Health

Starkman: Beaumont Hospital Staffers Horrified After Patient Dies During Routine Colonoscopy

January 25, 2021, 9:29 PM

The columnist, a Los Angeles freelancer, is a former Detroit News business reporter who blogs at Starkman Approved.

By Eric Starkman

The inevitable tragedy Beaumont Health chairman John Lewis and Michigan Attorney General Dana Nessel were warned about occurred last Thursday in the early afternoon: A 51-year-old man walked into the colonoscopy suite at Beaumont’s flagship Royal Oak hospital at 13 and Woodward thinking he’d be undergoing a routine screening and heading home a few hours later.

Instead, the patient, the sole caregiver for his elderly mother, wound up in Beaumont’s basement morgue.

Veteran employees at Beaumont's Royal Oak campus are both angered and saddened by the death, which they say was an expected medical catastrophe resulting from COO Carolyn Wilson’s money-saving decision last April to award Texas-based NorthStar Anesthesia, a controversial low-cost outsourcing firm, a contract to manage anesthesiology services at the flagship hospital and previously one of the busiest surgical centers in the country. 

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NorthStar’s Royal Oak contract began Jan. 1. The company is controlled by The Cranmere Group, whose previous CEO Jeffrey Zients resigned in December to co-head President Biden’s transition team and will oversee the administration’s Covid response.

“I’m not shocked this tragedy happened three weeks into NorthStar taking over,” said one Beaumont anesthesiology veteran.

Eliizabeth Squire, a Washington-based spokeswoman for NorthStar, issued this statement: “We express our deepest sympathy to the deceased’s loved ones, but, due to health privacy laws, we cannot comment further at this time.”

Beaumont spokesman Mark Geary ignored requests for comment.

The Certified Registered Nurse Anesthetist (CRNA) handling the colonoscopy anesthesia and the anesthesiologist overseeing her both had less than five years of experience. They were not full-time employees of Beaumont Royal Oak, a Tier 1 Regional Trauma Center whose anesthesiology staff was uniformly top-notch before Wilson awarded NorthStar its contract.

More Experienced Before

Virtually all of the previous anesthesiologists had advanced fellowship training in various subspecialties. The CRNAs were highly skilled, having on average more than 10 years of experience. They were a cohesive group that worked together well and trusted each other.

NorthStar isn’t highly regarded among fellowship-trained anesthesiologists. Approximately half of the more than 70 working at Royal Oak bolted, along with 50 CRNAs, in advance of NorthStar taking over this month. The exodus of anesthesiologists prompted more than a dozen prominent surgeons and other specialists to quit, including many with national reputations.

According to multiple sources, the colonoscopy patient weighed about 300 pounds and had obstructive sleep apnea. Due to the patient’s weight, a decision was made to intubate him, which was handled by the CRNA from Beaumont Dearborn.

When the breathing tube was removed, the patient began to thrash around and then stopped breathing. The visiting NorthStar anesthesiologist was called and worked with the CRNA to reintubate the patient. When that procedure failed, they called for an emergency team to revive the patient. By then, he’d been without a pulse for 30 minutes. The team arrived too late.

Karen Sibert, a prominent anesthesiologist and former president of the California Society of Anesthesiologists, told Deadline Detroit that it’s rare to intubate a patient for a colonoscopy unless there is a bowel obstruction, even if the patient is obese. Sibert said that familiarity with hospital procedures and staff is critical to maintaining a safe anesthesiology working environment.

Zero deaths should be the norm

Sibert declined to comment on specifics of the Beaumont case, except to say: “In a colonoscopy the mortality rate should be zero.” 

A veteran Beaumont anesthesia specialist said prior to NorthStar’s arrival Beaumont required that even routine procedures requiring intubation be performed in the surgical wards, where there’s emergency backup immediately available if things go south, as they did with the colonoscopy patient.

The CRNA from Dearborn was working again at Beaumont Royal Oak the following day. Deadline Detroit couldn’t determine if the visiting NorthStar CRNA will be returning.

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Beaumont Chair John Lewis

Beaumont’s co-heads of cardiology in September wrote to Beaumont board chairman John Lewis putting him on notice they had “serious concerns” about NorthStar. Their pleas and warnings from other doctors and Beaumont’s top donors that patient care was at risk unless CEO John Fox, COO Wilson, and Chief Medical Officer David Wood Jr. were fired, fell on deaf ears. 

