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Report tells of errors in organ case

U.S. regulators detail how a potential donor was given huge doses of sedatives and painkillers as six people watched.

March 02, 2007|Tracy Weber and Charles Ornstein | Times Staff Writers

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.

In the operating room that night were the transplant surgeon and a colleague, both from Kaiser Permanente's now-defunct kidney program in San Francisco, as well as a nurse and coordinator from the regional organ procurement group that serves most of Central and Northern California, the report said. Also on hand were the doctor treating Navarro at Sierra Vista, the patient's intensive care nurse, an operating room nurse and other staff.

At 11:10 p.m., a transplant surgeon ordered 100 mg of morphine and 40 mg of Ativan for Navarro, the report said. The surgeon is not mentioned by name, but several sources confirmed his identity as Hootan Roozrokh.

At some point soon after, Navarro's breathing tube was removed.

Legal restriction

According to state law, Roozrokh might already have crossed a line. Transplant doctors are not to direct the treatment of potential organ donors before they are declared dead. This restriction is designed, in large part, to ensure that organ retrieval does not take priority over patient care.

Moreover, the report said, Roozrokh was not authorized to care for patients or order drugs at the hospital, according to the hospital's own policies.

When Navarro's heart did not stop, Roozrokh ordered another 100 mg of morphine and 40 mg of Ativan, which the ICU nurse administered, the report said.

Navarro still did not die. After about 30 minutes off life support -- the time limit set to ensure the viability of the organs -- the process was ended. Navarro was returned to the intensive care unit, where he died early the following morning. His organs were not retrieved.

Later, the report said, the hospital's operating room nurse told inspectors that she had never seen narcotics or sedatives given to a patient during an organ donation procedure and that she "repeatedly asked" the ICU nurse and representatives from the organ procurement group about the medications. But she did not alert her superiors or attempt to intervene.

The nurse's supervisor told inspectors she would have "gone to the OR and stopped the events" if the nurse had called, according to the report. (Operating room staff reported concerns about the incident days later.)

Navarro's treating physician told inspectors she was "surprised at the quantity of the medications" given to her patient. Another nurse, who obtained the medications for the ICU nurse, said that the amount of drugs was "a red flag."

According to critical care specialist Barie, 5 mg of Ativan an hour is enough to keep a desperately ill patient in an intensive care unit "very heavily sedated."

He and other experts said doses of medication can vary depending on each patient's circumstances.

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