How would you feel if the organs you'd donated from your dying child wound up killing another child because of a clerical mix-up? An investigation into the aftermath of the Jesica Santillan story
The layers of suffering here are immense. The process of illegally immigrating, the failure of the Duke medical system, the unsettling relationship between Mack/Nita and Jesica's family... The family needed an advocate, but it seems this relationship was off. I never really grasped what their true motivations were. I got goosebumps reading about your visit and your interactions. It's just mind blowing that this happened. How was there such a breakdown between UNOS and Dr. Jaggers regarding blood type?? I have to take myself back to 2003 and remind myself that quality assurance was probably less automatic/tech-centered. This is just unbelievable heavy shit.
I happen to live close to DUMC and obtain most of my medical care through the Duke Health System. I consider myself very fortunate to have access to such excellent care. I've also been an RN since 1989. I remember vividly when this sad event occurred. I recall thinking that the only way that it could have happened was if every single safety checkpoint that was in place to verify the blood type compatibility between donor and recipient was compromised, rendering the heartbreaking outcome a rare catastrophic cascade of errors. It would have taken just ONE employee of undoubtedly many who were part of the chain of custody of the donor organs, right up to the surgical team, to identify the mistake to avoid what happened and spare Jesica's life. But every single fail safe, incredibly, broke down. The surgeon admitted that he had assumed that the blood types had been reconciled and that it wasn't until the first surgery was over that he learned of the mistake. I have to wonder how many others in the process were complacent and made assumptions about previous checks?
As a hospital nurse in the early 90s, when a patient was to receive a blood transfusion, every single transfer of the blood product from employee to employee (from the blood bank right up to the nurse administering it) required exhaustive verification and reverification that the blood type of the product and of the recipient were a match. The procedure was involved and strictly adhered to because a mistake could cost patients their lives. Back then, and when this happened to Jesica, unfortunately, safety checks were susceptible to human error.
Nowadays technology has made things incredibly more secure and safe, therefore bypassing a majority of the potential for human mistakes. The use of bar codes and bar code readers are an example. I've observed, for example, that nurses administering medications to hospital patients must scan bar codes on the patient as well as the meds to ensure a match. I'm sure similar technology is currently used in other areas as a safety check. The bottom line is, though, that regardless of technological advances, employees that are part of a medical chain of custody must remain vigilant and NEVER assume someone else has done their job!
On a different note, I saw a 2013 online article by the local news channel in Raleigh, WRAL, about an investigation into possible mishandling of the funds taken in by Jesica's Hope Chest, a charity begun and managed by Mack Mahoney. I couldn't find anything more on it, so it seems it never went anywhere, but after reading Nancy's article illustrating what a creepy and controlling person he was, I'm not surprised. He actually passed away in Texas in 2021.
“We cannot ignore the tough public-policy questions in Jesica’s case that the sob-story writers at The New York Times prefer to paper over: When resources are as scarce as the supply of voluntarily donated organs notoriously are, why shouldn’t U.S. citizens get top priority? If Jesica recovers from the second heart-lung transplant, will any federal immigration authority have the guts to enforce the law and send her and her family home?”
The United States is a rich and powerful country, but not to an unlimited extent. I would argue that America cannot be the world's policeman for precisely that reason. Isn't the flip side of that argument that the US can't be the world's hospital either?
When the fundamental issue is accounting how can it be xenophobic to address the question of costs?
That's a tricky question. I guess I didn't see it so much as, "We need to settle this policy question now, as this girl lays dying", as I did, we need to care for this child now; we will figure out later, later. I don't see kindness in Malkin's comment; sure, okay, we can and should have policy questions. But right now? Now?
There is never going to be a good time to discuss this question because human suffering never takes a recess. How many Jesica's are among the millions detained at the border over the last year or the millions that slipped through? And how many in the millions living in crushing poverty in places like El Salvador or Guatemala who desperately hope for a chance to get in?
