THE LAST DAYS OF TAMMY GENTRY
The Gentrys have photo albums full of pictures of their daughter Tammy. In many of the photos, smiling, cute-as-can-be Tammy wears across her upper body a ribbon with the words "March of Dimes." Her tiny legs barely dangle over the seat of her wheelchair.
Tammy was 8 years old when she became a poster child for the March of Dimes. She had spina bifida, a birth disorder that left her with no feeling in her lower body and an abnormal curve in her spine.
Despite her disorder, she had normal mental capacities and was always full of energy.
When she reached 13, though, that changed. That's when Tammy underwent surgery to straighten her spine.
Of the 40 surgeries Tammy had endured, the one in August 1988 was the most intense. Fortunately, she had a top pediatric orthopedic surgeon to perform the operation: Phoenix physician Jack Mayfield. One of a handful of surgeons in the Valley capable of performing the operation, Mayfield had successfully treated 20 other patients similar to Tammy.
This time was no different. The two-step procedure took 20 hours and left Tammy with an incision from the bottom of her neck to the bottom of her back. The surgery was a success.
But for Tammy, the problems began after she left the operating room at Phoenix Children's Hospital and ended with her death two months later.
During that time, Tammy's parents claim in a lawsuit, Mayfield, Phoenix Children's Hospital and the medical staff of CIGNA provided "substandard medical care that clearly violated reasonable practice." They filed the wrongful-death suit against half a dozen individuals and institutions involved in Tammy's care--not because they sought to sue everyone they could, but because they believed so many people contributed to Tammy's death.
The Gentrys accuse Mayfield of discharging Tammy from the hospital on his way out of the country even though she showed ominous signs of a potentially lethal deep-wound infection. They accuse Mayfield of not providing an adequate follow-up plan in case Tammy's infection became severe.
They charge the hospital's nursing staff couldn't keep Tammy's surgical incision free of feces and urine. Because Tammy had no feeling in the lower part of her body, that problem was particularly hard to control. But her mother, a friend and even Mayfield say they complained repeatedly to nurses that the helpless girl was forced to lie in her own excrement.
They charge that CIGNA doctors responsible for Tammy's care after she left the hospital didn't discover Tammy's fatal infection until it was too late. Nor, they contend, would the insurer approve frequent enough visits by a nurse to check on Tammy. And when Tammy, showing signs of a deep-wound infection, visited a CIGNA staff doctor, instead of sending her back to the hospital or referring her to a specialist, the doctor sent her home with an antibiotic that proved ineffective.
The charges speak to some of the problems that face healthcare today, from overworked nurses to insurance companies that, some charge, put the bottom line before patients' health.
The case also points up possible problems in the growing popularity of health maintenance organizations, as more and more companies seek lower-cost group health plans. Critics say that HMOs such as CIGNA bend over backward to make sure their medical staffs keep costs down, running the risk of sacrificing patient health.
"The care and treatment CIGNA provided to Tammy graphically illustrate that financial considerations compromised CIGNA's care and treatment of Tammy from the very beginning," the Gentrys' attorney, Ray Slomski, charges in a court document.
But in interviews, legal documents and court proceedings, all the parties named as defendants in the Gentrys' lawsuit hotly deny wrongdoing, although some admit mistakes were made.
Mayfield says Tammy showed symptoms only of a minor problem--her skin wasn't healing--when he decided to send her home. Mayfield's attorney says the Gentrys knew the high risks of the surgery, and how hard it was to prevent infection in a patient such as Tammy.
Hospital nurses testified that because of her incontinence, it was almost impossible to keep Tammy completely clean from excrement. An expert witness for the hospital challenged whether Tammy's infection was actually caused by exposure to her own excrement, as her parents say, or was brought on by bacteria already in her body and skin.
In court depositions, CIGNA workers say that in treating Tammy, they did not fall below the standard of care specified. They also say that the family prevented some care.
Other CIGNA officials refused to comment, saying corporate policy prohibited them from discussing cases that have been in litigation--even though the case is now closed.
