Carmacks woman’s death spurs coroner’s recommendations

The coroner is calling for a review of how patients are medevaced from the communities to Whitehorse after the death of a Carmacks woman, Cynthia Blackjack.
 

The coroner is calling for a review of how patients are medevaced from the communities to Whitehorse after the death of a Carmacks woman.

Cynthia Blackjack called the Carmacks Health Centre for help with her dental pain on Nov. 4 and 5, 2013.

Backjack was seen by staff the next day, who tried to find her a ride to Whitehorse. She was given medication for nausea and pain, and told to come back if she could not find a ride on her own.

On Nov. 7, family called the health centre, saying Blackjack was disoriented and yelling out in pain. Blood was taken for tests, but the samples had to be sent to Whitehorse for analysis.

The results wouldn’t come back until after Blackjack died.

When the medevac team arrived to take the 31-year-old to Whitehorse, they brought blood for a transfusion, but the wrong type of tubing.

“The investigation revealed that in preparing for the medevac, IV tubing for the blood transfusion was obtained from a storage area in Whitehorse,” chief coroner Kirsten Macdonald writes in her report.

“An incorrect size of IV tubing had been inadvertently stocked together with the proper size for transfusion.”

The health centre’s ventilator wasn’t working properly and a second system had to be set up. That one worked fine.

The health centre’s suction device did not work and staff had to rely on a manual system.

Backjack was eventually airborne at 5:11 p.m. That’s six hours after staff decided to send her to Whitehorse.

“About 10 minutes prior to landing in Whitehorse Ms Blackjack became bradycardic. Bradycardia occurs when someone’s heart slows down,” Macdonald writes.

“Bradycardia can be a serious problem if the heart doesn’t pump enough oxygen-rich blood to the body. At 5:40 p.m. vital signs were lost and CPR was started.”

She was pronounced dead at 5:59 p.m.

The cause of death was multi-organ failure secondary to liver failure.

The pathologist speculated that Blackjack’s use of ibuprofen and acetaminophen on a regular basis for her dental pain, combined with chronic alcohol use, may have contributed to her liver failure.

A dental examination after her death found she had 10 abscessed teeth and rampant tooth decay.

Macdonald makes eight recommendations to the Yukon government.

These include that point-of-care blood testing be made available in rural communities and a review of the policies and procedures for transferring patients to Whitehorse.

Contact Ashley Joannou at ashleyj@yukon-news.com

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