Cardston Medical Personal Inconsistent reports / testimony / fatal tracheal tear
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What happened:
-Ambulance logs indicate that EMS had intubated Ezekiel at 22:11, 8 minutes before the first in hospital intubation.
-In Cardston the Cardio Pulmonary Arrest Record shows that Dr. Alexander Cunningham performed two intubations.
-He arrived at 22:18 and performed the first intubation at 22:19. Medical logs show him performing a second in hospital intubation with a sized 4 cuffed tube 60 minuted later after the proper sized equipment arrived from Raymond AB.
Dr. Lloyd Clarke indicates in his report that the ambulance crew had not achieved intravenous access or secured an airway.
-Dr. Lloyd Clarke in his report indicates that the size three E.T. tube was inserted in the ambulance bay at the Cardston the hospital. Records show that this took place one minute after Dr. Alexander Cunningham arrived on scene to assist with managing Ezekiel's airway.
-Dr. Clarke indicated in his report that the intubation tube slid easily past the vocal cords which placed him at the procedure.
-In his first day of testimony Dr. Clark indicated his and Dr. Cunningham's involvement in the initial in hospital intubation and described it in detail.
The next day Dr. Clark recanted what he had said the day before and indicated that he was not involved whatsoever in the intubation.
-In testimony Dr. Clark identifies two key issues. The unsecured airway and severe dehydration. The unsecured airway lines up with his first day of testimony and the medical logs and reports but not with his second day of testimony or Dr. Cunningham's testimony. Dr. Clark's claim of severe dehydration is difficult to believe as the parents had given Ezekiel 250 mL of electrolyte drink three hours before and the ambulance logs showed a 200 mL bolus just minutes before arriving at the hospital. A toddler of his size and weight would have approximately 800 mL of blood in his entire body. The fluids he had taken in were well over half of the total volume of blood he would have in his body. Medical records would show that Dr. Clark gave him 300 mL of fluid an hour after arriving at the hospital. If he was dehydrated and his airway was not secured then the medical records show that both of these critical issues were ignored by doctors for over an hour after Ezekiel arrived in the Cardston hospital. As an alternate reason for giving the 300 ml bolus, Dr. Clark may have been attempting to follow standard protocols for post cardiac treatment. Making the accusation of severe dehydration would give Dr. Clark the ability to further cast blame on the parents and distance himself from the medical errors that took place which he was involved in.
-Dr. Cunningham in testimony indicated that he had been involved in one intubation in conflict with the medical logs.
-Dr. Cunningham's testimony conflicts with medical records and would suggest neglect on the part of the doctors. The neglect that is apparent from the testimony of Dr. Alexander Cunningham could impact the doctors professional standing. This leads us to believe that something happened during the first in hospital intubation that was so horrifying that the medical staff are distancing themselves from it even at a risk of possibly losing their licenses for malpractice and criminal and civil liability for perjury.
-This led us to the x-ray taken in Cardston that had been removed from medical examiner file and RCMP production orders before disclosure was provided to the defence. Upon examination of the x-ray from Cardston it was found that there was a deep depression or tear in Ezekiel's trachea. Autopsy photos of the same area would confirm that the intubation tube was inserted with such force as to not only puncture the trachea but to also leave a deep gouge on the pleura covering his spine in the upper thoracic cavity.
-The tear in the trachea would allow the vomit that was recorded on the 911 call to leak into his thoracic cavity resulting in a severe lung infection that was not seen in the Cardston x-ray but was quickly progressing in the three subsequent x-rays taken over the next 24 hours.
-The x-ray also shows that Ezekiel's gastric sphincters were not relaxed and as a result his stomach was blown up with air to the point of pushing his trachea and heart almost a full inch to the right side of his body. This is an irrefutable indication that he was not brain-dead at this point. It also leads us to the conclusion that a differential diagnosis other than meningitis must have been the cause of his cardiac arrest. See Synopsis Calgary file.
-What is most disturbing about this event is that the doctors made no attempt to repair his trachea, thus resulting in further hypoxic issues and severe vascular congestion. In essence they just left him for dead and sent him off to the next hospital.
-Ambulance logs indicate that EMS had intubated Ezekiel at 22:11, 8 minutes before the first in hospital intubation.
-In Cardston the Cardio Pulmonary Arrest Record shows that Dr. Alexander Cunningham performed two intubations.
-He arrived at 22:18 and performed the first intubation at 22:19. Medical logs show him performing a second in hospital intubation with a sized 4 cuffed tube 60 minuted later after the proper sized equipment arrived from Raymond AB.
Dr. Lloyd Clarke indicates in his report that the ambulance crew had not achieved intravenous access or secured an airway.
-Dr. Lloyd Clarke in his report indicates that the size three E.T. tube was inserted in the ambulance bay at the Cardston the hospital. Records show that this took place one minute after Dr. Alexander Cunningham arrived on scene to assist with managing Ezekiel's airway.
-Dr. Clarke indicated in his report that the intubation tube slid easily past the vocal cords which placed him at the procedure.
-In his first day of testimony Dr. Clark indicated his and Dr. Cunningham's involvement in the initial in hospital intubation and described it in detail.
The next day Dr. Clark recanted what he had said the day before and indicated that he was not involved whatsoever in the intubation.