But in a field where workers regularly shy away from criticizing colleagues, the amount of finger-pointing in Tammy's case is remarkable.
Mayfield, for example, testified that he chided nurses for not keeping Tammy's wound clean. The nurses, however, deny under oath that Mayfield said anything to them. A CIGNA document indicates that CIGNA tried to contact Mayfield immediately after Tammy's discharge from the hospital. Mayfield denies that.
The CIGNA staff physician who treated Tammy says his own nurses didn't give him key information on the seriousness of the infection. The home-health nurse assigned to look after Tammy complained that there was "no discharge plan" for Tammy and said she couldn't find a CIGNA doctor who would take responsibility for the girl's care.
But after two and a half years of litigation--involving testimony from dozens of witnesses and medical experts, more than 100 hours of depositions and hundreds of thousands of dollars in legal fees--all the parties agreed to settle the case rather than go to court.
While the agreement earlier this year included a ban on disclosing the amount of the settlement award, for the parents of Tammy Gentry, it was a hollow victory.
"I have lived through her death over and over for four and a half years," says mother Luann Gentry. "I believe justice has been done. Tammy, in her short life, accomplished a lot."
@body:Even at age 8, when the March of Dimes photo was taken, Tammy had a composure and a smile you could not easily forget. Her friends and family describe her as bubbling with energy.
"I remember Tammy as being very vivacious," says Paula Mindiola, of the local Spina Bifida Association. "Always curious and wanting to know about everything."
It was Tammy's smile and spunk that led the March of Dimes to feature her as its official Arizona Poster Child in 1982 and 1983.
"She was absolutely enthusiastic," remembers Bob Perry, the March of Dimes director at the time. "She was very articulate."
March of Dimes organizers wanted Tammy to "go national"--travel around the country, raising money for the charity--but her parents didn't want her to take time away from her schoolwork and her other activities.
She met former governor Bruce Babbitt, received a tennis racquet from the now-deceased Arthur Ashe and accepted an award as Handicapped Student of the Year from the then-mayor of Phoenix, Margaret Hance.
Although she was confined to a wheelchair, the tiny child--only three feet seven inches--loved to swim and fish, and she competed in the Frisbee throw and the wheelchair race at the Special Olympics organized by Phoenix College.
She donned pompoms as a cheerleader for several of her two older brothers' sports teams. She even tried out for Desert Sands Junior High's track team.
"She came in dead last," remembers her mom. "But she tried."
While she didn't make that team, Tammy had no trouble in school. Despite all the time she spent in the hospital, she remained a B student in the mainstream program, in the same grade as other children her age.
And she was popular. "She had lots and lots of friends," says her mom. "She went to school dances. She talked on the phone all the time."
Around the block, neighbors built ramps up to their homes so Tammy could visit. The ramps are still up.
"She was normal in every way but her spina bifida," says Luann.
@body:Luann Gentry gave birth to her third child on November 29, 1974, her husband Jerry's 27th birthday.
The couple had little reason to suspect that their daughter would be one of only 25 babies born each year in the Valley with spina bifida. The family's two sons were healthy, and no other relatives suffered from the disorder, thought to be hereditary.
Ultrasound testing that can alert parents to the condition early in a pregnancy wasn't performed routinely then. Had it been, doctors might have noticed a kink in the fetus's upper spinal cord, which probably developed sometime within the first weeks of Luann's pregnancy.
Shortly after Tammy was born, doctors began to warn the family that the little girl would not survive.
Tammy's degree of spina bifida, known as myelomeningocele, occurs in only one out of every 1,000 births. It is one of the most costly of all birth disorders to treat.
Before Tammy was a year old, she had gone through six surgeries to treat the hydrocephalus common in spina bifida patients. Doctors were able to successfully install a shunt in Tammy's brain that drained excess spinal fluid into her stomach. In earlier decades, children who suffered from hydrocephalus (then wrongly known as "water on the brain") often died before they reached their early teens.
Tammy was also born with a defective kidney, which later failed altogether. And she had a chronic urinary tract infection because her bladder didn't function properly.
