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Trouble at Midnight

— In early September 2001, Carol Eklund went to Paris for a fashion show. She was looking for new lines to offer sales representatives of a wholesale business she had started two years earlier. Her return to San Diego was scheduled for September 10, but early that morning she phoned her husband to say she wanted to stay longer. Would he change her airline reservations by 24 hours? He could pick her up at Lindbergh Field late the following day, she told him.

I spoke with Sven Eklund in March of this year. His wife's flight home was well under way, he said, when it was directed to return to London due to terrorist attacks on the World Trade Center. During a call from London, he said, she complained that the flight was the worst she'd ever experienced. Everybody on the plane seemed to be coughing and sneezing. And now she too felt a cold coming on.

Most passengers from the flight had to spend four days in London. "Carol had a room one or two nights," said Sven Eklund, "but not every night. She stayed in the airport waiting for a flight home. Thousands of people were there in the same situation."

Carol complained of headaches, a backache, and a sore neck upon her arrival in the couple's Encinitas home. After several days of bed rest, according to Eklund, she visited a medical clinic, returning two more times after feeling no better from taking medications she received there. Each day a different doctor diagnosed her as having migraine headaches. "But the third one," said Eklund, "told her that it might be meningitis and that if she didn't get better soon, she'd better get to a hospital.

"So on Sunday morning, September 23, I drove her to Scripps Memorial Hospital Encinitas, and they diagnosed very quickly that it was viral spinal meningitis, which they said was not life threatening." Nevertheless, the hospital admitted Carol and put her on antibiotics in case she was suffering from the more dangerous bacterial meningitis. On Tuesday evening Carol began feeling better and called her husband to say that she had eaten and would come home soon.

But in the middle of the night, said Eklund, his mother-in-law, Teresa Garcia, staying bedside, noticed that her daughter was having trouble breathing. At seven the next morning, a code blue sounded, and Carol Eklund was pronounced dead. She was 34 years old. In addition to her parents and husband, she left behind a daughter, Tova, 9, and a 3-year-old son, Sven Diego.

What happened and didn't happen in Carol's hospital room between midnight and 7:00 a.m., September 26, 2001, became the focus of a lawsuit that Sven Eklund filed seeking damages from Scripps Memorial Hospital Encinitas on behalf of himself and his children. While waiting for the trial, Eklund in 2002 moved his family to Sweden, where they live today. In the meantime, he hired attorney David Miller to handle his case. After several delays, the case went to court in February of this year. Eklund attended the trial and returned in March to handle further matters relating to the case.

As the trial unfolded, the main point of contention became whether Scripps Hospital breached the "standard of care" that a patient in Carol Eklund's condition could expect to receive. Not long after midnight on the morning of her death, according to records presented at trial, Carol again began experiencing a lot of headache pain. To counteract the pain, hospital staff reminded her and her "family" to use the patient-controlled morphine pump attached to her body. The device has a button for the patient to increase the morphine dosage up to, but not beyond, the maximum dose. But when she began experiencing difficulty breathing, hospital staff apparently thought it was due to an overdose of morphine.

Scripps Hospital nurse Joan Loftin made the following nursing chart entry for Carol at 3:00 a.m.: "[Patient] found lethargic and unresponsive to verbal and painful stimulation. Medicate." It then notes intravenous administration of two milligrams of Narcan, a drug that counteracts the effects of morphine. Subsequently, the log records, Carol was observed "thrashing" about in her bed.

But Teresa Garcia testified during trial that throughout the early-morning ordeal, hospital nursing staff did little more than make their routinely scheduled checks of Carol's vital signs. Scripps Hospital's nursing supervisor, Rebecca Long, seems to corroborate the point in a pretrial deposition. There she agrees with a hospital attorney's summary of her position that reads: "The nursing staff...all failed to recognize the acuity of the patient and that this patient needed a higher level of care than could be provided in a med/surgery area." Long also stated that although nurses did "assess" Carol's pain, they did not ask why she was having it. And Long agreed that among the nurses, there was a "lack of in-depth neurologic assessment after the administration of Narcan as well as a lack of continuous respiratory assessment."

