Communications at the hospital break down, and a teen-age girl dies

THE BALTIMORE SUN

At the wake, some well-meaning friends, not knowing what to say, told Mark and Debbie Troch their daughter had died because "it was her time." Though Mark Troch understood how difficult it is for mourners to express their sympathy for parents who have lost a child, he rejected the sentiment. "We lost our daughter," he would say after the funeral, "but we know it wasn't her time to die."

It might never be possible to convince him or his wife otherwise.

The questions surrounding their daughter's death will hammer at the Troches' hearts and minds every time they recall the 13 1/2 hours between 4:30 p.m., Thursday, April 16 and 6 a.m., Friday, April 17. That span of time began with an accidental injury to their 13-year-old daughter, Tiffany, and ended with her death, the cause officially listed as cardiac arrest.

Every time the Troches think about those hours, they wonder whether enough was done at St. Joseph Hospital to save their daughter's life. Apparently, the Troches are not the only people who are trying to get complete information about the hospital's handling of the case. A hospital spokeswoman says a review committee at St. Joseph, headed by its chief operating officer, Dr. Robert Mahon, is conducting an investigation, standard procedure when questions are raised about treatment. Beyond that statement, hospital officials will not comment on the specifics of the case.

Debbie and Mark Troch, however, decided to tell their story, and in excruciating detail, with the hope that their experience might provide warnings to other parents and children. This is how they remember it.

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That Thursday afternoon, Tiffany Troch, an honor student at Perry Hall Middle School, was at home in the Oakhurst development. Her mother thinks it was between 3:30 and 4 p.m. when Tiffany grabbed a granola bar, put on her jacket and asked permission to walk to a friend's house with another girl, Shannon Harris. Tiffany's destination was "just down the road and across the street."

"But," Debbie Troch said, "Tiffany and Shannon decided to detour through this wooded area. There's a rope in a tree there. Everyone calls it the Tarzan Rope. Everyone in Oakhurst knows about the place. It's in a tree at the top of a hill. Kids get a running start and then swing out on the rope over the hill, then swing back and jump off on level ground."

Tiffany, Shannon and Tiffany's 12-year-old brother, Marc, played on the rope. Tiffany locked her teeth around the granola bar while she took some swings. On what she had announced would be her last turn, Tiffany swung out over the hill. The rope started spinning. The granola bar slipped out of her mouth. Tiffany tried to catch it. She lost her grip. She fell, her mother estimated, about "8 1/2 or 9 feet" and landed on a small tree stump, hard against her stomach.

Once she managed to get home -- a neighborhood woman drove her there -- Tiffany confessed how she had been injured. "Mom," she said, "I was down at the Tarzan Rope."

Though Tiffany was in pain, mostly from her abdominal area, there were no cuts on her body.

"I checked Tiffy's stomach and noticed some swelling and it seemed warm," Debbie Troch said. "I said, 'That's it, we're not fooling around with this.' We took her to St. Joseph's Hospital. We didn't call 911. We thought all she needed was an X-ray. My husband and I drove her there. We got her there at 5 p.m. We left our house about 25 minutes to 5."

Tiffany walked from her parents' car to the emergency room of the Towson hospital.

The Troches hoped for the best, of course -- nothing serious, no internal bleeding, just a bad bruise. Whatever it was, they believed, the hospital would take care of it. They had done their duty as parents.

A triage nurse examined Tiffany, helped her into a wheelchair and sent her to the emergency room, where a staff doctor examined her. The Troches said the emergency room was not crowded on that Holy Thursday before Easter.

The emergency room doctor suspected internal bleeding, with possible damage to the spleen, abdominal wall or the liver. Tiffany's blood pressure was stable, but her heart rate was faster than normal. Debbie Troch said she was told this meant "the body was being compensated for blood loss."

"We were under the impression there was going to be an operation," Debbie Troch says. "We were told that Tiffany needed a CAT scan because that would give a better view of the area. . . . I was with her the whole time while she [lay] there in the emergency room. She was conscious the whole time."

But the whole time, Debbie Troch was becoming increasingly nervous about her daughter's condition. As the clock ticked away, the questions started forming in her mind: Did she and her husband make a mistake in bringing Tiffany to St. Joseph instead of having her taken by ambulance to a shock-trauma center? If she had suffered an injury to an organ, which one? Would surgery be needed? If so, when?

Finally, Tiffany got the CAT scan. Debbie and Mark Troch believe it was between 6:30 and 7 p.m. that the examination took place -- 90 minutes to two hours after Tiffany arrived in the emergency room.

"Why this took so long we still don't know," Debbie Troch says. "It seemed like we were waiting forever for the CAT scan. Tiffany said she was cold. They finally took her in for the CAT scan and suddenly, right in the middle of it, the door swung open and the technician running the CAT scan stopped everything and said, 'Get this girl in the OR [operating room] immediately, she has a lacerated liver!'

"I helped them put her back on the stretcher," Mark Troch says. "And they wheeled her back into the emergency room."

(A specialist in emergency medicine, not affiliated with St. Joseph, said in a separate interview that it is common for doctors to "watch and wait" in their treatment of lacerated livers. Two factors -- the liver's snug position in the body, and blood filling the tiny cavities around it -- create an internal pressure that can arrest hemorrhaging. Not every lacerated liver is remedied by surgery, the doctor said. But a patient needs to be carefully monitored for the slightest changes in condition. The body, the doctor said, is under tremendous stress as it compensates for the trauma to the liver. Emergency medical centers and shock-trauma units are best equipped to handle this type of injury, he added.)

