Simple device could have saved young kidney donor’s life – NBC Bay Area

After a healthy young man died at UCSF hospital, an NBC Bay Area investigation revealed the events that caused his heart to stop just one day after surgery.

Photographic evidence shows Anders Pederson was not monitored with a pulse oximeter, even after a nurse practitioner changed his medication from Fentanyl to another strong opioid: Dilaudid. While Fentanyl is more potent than Dilaudid, the dose of Dilaudid prescribed to Anders, according to court testimony, was 380% more potent than the original Fentanyl prescription.

A pulse oximeter, a readily available medical device that attaches to a patient’s finger, could have alerted hospital staff that Pederson’s blood oxygen level was dangerously low.

A pulse oximeter can continuously monitor a patient’s vital statistics, including blood oxygen level, blood pressure, and temperature.

Pederson, 28, and his sister, Kelly, were recovering on the ninth floor of UCSF Parnassus, a day after doctors removed a kidney from Anders and transplanted the organ to Kelly. According to transplant surgeon, Dr. Garrett Roll, there were no complications during the operation and everything went as planned.

“I remember texting my friend saying, ‘It’s over, it went great…so happy!'” Kelly and Anders’ mother, Melissa Pederson, said. Anders even found the energy to visit Kelly’s hospital room, across the hall from her room.

“It was wonderful,” Melissa said. “And he told her it was the best day of her life. They were just the two of them together, they were so cute.

Kelly Pederson’s medical problems had started decades earlier with a childhood E. coli infection. At 15 months, doctors gave him a 30% chance of survival. But as Kelly got older, she seemed to have beaten all odds.

Despite a kidney infection as an infant that involved her kidneys, Kelly grew up “extremely well,” said her mother, Melissa Pederson. But just after Kelly’s 30th birthday, the family received terrible news: “She had practically no kidney function,” Melissa said.

“She was on the debate team, which she absolutely adored. She was into cheerleading, she really liked to dance,” Melissa Pederson said.

Throughout childhood and into adulthood, Kelly and Anders have always been best friends. “People have their partners who are their twin flames. Anders was my twin flame. We were like twins,” Kelly said.

Learning that his sister needed a transplant, Anders Pederson immediately volunteered to donate his kidney to Kelly. “I had five other friends who came forward…and Anders said to all of them, ‘No, I want to donate for you,'” Kelly said.

When Kelly turned 30, the results of a blood test prompted an immediate call from her doctor. “She called me immediately and just said, ‘you have kidney failure’.” He was the first person to say, “I don’t want anybody else to test this; if I’m compatible, I’m going to donate to you,” Kelly said.

This wish started a year-long journey. The most critical decision: choosing the best transplant center, which turned out to be right in their backyard. The Organ Transplant Program at the University of California, San Francisco performed more kidney transplants than any other center in the country.

“They are number one. They have to be the best,” Kelly said.

In 2015, Anders began a rigorous 6-month evaluation. Among the many requirements, according to UCSF websitea donor must be in “excellent health”.

“He just wanted me to be happy and be able to have kids,” Kelly said. The surgery was performed on the Parnassus campus of UCSF on October 23, 2015 at 8:20 a.m. After the surgery, Kelly began to improve immediately, but a nurse’s diary shows Anders was in a lot of pain – up to “8” on a scale of “1 to 10”.

At 4:29 p.m., a nurse practitioner switched her medication from Fentanyl to another strong opioid: Dilaudid.

Pain 7-8/10, can we get higher PCA orders?

Exhibit 45, October 23 at 1:28 p.m.

“Opioids have powerful side effects,” said Dr. Mike Ramsay, CEO of the Patient Safety Movement. “They slow down your breathing rate and to the point that if you are sensitive to them or have too much of them, you will stop breathing.

The morning after the operation, Anders had spent a restless night, marked by multiple bouts of vomiting. Anders asked his mother for his sunglasses so he could sleep.

“I actually took a pic once he fell asleep,” Melissa said, as he looked so cute in his sunglasses.

A photo taken by Anders Pederson’s mother will later serve as evidence in court that he was not wearing a pulse oximeter, a simple device that attaches to a patient’s finger and alerts medical staff to various vital statistics , including a low level of oxygen in the patient’s blood. .

