The family of a Vineyard woman is suing a Utah hospital, saying she died after surgery because doctors left an open tube from her heart that drained her blood into a garbage can.
Doctors at St. Mark’s Hospital in Millcreek performed heart surgery on Donnamay Brockbank in July 2018 to remove a medical device that was causing an allergic reaction, according to a complaint filed last week in Utah’s 3rd District Court.
The surgery required a cardiopulmonary bypass, with blood exiting Brockbank’s body through a large needle and tube near her neck going through a blood reservoir and re-entering through her femur.
After the surgery, when Brockbank’s heart was beating on its own again and the surgical wound was closed, the head surgeon left the operating room and a technician began to break down the bypass machine, the lawsuit states.
The tube and needle, or cannula, returning blood to Brockbank's femur was removed. But blood was still leaving Brockbank's body through the other cannula, which was left in her body, unclamped, the lawsuit states. The technician removed the blood reservoir from the bypass machine and put it in a medical waste garbage can as Brockbank's heart continued to pump blood into it, the suit alleges.
As Brockbank’s blood pressure crashed, the surgeon, Shreekanth V. Karwande, returned to the operating room.
Over the course of 40 minutes, doctors performed plasma transfusions that added seven pints of blood to Brockbank’s veins, nearly doubling the amount of blood typically in a human body, said Rand Nolen, an attorney for her family.
But none of the medical professionals in the room addressed the tube piping blood out of Brockbank and into the garbage can, the lawsuit states.
"It boggles the mind, with how experienced this team was, that nobody would catch such a simple oversight," said Rhome D. Zabriskie, another of the family's attorneys.
Brockbank briefly stabilized with the transfusions, but as that blood also passed through the cannula, her heart began to give out, said Nolen, a Houston-based personal injury attorney. Eventually Karwande reopened Brockbank's chest and tried to manually manipulate her heart, Nolen said, but he could not revive her.
When Karwande left the operating room the first time, he told Brockbank’s family the surgery had gone well, Nolen said.
"An hour and a half later, he tells the family this is on him, and that she has died," Nolen said.
In a meeting about two days later, hospital employees told Brockbank's family that the reservoir of blood had been found in the garbage can, Nolen said.
"We want to express our deepest condolences to Donnamay Brockbank’s family for their loss," said St. Mark's CEO Mark Robinson. "Unfortunately, we are unable to comment on any pending litigation. That said, we continuously seek to learn from every patient situation to improve the quality and safety of the care we provide in our operating rooms and throughout the hospital."
But Nolen and Zabriskie say they have largely had to piece together what happened with the help of outside medical experts and family recollections of their conversations with hospital staff — because, they said, the medical records from the surgery “fell well below any known standard of care in the United States of America.”
“The records relating to this surgery are as poor, if not poorer, than you would find in a third world country,” the lawsuit states.
For example, Nolen said, the whereabouts of the assistant surgeon, David Affleck, are not documented after the initial surgery.
"The records are as poor as any I have seen in 27 years," Nolen said. "They're amazingly bad. Normally when a patient dies in a hospital, you get a discharge summary and an operative summary that will detail for you ... exactly what is happening throughout the procedure. Normally what you anticipate, particularly if a patient has passed away, is that you will get a step-by-step recitation from the surgeon as to what was happening in that operating suite. If those exist, they have not been provided to us."
Brockbank, 63, was survived by her husband, four children, five stepchildren, more than 20 grandchildren, as well as her parents and six siblings.
"Her family is devastated by this," Zabriskie said.
The lawsuit names as defendants St. Mark’s Hospital, Karwande, MountainStar Cardiovascular Surgery, SpecialtyCare Cardiovascular Resources, and Kyle Enslin, who was the anesthesiologist for the surgery.