Government acting on coroner’s recommendations

Yukon's minister of health says his department is acting on the coroner's recommendations made following the death of a Carmacks woman.

Yukon’s minister of health says his department is acting on the coroner’s recommendations made following the death of a Carmacks woman.

Coroner Kirsten Macdonald made eight recommendations after 31-year-old Cynthia Blackjack died while being medevaced from Carmacks to the Whitehorse General Hospital.

“She said there are a few other things that might be improved. And we agree. There’s always things that can be improved, and that’s what we’re going to do,” said Doug Graham.

Blackjack was a familiar face at the Carmacks Health Centre. She called in with dental pain on Nov. 4 and 5, 2013.

After her death, a dental examination found 10 abscessed teeth and rampant tooth decay.

On Nov. 6 she was seen at the health centre and advised to try and get a ride to Whitehorse and come back if she couldn’t find anyone.

“The medical triage, assessment and management of Ms. Blackjack at the health centre in Carmacks November 4, 5 and 6 was reasonable given the presenting symptoms, medical and social history,” Macdonald said.

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.

It was decided she would be medevaced to Whitehorse. Her heart slowed down about 10 minutes before arriving at the hospital.

The cause of her death was ruled to be the failure of her liver and other organs.

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.

In her report, Macdonald lists a number of significant factors in Blackjack’s death. These include that the wrong IV tubing was brought for a blood transfusion and that the health centre’s suction machine did not work so Blackjack had to be suctioned manually.

The eight recommendations include that point-of-care blood testing be made available in rural communities and that health centres have functioning suction devices at all times.

“Yes, the first suction device they used didn’t work properly, but they have backups. So they immediately went to their backup. It worked properly and there was very, very little time lost,” Graham said.

The minister said staff in the communities have regularly-scheduled telehealth meetings. He said management will be highlighting the importance of the quality assurance checklist. That list instructs staff to check that all the equipment is working.

But when it comes to whether or not blood testing should be done in the communities, Graham said that’s something that will take time to look into. It’s likely an expensive proposition, and there may be problems when it comes to the ongoing skilled staff that would be needed, he said.

“We’ll have to do an evaluation and the department is in that process right now. We’re going to take a look at it, but we’re not going to rush out and do it in all community health centres.”

Similar to the issues with the suction device, the wrong tubing for the blood transfusion was replaced quickly, Graham said.

“The first tubing that they took was incorrect. But again, they have backup systems. So again, there was a short delay but they did have the correct equipment necessary.”

In Macdonald’s report, she points out that “the intubation of Ms. Blackjack was delayed because there was a lack of pressure oxygen to attach to the ventilator at the heath centre, and by failure of the first ventilator tubing circuit.”

A second system was set up, and worked.

Graham said health centres don’t have ventilators.

“The only thing I can think of is that’s part of the equipment that the EMS folks brought with them because we don’t have ventilators at health centres,” he said.

A call to Macdonald for clarification was not returned in time for today’s deadline.

Graham said Yukon EMS is currently reviewing its practices.

Anyone involved with a medevac is properly trained, he said.

“The money is there to provide that education and to the best of our knowledge, the people involved with this one were all skilled, trained people”

Contact Ashley Joannou at

ashleyj@yukon-news.com

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