Lewis Blackman
Lewis - healthy 15 yr old male with mild asthma and a congenital deformity of the chest (pectus excavatum)
Initial Assessment

What do you think is going on with this patient?
(everyone to answer)

Initial Assessment ( ~3 min)

Lewis - In hospital for elective surgery for pectus exacuvatum (chest wall repair) - 3 days post surgery, pain not well managed ... opioid via epidural, Toradol injection every 6 hrs. Pulse Ox keeps alarming.

Patient now complaining of excruciating abdominal pain (on a scale of 1 to 5 ... 5)
Lewis Colorless
Assessment Review

Share what you are most concerned about.
(everyone to answer)

Assessment Review ( ~3 min)

Next morning ... Lewis is very weak, but conscious, lacks color, unable to acquire blood pressure by 4 different staff and different instruments (note: monitors shut off to allow Lewis to sleep overnight)
Lewis - goes unconscious

Lewis died November 7, 2000 (5 days after his elective surgery)

Lewis bled to death internally because of a perforated ulcer. His abdomen was filled with almost 3 liters of blood and digestive fluid.

Perforated ulcer was from administration of Toradol without enough fluids and urine output.
Team Debrief
What can our team learn from this case to improve the care in a similar situation?
Team Discussion (~5 min)
Systems Discussion
What systems do we have in place to prevent this?
(every team member to answer)
What system issues might have contributed to this outcome?
(every team member to answer)
Systems Discussion (~5 min)
- improper administration of medication
- failure to recognize declining patient
- premature closure
- failure to trust equipment readings/alerts
- failure to advise senior medical staff of situation
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