It was to be the final medical procedure for Ruben Navarro, an altruistic end to the life of a critically ill 26-year-old who doctors said had no chance to recover.
Staffers at Sierra Vista Regional Medical Center in San Luis Obispo were to disconnect him from the machine pumping oxygen into his lungs. After his heart stopped, transplant surgeons were to remove his organs so they could be used to save the lives of others.
But in the late night quiet of an operating room Feb. 3, 2006, plans for that dignified end went terribly awry, according to a 76-page report by federal inspectors released this week in response to a Freedom of Information Act request from The Times.
Police and the state medical board are now investigating whether the transplant surgeon brought in to retrieve Navarro's organs attempted to hasten the patient's death by ordering him pumped full of massive amounts of narcotic painkillers and sedatives. If true, the allegation would constitute a grave breach of the nation's transplant rules.
In a stark recounting, federal regulators detailed how at least six people in the room, including Navarro's treating doctor, stood by without intervening, even though some later said they were disturbed by the actions of the surgeon and a nurse administering the drugs. The regulators from the U.S. Centers for Medicare and Medicaid Services have been looking into the hospital's role in the case.
The amounts of the painkiller morphine and the sedative Ativan that the report says were given to Navarro were "between 10 and 20 times a usual dose of these drugs," said Dr. Philip S. Barie, president-elect of the Society of Critical Care Medicine, who was not involved in the preparation of the document.
"I don't think I've ever given doses of either drug in that amount," said Barie, professor of surgery and public health at Weill Medical College of Cornell University in New York.
According to regulators, the mistakes began almost from the moment Navarro was wheeled into the operating room from the intensive care unit, where he had been on life support after arriving at the hospital in cardiac and respiratory arrest Jan. 29. Navarro, who suffered from severe mental retardation, had been living at a nearby long-term care home.
