Parental Questions Didn't Halt Fatal Dose

Pittsburgh Post-Gazette (PA) November 13, 1993 Section: LOCAL Edition: SOONER Page: A-1

Steve Twedt, Post-Gazette Staff Writer

Before a fatal overdose of salt was added to Zackery Gutierrez's feeding tube at Children's Hospital this summer, both of Zackery's parents questioned the order, according to a lawsuit filed yesterday.

But a nurse assured them the salt was necessary for the young transplant recipient, and she told Eugene and Betty Gutierrez that she had questioned a physician about it and the doctor told her the order was appropriate, the lawsuit says.

On Aug. 24, Zackery, 3, who was nearing the end of a short hospital stay for dehydration, received nearly two tablespoons of table salt -- several times more than the normal dose -- through a tube connected to his intestine.

About an hour later, he began to vomit, had convulsions and then lapsed into a coma.

Doctors tried to flush the salt from his system and eventually performed emergency surgery to relieve pressure caused by swelling in his brain. But it was too late to prevent irreversible brain damage. Zackery never regained consciousness, and his mechanical life-support equipment was removed in the early hours of Aug. 26.

The lawsuit, filed in Allegheny County Common Pleas Court by attorney Jerry Meyers on behalf of Zackery's parents, asks for damages in excess of $25,000. Named as defendants in addition to the hospital are Deborah Beatty, Dr. Farrukh Khan and Denise Booher.

The lawsuit identifies Beatty as the physician's assistant who wrote the order for salt, Khan as the transplant surgeon fellow who cosigned the order, and Booher as the nurse who added the salt. Children's Hospital officials declined to comment on the suit.

Zackery, born with a condition known as short-gut syndrome that left him unable to digest food, had moved with his family to Pittsburgh from San Diego last year to await a life-saving transplant.

On June 2 he received a new liver and intestines at Children's and was discharged Aug. 10. He was readmitted Aug. 23 after showing signs of dehydration. Information in the lawsuit and in sworn testimony during a coroner's inquest in August and September show that Zackery had a mild salt deficit for which he was treated with intravenous fluids after he was admitted.

By Aug. 24, according to county Coroner Dr. Joshua A. Perper, his sodium levels were near normal. Hospital staff and others described Zackery as awake and playful the morning of Aug. 24. It was then, according to testimony at the inquest, that Beatty wrote a treatment order for Zackery that included adding two tablespoons of salt to his tube feeding.

Because Beatty is a physician's assistant, the order had to be cosigned by a doctor before it was carried out. According to testimony at the coroner's inquest, the order was put in an order box and a charge nurse then paged Khan, who was in another unit. Khan testified that the order was mixed in with others and that he cosigned it without reading the part calling for two tablespoons of salt.

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