As Tammy learned to "walk" using her arms and hands, she would bump into things. With no sensation in her lower body, she broke her fragile leg bones several times.
But as she grew older, surviving surgery after surgery, doctors sounded their death warnings less and less frequently.
When Tammy was 7, her doctors began to recommend major surgery to correct Tammy's potentially life-threatening kyphoscoliosis. The surgery would straighten her spine, which had formed a hump in her upper back. Uncorrected, her spinal cord could crowd her major organs, especially her lungs and kidneys.
"She would turn into a pretzel," says Lura Halstead, the head nurse at a spina bifida center where Tammy was treated while she was growing up. "She would get to an age where she'd have absolutely no chance to survive."
By the time Tammy turned 13, she had just about stopped growing at a little more than three and a half feet tall. After consulting with doctors, Tammy and Luann decided that the summer before Tammy entered the eighth grade would be the best time to undergo the surgery.
That operation would place metal rods, known as Harrington rods, in Tammy's back in order to straighten her spine. The surgery could have enabled Tammy to live until she was 30 or 40 years old, if not longer.
The Gentrys knew the surgery was dangerous. But they also knew that to improve Tammy's life, indeed, for her to have a life at all, it had to be done.
@body:Luann Gentry was an insurance rater with Fireman's Fund Insurance in the mid-1980s when her company began to offer the CIGNA Healthplan to its employees. Luann says she switched her family's coverage from Aetna to CIGNA because it paid for substantially more services.
While the Gentrys' lawsuit did not find fault with CIGNA's coverage, the parents did cite problems. At first, Luann says, CIGNA allowed Tammy to continue seeing the specialists at the spina bifida center, then called Arizona Children's Hospital.
For Tammy's routine care, however, she began seeing Dr. F. Gerald Figgs, chief of staff at CIGNA's office in Maryvale.
But eventually, Luann says, CIGNA would pay only for visits to specialists within the organization. "All of a sudden, they told me Tammy could not see her doctors that she had since birth," Luann says.
Then, in February 1988, CIGNA sent a letter saying it was canceling the Gentrys' coverage because Jerry Gentry allegedly refused to get treatment for an alcohol problem.
While it is unclear whether CIGNA planned to cancel the whole family's coverage or just Jerry Gentry's, the letter came months after Luann began discussing her daughter's need for the costly surgery with CIGNA staff.
"Every inch of the way I fought them over the surgery," Luann claims.
Upon appeal, CIGNA agreed to continue coverage. (CIGNA officials declined repeated requests for an interview.)
CIGNA did finally recommend that Phoenix surgeon Jack Mayfield perform the operation to straighten Tammy's spine.
A graduate of Indiana University Medical School in 1968, Mayfield had taught at the University of Minnesota's prestigious Department of Orthopedic Surgery.
Mayfield began practicing regularly in Phoenix in 1982 and later opened the Papago Medical Park on Seventh Street, just south of McDowell Road. In 1987, he published a book, Surgical Management of Kyphosis, the medical term for Tammy's curved spine.
He was one of a handful of surgeons in the Valley capable of performing the delicate surgery Tammy needed.
Tammy and Luann first saw Mayfield in April 1988. The doctor carefully explained the two-step procedure. During the first surgery, Mayfield would open Tammy's back and place the metal rods inside her body. During the second surgery, he would cut in anteriorly to fuse the spine.
Mayfield cautioned Luann and Tammy about the difficulty of the procedure. He later gave Luann a "teaching check list" that outlined the possible complications. Number one on the list was "infection: wound."
But Mayfield's nurse reassured the mother and daughter. She showed them photos of other children who had successfully undergone the operation at Mayfield's hands.
Having gone through nearly 40 operations together, mom and daughter felt ready for the most intense surgery of Tammy's young life.
"I felt really confident," Luann says. "Tammy was scared, but she knew she wanted it done."
@body:On August 14, 1988, four days before her surgery, Tammy was admitted to Phoenix Children's Hospital at 11th Street and McDowell.
The date was just a few weeks before Mayfield was leaving the country to attend a medical conference in Yugoslavia.
