KAMLOOPS, B.C. - A woman recovering from spinal neck surgery in Royal Inland Hospital asphyxiated while hospital staff frantically searched for equipment to resuscitate her, says a coroner's report.
Attempts to perform CPR on Jill Olsen were hindered twice because of problems locating instruments and because nurses were not aware that some equipment had been replaced with a new model, coroner Elaine Woods said.
Olsen, 46, died in Royal Inland in June 2001, a month after undergoing surgery for a spinal fracture.
After the surgery, doctors placed Olsen in a cervical brace. She was transferred to a room on the seventh floor, where doctors reported she appeared to have no post-operative problems.
At about 10 p.m. on June 18, a nurse administered morphine to Olsen, who was complaining of a sore throat. Within 20 minutes of the shot, Olsen reported breathing problems.
The nurse noticed Olsen's neck had become swollen and believed she may have suffered an allergic reaction to the morphine. Within minutes Olsen stopped breathing.
A team of hospital staff rushed in, including two respiratory therapists, a neurosurgeon and an emergency room physician, to resuscitate her.
The staff brought a crash cart, which contains emergency equipment.
The emergency room doctor twice tried to force a breathing tube down
Olsen's throat to assist the resuscitation but was unsuccessful because of the swelling.
Olsen went into full respiratory arrest and doctors began cardiopulmonary resuscitation but had difficulty because of the brace around her head, neck and chest.
They called for a wrench from the operating room to remove the brace, because the wrench on the crash cart did not fit. But the brace didn't require a wrench because it was the type that can be easily unsnapped.
The emergency room physician searched the crash cart for a cricothyroidotomy kit - instruments that would allow doctors to cut open Olsen's throat to allow her to breath.
He couldn't find the kit so one had to be brought from the ground-floor emergency room.
It was later discovered that the crash cart cricothyroidotomy kit was buried under other equipment.
Doctors eventually removed the brace and were able to establish an airway, however, Olsen had already suffered irreversible brain damage and died.