The layers of suffering here are immense. The process of illegally immigrating, the failure of the Duke medical system, the unsettling relationship between Mack/Nita and Jesica's family... The family needed an advocate, but it seems this relationship was off. I never really grasped what their true motivations were. I got goosebumps reading about your visit and your interactions. It's just mind blowing that this happened. How was there such a breakdown between UNOS and Dr. Jaggers regarding blood type?? I have to take myself back to 2003 and remind myself that quality assurance was probably less automatic/tech-centered. This is just unbelievable heavy shit.
I happen to live close to DUMC and obtain most of my medical care through the Duke Health System. I consider myself very fortunate to have access to such excellent care. I've also been an RN since 1989. I remember vividly when this sad event occurred. I recall thinking that the only way that it could have happened was if every single safety checkpoint that was in place to verify the blood type compatibility between donor and recipient was compromised, rendering the heartbreaking outcome a rare catastrophic cascade of errors. It would have taken just ONE employee of undoubtedly many who were part of the chain of custody of the donor organs, right up to the surgical team, to identify the mistake to avoid what happened and spare Jesica's life. But every single fail safe, incredibly, broke down. The surgeon admitted that he had assumed that the blood types had been reconciled and that it wasn't until the first surgery was over that he learned of the mistake. I have to wonder how many others in the process were complacent and made assumptions about previous checks?
As a hospital nurse in the early 90s, when a patient was to receive a blood transfusion, every single transfer of the blood product from employee to employee (from the blood bank right up to the nurse administering it) required exhaustive verification and reverification that the blood type of the product and of the recipient were a match. The procedure was involved and strictly adhered to because a mistake could cost patients their lives. Back then, and when this happened to Jesica, unfortunately, safety checks were susceptible to human error.
Nowadays technology has made things incredibly more secure and safe, therefore bypassing a majority of the potential for human mistakes. The use of bar codes and bar code readers are an example. I've observed, for example, that nurses administering medications to hospital patients must scan bar codes on the patient as well as the meds to ensure a match. I'm sure similar technology is currently used in other areas as a safety check. The bottom line is, though, that regardless of technological advances, employees that are part of a medical chain of custody must remain vigilant and NEVER assume someone else has done their job!
On a different note, I saw a 2013 online article by the local news channel in Raleigh, WRAL, about an investigation into possible mishandling of the funds taken in by Jesica's Hope Chest, a charity begun and managed by Mack Mahoney. I couldn't find anything more on it, so it seems it never went anywhere, but after reading Nancy's article illustrating what a creepy and controlling person he was, I'm not surprised. He actually passed away in Texas in 2021.
First, I loved the article. But...
“We cannot ignore the tough public-policy questions in Jesica’s case that the sob-story writers at The New York Times prefer to paper over: When resources are as scarce as the supply of voluntarily donated organs notoriously are, why shouldn’t U.S. citizens get top priority? If Jesica recovers from the second heart-lung transplant, will any federal immigration authority have the guts to enforce the law and send her and her family home?”
The United States is a rich and powerful country, but not to an unlimited extent. I would argue that America cannot be the world's policeman for precisely that reason. Isn't the flip side of that argument that the US can't be the world's hospital either?
When the fundamental issue is accounting how can it be xenophobic to address the question of costs?
That's a tricky question. I guess I didn't see it so much as, "We need to settle this policy question now, as this girl lays dying", as I did, we need to care for this child now; we will figure out later, later. I don't see kindness in Malkin's comment; sure, okay, we can and should have policy questions. But right now? Now?
There is never going to be a good time to discuss this question because human suffering never takes a recess. How many Jesica's are among the millions detained at the border over the last year or the millions that slipped through? And how many in the millions living in crushing poverty in places like El Salvador or Guatemala who desperately hope for a chance to get in?
Huh? Is this about a tragic and preventable accident or a journalist’s angst? I need a TLDR!
Both, but in the angst, uncovering much more of the story than simply the accident