Because of Tammy's chronic urinary tract infections, a urologist under contract with CIGNA had recommended Tammy enter the hospital 10 to 14 days ahead of time for antibiotic treatment; Mayfield said he expected Tammy would be admitted seven days beforehand.
CIGNA, however, would only authorize four days of the treatment. The Gentrys theoretically could have paid for the extra days out of their own pockets, but the cost would have been prohibitive.
While doctors knew it was extremely difficult to completely sterilize a patient like Tammy--because of abundant bacteria in both her skin and body--she appeared to be ready for the first and more complex operation on August 18.
Luann Gentry remembers that first surgery lasting 10 to 15 hours. Between the first and second surgeries, while her daughter was in intensive care, Luann slept in the same room with Tammy.
The second surgery two weeks later was shorter, but still lasted several hours. Again, Luann stayed with her daughter as much as possible.
"She did real well," says Luann. "Within a couple of days, she was giggling, talking on the phone, acting like Tammy."
Indeed, no one disputes the success of either surgery. Tammy, it seemed, would become another smiling picture on Mayfield's wall.
But that was contingent on the care Tammy received in the critical recovery period after her second surgery on August 29.
@body:After any surgery, protecting against wound infections within the body is the most critical part of a patient's postoperative care. These infections, known as subfascial deep-wound infections, can lead to death.
According to Mayfield's own testimony, the risk for deep-wound infection is highest seven to 14 days after surgery.
In a patient like Tammy--who had just had a foreign object placed in her body and had a history of urinary tract infections--the chances of contracting any infection were particularly high, anywhere from 8 to 30 percent.
Coupled with the fact that Tammy had no control of her bladder or bowel and had diarrhea, constant monitoring of her wound was essential.
But during those critical days, the Gentrys say, Tammy's care was inadequate.
Luann and her husband say that on several occasions, they arrived at the hospital to find Tammy lying in her own excrement. "I'd go up there and find her in horrible condition," Luann says. "She'd tell me she hadn't seen a nurse for an hour."
"It stunk," remembers her father. "Her wound bandages and sheets would be soiled."
One family friend who visited Tammy frequently said she witnessed the same thing. What's worse, both parents and the family friend say, is that Tammy's call light--the button she could push to summon the nurse--was often out of her very limited reach.
Even Mayfield complained that he observed "soilage in the sheets" close to Tammy's surgical incision.
"That upset me," he said. "That's standard nursing care. . . . If they needed more nursing staff, get it."
Nursing records from the time show that nurses checked Tammy approximately every hour, and usually checked off a box on the records indicating that Tammy could reach the call light. Attorneys for the hospital say at times nurses may have checked Tammy as frequently as every 15 minutes.
"Tammy received excellent care by excellent nurses," said Joyce Niemec in a court deposition. Niemec is a registered nurse who treated Tammy.
Still, she said, at times the wound did become contaminated. "There are certain days that you probably are not able to do as many things for every patient as you would like to be able to do. That is reality."
It was also critical that Tammy maintain high levels of fluid and food intake. Mayfield ordered Tammy to receive between 1,300 and 1,500 cc of fluid a day--about 45 ounces. In the days after her surgery, however, nurses charted her intake at levels as low as 600 cc. They also said that Tammy frequently skipped meals.
Attorneys for the hospital, however, point to the fact that Tammy didn't show signs of being clinically dehydrated, and that Tammy often ate food brought in by a friend of the family.
"Every time [the friend] visited Tammy, she brought food and drink from McDonald's," attorneys argued, "of which Tammy partook. There is simply no evidence that she was dehydrated or malnourished while at Phoenix Children's Hospital."
Tammy was still in the hospital a week after her second surgery--when Mayfield said an infection was most likely to develop--when a nurse noted that part of Tammy's surgical incision wasn't healing properly. The area, which she described as "gaping," was about a quarter-inch in size. She documented that she observed a "purulent drainage"--pus--coming from the wound.
On a later check, a hospital intern also noted purulent drainage coming from the same part of Tammy's wound.
While without tests it was impossible to tell whether it came from a surface infection or a deep-wound infection, the drainage was a potentially ominous sign.
