Last week, I was very encouraged but humbled, to receive the following email from my friend, Dr. Dan Degnan and his colleague Dr. Ephrem Abebe at Purdue University College of Pharmacy. They had invited me to speak last… Read More
Emily was diagnosed with a yolk sac tumor when she was about a year-and-a-half old. The tumor was the size of a grapefruit inside her tiny little abdomen. Even though our Emily was diagnosed with this frightening form of cancer, her team of doctors and nurses assured me that Emily’s cancer was not only treatable but highly curable! Emily endured months of surgeries, grueling testing and rigorous chemotherapy sessions (which would last for five straight days). If Emily’s blond ringlets had not fallen out due to the chemotherapy, no one would have been able to tell that she was even sick. She maintained her sweet disposition and contagious little giggle through out all of her treatments. Emily loved to play dress up with her big sister, Katherine, with all of their princess outfits! Nate, her big brother, would read to her for hours and hours, the same books over and over. How Katherine and Nate adored their little sister, Emily!
Emily’s treatment had been so successful that her last MRI clearly showed that the tumor miraculously disappeared. In fact, three radiologists had to review her MRI films due to the fact that there wasn’t even any residual scar tissue left. Emily’s doctors said it was as if she never had cancer! Regardless she was scheduled to begin her last chemotherapy session on her second birthday, February 24, 2006. This last treatment was just to be sure that there were no traces of cancer left inside of her little body. We celebrated Emily’s second birthday in the hospital. Some of her doctors and nurses had planned a surprise party for her and showered her with gifts, balloons and the whole works! She had a constant flow of visitors to help with the celebration. After Emily’s grandparents left, Nate and Katherine came with me bearing cupcakes for everyone on the floor. I could not think of a better birthday present than being told that this was Emily’s last chemotherapy and she would be coming home cancer free!! Emily would finally be able to live as a normal two year old! Tragically, that never happened.
Sunday, February 26th was Emily’s third day of her last chemotherapy treatment. It started out as any typical morning in the hospital. Emily ate her breakfast while watching her favorite Barney episode as doctors and nurses made their morning rounds. Emily and her mom took a few laps around the floor with her IV equipment while she pedaled her big wheel with all of her might. After playing in the activity room and scrubbing the play kitchen set with the nurses’ stash of alcohol swabs, it was time for lunch and an afternoon nap. Emily’s grandparents stopped by for a brief visit. That was the last time they ever saw their little “Emmy” alive.
Emily’s fatal dose was administered at 4:30 Sunday afternoon. She woke up from her nap very groggy which was so out of character for her. She kept trying to sit up and asked her mom to hold her in her lap. As she picked her up to cuddle with her, she noticed how her little body was so listless. She kept grabbing her head and moaning that it hurt. Emily spotted her mother’s can of Coke that she had on the tray and begged to have a sip. She sipped the rest of the can through the straw in a matter of seconds. She cried for more before she started screaming, ‘Mommy, my head, my head hurts! MY HEAD HURTS! The whole time she was screaming she was holding the sides of her little head. Her mother frantically called for the nurses as Emily began profusely vomiting. I was just walking in as the nurses were grabbing her from her mom’s arms. Emily went completely limp and the nurses began to resuscitate her. Within seconds, there were doctors and nurses everywhere. Emmy was rushed to the intensive care unit as the team was urgently attempting to find out what could possibly be going so very wrong. Within the hour, my precious daughter, Emily, was on life support.
We held Emily’s little hand and ran along beside her bed as she was rushed to have CT scans and other tests to determine the extent of damage to her brain. Since the life support machines could not go through the scans with her, the nurses climbed on the bed and manually kept her breathing during the testing. This was so surreal to have this happening and still no answers as to why Emily was dying. This couldn’t really be happening! We should have been having dinner and talking with Nate and Katherine on the phone to make sure that they had their book bags packed and ready for school. What was I going to tell Nate and Katherine? The last time they saw their little sister alive was on her birthday, February 24th. They were not allowed to visit on the weekend due to the cold and flu policy. What a joke. No one got any sleep that night. We sat on Emmy’s bed holding her hands and kissing her little toes as the machines kept her body alive, hoping that we would wake up and this terrible nightmare would be over. It never ended. It just got worse.
The next morning the room was filled with strangers’ horror-filled faces as we were told of how my little angel, Emily wound up brain dead and on life support. Her mom and I were told that even though she was still being kept alive by life support, Emily was essentially dead due to the massive brain damage she had incurred. Our Emily was killed by an overdose of sodium chloride in her chemotherapy IV bag.
Wednesday, March 1st was supposed to be a day of celebration. Before entering the hospital, we had planned a belated birthday and a cancer-free party for our Emily. Instead, our little Emily was delivered to the Cuyahoga County Morgue.
My family has been completely destroyed by the preventable and tragic death of sweet little Emily. A pharmacy technician that had been working for the hospital for quite a number of years decided not to use a standard prepared bag of sodium chloride solution ( with less than 1% of sodium chloride solution). Instead, the pharmacy technician filled a plastic bag with a concentrated sodium chloride solution of 23.4% of which she had compounded herself. When the pharmacy board investigators and other officials investigating Emily’s death asked the technician why she had made this outrageous error, she replied that she did not know. She claimed that she knew that something was not right but she was not sure. The pharmacy technician was asked if she knew that an overdose of sodium chloride could result in death. She claimed that she was not aware of that fact. How can a person who works in a pharmacy and compounds medications daily not know that? At the time of Emily’s death, Ohio didn’t even register pharmacy technicians. In fact, there weren’t even any training or licensing requirements.