Insult to Mortal Injury

The short life and times of Johnny Jardine, Part 2

John Brooking Jardine's death was tragic and grotesque. The 37-year-old epileptic was pronounced dead at Tempe St. Luke's Hospital on March 30, 1999, after suffering a seizure during his geography class at Arizona State University.

He was needlessly manhandled. Contrary to accepted protocol for seizure patients, emergency personnel from the Tempe Fire Department and Southwest Ambulance restrained Jardine. An ASU police officer handcuffed his hands behind his back.

A lawsuit filed by Jardine's parents alleges that Johnny was thrown face down and that the cop pinned him down with his knee while an EMT straddled his back as Johnny struggled to breathe. Johnny, who was obese, was then loaded, still prone and handcuffed, on a gurney (which had an airtight pad) and perfunctorily carted to the hospital. The disoriented and oxygen-starved seizure victim could only protest with pathetic moans.

Emergency personnel apparently didn't realize Johnny was in such peril. If they did, one key witness says, they didn't react properly. Attempts to resuscitate him in the emergency room failed.

From the moment they learned of Johnny's death, his parents, Debbie and John III, heard a barrage of explanations. A distressing number of them were wrong. Some seemed intentionally misleading.

When Debbie saw her son's body and asked about the deep bruises around his wrists, an ER staffer said they came from tying off intravenous tubes. In fact, they were caused by the handcuffs, which had hampered attempts to revive him.

Somebody told Debbie that because Johnny had died in the hospital, no autopsy was required, but that she could pay for one if she wanted. The distraught mother said none would be necessary. After Johnny's personal physician refused to come to the hospital and sign a death certificate, however, his body was released to the medical examiner. The physician who did the autopsy took the extraordinary step of contacting the Jardines the next day to tell them that their son had been brutalized.

An emergency room doctor told Debbie that Johnny had suffered a "widowmaker" heart attack. The autopsy report said nothing about a heart attack, and determined that "positional restraint" was a factor in Johnny's death.

And these inaccurate assertions were just the beginning. Crucial records were lost or altered in the wake of Johnny's death.

The Jardines call it a "cover-up."

Their lawyer, Michael Manning, says, "We were very dismayed to see that records had been changed. When we took the case, we didn't take it with the expectation that evidence had been tampered with."


Pushed to his physical limit by an intense grand mal seizure and deprived of precious oxygen by his would-be rescuers, Johnny Jardine may well have been beyond saving by the time paramedics got him to Tempe St. Luke's.

In my estimation, the actions of the police, paramedics and EMTs outsidethe hospital form the linchpin in the Jardines' $20 million lawsuit against ASU, the City of Tempe, Southwest Ambulance and the hospital.

Did they create the conditions that doomed Johnny? Some of Johnny's classmates say claims that Johnny had to be restrained because he was violent are overblown. Were they "oblivious" to the trouble he was in?

Once Johnny was placed in their care, the ER staff's medical actions seem defensible and reasonable.

But the hospital's behavior in the wake of Johnny's death is simply appalling -- flagrant enough, perhaps, to cost it a bundle of money.

A couple of months after her son died, Debbie Jardine asked St. Luke's for her son's medical file. When she picked it up, Debbie, a licensed practical nurse, noticed that one form indicated that an ER physician had dictated notes about her son's condition and treatment. But she had been given no such notes.

She went back to the hospital and demanded the notes. The doctor's dictation was printed out of a computer file and given to her. Before she left, she says, she sat down and compared her records with the hospital's and made certain both sets were identical. The newly printed doctor's notes had been belatedly inserted into the hospital's file.

Months later, Manning requested the same records. But when the attorney received them, the doctor's dictation had changed. In fact, the new notes had been dictated within days before Manning acquired them. The differences between the two versions are significant.

The initial notes indicate that Dr. James McEown was the admitting and attending physician. The new version listed Dr. Kevin Haselhorst. The initial notes say that Johnny had suffered a grand mal seizure. The second set mentions no seizure at all, but instead says he was acting in a bizarre manner, and was struggling even after he was handcuffed. The first version says ER monitors registered some electrical activity -- but no regular pulse -- in Johnny's heart. The second version omits this important fact. The initial notes say that Johnny battled rescuers until a couple of minutes before his arrival at the hospital, when he became pulseless. CPR was then started. The second version says CPR was started en route to the hospital, and that Johnny was hooked to a heart monitor.

Whether the EMTs who transported Johnny did, in fact, attach heart monitors is a crucial and contentious issue. Such monitoring should have occurred if the rescue crew was alert to Johnny's grave condition.

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