October 30, 2014
Two weeks after his brush with death, Nicholas Bravi stepped out of his shower with the Steri-Strips washed away and the angry red scar on his chest fully visible for the first time.
For his mom, Carola Bravi, the sight of that scar sent her mind tumbling back to a chaotic hospital scene, moments after the routine had suddenly snapped into the critical, with baffled medical personnel swarming around her 15-year-old boy, fighting to keep him alive.
“The thing that really stood out for me was that his scar was crooked,” Carola says, her voice breaking. “And so I knew that they were in a hurry.
It just really hit me hard that this was a life-threatening critical event that affected the staff just as much as it probably affected me. They’re in the room trying to save him. I can't imagine what they would have gone through wondering what the hell happened.”
Determining just what did happen has become Carola’s private mission in life ever since that April day back in 2010 when things went so startlingly wrong.
Earlier in his childhood, Nicholas had been diagnosed with a heart condition called Wolff-Parkinson-White syndrome, or WPW, an abnormality of the electrical system of the heart that can cause rapid and erratic heart rates. He’d been symptom free for several years but fell ill one day at his Penticton school with a racing heart. After being stabilized, he was booked for cardiac ablation treatment at BC Children’s Hospital in Vancouver.
People with WPW essentially have an extra electrical pathway in their hearts. Under cardiac ablation, tiny metal-tipped catheters are inserted through the femoral artery in the leg up into the heart. During a four or five hour procedure, doctors map out the electrical systems of the heart and then ablate, or burn, the extra, abnormal pathway that is the cause of the problem.
Cardiac ablation is not without risks but it has virtually eliminated surgical open heart treatments in the vast majority of WPW patients. Nicholas’s procedure was performed in the hospital’s cardiac catheterization lab, as opposed to an operating theatre. Everything seemed to be going according to plan. Carola stepped out from the waiting room for a bit and when she returned there was a woman waiting for her, telling her that something had happened.
It was only afterwards that Carola learned that before the ablation was done, a cardioversion (shocking of the heart) had triggered a dangerously abnormal, unintended arcing within Nicholas’s chest, causing three burns to the top of his right atrium. The actual intended ablation was performed on the left side of his heart.
In the moment, though, none of that was clear. After the ablation, Nicholas was somehow still in cardiac distress. An emergency ultrasound found his heart was being compressed by blood filling his heart sac. At this point, the heart wasn’t beating, it was just vibrating. Doctors drove a needle through the boy’s chest wall to try and drain some of the pressure off his heart. That was unsuccessful. CPR was performed. A cardiac surgeon cut a pericardial window to try and locate the source of the bleeding, to no avail. It was only after an emergency sternotomy, with Nicholas’s chest cut open that the three errant burns were spotted, including the one that had holed his heart.
Nicholas was rushed into an operating room and underwent open heart surgery. He wound up on a ventilator in an intensive care unit, and was kept hypothermic for awhile over fears that he might have suffered brain damage.
Carola was still absorbing all the shock of this the next day when a concerned hospital anesthetist allowed that Nicholas had “suffered quite the assault yesterday.” Those words put everything into focus for her. She simply had to find out what had happened. No-one had any explanation for why those three extra burns occurred. Nicholas’s doctor said such a thing had never happened before at BC Children’s or, as far as he knew, anywhere else. Nicholas’s hospital experience wasn’t one in a million, Carola was told, and it was the only one on record.
Carola, who has worked in a clerical capacity in hospitals for 27 years, found that difficult to believe. After extensive research and relentless questioning her suspicions fell upon the catheters used in the procedure. First, she wondered how it could be safe to have metal-tipped catheters in place in the heart at the same time as the organ is being electro-shocked to get the heart rate back to a normal rhythm, a key step in the ablation procedure. But the doctor insisted this is often used during an ablation and that’s the way the procedure is performed.
Next Carola turned her attention to the actual catheters themselves. In questioning Nicholas’s doctor, she learned that one of the catheters used on her son was “a sent product” or reprocessed single-use medical device.
“I know from working in the OR that using out of country single use reprocessed medical devices is an accepted form of practice in British Columbia,” Carola says. “I fixated on that. I thought, I really hope that my son’s device was safe if it had been used before.”
Months later, deep into her persistent grilling of medical authorities and manufacturers, Carola learned that her son’s catheter had been on its third reprocessing cycle. He was the fourth user. She also uncovered worrisome gaps in the tracking and testing of such reprocessed devices across Canada. Knowing what questions to ask to find the answers is key in any such circumstance, she says, but what about those patients who don’t? A mother should never have to be the one to report her son’s near death incident to the governing health body.
“How can I now put my trust in the system when I know there are concerning gaps?”
If pharmaceuticals are approved by the FDA they still require the stamp of approval at the federal health level here in Canada, Carola points out. How can these devices be any different?
Carola has won a few small triumphs along the way. Nicholas’s doctor has decided he will no longer use single use reprocessed catheters during his ablation procedures and also now pulls the catheters down before he shocks a patient. Carola is not sure however if there are other physicians that still use them.
Nicholas is fully recovered today, a robust 19-year-old living in Kamloops, soon to embark on a four-year heavy duty mechanic course. “I’m thankful that he’s having to struggle paying his bills because it means that we still have him with us,” Carola says. “He’s a healthy, happy guy.”
When you’re investigating a loved one’s harm, you can sometimes feel very alone, Carola says, but adds that she’s found a great camaraderie and support network within Patients for Patient Safety Canada. The persistence of the other members encourage her to carry on asking the questions that need to be asked.
“As a patient and as family members, you have to be your own advocate, you really do. Just keep your eyes open and your ears open and if something doesn't feel right, you have to ask the question,” Carola says.