-In testimony Dr. Clark identifies two key issues. The unsecured airway and severe dehydration. The unsecured airway lines up with his first day of testimony and the medical logs and reports but not with his second day of testimony or Dr. Cunningham's testimony. Dr. Clark's claim of severe dehydration is difficult to believe as the parents had given Ezekiel 250 mL of electrolyte drink three hours before and the ambulance logs showed a 200 mL bolus just minutes before arriving at the hospital. A toddler of his size and weight would have approximately 800 mL of blood in his entire body. The fluids he had taken in were well over half of the total volume of blood he would have in his body. Medical records would show that Dr. Clark gave him 300 mL of fluid an hour after arriving at the hospital. If he was dehydrated and his airway was not secured then the medical records show that both of these critical issues were ignored by doctors for over an hour after Ezekiel arrived in the Cardston hospital. As an alternate reason for giving the 300 ml bolus, Dr. Clark may have been attempting to follow standard protocols for post cardiac treatment. Making the accusation of severe dehydration would give Dr. Clark the ability to further cast blame on the parents and distance himself from the medical errors that took place which he was involved in.
-Dr. Cunningham in testimony indicated that he had been involved in one intubation in conflict with the medical logs.
-Dr. Cunningham's testimony conflicts with medical records and would suggest neglect on the part of the doctors. The neglect that is apparent from the testimony of Dr. Alexander Cunningham could impact the doctors professional standing. This leads us to believe that something happened during the first in hospital intubation that was so horrifying that the medical staff are distancing themselves from it even at a risk of possibly losing their licenses for malpractice and criminal and civil liability for perjury.
-This led us to the x-ray taken in Cardston that had been removed from medical examiner file and RCMP production orders before disclosure was provided to the defence. Upon examination of the x-ray from Cardston it was found that there was a deep depression or tear in Ezekiel's trachea. Autopsy photos of the same area would confirm that the intubation tube was inserted with such force as to not only puncture the trachea but to also leave a deep gouge on the pleura covering his spine in the upper thoracic cavity.
-The tear in the trachea would allow the vomit that was recorded on the 911 call to leak into his thoracic cavity resulting in a severe lung infection that was not seen in the Cardston x-ray but was quickly progressing in the three subsequent x-rays taken over the next 24 hours.
-The x-ray also shows that Ezekiel's gastric sphincters were not relaxed and as a result his stomach was blown up with air to the point of pushing his trachea and heart almost a full inch to the right side of his body. This is an irrefutable indication that he was not brain-dead at this point. It also leads us to the conclusion that a differential diagnosis other than meningitis must have been the cause of his cardiac arrest. See Synopsis Calgary file.
-What is most disturbing about this event is that the doctors made no attempt to repair his trachea, thus resulting in further hypoxic issues and severe vascular congestion. In essence they just left him for dead and sent him off to the next hospital.
Cardio Pulmonary Arrest Record for Cardston Hospital showing two in hospital intubations by Dr. Alexander Cunningham
Ambulance logs showing out of hospital intubation and IV fluids.
In conflict with his second day of testimony, Dr. Lloyd Clarke's report indicating that the ambulance crew had not obtained intravenous access or secured an airway and that hospital staff undertook to correct these issues prior to moving into the hospital.
Dr. Alexander Cunningham's report indicating that an endotracheal tube was placed in the ambulance while the ambulance was in the ambulance bay. In conflict with the cardiopulmonary arrest report he indicates that he arrived at the time the patient was brought into the trauma bay in the Cardston Hospital. Dr. Cunningham's report conflicts with Dr. Lloyd Clark's report, Dr. Lloyd Clark's first day of testimony, as well as the Cardio Pulmonary Arrest Report.
Dr. Lloyd Clark in testimony expressing that the events of that night were indelibly imprinted on his brain.
Dr. Lloyd Clark in testimony indicating that he and Dr. Cunningham had replaced the endotracheal tube in the back of the ambulance
Dr. Lloyd Clark claiming that Ezekiel was suffering with severe dehydration at the time of his arrival in Cardston
Dr. Lloyd Clark now indicating that he had forgotten what had taken place and recanting on events that were "idelibly imprinted on his brain" which he had testified of the day before with respect to the intubation in the ambulance bay
Dr. Cunningham indicating that Ezekiel was in the emergency room when he replaced the intubation tube in conflict with the Cardio Pulmonary Arrest Report and Dr. Lloyd Clarkes first day of testimony as well as his report.
Dr. Cunningham in testimony speaking to the fact that he was the airway management specialist and that he re-intubated Ezekiel with the size 4 intubation tube upon arrival which conflicts with the cardiopulmonary report as well as Dr. Lloyd Clark's report and Dr. Lloyd Clark's initial day of testimony.
The Cardston x-ray that was removed from both a RCMP production order and the medical examiners file. The x-ray shows evidence that the gastric sphincters were intact which is a sign that he had not suffered brain death upon arrival. It also shows a tear in Ezekiel's trachea at the end of the endotracheal tube that would have resulted in gastric aspirant leaking into his thoracic cavity and causing a massive and potentially fatal infection.
A zoomed in image of the x-ray showing the tear in the trachea
An autopsy photo showing Ezekiel's thoracic cavity and the deep gouge left on the upper portion of his spine as a result of the force with which the endotracheal tube was inserted. This photo also shows the resulting injury to the right side of his thoracic cavity as a result of gastric aspirant leaking in through the tear in the trachea.
A zoomed in autopsy photo showing the deep gouge left by the botched intubation
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