Shirley Adams survived a drug-induced coma alternating with drug-induced delirium only because her husband insisted on getting a new doctor and a new hospital. Her first team of doctors said she was hopeless. Her husband said she was just getting too many drugs.
After a heart attack, Shirley spent 27 days in her local hospital with wrist restraints and sedatives to keep her from tearing out the sutures from her angioplasty and coronary artery bypass grafting. For most of this time, she was on a breathing tube. Her doctors gave her an erroneous diagnosis of anoxic encephalopathy, and recommended withdrawing care. Her husband insisted on a referral to the Mayo Clinic.
Her new doctor gave her a drug that counteracts the effects of the sedative (lorazepam). She immediately regained consciousness. After 8 more days in rehab, she went home with her devoted husband. Two years later, she was well enough to share her story.
The medical journal Chest published a case report of this near tragedy. Shirley and her husband are co-authors, along with Dr. William F. Dunn of the Mayo Foundation. The editors note:
This submission to the “Transparency in Health Care” series focuses on a case of a “near miss”, actually a near death, imposed by two “systems”. When we view adverse events as “system issues” rather than as opportunities to identify the individual responsible to “blame and shame”, we can more responsibly develop system responses of broadly improved care.
Robert Adams, Shirley's husband, notes:
What is the lesson for those reading my thoughts? Stay close to loved ones in a medical emergency. Ask questions of all medical treatments. Find doctors who will listen to those who know the patient best, and get a second opinion if needed. Beware, though, because sometimes doctors make diagnostic mistakes; they did so in this case.
Linda Fugate, Ph.D.
Iatrogenic delirium and coma: a near miss, Chest 2008 May;133(5):1217-20.