An emergency room physician at Capitol Hill Hospital ordered a 52-year-old charity patient with pneumonia shited to another hospital last January despite vital signs that showed him critically ill and entering shock.
Moments after Benny Butler was carried into D.C. General Hospital's emergency room 12 blocks away, his heart stopped beating. He was resuscitated and six weeks later he was dead, never having regained consciousness.
The Butler case is the third known to have occurred since Thanksgiving in which a patient critically ill or injured was discharged from the Capitol Hill emergency room and was dead a short time later.
Informed of Butler's vital signs at the time of transfer-but not what hospital were involved-directors of emergency medicine at four major Washington hospitals said the patient should never have been moved.
"I can't conceive of transfering him out of the emergency room," said one doctor, unless "the hospital was on fire . . ."
Dr. Keith Manley, director of medical education at Capitol Hill, agreed in retrospect that the transfer was "inappropriate," but said "everybody makes bad judgments."
James McCallum, assistant administrator of Capitol Hill, said Butler "wouldn't have" been transferred had he had Medicaid coverage, which reimburses hospitals on a cost-of-treatment basis.
The patient, he said, was covered only by the city's medical charities program, which pays hospitals only $76 per day of the $225 to $350 per day cost of a hospital visit.
Butler was taken to Capitol Hill Jan. 20 by city fire department ambulance-which takes patients either to the nearest hospital or the one the patient requests-with blood pressure of 98 over 70, pulse of 144, respiration of 36 and a temperature of 101.8, which rose to 105 during his six hours in the hospital's emergency room.
Those signs indicate a patient "as seriously ill as somebody could be without bleeding," according to the director of emergency medicine at one of the city's major teaching hospitals.
Like every other physician interviewed, he said Butler's vital signs plus a chest X-ray indicating pneumonia in his right lung, showed him probably slipping into shock and far too ill to be moved anywhere but into an intensive care unit. Capitol Hill has such a unit.
"The guy was clearly very sick when he arrived, and he was clearly very sick when he left," said Capitol Hill's Manley during an interview yesterday. "With the (vital signs) , it's easy to say (the transfer) was inappropriate. Obviously."
According to Manley, who reviewed Butler's record for a reporter, the unemployed Southeast Washington resident came in to the hospital with a two week history of chest pain and cough. He had stomach pains and a fever of two weeks' duration."
Butler was given aspirin for his fever, a chest X-ray, intravenous fluids, and an EKG to measure the electrical activity of his heart. In addition, his blood was cultured to determine the cause of his infection, Manley was.
Manley said that Butler's EKG "showed just a rapid heart beat" but no irregularities in the heart's rhythm. When the results of the blood tests came back. Manley said, Butler was started on an antibiotic.
Each of the physicians interviewed said that, in addition to what was done for Butler at Capitol Hill, his blood gases should have been measured-as a way to monitor the efficiency of his breathing-and his urine output should have been measured.
Neither of these things was done, said Manley, who said the physician might have decided to give Butler oxygen had his blood gasses been monitored.
According to Manley, Butler continued to receive intraveneous fluids during his trip to D.C. General. However, sources at D.C. General said there is no indication in the records that Butler arrived with IV fluids. Such a fact would usually be noted, the sources said.
"He was in shock when he came over here," said a source at D.C. General, and "had pneumonia and an overwhelming infection. He arrested [his heart stopped] within five to 15 minutes of arriving. He was admitted to Medical Intensive Care immediately after being resuscitated.
"He definitely was not treated as aggressively [at Capitol Hill] as he knowledgeable physician.
Butler was in the D.C. General Medical Intensive Care Unit, comatose and on a respirator, until his death March 5.
According to his autopsy report, he "had severe bronchial pneumonia with lung abcesses" and multiple blood clots in the lungs, which may have been" the final cause of death, a source said.
"This man had a lot of evidence [available to Capitol Hill] to show he was very sick," said a D.C. General source. "Apparently he had a long history of alcohol abuse. All of these things together imply somebody whose cardiovascular status was quite critical."
Asked how the physician could have decided to transfer Butler from Capitol Hill, Manley said "everybody makes bad judgments. I can still remember the name of the first bad judgment I made." Butler's death, he said, was a "tragedy."
The Butler case comes to light at a time when Capitol Hill is already being closely watched by inspectors from the hospital licensing division of the District's Department of Human Resources.
The license of Capitol Hill's emergency room was downguarded to "provisional" status following reports last month of the death of a District man 55 minutes after the hospital discharged him as basically sound.
Doctors at Capitol Hill said Howard B. Smith, a 28-year-old security guard, was suffering from only three rib fractures, when in fact he had 10 rib fractures, a lacerated liver and lacerated adrenal grand and about two quarts of blood in his abdomen.
Following newspaper reports of the Smith case, D.C. Mayor Marion Barry put administrators of the city 12 private, acute care, hospitals on notice that in exchange for maintaining their tax-exempt status the city expects them to do their share to provide free care to the poor.
Las Saturday The Washington Post reported that a physician in Capitol Hill's emergency room last Thanksgiving pronounced 75-year-old John Henry Hall "sound as a silver dollar." Physicians at D.C. General the next morning found him suffering from acute dehydration and a possible bowel obstruction. He hadn't eated in at least four days.
Eight days after his admission to D.C. General John Henry Hall died of complications from a ruptured, gangrenous, gall bladder.
Both DHR inspectors and Capitol Hill's own investigators reached independent deteminations that the hospital mishandled the Smith case and should have kept smith for observation.
Officials at Capitol Hill said the Hall case was "borderline," but Dr. Stanford Roman, the medical director of D.C. General, said Hall was so dehydrated when admitted that his condition had to be evident when he was examined at Capitol Hill about 10 hours earlier.