Michigan Attorney General Dana Nessel ignored a warning from a former board member and donor that Beaumont could become “another Flint.”

Although Fox and Wilson have maintained the NorthStar transition was seamless, insiders describe conditions at Beaumont’s flagship hospital as the “Wild West.” NorthStar has been flying in anesthesiologists from around the country for one to two-week stints, paying them lucrative compensation and covering all their expenses. Beaumont veterans are appalled by the limited experience and skill levels of many of the replacements and temps.

One veteran Beaumont anesthesiology professionasaid there has been a surge of rare epidural complications at the hospital known as Post Dural Puncture Headache, including four over a two-day period. Another issue is lack of backup.

Beaumont has always had two anesthesiologists readily available to accommodate emergencies, which are expected with considerable frequency at a Tier 1 trauma center.The “regional director” of Obstetrics appointed by NorthStar refuses to work in other areas, meaning the only other anesthesiologist in house when she’s on duty must singlehandedly cover both North and South tower surgeries, calls to the Emergency Center, COVID intubations, and other procedures

The reports I hear about NorthStar anesthesiologists at Royal Oak are consistent with criticisms I heard about them when the company took over Beaumont’s southern hospitals. One NorthStar anesthesiologist declared he wouldn’t work weekends, while another showed up late for a procedure. A veteran Beaumont specialist said it was a “shit show” when NorthStar took over.

Dangers of Speaking Up

Speaking up about patient safety issues at Beaumont can be hazardous and humiliating. Brian Berman, Beaumont’s former head of pediatrics, was fired and escorted from Beaumont’s Royal Oak building by hospital president Nancy Susick after he objected to cutbacks that he said would harm patient care.

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John Fox and Carolyn Wilson

According to Robert Safian, a Harvard-trained cardiologist who sent a blistering letter about Fox and his deputies to Beaumont’s directors and trustees, another physician was fired for protesting Berman’s firing. Safian also disclosed that a Beaumont emergency room doctor was fired for protesting cutbacks.

Beaumont’s medical staff has yet to receive the results of an internal annual “Culture of Safety” survey gauging their views of the hospital’s protocols to ensure quality patient care. Speculation is rife that the results are so damning that Fox, Wilson, and Wood want it kept under wraps.

Deadline Detroit has also learned that Beaumont has more than 3,500 Alaris infusion pumps in use that, according to the FDA, have contributed to more than 30,000 adverse incidents nationwide in the fourth quarter of 2020 alone. For the entire year, there were 38 deaths nationally associated with pump-related incidents, and 326 involving injury. Class action attorneys are clamoring to represent patients who have been harmed by pump-related incidents. 

The colonoscopy patient death isn’t a one-off tragic Beaumont incident. Channel 7 reported in May that at the height of the COVID pandemic in Michigan Beaumont was transferring patients on ventilators to other area hospitals, including one listed as unstable for transport. That patient died during the transfer. Spokesman Mark Geary said the transfer was done with the approval of Gov. Gretchen Whitmer’s office, which a spokeswoman denied.

Other Oddities

Additionally, Channel 7 reported in October 2019 that a patient taken to Beaumont Dearborn remained unidentified as “John Doe” for several days despite being admitted with ID.

Federal prosecutors this month charged two former Beaumont employees with stealing medical devices from the hospital and selling them via the internet for more than $560,000. A healthcare industry expert told me the theft speaks poorly of Beaumont’s internal controls, and that replacement costs for the stolen equipment were likely considerably more than the devices sold for in the black market.

Security and IT aren’t Beaumont’s strong suits. The hospital network suffered two data breaches within months last summer.  Beaumont’s website to book Covid vaccines also crashed.

Deadline Detroit is trying to reach the family of the colonoscopy patient. We plan to follow this case and Beaumont’s response. Reader assistance matter would be appreciated.

Also read the Deadline Detroit obituary on Richard Curbelo, the man who died while undergoing the colonoscopy.

Reach Eric Starkman at eric@starkmanapproved.com. Beaumont employees and vendors are encouraged to reach out, with confidentiality assured.
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