At the trial's conclusion, the jury responded "yes" to the question, "Was the defendant negligent in the treatment of Carol Eklund?" They then were asked, "Was the defendant's negligence a substantial factor in causing the death of Carol Eklund?" Their answer of "no" has denied to Sven Eklund any monetary compensation for damages to him and his family.

In all, including money to hire three expert witnesses, Eklund maintains he paid attorney David Miller over $90,000 to pursue his case against Scripps Hospital. At the beginning of their relationship, according to Eklund, Miller exuded confidence at the lawsuit's prospects. At trial's end, the two were feuding over courtroom tactics. Eklund has found another attorney to take the trial's verdict to California's courts of appeal. Miller did not return phone calls seeking comment on the situation.

Eklund's disappointment in the lawsuit's outcome is heightened by his feeling that Miller did not make Ativan, the last drug given to Carol before her death, a major focus in the trial. After Narcan counteracted the effects of morphine in Carol's body, nurse Loftin sought a decision from physician and neurological specialist Benjamin Frishberg about how to address Carol's "agitation." According to trial records, Frishberg, on duty at the hospital that morning, prescribed one milligram of Ativan, a common antianxiety medication. He did not look in on Carol, making his decision on the basis of nursing information.

According to court documents, Frishberg also testified at trial that he did not prescribe any further administration of morphine. Nevertheless, trial transcripts reveal that someone turned Carol's morphine pump back on between the time she received the Ativan dose and the pronouncement of her death at 7:00 a.m. But this information did not appear on Carol's nursing log.

In consulting with doctors in Sweden, Eklund has come to believe that a combination of Ativan and morphine in his wife's body is what killed her. Eklund put me in contact with Bengt Nellgard, head of the neuro intensive care unit at a university hospital in Gothenburg, Sweden.

Nellgard wrote me that an unconscious patient given morphine must be monitored at all times. "If an unconscious patient is given Narcan to reverse morphine treatment, that patient should be transferred to an [intensive care unit] and not be given Ativan. Ativan given after morphine can decrease breathing drive and in a meningitis, supposedly with higher intercranial pressure than normal, this may be deleterious."

I took the issue of morphine and Ativan interaction to several local pharmacists and to Professor Gordon McGuire at UCSD's School of Pharmacy. The pharmacists requested anonymity but agreed that nothing they know forbids Ativan from being given patients already on morphine. One of them, however, said that the situation can be similar to someone drinking heavily and then taking sleeping pills, which also depress the central nervous system. That combination has had fatal consequences, she said. Both Ativan and morphine depress the central nervous system too.

McGuire told me it is not uncommon for hospital patients already on morphine to be given Ativan to relax them. He also states that Narcan, even though its action lasts only an hour, permanently reverses the effects of a morphine dose.

In appealing the trial's verdict, Eklund may only be acting out his grief. But most medical experts contend that viral meningitis is rarely, if ever, deadly. Steven Campman, of the San Diego County Medical Examiner's Office, testified at trial, however, that an autopsy of Carol Eklund's body revealed the cause of her death to be "meningoencephalitis." He explained that the Coxsackie B2 virus that had caused her meningitis had entered her brain.

Eklund remembers the only time he spoke with Campman. The doctor called him nine days after Carol's death, according to Eklund, to say there was no evidence of the virus having entered her brain and that he was puzzled as to the cause of her death. Several weeks later, Eklund received the autopsy report. But it was a report on the death of a 65-year-old man. After notifying the medical examiner's office of the mistake, Eklund said he finally received Carol's autopsy report. He observed immediately that it was dated the day after her death, yet it identified the cause of death as meningoencephalitis. "So apparently Campman declared the cause of her death," said Eklund, "well before he called me to say he couldn't explain it."

Campman, said Eklund, "never returned the eight or nine calls I made to his office to get clarification of the inconsistency." The next time Eklund saw Campman, he was testifying from the witness stand.

Reached by phone, Campman told me that in their conversation he told Eklund that he couldn't "see" meningoencephalitis as the cause of her death. But that's because the naked eye cannot detect it in the brain. Later, when results of microscope analysis came back, he learned that the cause of death was meningoencephalitis. The medical examiner's toxicology report did show that morphine was present in Carol's body but not in excessive amounts, said Campman. And he maintained that a combination of Ativan and morphine could not have killed her because her body had no remnants of the Ativan.

