Pubdate: Sat, 11 Dec 2004
Source: Washington Post (DC)
Copyright: 2004 The Washington Post Company
Contact:  http://www.washingtonpost.com/
Details: http://www.mapinc.org/media/491
Author: Colbert I. King
Bookmark: http://www.mapinc.org/people/Magbie (Jonathan Magbie)
Bookmark: http://www.mapinc.org/mmj.htm (Cannabis - Medicinal)

MISSING ANSWERS ABOUT JONATHAN MAGBIE

The first thing you notice when you read the D.C. Health Department's
report into the death of 27-year-old quadriplegic Jonathan Magbie is
that several critical pieces of information have been blacked out. The
second thing that becomes obvious is that while the Health Department
correctly points an accusing finger at Greater Southeast Community
Hospital for giving Magbie substandard care, the report gives the
medical staff at the Corrections Department a pass, even though the
jail's doctors failed to make it clear to the hospital that Magbie
could not be properly cared for at the Correctional Treatment
Facility. Third, the report raises as many questions as it answers.
And finally, you can't help wishing that Superior Court Judge Judith
Retchin would read the report too, because there is no way on earth
that a human being in Magbie's condition, and a first-time offender
found guilty of simple possession of marijuana, should have been sent
to a place such as the D.C. jail.

This week I turned to two sets of practiced eyes to review the Health
Department's report. These health experts -- one in Washington, the
other in Virginia -- reached similar conclusions about the quality of
care provided at Greater Southeast. It was poor. But they also said
that a failure of communication between the hospital and the jail
contributed to the tragedy, as did the decision to incarcerate him in
the first place.

Now for the report.

Let's start with salient aspects of Magbie's physical state in the
days immediately preceding and at the time of his death, which
occurred Sept. 24 while he was under the jurisdiction of the
Department of Corrections.

On Sept. 20 Retchin sent to jail a man who had a high spinal cord
disruption leading to no -- or limited -- use of his arms and no use
of his legs. He had a permanent tracheotomy; was ventilator-dependent
at least part of the time, especially when tired or sleeping; had
partial diaphragm paralysis requiring the use of a diaphragm pacer;
had a permanent indwelling stomach tube and a permanent indwelling
urinary catheter, and contracture of the muscles and tendons.

What other conditions were present at the time of death?

Magbie had heart disease, asthma, chronic obstructive lung disease,
low blood pressure, low blood sugar and pressure (or bed) sores. He
also had a probable urinary tract infection leading to sepsis (or the
absorption of microorganisms into the bloodstream), and probable
pneumonia in his left lung.

Magbie was severely ill when he was released from the hospital and
returned to the Corrections Department on Sept. 21. According to the
report, his white blood count was abnormal -- but the result was
blacked out. Rale and wheezing -- a possible indicator of asthma,
pneumonia or heart failure -- had been heard during his hospital
examination. But the report did not include any lab results or the
result of a portable chest X-ray that Magbie had been given.

The Health Department was also silent on why the initial plan to admit
Magbie to the hospital on Sept. 21 was changed to discharge him back
to the Corrections Department. Also unanswered is the question of
whether Magbie's problems, as documented in the hospital's emergency
department on Sept. 21, had been fully disclosed to Corrections
Department medical staff -- and if not, why. And if the Corrections
Department had been informed, why did it take him back? The Health
Department report did not address those critical questions.

There are other mysteries, too.

On Sept. 24, the day he died, Magbie was found unresponsive at the
jail and was returned to the hospital's emergency room and given lab
and X-ray tests. But the results of the chest X-ray, urine toxicity
test and white blood count were blacked out in the Health Department
report. Part of the urinalysis was blacked out, too. Why? Did the
chest X-ray and white blood count show he had significant pneumonia?

And why was the urine drug screen result also blacked out? A possible
clue: Page 11 of the report contains this entry at the time of his
second and final admission to Greater Southeast on Sept. 24: "1:20 pm:
Disposition time: Clinical impression: Altered mental status,
Multi-substance abuse, Pneumonia, Urinary tract infection-Urospesis."

"Multi-substance abuse"? Yes, drugs. Magbie, the report shows, was
given Narcan, which is a reversal agent for narcotics.

Which raises the question: What kind of recent narcotic substance
would Magbie have had in his system, since at the time of the test he
had already been in the custody of the Corrections Department for four
days? As a quadriplegic, Magbie surely couldn't have taken anything by
himself. There are no answers in the Health Department report.

Finally, there's the cause of death. The chief medical examiner
attributed it to dislodgement of Magbie's tube. Who dislodged it, when
and where? And what happened to the inner cannula, the device to be
connected to a tracheotomy tube that helps a patient breathe? The
report doesn't say, except to note that when emergency medical
services staffers were ready to transport Magbie to the hospital on
the morning of Sept. 24, "the EMS could not connect the oxygen to the
tracheotomy tube, it would not connect. The [Correctional Treatment
Facility's chief medical officer] stated he cut some tubing from
another product and attached the tubing into the tracheotomy so the
patient could receive oxygen." At that point, Magbie was unconscious
at the jail and the inner cannula tube was missing.

And the Health Department considers this case closed?
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MAP posted-by: Richard Lake