Statement From Shirley Barker, RN, BSN:
As nurses, we’re expected to be the “advocate” for our patients. Unfortunately, we are often stifled from fulfilling that role. I retired in 2013. During my 30 years of nursing for Los Angeles County, I was aware of medical errors that led to harm and even death for patients in the hospitals where I worked. Yet, hospital policy did not permit nurses to discuss errors with patients and families.
Q & A:
In the following Q & A, Nurse Barker recalls the circumstances surrounding the death of Nelson Yamamoto, a patient she cared for in a Surgical ICU. Mr. Yamamoto was a Los Angeles Sheriff’s Deputy shot by a murder suspect in Los Angeles in 1992. Tragically, he died two days later in the ICU. The hospital’s Medical Director, Dr. James Haughton III, said: “Yamamoto had lost so much blood by the time he underwent surgery that, even with a transfusion of more than 25 pints, doctors could not revive him.” Not true, according to the Los Angeles District Attorney. The DA, after a lengthy investigation along with the Medical Board of California, determined that medication errors caused Nelson Yamamoto’s death. The Medical Director had participated in a cover-up.
(The following interview with Nurse Barker was edited for clarity and brevity.)
Sheriff’s Deputy Shot By Murder Suspect
By Bob Aller: November 6, 2020
On Sunday evening, March 29, 1992, Los Angeles County Sheriff’s Deputy Nelson Yamamoto and two fellow officers responded to a complaint that someone had been threatened by a “man with a gun.” Upon arrival, one of the officers observed three men with handguns in a garage converted into living quarters. The deputy ordered the men out of the garage. Two men ran out firing at the officers as they tried to escape. Deputy Yamamoto returned fire. A suspect, Isidoro Ibarra, 30, died in the gunfight. However, Officer Yamamoto suffered potentially fatal wounds from .357 shots in the abdomen and shoulder. He was rushed by ambulance to the nearest trauma center, the Martin Luther King Jr./Drew Medical Center, a Los Angeles County 480-bed teaching hospital located in the Watts area of Los Angeles.
That night Mr. Yamamoto received extensive trauma surgery. It was reported that “surgeons worked nearly eight hours in two consecutive operations to repair his colon and intestine, and to tie off blood vessels in his pelvic area and thigh.” After surgery, he was moved to the 12-patient Surgical ICU, an open area with curtains separating patients. Nurse Barker worked in the ICU.
Q. Could you describe Mr. Yamamoto’s condition?
A. Nurse Barker: My weekend was Saturday through Monday. I came onto my Tuesday 12-hour shift at 7 am to care for Mr. Yamamoto. He was my only patient. I paid close attention to the nuances of his condition. I remember reviewing his flow sheets from the Sunday night surgery. He had experienced both hemorrhagic and hypovolemic shock from the gunshots. Nelson had been on a ventilator with multiple drips for just over 40 hours. He was making good progress. Epinephrine had kept his blood pressure in safe limits, around 140 over 80. Pretty decent for the circumstances.
Even though Mr. Yamamoto suffered severe shock, he never lost perfusion to the brain. His pupils were not fixed or dilated. He was responding with a gag, with blinking, with squeezing people’s hands. In short, he was recovering. His response to stimuli and commands was evidence of his progress. The way he responded to visitors was another strong signal he was getting better.
Mr. Yamamoto’s parents and fiance regularly came into the room to see him during the course of the day. They shared their concerns with me.
Fellow officers also came to see Officer Yamamoto. During their visits, he would squeeze their hands. I slowed down the visits to give him some rest. His eyes were not fixed and dilated. He had a gag reflex. I would say to him, Mr. Yamamoto, “Can you hear me?” Though he couldn’t speak since he was on a ventilator, he would squeeze my hand and nod his head affirmatively.
Q. What happened when the Chief General Surgery Resident arrived?
A. Nurse Barker: Around 5 pm the Chief General Surgery Resident, Jonathan Heard, arrived at Mr. Yamamoto’s bedside with a first-year resident, Charles Jones. They both were in surgery with Mr. Yamamoto on Sunday night. We discussed the flow sheet, the trends in vital signs, the labs, the blood gasses, the urinary output. Though Mr. Yamamoto was still in critical condition, I described how he was clearly trending in the right direction.