The Troches say no suggestion was ever made by anyone at St. Joseph that Tiffany be moved to another hospital, even after the CAT scan confirmed the lacerated liver.

"Finally," Debbie Troch says, "a doctor in blue surgical gear came out to the emergency room. He had been doing an appendectomy on a pregnant woman. He was the only surgeon on duty. He came out and listened to Tiffany's stomach."

"He said that he thought a hematoma [a swelling of blood] was developing against Tiffany's liver and that that was keeping the liver from bleeding more," Mark Troch recalls.

"He said he wanted to call in another surgeon, a pediatric surgeon, to look at her," Debbie Troch says. "And he just said she should be monitored. . . . By now, Tiffany had olive-colored skin. And that surgeon, he just walked away. He went back to the other operation. . . . I was with Tiffany and she was getting worse. Her body stiffened. She was getting scared. I said, 'Try and calm yourself down.' I've been with two people who have passed away, and I know the look. But they were still telling me everything was fine."

After the surgeon left Tiffany's side, the emergency room doctor said, "I'm tired of hospital politics. Your daughter needs surgery now." Both the Troches remember hearing those exact words.

The emergency room doctor offered to call in another surgeon who lived near the hospital. In the meantime, a nurse started giving Tiffany blood transfusions.

When the second surgeon arrived -- the Troches believe it was within 30 minutes -- he calmly leaned to examine Tiffany with a stethoscope. He listened to her abdominal area. His demeanor changed radically in seconds.

Suddenly, the Troches say, the doctor was pulling off his sport coat, ripping back the privacy curtains in the emergency room and shouting commands to nurses. "They tore down the hall with Tiffany," Debbie Troch says. "And they threw me all the papers [consent forms]. I was dumbstruck."

"The doctor handed me his card and said, 'I'm going to try and save your daughter," Mark Troch says.

It was 8:20 p.m. -- the Troches know because they looked at a clock in the waiting room -- when surgery commenced. Three hours and 20 minutes had gone by since Tiffany Troch arrived in the St. Joseph Hospital emergency room. That's what angers the Troches -- the time that elapsed. One moment, Tiffany was being "monitored" under the orders of a surgeon, the next moment another doctor was rushing Tiffany into surgery. The Troches wonder if doctors responded fast enough, if St. Joseph made the proper diagnosis, if the first surgeon who examined Tiffany should have responded more aggressively.

"They were in surgery for two hours," Debbie Troch says. "The [second surgeon] told me they drained eight pints of blood from her abdomen."

"They had to give her eight pints of blood," Mark Troch says. "How many pints of blood in the human body? Eleven?" (Actually, there are about 10 pints of blood in the average adult.)

Tiffany was moved to a recovery room. The surgeon said she had stabilized.

"But we waited and waited and waited," Debbie Troch says. "I knew something was wrong. Three hours later, two nurses came out and said the doctor wanted to see me. We followed them. We spoke with the doctor. He had tears in his eyes. He said Tiffany was no longer bleeding internally, but there was another problem. He said she was suffering from "shock lung."

(The emergency medicine specialist consulted for this story said "shock lung" is not a common term, but one that suggests not one problem but a "cascade of problems." The cumulative effect of all problems associated with Tiffany's lacerated liver -- the seepage of blood, the buildup of fluids in her lung tissue, her increased heart rate, chemical reactions in her body -- would diminish the integrity of her blood vessels. Water leaks into areas where it should not be, and it creates a barrier between blood and oxygen.)

For several hours at St. Joseph, the surgeon who had operated on Tiffany Troch continued to work on her, trying several different treatments for "shock lung."

"Mrs. Troch, she's not responding," the doctor told Tiffany's mother. "I'm doing everything I can. I'm treating her as if she were my own daughter." Nothing worked.

Tiffany went into cardiac arrest and died just before 6 a.m., Good Friday, 13 hours from the time she arrived at St. Joseph.

"I wanted to talk to that [first] surgeon who had walked away from Tiffany earlier," Mark Troch says. "They got him on the phone for me after she died. He said, 'I thought the hematoma was developing. I told them [emergency room staff] to monitor her and, if there was any change, to call me. They never called. . . . Frankly, there was a breakdown in communication.' He said at no time, when he examined her, was my daughter in any danger. I said to him, 'Doctor, if my daughter has an internal injury, are you saying I shouldn't bring her to St. Joseph's?' And he said, 'Frankly, they should have sent her to Shock-Trauma.' "

Debbie Troch's father, James Hobbs, released his anger at the hospital after he learned his granddaughter had died. "What happened?" he barked at the attending surgeon. "There was a breakdown in communication," he was told.

The Troches say the emergency room doctor used the same phrase to describe what happened during the course of Tiffany's treatment. But what they meant by that -- a "breakdown in communication" with Tiffany's parents? among doctors? -- is not clear. Nor is it clear whether the doctors believed better communication would have changed the outcome.

The day after Tiffany died, her father spoke on the telephone with the chief of surgery at St. Joseph. Mark Troch says he was told the hospital already was conducting an investigation into the handling of Tiffany's injury, though Lori Vidil, the hospital's director of public relations, says the investigation was prompted after Tiffany's parents raised questions about her care.

Vidil says St. Joseph Hospital was "very sad" at the death of Tiffany Troch, but would not answer specific questions about the case, citing "patient confidentiality" and the fact that the Troches "have retained legal counsel." Bruce Ezrine, attorney for the parents, confirmed last week that he has requested the records of Tiffany's treatment from the hospital. The Troches, meanwhile, have buried their daughter. "You can't imagine, no one can imagine, how upset my husband and I are," Debbie Troch says. "We were helpless after we brought her to St. Joseph's. She was in their hands."

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