This photo taken by Melissa would later serve as a critical clue to what happened to Anders. It shows he wasn’t on a pulse oximeter, a common electronic device that clips onto a patient’s fingertip. It is used to monitor blood oxygen levels and alert hospital staff if they drop dangerously low.

But there was no pulse oximeter, no alarm and no warning for the morning shift nurse, who entered Anders’ hospital room around 9 a.m. .

“A nurse came in, she was on her computer,” Melissa Pederson said. “She was working on a machine and he was so quiet. And I thought, you know, I’ll just check him out, see how he’s doing. So I went and put my hand on his hand and his hand was cold. And then I took off his sunglasses and realized his face was yellow. And his lips were blue, and I knew he wasn’t breathing. And I started screaming his name.

When the nurse started the code blue alarm to signal that a patient was in cardiac arrest, Kelly Pederson, across the hall, began to struggle.

“I felt like I couldn’t breathe and I started screaming, ‘I can’t breathe! I can’t breathe! Something’s wrong with me. I can’t breathe,'” said Kelly “I felt him die as I screamed because it felt like the air was coming out of my body.”

The medical team managed to revive Anders and put him in an artificial coma. After nine days on life support, he was declared brain dead. He was only 28 years old.

“They told us they thought he had a genetic defect in his heart, and his heart just stopped,” Melissa Pederson said.

Melissa Pederson said she thinks about her son every day. “Our dynamic changed so much with his loss,” she said.

NBC Bay Area’s investigative unit consulted with several outside doctors and reviewed thousands of pages of hospital records, including an autopsy that showed Anders had a healthy, normal heart.


Medical examiner’s report, page 16

The documents also revealed that it was not UCSF protocol to use a pulse oximeter on low-risk patients like Anders, even though it is a readily available and inexpensive device that would have triggered a critical alarm. This is especially important for patients receiving opioids for pain.

Anders was hooked up to what is called a PCA pump, short for Patient-Controlled Analgesia. The pump allows patients to press a button and get extra doses of medication, up to a set limit.

Dilaudid PCA pump ordered

List of medications, October 23, 4:29 p.m.

Through the PCA pump, he was receiving doses of the opioid, Dilaudid. The drug’s label states that a starting dose should be reduced in special risk patients with renal or renal impairment. After the operation, Anders had only one kidney. According to Dilaudid’s package insert, the drug itself could put him at risk for respiratory depression.

In general, opioids should be administered with caution and the initial dose should be reduced in the elderly or debilitated and in those with impaired renal function…

Dilaudid Package Insert, Page 13, Patients at Special Risk

“If you stop breathing, you build up carbon dioxide in the blood,” said Dr. William Klein, “and that makes the blood much more acidic and on its own can cause cardiac arrest.”

Klein was a professor of medicine at UC Irvine for more than 40 years. Despite his decades-long relationship with the University of California, he became a key witness in the Pedersons’ trial. Klein testified that the photo taken by Melissa, showing no pulse oximeter on Anders’ finger, indicates a critical error by the hospital.

“Side effects of Dilaudid include respiratory depression,” said Dr. William Klein, an internist who specializes in lung disease and critical care. “If a patient has, in fact, had the kidney removed … the clinical pharmacologist should take that into account.”

I can’t think of a reason not to use you as such,” Klein said of the pulse oximeter. “They’re not that expensive to have at the bedside, and they have a system of alarm that would actually help detect the side effects of the opioid itself and get people to come to the bedside much faster. In this gentleman’s case, it probably would have saved his life.

UCSF said the hospital could not comment on the matter due to patient confidentiality, but in a statement, NBC Bay Area said they “modified” their “transplant protocol after this incident.” and now provided “continuous pulse oximetry monitoring”. (See UCSF statement here)

UCSF also contends that two investigations, one by the United Network for Organ Sharing and the other by the Centers for Medicare And Medicaid Services, found no wrongdoing on the part of UCSF.

“They fought us on every possible legal issue,” said Steve Hillyard, a medical malpractice attorney hired by the Pedersons. “They would never admit wrongdoing.”

NBC Bay Area learned that this was not an isolated case. A Stallion 2021y led by Dr. Susan McGrath and Dr. George Blike at Dartmouth-Hitchcock Medical Center estimates that 180,000 people suffer from opioid-related adverse events in hospitals each year and about 5,000 patients die.

“My life is consumed by trauma because of this,” Kelly Pederson said. “I hope no family ever has to go through this again.”


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