Q: Did Dr. Heard alter Mr. Yamamoto’s medication regimen?
A. Nurse Barker: After I finished describing the patient’s status, Dr. Heard said he wanted to lower Nelson’s heart rate. He said he was going to administer the medication Verapamil. As I recall, Nelson’s heart rate was around 110. Only moderately high. Based on Nelson’s condition, I thought Dr. Heard’s plan to administer Verapamil was not a good idea. Nelson’s current medication, Epinephrine, was working well and his overall condition was improving.
Q. Did anyone object to Dr. Heard’s plan?
A. Nurse Barker: Dr. Jones, the first-year resident who was also standing at the bedside, spoke up: “I believe titrating down the Epinephrine drip would be best.” I completely agreed with Dr. Jones, hoping Dr. Heard would consider Dr. Jones’ opinion. Instead, Dr. Heard resented Dr. Jones’s comment. I recall he said: “Shut up, if you know so much, I wouldn’t be here.” That was a tense moment. I believe Dr. Heard meant he thought he was smarter than Dr. Jones.
I recall that Dr. Heard then sat down at the desk. He made a short phone call. Since our ICU was a noisy area with monitors beeping, phones ringing, staff talking, I could hear the sound of his voice but I didn’t hear what he said. It was very brief. I don’t know if he consulted with his attending or anyone else.
Dr. Heard then went ahead and pushed in the Verapamil with an IV. I started documenting vital signs so I would have a baseline to Nelson’s response to the Verapamil. However, there was little or no response.
As a resident, Dr. Heard would often consult with the Director of the ICU, Dr. Meade. I found it odd that he didn’t consult with Dr. Meade, who was also nearby in the ICU.
Q. What happened to Mr. Yamamoto’s chart?
A. Nurse Barker: After Mr. Yamamoto was declared dead I went to enter that information into the chart. But the chart was gone. I couldn’t find it anywhere. I paged Dr. Heard and asked: “Where’s the chart?”. “Oh,” he said. “I have it. I’ll bring it back.”
Taking the chart out of the room was concerning to me. We never let a chart leave the patient. Dr. Heard could have left the ICU and drafted a note and come back to make an entry. He didn’t do that. He took the whole chart. He might have consulted with others about the chart. I don’t know what transpired.
Q: What was Mr. Yamamoto’s family told?
A: Nurse Barker: When Dr. Heard returned to the ICU he said to me, “Do you want to go with me to tell the family?” Though I was devastated, I went with him.
In the hallway just outside the ICU, Dr. Heard informed the family that Nelson’s complications were so severe that he couldn’t make it. He told them we tried to revive him but he just didn’t make it. Mrs. Yamamoto was crying. Her husband was holding her up. His girlfriend was screaming and crying. I tried to console her. Other sheriff’s deputies standing nearby could sense what happened. I was shaken and upset. In a state of speechlessness, I went back to the ICU. For me, personally, the tragedy was devastating.
Q: Did you report the incident to an administrator?
A: Nurse Barker: I reported what happened to my Nurse Manager, Barbara Bundage. She was not present in the ICU when it happened. When she came over to me and asked what happened I told her exactly what happened.
Hospital Covered Up Cause of Death
The hospital’s Medical Director informed the press that Nelson Yamamoto’s death was due to gunshot wounds. The Autopsy Report from a Deputy Medical Examiner states the patient died from “multiple gunshot wounds.”
However, the toxicology report in the Autopsy omitted Epinephrine, Verapamil and Labetalol. These medications were administered just before Mr. Yamamoto’s death. According to a physician consulted by Hospital Watchdog, the Autopsy Report’s conclusion that “multiple gunshot wounds” constituted the “immediate cause” of death was reached without the required information for a toxicology report. This omission suggests the hospital may not have provided the medical examiner with critical chart notes and medical records. Alternatively, the medical examiner may have received that information but he made the decision to ignore it.
A Hero’s Funeral
An estimated 4,000 uniformed officers traveled from throughout Southern California to attend Mr. Yamamoto’s funeral with family and friends. They believed Nelson died from his gunshot wounds.
Nelson Yamamoto had been with the Sheriff’s Department for three years. He had been in the field for just two months. He held a degree in criminal justice, was a fitness devotee, and was engaged to be married to schoolteacher Michelle Tomi.
