ONE
April 10, 2001
It was considered routine plastic surgery.
Sandra Joyner was scheduled to have a mini-facelift, liposuction and fat grafts to fill in a couple of scars on her face and plump up her lips. While she was under, she decided to have her lower eyelids resurfaced to smooth out the tiny lines that had begun to form.
At 45, Sandra was still a beauty. She was a striking blonde, 5 feet 6 inches tall, and a toned and taut 115 pounds. But her life had fallen apart. She and John, her high school sweetheart and only real boyfriend, married after college and had two children. In 1999, after eighteen years of marriage, they had separated. Sandra's family had been her life, and now she was struggling to find her own identity. She thought the surgery would make her look more rested and help her to feel better about herself in general.
Her only job experience had been teaching high school, and she hadn't worked since her now teenaged sons were born. It was difficult enough trying to get a job without any marketable skills, but even more daunting was the singles scene. Sandra hadn't been single since she was 17 years old, and dating in 2000 at 45 was very different from dating as a high school student in the 1970s.
Sandra's parents and sister, with whom she had always been close, were not happy about her decision to have plastic surgery; they didn't understand why she thought she needed it. She had always been incredibly pretty and popular. In fact, she had been the belle of the ball wherever she went.
Sandra's estranged husband, John, who was paying for the surgery, saw no harm in it if she felt it would boost her self-esteem. Besides, the same doctor had completed a minor surgery on one of her eyes a couple of years earlier and she had been delighted with the results.
Sandra scheduled her appointment for 7 a.m., Tuesday, April 10, at the Center for Plastic and Cosmetic Surgery. It was only twenty-five minutes from the upscale South Charlotte apartment where she had been living by herself since separating from her husband the previous June.
Sandra was up early, around 5:30 a.m., but there wasn't much to do, since she couldn't wear makeup and wasn't allowed to eat or drink after midnight. All she had to do was brush her teeth, shower and run a brush through her shoulder-length, highlighted hair. She decided to wear jeans, a lightweight sweater and casual flats so she would be comfortable. It was early spring and the temperature would eventually hit 70 degrees, but at 6:15 a.m. the air was chilly. Sandra had been cold-natured all her life, so she threw on a light jacket at the last minute.
Around 6:20 a.m. she called a taxicab to take her to the center at 300 Billingsley Road. The night before, John had offered to take her to the appointment, but she told him that her mother and sister were taking her. To this day John has no idea why Sandra decided to take a cab to her appointment. He never found out if it was because her family had bowed out at the last minute, if they were going to pick her up after the surgery, or if she had simply lied to him about who was taking her. Regardless, it was odd that she went to the appointment alone, since she had a lot of close friends who would have been happy to accompany her.
The trip took longer than expected due to rush hour traffic. Dr. Peter Tucker, the plastic surgeon, and his nurse anesthetist, Sally Hill, had everything ready when Sandra arrived a few minutes late.
Sandra hadn't slept well the night before. In spite of taking a mild tranquilizer to help her sleep, she'd tossed and turned throughout the night. Admittedly she was feeling a little nervous about the surgery, and was more talkative than usual as she went through the pre-surgery procedures.
While Sally checked Sandra's vitals—her temperature, blood pressure and heart rate—Sandra rattled on about the traffic and her unproductive job search. She had just missed out on a job that she'd really wanted with US Airways, and felt sure it was because the company wanted someone younger. She also confided in Sally that she was going through a nasty divorce.
Sally had her own set of problems. Her marriage was on the rocks, too, and a year before, she'd been diagnosed with leukemia. But she always managed to put personal problems aside, to be a professional on the job. She had always been focused on her nursing career and took pride in her accomplishments. That day all Sandra's vital signs were normal except her hemoglobin, which had been tested a week earlier. It was a little low—11.5 ccs instead of 13—but when Sally mentioned it to the doctor, he didn't seem concerned. To Sandra's knowledge she was not allergic to any medications, so no additional allergy testing was done prior to the surgery.
At one point during her pre-operative check, Sandra became visibly apprehensive about going under the knife, as if questioning whether she was doing the right thing. This is not uncommon when patients are under stress, and Sally reassured her, telling her there was nothing to worry about.
More than 11 million cosmetic procedures are performed every year in the U.S., which makes plastic surgery almost as common as teeth whitening. In addition, the chance that anything serious will go wrong is incredibly small. Besides, Sandra had every confidence in Dr. Tucker, who had corrected her drooping eye just two years earlier. She'd done her homework before deciding to have the surgery performed by Dr. Tucker: He came highly recommended by several people, and he had a framed award hanging in his office saying he was voted "Best Plastic Surgeon." However, there was no information available about how that choice was made, or by whom.