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— In early September 2001, Carol Eklund went to Paris for a fashion show. She was looking for new lines to offer sales representatives of a wholesale business she had started two years earlier. Her return to San Diego was scheduled for September 10, but early that morning she phoned her husband to say she wanted to stay longer. Would he change her airline reservations by 24 hours? He could pick her up at Lindbergh Field late the following day, she told him.

I spoke with Sven Eklund in March of this year. His wife's flight home was well under way, he said, when it was directed to return to London due to terrorist attacks on the World Trade Center. During a call from London, he said, she complained that the flight was the worst she'd ever experienced. Everybody on the plane seemed to be coughing and sneezing. And now she too felt a cold coming on.

Most passengers from the flight had to spend four days in London. "Carol had a room one or two nights," said Sven Eklund, "but not every night. She stayed in the airport waiting for a flight home. Thousands of people were there in the same situation."

Carol complained of headaches, a backache, and a sore neck upon her arrival in the couple's Encinitas home. After several days of bed rest, according to Eklund, she visited a medical clinic, returning two more times after feeling no better from taking medications she received there. Each day a different doctor diagnosed her as having migraine headaches. "But the third one," said Eklund, "told her that it might be meningitis and that if she didn't get better soon, she'd better get to a hospital.

"So on Sunday morning, September 23, I drove her to Scripps Memorial Hospital Encinitas, and they diagnosed very quickly that it was viral spinal meningitis, which they said was not life threatening." Nevertheless, the hospital admitted Carol and put her on antibiotics in case she was suffering from the more dangerous bacterial meningitis. On Tuesday evening Carol began feeling better and called her husband to say that she had eaten and would come home soon.

But in the middle of the night, said Eklund, his mother-in-law, Teresa Garcia, staying bedside, noticed that her daughter was having trouble breathing. At seven the next morning, a code blue sounded, and Carol Eklund was pronounced dead. She was 34 years old. In addition to her parents and husband, she left behind a daughter, Tova, 9, and a 3-year-old son, Sven Diego.

What happened and didn't happen in Carol's hospital room between midnight and 7:00 a.m., September 26, 2001, became the focus of a lawsuit that Sven Eklund filed seeking damages from Scripps Memorial Hospital Encinitas on behalf of himself and his children. While waiting for the trial, Eklund in 2002 moved his family to Sweden, where they live today. In the meantime, he hired attorney David Miller to handle his case. After several delays, the case went to court in February of this year. Eklund attended the trial and returned in March to handle further matters relating to the case.

As the trial unfolded, the main point of contention became whether Scripps Hospital breached the "standard of care" that a patient in Carol Eklund's condition could expect to receive. Not long after midnight on the morning of her death, according to records presented at trial, Carol again began experiencing a lot of headache pain. To counteract the pain, hospital staff reminded her and her "family" to use the patient-controlled morphine pump attached to her body. The device has a button for the patient to increase the morphine dosage up to, but not beyond, the maximum dose. But when she began experiencing difficulty breathing, hospital staff apparently thought it was due to an overdose of morphine.

Scripps Hospital nurse Joan Loftin made the following nursing chart entry for Carol at 3:00 a.m.: "[Patient] found lethargic and unresponsive to verbal and painful stimulation. Medicate." It then notes intravenous administration of two milligrams of Narcan, a drug that counteracts the effects of morphine. Subsequently, the log records, Carol was observed "thrashing" about in her bed.

But Teresa Garcia testified during trial that throughout the early-morning ordeal, hospital nursing staff did little more than make their routinely scheduled checks of Carol's vital signs. Scripps Hospital's nursing supervisor, Rebecca Long, seems to corroborate the point in a pretrial deposition. There she agrees with a hospital attorney's summary of her position that reads: "The nursing staff...all failed to recognize the acuity of the patient and that this patient needed a higher level of care than could be provided in a med/surgery area." Long also stated that although nurses did "assess" Carol's pain, they did not ask why she was having it. And Long agreed that among the nurses, there was a "lack of in-depth neurologic assessment after the administration of Narcan as well as a lack of continuous respiratory assessment."

