Ref. # 77658
A 46 year old West Virginia woman was in a motor vehicle accident and suffered multiple trauma including: closed head injury; multiple fractures; extraperitoneal bladder tear; and rectal laceration. The patient underwent surgery which included decubiti, sigmoid diverting, colostomy, fracture fixation and feeding tube placement. Her prolonged hospital course was complicated by acute renal failure, chronic vent dependence, sepsis, ARDS, and a required tracheostomy. Vent wean took place six months later. One month later, in a neurologically compromised state, the patient was discharged to rehabilitation. She eventually expired. A medQuest critical care expert reported that the overall care was excellent, yet noted a documented, reversible lapse in the care rendered one month after the surgery. The patient's monitor alarms went off, indicating a lack of observation; she was found to have suffered a seven-minute arrest, asystole without respiration. She was resuscitated with return of rhythm after reintubation. Furthermore, for an unknown time period prior to the arrest, the patient experienced hypoxemia and poor cardiac output, with vent peaks falling from 100+ to 70-80, making the subsequent arrest predictable.