In 1999, Sandra had breezed through the procedure and post-operative recovery without a hint of a complication. Even more important, she had been very pleased with the results.
Sally had been a Certified Registered Nurse Anesthetist (CRNA) since 1982, and worked for the Presbyterian Hospital system for ten years in that capacity. It was there she first began working with Dr. Tucker.
Tucker and Sally had left the hospital system together when he became the third partner in an established plastic surgery office, then she'd gone with him when he decided to start his own practice in 1997. They had worked together on thousands of plastic surgery procedures without incident. In fact, Sally had been the nurse anesthetist on duty for Sandra's earlier surgery in 1999.
Although no one realized it, Sally and Sandra had known each other casually when they were young. They had attended the same elementary school and junior high, and at Olympic High School in the early 1970s, they'd run in the same crowd and had even gone out with the same boy at one point, although the girls weren't close friends.
Now assisting on Sandra's second procedure, Sally walked Sandra through the surgical process, turned on the oxygen and began to hook up the blood pressure machine, pulse oximeter and EKG monitor just as Dr. Tucker came into the room suited up in his green surgical scrubs, as he did almost every morning.
A personable man, Dr. Tucker stepped over to Sandra and patted her on the arm, assuring her that there was nothing to be concerned about, she would be happy with the final results.
At 7:30 a.m., Dr. Tucker gave Sandra a mild tranquilizer and Sally started the IV that would dispense the anesthetic and an antibiotic, which was customary during surgery to prevent any type of infection from occurring.
Dr. Tucker estimated that it would take three or four hours to complete all four of the scheduled procedures, barring any unforeseen complications.
He started with the mini-facelift, since it would be the most time-consuming and intricate of the four. First he did one side, then the other, which took a little over one and a half hours. One advantage to a mini-facelift is that there is a faster recovery period, since it is not as invasive as a full facelift, which requires larger incisions and heavier stitching. It is the perfect solution for baby boomers who just want to take five years off their faces, so they look like younger versions of themselves.
Next Dr. Tucker harvested a small amount of fat to mix with a commercial filler product and filled in a couple of scars on Sandra's face, and plumped up her lips.
Using laser therapy, he smoothed out lines around Sandra's eyes caused by the environment, crinkles that Sandra thought made her look tired all the time.
The mini-facelift and laser resurfacing were meant to give Sandra a more youthful and rested appearance, not to change her natural good looks. Three and a half hours later, all the work was completed and everything had gone as planned.
By 11:15 a.m. Sandra was on her way to the recovery room, where she would rest for a couple of hours before going home. She was groggy from the anesthesia, but was able to get into a wheelchair on her own for the short ride down the hall to the recovery area.
Before leaving the operating room, Sandra's vital signs were checked: Her blood pressure was 109/93; her pulse 99; respiration 16, and O2 saturation was 96 percent, all of which were normal. Her skin was warm to the touch and pinkish in color.
Sandra talked to the nurses while they got her settled into the oversized recovery room recliner that was hooked up to monitoring devices. A technician covered her with a lightweight blanket and carefully placed ice packs on her bandaged face and swollen eyes.
Within minutes Sandra complained that her face hurt.
Technically, the nurse anesthetist's job was finished. Once a patient was in the recovery room Sally was supposed to go to the waiting area to get the next patient. But this particular day, the recovery room nurse asked Sally to watch the patients. It was part of the recovery room nurse's responsibility to check the patients' vital signs every fifteen minutes and document them on their charts while they were in recovery. Of course the nurse would also observe the patient to make sure there were not any changes in her condition. If there was any change, the nurse was supposed to alert the doctor immediately.
Sally, who had been diagnosed with leukemia and undergone chemotherapy a year earlier, had gained a lot of weight because of her treatment and lack of exercise. She seemed to like working in recovery—quite possibly because she didn't have to make as many trips up and down the hall to the waiting room. Sally said she often volunteered to help out so others could take a break, in spite of the fact that she had recently been chastised by the Chief CRNA for staying in the recovery room too long when that was not part of her job. The supervisor also reminded her that she should not give medication in the recovery room without the doctor's permission and she should always document all medications on the patients' records.
"My face hurts. It feels like it's on fire," a restless Sandra had complained almost immediately as she tried to get out of the recliner.
The level of pain was not surprising considering the amount of work that had been done on Sandra's face. By this time the anesthetic used in the IV was also beginning to wear off. Around 11:20 a.m., Sally stepped into the hall where she kept her supply cart and retrieved a syringe, and gave Sandra 1 cc of fentanyl, a fast-acting painkiller, intravenously.
