nowhere near as divisive as the current Southern leadership. The Frist family founded HCA and in turn is why the area is known for its role in remaking Nashville as more than music city. Bill worked at Vanderbilt and was a successful transplant surgeon and is still affiliated with them and I am sure like all the wealthy families in the area have no interest in day to day operations as their legacy and footprint in contemporary Nashville is secure and well defined. That is the South, where money talks and the people talk out of two sides of their mouth to tell you what they think you want to hear and what they think they need to hear to be believed. Everyone lies in the South like a dog on a carpet on a hot day so they assume you too lie and if not it does you no favors.

The main players in almost every city, especially the South, are defined by "old money" meaning that most of the family earnings are at least three generations old and come from a business or industry started by a senior Patriarch. Think the Rockefeller's, the Kennedy's, the Mellon's and so forth. Then we have "new money" and that is the first generation who created wealth usually already from a well established family but they were not at that level until they hit the big well.  The Gates family define as such as the senior Bill was already a well established Attorney and the same for Warren Buffett whose father was well connected and in turn those connections enabled the son to better the father.  The Nouveau Riche are the current Tech heads like Zuckerberg who simply just got fuck all lucky.

Now the reality is that it takes three generations to piss off the cash and they usually do through a series of bad decisions and often you see that in many families, like the Hilton's who have Paris that can explain that a name can buy you entry but you still need to work for a living its just the kind of work one does that defines the distinction.  Anderson Cooper has the cache of Vanderbilt but he made his own way through the access that the name provides its just that he chose to actually develop an intellect and manner that demonstrates class is in fact earned and learned.  Try that Countess!  (Watch the housewives of NYC for that reference)

But Vanderbilt is just a name of the past for those in the present and when one thinks of it you think of the school, the football team and the reputation as the "Ivy League" school of the Athens of the South.   A dated reference that has no relevance in the New South as few who live and come from the area go to Vanderbilt let alone any of the schools that encircle the area.  Keep em dumb and they stay stum.   Which is why they rarely vote, have few opinions as those requires thoughts and the ability to think critically, a skill set lacking in the South given its attitude and history regarding public education.   Smarts is for the rich and the rich keep it that way.

I go for my next surgery in a few days the one that was fucked up by the incompetence of the last Intern who was so busy worrying about my Vagina (meaning as a woman how can I function and cope on my own - just fine, thank you.) then the jaw and the bone structure where the implant was being placed. And naturally the implant failed.  A bone graft and implant replacement made simultaneously was done and I was sent on my way pushing back all of my work for another three months. Thanks asshole as he is like all of them in the revolving door of medical care, fuck up one and done.

Vanderbilt has a legacy of problems and a history that includes many issues like the one below.  It is probably why they are pushing back against those who do not want to be anesthetized. Trust me if I had an option on my first run around I would have, they did not even bother to give me a Valium to ease my nerves and were so utterly bizarre pre-surgery that my already high blood pressure was rising and in turn putting me further at risk after keeping me under two hours longer than necessary as they were overbooked. Another problem which they have repeatedly.   My former neighbor who was just out of Nursing school two years earlier was the senior Nurse in the NICU, that must be comforting to parents of at risk babies.   That is nothing compared to all the folks I have seen come and go in my three years there.  I finally quit trying to know names there was no purpose.  Vanderbilt is a dump. But then little in Nashville is anything but.

And this may be why.....

After a patient was killed by the wrong drug, Vanderbilt didn’t record fatal error in four ways
Brett Kelman, Nashville
The Tennessean Published  Dec. 15, 2019 |

Vanderbilt University Medical Center's actions effectively hid the cause of death of Charlene Murphey for 10 months until an anonymous complaint prompted investigations by federal health officials and state law enforcement.

Charlene Murphey, 75, died at Vanderbilt after being injected with the wrong drug.
The hospital didn't report the error to government regulators or its accrediting agency.
Vanderbilt doctors falsely told the medical examiner the death was "natural."

After a Nashville-area woman died two years ago from a grievous medication mistake at Vanderbilt University Medical Center, the hospital's response obscured the error from the government and the public. Vanderbilt violated state law, reported the patient's death as "natural" and swore her family to silence, according to a Tennessean review of hundreds of pages of county, state and federal records.

The hospital’s actions effectively hid the cause of death of Charlene Murphey, 75, for 10 months until an anonymous complaint in October 2018 prompted investigations by federal health officials and state law enforcement.

