Tyson Horton Story Part II --- Near Fatal, Life-Changing Medical Errors

Last week you were introduced -- or reintroduced -- to Tyson Horton, a 13-year old boy from Oregon.  You were also introduced to Tyson's mom, Lori.  With Tyson, you met a young man who has similar likes and quarks of the teenagers in your life --- except Tyson is living with medical errors and his family continues to struggle from how those medical errors were handled by the medical professionals they entrusted. 

This week, we will provide a glimpse into the medical errors that nearly killed Tyson as an infant, and forever changed his life, Lori's life, and the surely the lives of everyone involved in this case, including the surgeons, nurses, and other healthcare professionals along with insurance and legal professionals.  By telling this story it is the hope of Tyson, Lori, and Sorry Works! that people can learn and improve healthcare organizations along with the insurance and legal organizations that support doctors and nurses.  

Again, what follows is a glimpse of care gone terribly wrong.  Lori, Tyson's kept detailed notes for several years on Caring Bridge and you can request access here.  You have to register (it's free).  Lori also created a Facebook page about Tyson's story:  Lori took down both of these pages after her son's case went all the way to the Oregon Supreme Court, partially due to negative and ill-informed comments made by members of the public (more on next week and beyond).  She re-activated both pages for these Sorry Works! e-newsletters/blog posts.  

In July 2009, Tyson suffered from unexplained constipation which led to a diagnosis of an inoperable tumor in Tyson's liver. The diagnosis was made at a local/smaller hospital near Tyson's home. Tyson needed three months of chemotherapy to shrink the tumor and have a chance for a successful operation.  His care was beyond the scope of the family's local hospital, so Tyson was referred to Oregon Health Science University Medical Center, or OHSU, a teaching hospital. 

By early September (2009), the tumor had been shrunken to the point that surgery could be attempted.  The game plan was to remove only the tumor and leave the healthy portion of Tyson's liver alone. Then, hopefully, Tyson would grow up like any other kid, without the lasting effects of the cancer or the operation, with his healthy immune system, his spleen, and no need for constant monitoring or medications.. Sadly, the surgery went terribly wrong.  Here is a quote from Lori's Caring Bridge Journal dated September 18, 2009 which graphically captures how medical errors literally come screaming out of left field for patients and families:

"He went in to surgery at 11:00 this morning.  At 12:30 PM we received an update from the nurse over the phone that he was stable.  At 1:30 PM we got another update over the phone, from the same nurse that said they were almost finished removing the tumor and they expected to be finished by 3:00 PM. Then at 3:00, instead of a phone call from the nurse, the surgeon came out to talk to us.  He took us to a private room where we expected him to tell us that Tyson was in recovery and the procedure went smoothly. But instead, he looked us straight in the eye and gave us the bad news.  Somehow, and we don't know exactly what the sequence of events were at this point, somehow they severed the hepatic vein and the bile duct connecting the left lobe of his liver.  They cut the wrong stuff."   

They cut the wrong stuff. Somehow, inexplicably, a surgeon in training (a Fellow) was able or allowed to get on the wrong side of Tyson's liver and literally cut the wrong stuff.  A "never event" happened to a nine-month old baby. 

Going forward, Lori's Caring Bridge Journal provides a day-by-day account of how Tyson struggled to stay alive and how the family and medical professionals fought hard to save Tyson. The OHSU surgical team labored to control the bleeding that emptied Tyson of his blood volume more than ten times over. In fact, Tyson had laid there bleeding uncontrollably for 45 minutes before the error was discovered by specialists.  An adult liver transplant specialist was brought in to say Tyson's life.  Nine-month old Tyson endured two more trips back to surgical suite in just 24 hours, but the train wreck could not be stopped. Tyson's liver and kidneys began to fail, and on the third day he and Lori were medivacked to Stanford Hospital in Palo Alto, California while Lori's husband, Steve, drove the eight plus hours to the hospital.  

Stanford physicians informed the family that Tyson's liver was dead and poisoning his body, and he would need a liver transplant in order to survive.  Tyson was put at the top of the national donor list, but no donors were available.  The Stanford medical team worked overtime to keep Tyson alive while Lori was evaluated for a possible donation.  Lori was cleared to donate and, after fighting through insurance and bureaucratic red tape, she was on the operating table donating the left lobe of her liver. Lori's donation saved Tyson's life, but the medical roller coaster was just beginning for the family. 

For the next two years, Tyson experienced multiple complications and life-threatening emergencies, and even coded in a hospital elevator.  Numerous times Lori and Steve were informed their son would not survive the night.  Tyson fought through line infections, staff infections, pneumonia, uncontrollable blood pressure spikes, his spleen and major blood vessels dying, and constant concern about his liver and kidney functions. The family had to rent an apartment in Palo Alto due to his extended stays at Stanford Hospital.  Lori also suffered her own complications from the donation surgery -- a flipped stomach -- which made her terribly sick and, after a month of being in the hospital while doctors worked to diagnose what was wrong, required an additional operation.  All told, the family initially racked up over $3 million in medical bills with Tyson's care and an additional $500K with Lori's care, and would eventually incur $5 million in medical debt and related expenses.  Tyson's life did not reach some level of normality until the end of 2011.  However, as you will learn in future e-newsletters, Tyson's life is anything but normal even eleven years after the medical errors that nearly took his life.  Again, Lori transcribed every step on this awful journey in her Caring Bridge Journal.

Next week we will begin to explore OHSU's response to this tragedy, including how the surgeons interacted with the family.  Please forward/share these this e-newsletter and last week's e-newsletter with colleagues and friends.  Help us spread the word...this is a very powerful story that can help countless individuals, especially medical and nursing students.  Thank you.  

Sincerely,

- Doug

Doug Wojcieszak, MA, MS
Founder and President
Sorry Works, a 501c3 patient safety organization
618-559-8168 (direct dial)
doug@sorryworks.net