WHY DID LISA DIE?

That is the question I have been trying to get answered since the evening in November 2003 when Lisa, a 42-year-old insulin-dependent diabetic, went into a coma while a patient at Samaritan Hospital In Troy, New York. So far, no one has explained why Lisa’s blood glucose level dropped 114 points in less than three hours, causing catastrophic damage to her brain and other organs that left her unable to survive without life support. My name is David Baker. I was married to the former Lisa Zenzen for 19 years. Now I am the administrator of her estate. Four days after Lisa collapsed, and while she was in critical condition in Samaritan Hospital’s intensive care unit, I wrote to the New York state Health Department, the agency that is supposed to regulate healthcare facilities in New York. Here is the text of that letter:

“November 16, 2003 NYS Department of Health Capital District Regional Office Frear Building 2 Third Street, 2nd floor Troy, NY 12180-3298 RE: Lisa M. Baker “Dear Sir or Madam: “I write on behalf of my wife, Lisa, to request an investigation into the care given to her while she was a patient in a hospital in New York state. Lisa is currently in the CCU at Samaritan Hospital, following an incident last week while on a regular ward.

Here is what happened:

Lisa is an insulin-dependent diabetic. She has a number of complications resulting from the disease, including gastroparesis, a condition in which the digestive system slows down and sometimes stops altogether.

   On Thursday, November 6, Lisa was experiencing nausea and vomiting. During the evening I took her to the Emergency Department at Samaritan Hospital. After an evaluation, she was admitted and placed on the fourth-floor Progressive Care Unit.

   By the evening of Monday, November 10, the nausea had subsided. She told me that she had been informed that she would likely be discharged by the Wednesday. Also, all IVs had been removed, a fact that may well be significant given what occurred next.

At about 2:15 the next morning I received a call from a nurse in the Progressive Care Unit, who said that I should go to the hospital immediately because Lisa was “not doing too well.”

   On arriving on the floor, I was told that Lisa was about to be moved to the ICU; that a short time before she had stopped breathing and that the paddles had been used to restore her heart function to normal.

   She also had received glucose via an IV, because her blood/glucose level had been at 2.       That’s right, 02.

   Lisa had been placed on a respirator and was put on sedation. Lisa remained on the respirator until this past Friday, November 14. At that time, the sedation was stopped and she woke up and began breathing on her own. But she has not said a word, or made any attempt to speak. And she shows no indication that she knows who I am.

   So far, no one at the hospital has addressed with me the question of how the blood/glucose level of an insulin-dependent diabetic patient was allowed to drop to a fatal level.

   Also, I have been told that by Friday, all records relating to Lisa’s treatment prior to her transfer to the CCU had been removed from her file. Thus, those records were not available to a doctor when he began treating my wife on that day.

I now ask for an immediate, full and complete investigation of my wife’s care while a patient at this hospital, care that may well have left a bright, intelligent college-educated woman with severe, irreversible damage to her brain. Yours truly, David Baker” Two days later, I received a phone call from Karen Rant of the Health Department’s office in Troy. Rant said an investigation would start immediately with a request to the hospital for Lisa’s medical chart, and interviews with everyone involved with Lisa’s care. That ‘investigation’ took more than seven months, during which the Department sent the medical chart out to an organization called IPRO, which claims to conduct independent reviews of complaints against healthcare facilities but in fact is partly funded by the healthcare industry.

    In June of 2004, I received a letter from Robert Welch, program director of the Health Department’s Hospital and Primary Care Services office in Troy. After referring to the review by the expert at IPRO, Welch’s letter was to the point: “As was mentioned in a telephone conversation, the expert reviewer found that the standard of care was met. This office will keep your complaint on file for future tracking and trending of similar issues with this facility. Sincerely, Robert G. Welch.” 

    Case closed. But not answered, by the Health Department or Samaritan Hospital, are the following questions: 

   Why was Lisa’s blood sugar tested only once after – according to the hospital’s records – she had already had an insulin reaction at about 9 p.m. that evening, and was receiving no nutrition because at 5:30 p.m. that day Dr. Rajinder Jain had ordered her IV feeding to be stopped?

    Was Lisa put back on an IV insulin drip between 11 p.m. and 2 a.m., as a note by a doctor in the charts suggests? And if not, why did Lisa’s blood sugar plunge so far in the time between the last blood test at 10 p.m. and when she was found not breathing at 2:07 a.m.? Lisa faced a number of challenges as a result of complications of diabetes. She was blind, which would have made it difficult for her to find her call button if, as is likely, she became aware that her blood sugar was dropping to a dangerous level. That would be one more reason to monitor her closely, which the staff on duty that night clearly did not do.

    On the Monday evening during what would be the last time she was able to speak to me, she said she had been told she would probably be going home the next day or the day after. By the next day she was on life support. Three weeks later she was dead. Which leaves the question that I am still trying to get answered:

WHY DID LISA DIE?