Days after Mr. Yamamoto’s death, a credible complaint was filed with the Sheriff’s Department. The complaint, perhaps submitted by another hospital employee, alleged Mr. Yamamoto did not die from gunshot wounds. What followed was an escalating investigation lasting three years. Three government agencies participated: the Los Angeles Sheriff’s Homicide Division, the Medical Board of California, and the Los Angeles County District Attorney.
Early in the investigation, doctors’ attorneys strongly objected to aggressive DA interviews, conducted without a lawyer present. To counter the doctors’ reluctance to testify, the DA empaneled a Criminal Grand Jury.
All the doctors and nurses involved in Mr. Yamamoto’s care, including Dr. Heard, Dr. Jones, and Nurse Shirley Barker, were subpoenaed.
A senior hospital physician was reportedly designated by the administration to manage this high-profile case as the attending. However, Dr. Rosalyn Sterling Scott took the 5th and would not testify. She denied she was the attending physician. She claimed there was a misunderstanding, she only helped out temporarily.
Q. Did anyone try to influence your grand jury testimony?
A. Nurse Barker: Yes. Shortly before my scheduled testimony, I was called into a meeting with hospital administrators. I found they were leaning towards omitting the fact that Labetalol was administered! When I insisted the drug was administered by Dr. Heard, they insisted it’s possible Dr. Jones administered it since he was a first-year resident! I was adamant. I said Dr. Jones opposed using Labetalol. It appeared that the administrators were trying to make Dr. Jones the “fall guy.” My recollection of events did not sit well with them.
I was asked: “You’ve worked here for many years. Why wouldn’t you administer the Labetalol?” I said, “It wasn’t appropriate considering the meds Nelson was already taking.” They asked, “Have you administered Labetalol in the past in the ICU?” I said, “Yes I have, but it was under different circumstances. In this case, Labetalol wasn’t appropriate.”
The administrators left the room for a few minutes. When they came back, I was told an attorney will attend the grand jury session and advise me on my testimony.
Q. Did an attorney advise you on what to say to the Grand Jury?
A. Nurse Barker: An attorney tried. I was standing outside the Grand Jury courtroom, waiting to be called. A man came up to me and said, “Are you, Shirley Barker?” I responded, “Yes.” He said he was an attorney for the County. I was expecting this encounter. He said, “I’d like to discuss what you’re going to say in your testimony.” I had thought about my response if anyone tried to sway my testimony. I was prepared: “I don’t want to discuss the case. I’m sticking with what I know. I don’t wanna talk to you!” The lawyer could tell I meant it. He walked away.
Soon I went in and testified before the Grand Jury to exactly what I observed in the ICU. I told them I believed the use of Labetalol caused Nelson’s death.
A few weeks later, Dr. Jones, the first-year resident, approached me in the ICU and gave me a hug. He thanked me for telling the truth. Since Dr. Jones had also testified before the Grand Jury, I thought he may have learned he had been targeted as the “fall guy.” But that didn’t happen.
District Attorney Report Issued in 1995
Finally, in July of 1995, the District Attorney’s office issued a 160-page report, concluding that Dr. Heard had administered a lethal combination of cardiac drugs to Mr. Yamamoto. One of the report’s medical experts claimed the deadly error could have been avoided by checking the standard physician’s reference manual.
In addition, the report revealed that “progress notes” had been found missing.
According to the LA Times, District Attorney Gil Garcetti concluded there was sufficient evidence to charge Dr. Heard with involuntary manslaughter. However, Mr. Garcetti chose not to file an action. He thought it was unlikely a jury would convict a physician in this case. Nevertheless, the California Medical Board did require competency testing for Dr. Heard. He passed the test.
King/Drew Hospital Closed Forever
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This is so sad and probably more common than we think. Why wasn’t this physician charged criminally? Why didn’t the family pursue it even though they had been through enough? Nurses are expected to find the physician’s medical errors and report back to him/her so they can fix it. Problem is, why aren’t the physicians held accountable? I feel they can do the least since they know the nurse can be the one blamed for their error. However, in this case the nurse was phenomenal! Kudos to her and all those nurses that are willing to stand up for their… Read more »