It wasn't life-threatening.
As a general surgeon, he could easily fix it.
"It's routine," the surgeon said.
"I've done thousands of them."
Except it wasn't.
The young man trusted his doctor.
He liked him.
He had no reason to disagree with him.
It sounded simple enough.
The doctor certainly had plenty of experience.
There didn't see to be any risk with the surgery.
He knew he was in good hands.
In fact, the surgeon was great.
There were no complications.
There was no real blood loss.
The surgery went well.
He was groggy.
He was sleepy.
He wouldn't respond to the anesthesiologist's questions.
Following surgery, the anesthesiologist routinely asks the patient a series of questions to make sure they're oriented to 'person', 'place' and 'time'.
"Hey Mr. Jones, do you know where you are?"
"Do you know who the President is?"
"Do you know what month and date it is?"
After surgery, the anesthesiologist must reverse the anesthesia to wake the patient up.
Except in this case, the patient wasn't waking up.
He was not arousable.
That's a problem.
There was little effect.
This was not good.
The young man was transferred to the recovery room.
While there, the anesthesiologist decided it would be a good idea to keep the patient overnight.
"We'll watch him since this was the last case of the day and we can't discharge him in his condition anyway."
Rather than send him to a floor with continuous electronic vital sign monitoring, he was sent elsewhere.
He was sent to a medical floor to be watched.
On this unmonitored floor, the nurses only checked on patients every four hours.
And that's what they did.
When he was brought in, his vital signs were checked.
He was alive.
He was breathing just fine.
He wasn't on any breathing machine.
He wasn't on life support...at least not yet.
When a nurse returned to check on this patient in the early morning hours, she found him blue and not breathing.
The emergency doctors and nurses spent 30 minutes running a code to resuscitate him.
They successfully got his heart beating again.
But there was a problem.
A big one.
He could not breathe for himself.
He needed to be intubated.
He needed to be put on life support machines to keep him alive.
He never regained conciousness.
He had been without oxygen for an extensive amount of time.
In medical terms, a decreased amount of oxygen is known as hypoxia.
A total lack of oxygen is known as anoxia.
There was no question that this young man suffered both hypoxia and anoxia.
That severe brain damge led to all of his organs shutting down.
Medically, this is known as 'multi-system organ failure'.
The intensive care unit doctors said he was 'brain dead'.
That meant that machines were mechanically breathing for him and keeping him 'alive'.
He had no brain activity.
His brain suffered a tremendous loss of oxygen.
This 'routine' surgery should have been routine.
The surgeon did everything right.
The problem was that the anesthesiologist over-medicated the patient.
The problem was that the hospital failed to monitor this heavily anesthetized patient.
They also failed to recognize the patient wasn't breathing which led to his brain damage, respiratory failure and cardiac arrest.
The hospital staff's failure to recognize that the patient was in cardiac and respiratory arrest was a clear violation from the basic stanard of medical care.
That carelessness was directly responsible for this patient's untimely death.