TRANSPLANT
plant that day, his wife said, fearing he wouldn’t get another chance. But more than a month later, he still couldn’t sit up or breath on his own.
“He was in worse shape than when he went in,” said his wife, Marilyn.
Finally, in late January 2018, doctors said they identified a major cause of his continued struggles: A tear had formed in John’s respiratory tract where the transplant surgeon had connected the donor lungs to his air passageway.
Such airway complications occur in between 5 percent and 10 percent of lung transplant patients, experts say, but rarely are they as severe as the “Grade 4 dehiscence” that had opened in John’s respiratory tract.
Despite doctors’ efforts to repair the airway, St. Luke’s officials would later acknowledge that the complication triggered other serious problems — infections, pneumonia, inflammation, organ failure — that ultimately led to John’s death in April.
Marilyn believes there were other factors. She repeatedly complained to hospital staff about the care provided to her husband. The concerns are documented in a series of letters between her and hospital administrators.
In one instance, a nurse used a harness to lift her husband out of bed, Marilyn said, and in the process tore open his surgical wound, soaking his gown in blood. Other times, she said, staff inadvertently jostled lines connecting her husband to life-support equipment or failed to follow doctor’s instructions.
“It was one thing after another,” Marilyn said. “I couldn’t believe the way they treated him at that hospital.”
In the written statement, Gerry, the hospital spokeswoman, noted that St. Luke’s has maintained “magnet” status in nursing care for two decades, signaling that the hospital meets quality standards laid out by the American Nurses Credentialing Center.
“We have full confidence in our nursing professionals in the care they provided to the patients you highlighted and are aware of the patient concerns you relayed,” Gerry wrote, referring to the care provided to all of the patients included in this story. “We reviewed and responded to families’ questions and comments, and immediately followed up as necessary.”
In August, three months after John’s death, Marilyn met with Nord, the hospital’s president, along with Loor and others, to address her complaints. Chambers recorded the conversation and provided reporters with a copy of the audio.
During the meeting, Nord acknowledged that her hospital staff could have done a better job and said the hospital had educated staff based on some of her complaints.
Loor assured Marilyn that he and his team had done everything they could for John and that they were heartbroken with the outcome. Although it was another surgeon who performed John’s lung transplant, Loor said he was confident that it was done correctly. He said that the tear in John’s airway was likely the result of a common complication known as “graft dysfunction,” in which a set of donor lungs goes into shock after being implanted in a patient.
Loor explained that he had hoped that John was going to recover from that setback, but the infections and other problems eventually became too much.
“Ms. Chambers, I’m really sorry about all of this,” Loor said during the July meeting. “And I know it’s got to be really hard for you, but I know that you’re strong, and I know that he [ John] is with us. I feel him with us. And we get better and I get better, we all get better from talking about these things and learning from these things. … We’re going to take this to heart.”
A flipped lung
In early February, three days after doctors discovered the tear in Chambers’ airway, Edmund Flores sat in a waiting room, praying for his wife while she underwent a double-lung transplant. Patsy Flores, a 58-year-old mother of two adult children, had spent more than a year struggling to catch her breath as result of high blood pressure in her lungs and a devastating autoimmune disease.
It became clear a day after her transplant that something was wrong.
When Loor and another surgeon reopened Patsy’s chest two days after the transplant, they made a tragic discovery, her medical records show: One of the new lungs had inexplicably flipped over, pinching arteries and choking off blood flow to the organ. The complication, known as lung torsion, is so rare after lung transplants that only 12 cases had been publicly documented as of two years ago.
Researchers who examined each reported case concluded that the deadly complication can be mitigated in some instances if detected right away and corrected. But by the time St. Luke’s doctors flipped Patsy’s left lung back over, much of the organ had essentially died, according to her medical records.
In a statement, hospital spokeswoman Gerry wrote that initial Xrays following Patsy’s surgery did not indicate any twisting of the lung. “Additionally,” she wrote, “all of our standard intraoperative monitoring procedures confirmed correct alignment and orientation. … However, continued monitoring over the next 24 hours detected a misalignment in one of her lungs and a procedure was completed to address the alignment.”
In an effort to save her, Loor removed the damaged lung and doctors put Patsy back on the transplant waiting list, in urgent need of a replacement. Within days, they accepted another lung for her and implanted it.
But it was not enough. Patsy spent nearly four months connected to life support, her medical records show. Her kidneys failed. She suffered repeated infections and bedsores.
Edmund also complained to hospital staff about his wife’s care. A chaplain recorded some of the complaints in Patsy’s medical records. Edmund said there were not enough nurses on staff overnight and on the weekends, leaving his wife to sometimes wait too long for assistance.
A few weeks after his wife’s surgery, a nurse ripped open Patsy’s surgical wound while attempting to lift her out of bed, Edmund said, the first of two times that happened: “From that point forward,” he said, “it was taking that much longer to heal.”
Patsy smiled in photos as her family gathered around her hospital bed to celebrate her 59th birthday in April. But physically, she continued to decline. She lost weight. Her organs shut down. Infections spread through her body. And finally, on June 1, she aspirated vomit into her lungs and died two days later.
Twist called ‘avoidable’
A month later, Edmund sat looking through photos of his wife at their home in Channelview, a blue-collar town east of Houston.
“Woo boy, she was something else,” Edmund said, fighting back tears. “She was a beautiful woman. Strong, vibrant, full of life.”
Edmund said that he understands Patsy was critically ill, and that she wouldn’t have survived much longer without a transplant. But he’s struggling to come to terms with the rare complication that caused her first transplant to fail, and with what he felt were lapses in care from seemingly overworked nurses and other medical staff in the months that followed.
“The nurses were doing a fantastic job,” he said. “But there was only so much they could do because they were stretched so thin.”
Since Patsy’s death, Edmund has received two anonymous letters in the mail. He suspects they were from someone who was involved in his wife’s care, or another hospital employee.
The first note alleged that there were problems with Patsy’s transplant and claimed that her death “should have been avoided!!!” The second mentioned other lung transplant deaths this year and encouraged him to contact a Chronicle reporter.
“I need you to know that the lung twist was avoidable,” the letter read, “and the whole team feels so so bad for you and your family.”
Flores doesn’t know what to make of the notes.
For now, he has filed them away with other records documenting his wife’s stay at St. Luke’s.