But preparation for Tammy's discharge from the hospital was already under way. And by the following day, September 7, after three weeks in the hospital, Tammy was eager to go home.
@body:Mayfield, too, was eager to get Tammy home. He was leaving the country the next day.
In Mayfield's judgment, the area was not healing properly in part because Tammy had poor skin. He did not believe it was serious.
"Sort of like when you cut your finger a little bit or scratch your finger, you may have developed a little purulence on the top," he said.
Mayfield prescribed Betadine, a topical surgical dressing, to help prevent infection. He planned to see Tammy in two or three weeks to check her progress. He ordered a home-health evaluation. And then he signed Tammy's discharge papers.
But, "in his zeal to get out of the country," the Gentrys' attorney Ray Slomski charges, "Mayfield left before his job was done."
The surgeon never asked either the nurse or intern why they described the drainage as "purulent," or how much pus they had observed coming out of the wound. He didn't order a wound culture to determine what, if any, bacteria were inside.
He didn't order a follow-up visit during his absence to determine if the drainage was the body's normal healing process or a sign of an infection, or to see if the Betadine was working.
Tammy left the hospital late that evening. CIGNA had an ambulance waiting to take her home. No one in Tammy's family spoke with Mayfield that day; Luann says she didn't even know the surgeon was leaving town.
"It was a shock," she says of the discharge. Tammy's home-health nurse would later record that Tammy was "discharged unexpectedly."
From then on, Tammy's condition would get much, much worse.
@body:When Mayfield ordered the home-health evaluation, he later said he expected a nurse to visit Tammy every other day, if not every day.
The family wanted someone to see Tammy daily, too. Her wound dressing required changing four times a day, but Luann--the only one skilled in treating her daughter--couldn't get home during a three-hour period in the middle of the day. And no one else in the family was available during those hours.
But Luann soon learned that without a specific order from a physician, CIGNA would allow daily nursing visits only to terminally ill patients.
CIGNA would authorize only two visits a week. A patient-care coordinator says CIGNA made repeated attempts to reach Mayfield on his way out of the country to determine the level of care Tammy needed. Mayfield denies that. He says he always wore a beeper, and his nurse kept normal office hours.
Luann ultimately hired a family friend, a nurse, to look after Tammy at midday. But he wasn't qualified to provide the postoperative care she needed.
Not only were nursing visits not frequent enough, but Betty Boesen, a registered nurse assigned to the Gentry family, admitted she had virtually no information on Tammy or her condition. She didn't know of Tammy's high risk for a deep-wound infection. She didn't know of the pus discovered at the hospital.
When Boesen visited the Gentrys' north Phoenix home on Thursday, September 8, 1988--a day after Tammy left the hospital--only Tammy's grandmother was there to greet the nurse. Boesen checked Tammy's vital signs, noting a temperature of 99.6.
She did not check the wound. She says Tammy's grandmother, who was watching Tammy when Boesen arrived, told her not to check it because Luann had recently changed the dressing.
But Luann says that's unlikely. "This was not her first surgery," she says. "We're not going to say, 'Don't touch my daughter.'"
Boesen, though, had little way of knowing what to do. On a form she later filled out after seeing Tammy, Boesen complained that there was "no discharge plan . . . no written orders for care."
So Boesen began to figure out Tammy's needs on her own. She called a CIGNA doctor at the hospital, but the doctor didn't know enough about Tammy to make an assessment. She tried to call F. Gerald Figgs, Tammy's primary doctor, but he was gone until Monday, September 12. She later noted that it was "difficult to find [a] CIGNA M.D. to take responsibility."
On Saturday, September 10, the drainage from Tammy's wound was now cloudy. Tammy's diarrhea was starting again, and Tammy had no appetite. Her temperature was still high. Luann called Figgs' nurse, who told her to watch Tammy closely.
By Monday, Tammy had begun to break out in cold sweats; her temperature had risen to 103 degrees over the weekend. More ominously, the pus coming out of her wound, which soaked the bandages, had thickened and begun to smell. And the pus now had a green tint.