At the trial's conclusion, the jury responded "yes" to the question, "Was the defendant negligent in the treatment of Carol Eklund?" They then were asked, "Was the defendant's negligence a substantial factor in causing the death of Carol Eklund?" Their answer of "no" has denied to Sven Eklund any monetary compensation for damages to him and his family.

In all, including money to hire three expert witnesses, Eklund maintains he paid attorney David Miller over $90,000 to pursue his case against Scripps Hospital. At the beginning of their relationship, according to Eklund, Miller exuded confidence at the lawsuit's prospects. At trial's end, the two were feuding over courtroom tactics. Eklund has found another attorney to take the trial's verdict to California's courts of appeal. Miller did not return phone calls seeking comment on the situation.

Eklund's disappointment in the lawsuit's outcome is heightened by his feeling that Miller did not make Ativan, the last drug given to Carol before her death, a major focus in the trial. After Narcan counteracted the effects of morphine in Carol's body, nurse Loftin sought a decision from physician and neurological specialist Benjamin Frishberg about how to address Carol's "agitation." According to trial records, Frishberg, on duty at the hospital that morning, prescribed one milligram of Ativan, a common antianxiety medication. He did not look in on Carol, making his decision on the basis of nursing information.

According to court documents, Frishberg also testified at trial that he did not prescribe any further administration of morphine. Nevertheless, trial transcripts reveal that someone turned Carol's morphine pump back on between the time she received the Ativan dose and the pronouncement of her death at 7:00 a.m. But this information did not appear on Carol's nursing log.

In consulting with doctors in Sweden, Eklund has come to believe that a combination of Ativan and morphine in his wife's body is what killed her. Eklund put me in contact with Bengt Nellgard, head of the neuro intensive care unit at a university hospital in Gothenburg, Sweden.

Nellgard wrote me that an unconscious patient given morphine must be monitored at all times. "If an unconscious patient is given Narcan to reverse morphine treatment, that patient should be transferred to an [intensive care unit] and not be given Ativan. Ativan given after morphine can decrease breathing drive and in a meningitis, supposedly with higher intercranial pressure than normal, this may be deleterious."

I took the issue of morphine and Ativan interaction to several local pharmacists and to Professor Gordon McGuire at UCSD's School of Pharmacy. The pharmacists requested anonymity but agreed that nothing they know forbids Ativan from being given patients already on morphine. One of them, however, said that the situation can be similar to someone drinking heavily and then taking sleeping pills, which also depress the central nervous system. That combination has had fatal consequences, she said. Both Ativan and morphine depress the central nervous system too.

McGuire told me it is not uncommon for hospital patients already on morphine to be given Ativan to relax them. He also states that Narcan, even though its action lasts only an hour, permanently reverses the effects of a morphine dose.

In appealing the trial's verdict, Eklund may only be acting out his grief. But most medical experts contend that viral meningitis is rarely, if ever, deadly. Steven Campman, of the San Diego County Medical Examiner's Office, testified at trial, however, that an autopsy of Carol Eklund's body revealed the cause of her death to be "meningoencephalitis." He explained that the Coxsackie B2 virus that had caused her meningitis had entered her brain.

Eklund remembers the only time he spoke with Campman. The doctor called him nine days after Carol's death, according to Eklund, to say there was no evidence of the virus having entered her brain and that he was puzzled as to the cause of her death. Several weeks later, Eklund received the autopsy report. But it was a report on the death of a 65-year-old man. After notifying the medical examiner's office of the mistake, Eklund said he finally received Carol's autopsy report. He observed immediately that it was dated the day after her death, yet it identified the cause of death as meningoencephalitis. "So apparently Campman declared the cause of her death," said Eklund, "well before he called me to say he couldn't explain it."

Campman, said Eklund, "never returned the eight or nine calls I made to his office to get clarification of the inconsistency." The next time Eklund saw Campman, he was testifying from the witness stand.

Reached by phone, Campman told me that in their conversation he told Eklund that he couldn't "see" meningoencephalitis as the cause of her death. But that's because the naked eye cannot detect it in the brain. Later, when results of microscope analysis came back, he learned that the cause of death was meningoencephalitis. The medical examiner's toxicology report did show that morphine was present in Carol's body but not in excessive amounts, said Campman. And he maintained that a combination of Ativan and morphine could not have killed her because her body had no remnants of the Ativan.

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