A Deadly Mistake: What was to blame for a young boy's... -
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Published on: 4/7/2002
Last Visited: 3/21/2003
"Unfortunately, the operating rooms in hospitals are relatively dangerous places," says Dr. George Mclain, deputy chief of anesthesia at Martin Memorial Hospital in Stuart, Florida, where Ben Kolb had his ear surgery.
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"Yes, I think the public and a lot of doctors want to believe that," says Dr. Mclain."Everybody wants to believe that everything is always going to be fine.And nobody wants to be the victim of something that's going to happen one in 10,000, 100,000, or a million.It's just denial that it's going to happen to you.When you get on an airplane - most people aren't expecting it to crash.But people do know that airplanes do crash."
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"I got called to the operating room because the child's vital signs were grossly abnormal with very high blood pressure and very high heart rate," says Dr. George Mclain.
Anesthesiologist Mclain - who hadn't been involved in Ben's surgery until that point - couldn't explain why he was having this severe a reaction to a lidocaine injection.But he knew he had to get Ben's vital signs under control - fast.He gave Ben a series of drugs that within moments restored his heart rate and blood pressure back down toward normal.
"And everything looked good," he says."And the child looked really - all signs had returned to normal and he looked very stable.And we made the decision to continue."
Did he have a feeling that something wasn't quite right here?That he didn't have all the information?
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"Well, whenever you see something that you haven't seen before or is outside the range of what you've seen it makes you very concerned," says Mclain."When I left the operating room I went back and pulled out a couple of text books just to make sure that my drug regimen I had used was the appropriate one."
But just moments later, Dr. Mclain was summoned back to the O.R.This time, Ben's vital signs had plunged below normal and collapsed in a deadly free-fall.
"He was rapidly deteriorating," says Mclain."And pretty soon we lost what's called the EKG complex.And he just went flatline.And we did CPR, I think, for about an hour and 40 minutes."
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What did Mclain think had happened?"Right away you're worried about what happened but you're more focused on doing the resuscitation," he says."Because when you see something you've never seen in over - you know, 25-30 years in the operating room, you don't - I mean it's - you don't know what's going on."
That's a scary feeling.
"It's very scary," he says."It makes you feel very insecure very quickly."
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"When the surgeon and I went and talked to the mother," says Mclain, "I laid it out very seriously that he was currently in a coma, and that there was a chance that he might not wake up.And the mother said, ‚well, when can I give him his Christmas present?I bought him one, I want to give him the present today.' And I kept trying to tell her, ‚Well, he might not wake up.' And she said, ‚Well, I know he's going to wake up.' And I said, ‚Well, that's good.' She goes, ‚because everybody on TV wakes up.'"
Tim Kolb who'd spent that morning reassuring his son raced from his furniture workshop to the hospital.
"I was brought into the intensive care unit where my son was hooked up to a ventilator," he says.
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Mclain says, "To take a 7-year-old, healthy little, soccer playing, baseball playing child off the street and not return him to his parents is not the high point of your career."
Even though many in the community believed it was his mistake that had caused Ben's death, Dr. Mclain attended Ben's funeral.
"Why aggravate the situation by not being decent, kind and supportive of the family?"he says."If I'm going to get sued and torn apart I'm going to get sued by a plaintiff's lawyer, I'm going to get torn apart whether I was the world's nicest guy or the world's biggest toad.And I think about three nights later, I ended up going to the funeral and going up and viewing with the family.And that was probably the most difficult thing I've ever done in my career.But it probably stands out as the thing I'm most proud of having done."
And what did he get from that moment of interaction with the family at the funeral?
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"I don't know," says Mclain."I don't know what I gave.And I can't describe what I got."
But it's the most important thing of his career?"I think that, boy, I still have trouble with this after all these years," he says.
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"I reviewed I think, every piece of literature that's been written," says Dr. Mclain."The child certainly received what the literature would classify as a lethal dose."
So how did two completely different drugs with such opposite effects get mixed up during surgery?The drugs started out in vials: sealed and labeled at the factory, clear to everyone which is which.
But once inside the O.R., a nurse broke the seals, transferred the drugs into two open, sterile cups sitting next to each other - a common practice in hospitals around the country.
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"You go from, ‚Wait a minute, I'm off the hook,'" says Dr. Mclain."But we made a bad mistake.You know, we killed this kid.And you're part of the team, and it didn't matter who did what to whom, that child died on your watch."
It's no consolation to Dr. Mclain that he wasn't even called into the case until after the fatal drug mix-up and injection.You get the feeling no punishment could match the misery he already feels.
"Everybody has their demons," he says."And my demon is I don't know.I don't know whether I did all the right things, or all the wrong things.I don't know if I did the right thing in the treatment."
Uncovering the Truth
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says Mclain."So you have two choices.You can lie.You can cover up.You can spin it.Or you can be honest.And the nice thing about the truth - basically you only have to tell it once."
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Together, Dr. Mclain and Doni Haas drove to a meeting with the Kolbs at their lawyer's office, prepared to announce something almost unheard of - that Martin Memorial Hospital was responsible for their son's death.It was both a financial and an emotional gamble.
"It was real personal," says Haas."I have a grandson that age.And six of my own, right.I could really relate to this."
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Dr. Mclain says, "You know, you look in a parent's eyes that you know their child is dead because of a mistake.And that, you know, it's ‚How could you take my baby away?' Because you know, this was a very beautiful healthy child that should not have died."
What was the first thing in reaction that the Kolbs said to him?"I don't think they could speak, really," says Haas."I don't recall them saying anything.I remember a huge tear on Mrs. Kolb's cheek."
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"I think you know, what I find appalling about this whole thing is that it's still being held out as an example, and being unique," says Dr. Mclain."All we did was treat this patient's family the way we want to be treated.And we were honest and forthright."
The hospital says that one of their lessons from this whole experience is that truth works.
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The commission did sponsor a conference where Doni Haas and Dr. Mclain spoke on medical safety and they published an essay in their newsletter.But the medical industry's own watchdog has never issued a new safety standard based on the Ben Kolb case.
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"If an airline crashed we, as a public, would never stand for the airline not sharing the information that they learned from that crash," says Dr. Mclain."It's public knowledge so that that crash can be avoided on some other airline or some other airplane.In medicine, we don't do that."
The Joint Commission says that despite an alert it issued in 1998, reports of another type of medical mistake - operating on the wrong part of a patient's body - have more than tripled in the past three years.
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