Those investigations detailed how Murphey was accidentally given a fatal dose a vecuronium, a paralyzing medication that sent her into cardiac arrest while she waited for a medical scan in Vanderbilt's radiology department.

The nurse who injected Murphey with the drug, RaDonda Vaught, was criminally charged with reckless homicide and impaired adult abuse in February, and her case has become a rallying cry for medical professionals who fear honest mistakes will be criminalized. Meanwhile, Vanderbilt, the biggest and most renowned hospital in Nashville, largely avoided repercussions. For the first time, this story explores how the actions — and inaction — of Vanderbilt delayed and hampered scrutiny of Murphey’s death.

In the months after Murphey died in December 2017, Vanderbilt officials did not document or report the deadly medication error in four ways.

Two Vanderbilt neurologists provided false information about Murphey's death, saying she died naturally from a brain injury, according to the Davidson County Medical Examiner.
Vanderbilt did not report the fatal error to The Joint Commission, an independent organization that accredits the hospital, said a commission spokeswoman. Joint Commission policy strongly encourages but does not require hospitals to report fatal medical errors.

Vanderbilt officials "failed to report this incident" to the Tennessee Department of Health even though state law requires the hospital to do so, according to a federal investigation report.
The report also found that Vanderbilt staff did not document the medication mix-up in Murphey’s medical records, then subsequently provided different explanations for the omission.

More: 4 revelations from our story about Vanderbilt and the RaDonda Vaught case

Vanderbilt officials declined to comment for this story. Spokesman John Howser said the hospital would not speak further about Murphey's death "to avoid impacting either our former employee’s right to a fair trial or the district attorney’s ability to pursue the case as he deems necessary and appropriate."

In prior statements about Murphey's death, Vanderbilt officials stressed the medication error was immediately disclosed to her family. The hospital negotiated an out-of-court settlement that bars those family members from discussing her death or revealing the settlement agreement to anyone.

Vanderbilt officials confirmed the settlement during a public hearing earlier this year.

Charlene Murphey’s grandson, Allen Murphey, 35, who is not part of the settlement, said he thinks the hospital tried to hide its mistake and protect its reputation.

“A cover-up — that’s what it screams,” he said. “They didn’t want this to be known, so they didn’t let it be known.”

Court records show syringes and a vial of vecuronium that have become potential evidence in the trial of RaDonda Vaught, a former Vanderbilt nurse accused of killing patient Charlene Murphey with a medication error.

Vanderbilt leaders have acknowledged their response to Murphey's death was flawed. During a February meeting with the Tennessee Board for Licensing Health Care Facilities, Vanderbilt Health System CEO C. Wright Pinson confirmed Murphey’s death wasn't reported to state regulators and said the hospital's response was “too limited.”

At the same meeting, Mitch Edgeworth, who was then CEO of the hospital, said an internal review of Murphey's death led to “opportunities to improve the knowledge of our clinicians regarding reporting" to the medical examiner.

The health care facilities board, which oversees hospitals throughout the state, took no disciplinary action against Vanderbilt.

RADONDA VAUGHT: Vanderbilt largely to blame for deadly medication error, attorney says
‘She held us all together’

Charlene Murphey, who lived most of her life in the Gallatin area, was married for nearly six decades to her teenage sweetheart, Sam, and they had two sons, Gary and Michael.

She was the quintessential Southern matriarch who was always quick with a warm smile, a quip or a plate of food, said grandson Allen Murphey.

“She really was the glue of the family. She held us all together,” he said.

Charlene Murphey fell ill on Christmas Eve 2017. She was diagnosed with a subdural hematoma at Sumner Regional Medical Center, then transferred by ambulance to Vanderbilt, where her condition began to improve.

By Christmas Day, she appeared to be on the verge of leaving the hospital, her grandson said. Family members were so confident she was recovering they decided to delay celebrating the holiday until she was back home in a day or two.

“Everyone was saying at that point the best Christmas present ever would be to not have Christmas at the hospital,” Allen Murphey said. “But it didn’t work out that way.”

On Dec. 26, in preparation for her release, Charlene Murphey was scheduled for a PET scan in the hospital’s radiology department. This scan, similar to an MRI, requires a patient to lie still in a tubular machine for about 30 minutes. Murphey was claustrophobic, so a doctor prescribed her a sedative, Versed, to keep her calm.

In court records, prosecutors said Vaught, the Vanderbilt nurse, attempted to retrieve the Versed from an electronic medication dispensing cabinet but could not find it. She then disengaged one of the cabinet’s safeguards, unlocking more powerful medications, documents show, and typed "VE" into the cabinet's search tool.