The infection that would take Tammy's life had apparently set in. But it would be days before Tammy would go back to the hospital.
Luann called Mayfield's office; his nurse told her to call Figgs, because it would be difficult to get an authorization. Figgs told Luann to bring Tammy over right away.
Figgs, a pediatrician, was by no means an expert in assessing a patient who had just had major spinal surgery; in fact, he had never treated a patient in the stage of recovery Tammy was in.
Even so, his nurse did not document a complete history of Tammy's symptoms, such as how long the drainage had taken place or how long Tammy had a fever. Figgs says he wasn't aware of that crucial information, even though Luann insists she told him. Even Figgs admitted he should have asked those questions himself.
Figgs, considered a primary care doctor, didn't think Tammy needed to go back to the hospital. He didn't refer her to a specialist, such as an orthopedic surgeon, to make that decision.
Instead, Figgs prescribed Augmentin, an antibiotic Tammy had taken previously. He figured Tammy had some sort of infection, so he took cultures of her urine and the wound, noting that it was "oozing."
Then he sent her home.
Both Mayfield's nurse and CIGNA's home nurse Boesen would look at Tammy at different times that week. Luann even said she offered to pay out of her pocket to see Dr. William Li, the physician covering for Mayfield while he was out of town. But neither nurse told Luann to do anything more than call if there was a drastic change in Tammy's condition.
Boesen and Figgs talked Monday, but Boesen didn't communicate any of Tammy's symptoms to Figgs. In that conversation, they tried to determine how often a nurse could see Tammy. Boesen says Figgs told her that he would authorize only two visits a week. Figgs says he let Boesen make the decision.
For Tammy, it didn't matter who made the decision. She continued to get worse.
Luann remembers calling CIGNA six times over the next few days to find out the results of her daughter's cultures. She learned nothing.
The lab had completed a culture by Tuesday, the day after Figgs ordered it. But the results didn't make it back to Figgs' office until Thursday.
While it's not uncommon for labs to analyze results for more than 24 hours in order to allow bacteria to grow, no one in Figgs' office sought the preliminary findings.
The results revealed that Tammy's infection was resistant to the antibiotic Figgs prescribed. They also showed the presence of a bacteria most commonly found in stools.
But Tammy would take the drug for three days. By Thursday, CIGNA finally told Luann that Tammy would need a new prescription.
That evening, when Luann went to change Tammy's wound dressing, a half a cup of pus drained out. "Her back exploded," her mother says. Luann took Tammy to the emergency room.
They arrived, she says, then waited for an authorization that would allow doctors to proceed. Doctors then surgically debrided the wound, an aggressive cleanup procedure. Within the next few weeks, Tammy would undergo several similar surgeries, all to clean the wound.
But it was too late. By the time Mayfield returned from Yugoslavia, Tammy was getting weaker and weaker. She eventually developed sepsis, a poisoning of the blood, and then ARDS, Adult Respiratory Distress Syndrome.
All her major organs failed, and she had no chance to survive.
Her parents finally decided to pull the plug on her respirator on October 23, 1988.
Tammy's last words to her father were, "Take care of Mommy."
@body:In the Gentrys' modest home in Glendale, in a dimly lighted living room where there are many memories of Tammy, Jerry and Luann Gentry reflect on what they've gone through. Luann's memory for detail, particularly concerning her only daughter, is remarkable: She recalls dates and information as if her daughter had died last week--not four and a half years ago.
Luann Gentry didn't accept her daughter's impending death until the day the hospital took Tammy off the respirator. Luann had grown used to doctors warning that her daughter wouldn't make it, and she couldn't believe her daughter would go this time.
"Tammy held on tight for life until the last day," Luann says. "I can't measure what I've lost. It felt like my heart was tore out."
In January 1989, CIGNA sent the Gentrys a letter canceling their insurance because, it read, Jerry Gentry had never gotten treatment for alcoholism. Noting that Fireman's Fund had terminated its contract with CIGNA a month earlier, anyway, the letter said, "CIGNA Healthplan considers Mr. Gentry ineligible for future membership.
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