News From Transplant Week of March 17, 2002 / Vol. 3 No. 11

 

NY Hits Mount Sinai Liver Transplant Program With Maximum Fine, Partial Suspension
 

The New York State Health Department announced it was levying the maximum fine, and suspending Mount Sinai Hospital's living-donor adult liver transplant program for at least six months, for "woefully inadequate post-surgical care" that contributed to death of a patient who donated part of his liver to his brother.

State Health Commissioner Antonia Novello told the Times Union of Albany that she was "a little bit aghast" at the discovery of two dozen deficiences, including the fact that 34 transplant recipients and donors had been left in the care of an inexperienced first-year medical resident.
"There's clearly a problem there,'' said Dr. John Balint, director of the Center for Medical Ethics at Albany Medical College. "Not seeing a patient for four days after they've taken 60 percent of their liver is not right"

The resident had worked in the transplant unit for just 12 days before she was left alone in charge on Jan. 13, and she described herself as "overwhelmed."

"Our investigation has concluded that the patient did not receive appropriate care following surgery," Novello said at a news conference in New York City.

Mount Sinai, which has one of the most active adult-to-adult liver transplant programs performing about 35 a year, halted the operations on Jan. 15th following the death of Mike Hurewitz, 57. But it has continued to hold informational meetings for prospective donors and recipients.

Novello said she would order a suspension for at least six months of Mount Sinai's adult living-donor liver transplant program, as well as conduct an investigation into the hospital's pediatric liver transplant program. She also fined the hospital the maximum $48,000 on 18 violations

The state health department's 10-page report on its investigation found that besides leaving care of its transplant patients to one "inadequately supervised and overburdened" resident, the hospital had a shortage of nurses on the unit and the patient's vital signs were neither taken nor recorded "as frequently as necessary" to monitor his condition.

The state health department found that the surgeon who operated on Hurewitz, Dr. Charles Miller, never "saw the patient post-operatively," which is contrary to standard surgical policy.

Hurewitz, a reporter for the Times Union, donated about 60 percent of his liver to his brother, Adam Hurewitz, 54, a physician from Long Island, who since has recovered.

"There's clearly a problem there,'' Dr. John Balint, director of the Center for Medical Ethics at Albany Medical College and member of the ethics committee of the American Association of the Study of Liver Disease, told the Times Union.

"Not seeing a patient for four days after they've taken 60 percent of their liver is not right,'' he said. "I would expect a surgeon who has undertaken a major operative procedure to follow that patient closely.''

The state report said that almost 24 hours before Hurewitz's death, he started to show signs of trouble, including heart problems and, later, nausea. On Jan. 13, he began vomiting "brownish materials," generally a sign of blood. The transplant fellow on duty -- a doctor training in the transplant specialty -- was at a nearby bookstore and failed to respond to the resident's pleas for help.

When the transplant fellow returned to the unit, he "chose to work up a pediatric patient scheduled for surgery the next day instead of seeing this patient in serious distress," the report said.' Two hours later, Hurewitz was dead. Cause of death appears to be that he had inhaled large amounts of bloody vomit into his lungs.

An autopsy found a bacterial infection that had spread through his stomach, small intestine, portal vein, esophagus and into his lungs The bacteria were Clostridium perfringens, normally found in the intestines and in soil and sewage.

"The transplant technique was perfect," Novello said. "It was the aftercare that was sloppy ... I call it a 'Space Odyssey' operation and a Third World follow-up."

Barry Freedman, president of Mount Sinai, disagreed with the charge of a lack of post-operative supervision, but said: "Clearly, things didn't work the way we wanted them to work. We acknowledge and feel horrible about that. We're going to get that right."

Hurewitz, the first liver donor to die at Mount Sinai, is the second confirmed death of a liver donor in the United States. Several others have been reported from Europe.

Other sources: Times-Union, New York Times, NY State Health Department