Wrong Injection Leaves Photographer in Coma

Photographer Bob East lay in a coma Tuesday, apparently brain dead after doctors accidentally injected a toxic preservative into his spine in what the head surgeon called “a tragic series of human errors.”

The substance, glutaraldehyde, was mistaken for spinal fluid taken from the patient earlier during an operation to remove a cancerous eye, said the surgeon, Dr. James Ryan Chandler.

East underwent the operation last Friday and was found to be brain dead Monday. East, a photographer who retired earlier this year after more than 30 years with the Miami Herald, was listed in very guarded condition at Jackson Memorial Hospital.

“I don’t know what should be done,” Chandler said Tuesday. “We’ve done what we can for Mr. East, which seems pitifully little.”

May Cut Life Support

Hospital officials said that, if another scan indicated no brain activity, the family and doctors would decide whether to turn off life supports.

“I know nobody did this on purpose,” said East’s wife, Tina. “It just fills me with such terrible rage. I think that people who take other people’s lives into their hands should be more careful.”

The mix-up was not discovered until an ophthalmologist, who had dropped off the toxic chemical in an unmarked bottle, returned to the operating room to retrieve it. The substance was to be used to preserve the cancerous eye tissue that East was donating to research, Chandler said.

The substance “was misidentified and then mislabeled and then was injected into the spinal column of Mr. East, thinking of course that the labeled material was spinal fluid,” Chandler said.

Irreversible Damage

Within seconds of the injection, the glutaraldehyde had traveled through the spinal fluid that bathes the brain and spine, destroying tissue and causing irreversible brain damage.

“It was preventable,” Chandler said. “It didn’t have to be. It was a tragic series of human errors. It is due to the errors of many--doctors, myself included, who somehow bypassed all the safeguards to prevent such an occurrence.

“I accept full responsibility,” he said.

The surgeon said spinal fluid is removed from patients in such operations and then reinjected after the procedure to check for leaks in protective brain covering, which is exposed during surgery.

George Hill, the hospital’s claims administrator, said disciplinary action would be taken if an internal investigation disclosed “gross negligence on someone’s part of a serious enough nature.”

“We can’t blame just one person,” Chandler said. “The doctor who brought the material into the operating room is just as much to blame as the person who didn’t label it properly or me as a surgeon for even allowing this to happen.”