At first the fentanyl seemed to calm Sandra, but within minutes she complained that it wasn't helping. By then, she had begun to draw her knees up to her chest in pain.
"Am I being a bad patient?" Sandra asked.
"No, of course not," Sally reassured her.
Five minutes after the first fentanyl, Sally administered another 1 cc dose for the pain. Both injections were given without consulting the doctor.
When the staff knew they would be in a long surgery, or had back-to-back procedures, they would step into the break room to get a quick bite to eat—a bagel or some yogurt, for instance—since there wouldn't be time for anything more. It was during one such instance, when Sally had stepped out of the recovery room for some coffee and a biscuit, that a certified surgical technician (CST) who happened to walk through the recovery room glanced at the monitor and saw the number 38. She feared that it might be the patient's heart rate. Then she noticed that Sandra's color had changed—her lips looked blue.
At first the CST wasn't alarmed; she thought the discoloration might be due to the fat grafts done on Sandra's lips, which could have easily bruised them. But when she walked around to the other side of the recliner to take a closer look, the nurse saw that Sandra's fingernails were also blue.
She went over and patted Sandra, calling her name as she tried to get a response, but there was none. She pinched Sandra's toe and called out "Sandra," again trying to get her to respond.
About that time the recovery room nurse walked back in and asked Sally, who had just returned, if Sandra was OK.
"She's fine," Sally replied.
The recovery room nurse pushed the recliner back and asked one of the CSTs to put the oxygen mask on Sandra.
"Take a deep breath," the nurse urged.
Sandra responded instantly, so the recovery room nurse walked out again.
Then—after seeing Sally go into the other room and come out of the OR and get something from her supply cart when she should have been watching the patient—she was asked if everything was all right.
"Do you want someone to get Dr. Tucker?" a surgical nurse asked, since the doctor was supposed to be notified any time there was a change in a patient.
"I have more than enough help," Sally reportedly said.
Sally was going about her business as calmly as she always did. There was no sense of urgency as she got a pre-mixed syringe of Robinul, to regulate the heart, and ephedrine to open the bronchical tubes if there were breathing difficulties. Sally always kept Robinul/ephedrine ready, just in case. Still there was no change in Sandra's condition.
The second time the recovery room nurse walked back in, she immediately noticed that Sandra's O2 saturation and blood pressure had dropped. The blood pressure cuff and pulse oximeter monitors had been turned on when Sandra first arrived in the recovery room, but for some reason the alarm had not signaled that anything was wrong. Regardless, it was apparent Sandra's condition had deteriorated, so the recovery room nurse went next door immediately to get Dr. Tucker.
Dr. Tucker ran to the recovery room to find the staff hovering over Sandra; Sally met him at the door, but co-workers said she had been standing at the back of the room, doing nothing to help.
The air was thick, as if everything was happening in slow motion.
Dr. Tucker immediately began to intubate Sandra. But there was no change. He did compressions on her chest. His heart pounding, he yelled at the staff to get Sandra on the floor so he could use the paddles to revive her.
Still no change.
"Do you want me to call 911?" the recovery room nurse asked.
"Yes!" Dr. Tucker yelled.
Just twenty minutes earlier Sandra had seemed fine after being wheeled into the recovery room after her surgery. Now she was being rushed to the nearest medical facility, Mercy Hospital. En route, paramedics administered Narcan, a drug used to counteract the effects of an overdose of pain medication.
Once at the hospital a team of doctors worked feverishly on Sandra, trying to revive her. One of the nurses called Sandra's mother and sister, who were listed as emergency contacts on Dr. Tucker's consent form.
There have been complications, the nurse told them. That was the only information they had when they arrived at the hospital.
For the remainder of the day the doctors ran batteries of tests, including MRIs and brain scans, trying to find any signs of life. That night, around 10 p.m., after working on Sandra nonstop since noon, a grim-looking doctor met with the family in a private room.
"There is nothing more we can do for her. Sandra stopped breathing after the second injection of fentanyl, and she lapsed into a coma," the doctor told them.
In simple terms, Sandra was brain-dead, a diagnosis that was later confirmed by two isoelectric (flat-line) EEGs, twenty-four hours apart, that indicated that the end of all brain activity was irreversible. There was no clinical evidence of brain activity, her organs were merely being kept alive by life support equipment.
Five days later, on Easter Sunday, April 15, the family gave the hospital permission to remove Sandra from the machines that were technically keeping her alive. She died not long afterwards.
Following an autopsy, the medical examiner determined that Sandra had died from an overdose of a painkiller thought to be fentanyl. She had gone into respiratory arrest and stopped breathing.
While tragic, it was considered a terrible accident, and there would be no need for a police investigation.