She picked the first drug that was offered, documents show. It was not Versed. It was vecuronium.

In court records, prosecutors say Vaught ignored multiple warning signs that she had the wrong drug. While drawing the vecuronium into a syringe, Vaught must have looked directly at a medication bottle cap that said “WARNING: PARALYZING AGENT.”

Prosecutors say Vaught then injected Murphey with the syringe and left her for the PET scan as the vecuronium paralyzed her body. By the time the error was discovered, she had suffered cardiac arrest and partial brain death.

About nine hours later, Muprhey's family, who were once so confident she was coming home, gathered at the hospital to say goodbye.

“But it wasn’t really a goodbye,” Allen Murphey said with tears in his eyes. “I was talking to her, but she wasn’t there. She was long gone.”

Charlene Murphey officially died at 1:07 a.m. on Dec. 27, 2017, when she was disconnected from a breathing machine.

RADONDA VAUGHT: Health officials reverse decision not to punish ex-Vanderbilt nurse for fatal error

Vanderbilt didn't report error to state, feds or medical examiner

Vanderbilt staff told Murphey's family what happened but never documented the vecuronium injection in her medical records, according to a federal investigation report of the death.

One unnamed Vanderbilt official told federal investigators Vaught didn't document the injection because "everyone was focused on resuscitation" and there was "no opportunity" to update the records, the federal report states. Although Vaught is not named in the federal report, the document states the nurse who gave the vecuronium injection said she did not document it in medical records because she was told by a nursing manager it was unnecessary and would be recorded automatically.

The deadly injection wasn't reported to the Davidson County Medical Examiner's Office, which is responsible for investigating non-natural deaths in Nashville. Medical examiner records state Vanderbilt neurologist Dr. Adam Hartman reported the death as having “no foul play suspected" while another neurologist, Dr. Eli Zimmerman, attested Murphey died from "natural causes of complications of the intra-cerebral hemorrhage."

If a vecuronium injection had been mentioned, it would have immediately triggered an investigation, said Dr. Feng Li, the medical examiner.

"Especially with that kind of medication given, we would have investigated the case,” Li said. “We would have taken jurisdiction.”

Li said he changed Murphey’s manner of death — from natural to accidental — in August 2019 to correct the official record.

Vanderbilt did not report the fatal error to The Joint Commission, said commission spokeswoman Maureen Lyons. The commission did not learn about Murphey’s death until after media reports began the following year. It then evaluated the incident and took “appropriate actions,” which are confidential, Lyons said.

The hospital didn't report the fatal medication error to the Tennessee Department of Health, which would have then alerted the state Board for Licensing Health Care Facilities and the federal Centers of Medicare and Medicaid Services (CMS). State law requires Vanderbilt to report all incidents of abuse or neglect with within seven days.

Instead, regulators learned about the death from an anonymous complaint in October 2018. CMS responded with a surprise inspection at Vanderbilt, then threatened to suspend Medicare payments if the hospital did not take steps to prevent a similar death. Within days, Vanderbilt created a written “plan of correction” for CMS.

The Tennessean obtained a copy of Vanderbilt’s correction plan in November through a Freedom of Information Act request.

The corrective plan says Vanderbilt changed its medication dispensing cabinets so vecuronium can no longer be accessed by overriding a safeguard.

The hospital also made the process of obtaining other paralyzing medications more deliberate. These medications can only be accessed by searching a cabinet specifically for “PARA" and require two nurses for an "independent double check." Cabinets display new messages warning these drugs cause "respiratory arrest."

Vanderbilt also revised policies on documenting medical errors and reporting errors to the medical examiner and the Tennessee Department of Health. Hospital policy now specifically requires a medication error to be documented in medical records and reported to the medical examiner if it contributes to a death. Vanderbilt's Office of Risk and Insurance Management is now responsible for reporting errors to the health department.

The hospital added instructions to its medication policies, telling medical staff how to monitor patients after giving them drugs. Previously, Vanderbilt's policies included no such instructions, according to the federal investigation report.

Numerous officials would not comment or answer questions for this story. The Tennessee Department of Health said it would not comment because of pending litigation. CMS declined an interview request and to answer emailed questions. Tennessee Board for Licensing Health Care Facilities officials did not respond to requests for comment. Vaught and her attorney did not agree to an interview. The two Vanderbilt neurologists who misreported Murphey’s death did not respond to multiple email requests for comment. Edgeworth, who left Vanderbilt last year for an executive job at TriStar Health, declined to comment through a spokesperson.

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