"Jackson Memorial is one of the finest hospitals in the United States," said Tina East, sitting at her dining room table in southwest Miami, surrounded by her seven children. "Dr. Chandler is a wonderful doctor. I don't want one thing said about him. He was absolutely distraught. He was a basket case; so were the nurses."
She was talking about the events of March 1, when her husband, retired photographer Bob East, was accidentally injected during cancer surgery with a toxic chemical instead of spinal fluid. East, brain dead since the injection, died Wednesday at Jackson Memorial Hospital when he was taken off a respirator.
Dr. James Ryan Chandler is an old friend of the family, East's doctor for nine years. He acknowledges that he has lost "a good bit of sleep" since the mistake occurred. His chief assistant during the operation. Dr. Frank Kronberg, is "devastated," Chandler said. ". . . It's been hard for him to carry on this week -- and for me, too.
"Everyone in that operating room, and even some who were not present, could have prevented it," Chandler said. "There is no one who could not say, 'I could have prevented it all by myself.' "
East's children are painfully aware of that. "It's gross negligence," said son Patrick, 27.
"The whole system broke down," said son Kelly, 26.
"It's standard procedure that if you find something in an unmarked bottle in an operating room, you throw it away," said daughter Ann Elizabeth, 22, a nurse.
A week later, most of the tragic story is public knowledge.
"We ask the public for support," said Fred Crowell, president of the Public Health Trust, which operates the hospital for the Dade County commissioners. "We seek publicity when we do something we think is good, so when something goes wrong, it's our obligation to say so quickly and completely."
Hospital administrator George W. Hill said he met with East's family the day he died and told them he wanted to negotiate an early out-of-court settlement.
Here is a chronology, compiled from interviews by Hill and reporters Baker of The Washington Post and Steve Sternberg of The Miami Herald, of the events that led to East's death:
7:35 a.m. -- East was wheeled into Operating Room 17 of Jackson Memorial Hospital for surgery that included removal of his cancerous right eye and much of the surrounding bone. He had arranged to donate the eye to research at the adjacent Bascom Palmer Eye Institute, like the hospital a part of the University of Miami Medical School complex.
Before 10 a.m. -- Chandler, chief of the hospital's department of otolaryngology (head and neck surgery), and head of that department at the medical school, asked an anesthesiologist to remove 50 cubic centimeters of cerebrospinal fluid from East.
Chandler said that while some surgeons do not remove spinal fluid, he always does "to make room inside the head to perform the necessary manipulations." The fluid was left in a capped syringe, to be reinjected later.
10 a.m. -- Chandler, assisted by Kronberg, chief resident, and Dr. Lawrence Burns, a surgical resident, made the first incision. Also participating were Dr. Anthony Gyamfi, an anesthesiologist; Dr. Maimona Ghows, an anesthesiologist resident, and several nurses, including Norma Anderson.
10:30 a.m. -- Dr. Allan Slomovic, an ophthalmology fellow at the eye institute, walked across the street to Jackson Memorial.
Slomovic's supplies for taking the eye to Bascom Palmer included a pathology specimen bottle, about half the size of a baby-food jar, filled with 35 cubic centimeters of glutaraldehyde, a preservative chemical similiar to, but stronger than, formaldehyde.
The specimen bottles, which have a plastic cap, often perspire or leak, Slomovic said. For that reason, and because glutaraldehyde has such a strong odor, Slimovic had placed the bottle in a nonsterile surgical glove, which he had tied in a knot.
Slimovic introduced himself to the two resident surgeons (Chandler was out of the room at the time). One told Slimovic his services would not be needed before 2:30 and that he would be called.
Slimovic said he also introduced himself to Anderson, the charge nurse.
Slimovic recalls that the meeting occurred in the operating room and that Anderson told him to put the glove and his sterilized tray on a table near the door. Among other items on the table's two shelves, he said, was a plastic skull apparently used as a teaching device.
Anderson's recollection is different. She told Hill, who is investigating the incident for the hospital, that she met Slimovic, who was empty-handed, in the scrub room, as he left the operating room. After exchanging introductions, she said she asked the ophthalmologist, "Do you need anything to perform your procedure?" and that he answered, "No, I brought my own" equipment.
Noon -- Ghows, the anesthesiologist, took a 30-minute lunch break, and was relieved by Maria Harewood, a nurse anesthesiologist.
12:15 p.m. -- Nurse Anderson returned to operating room, walked to table, held up the bottle from the knotted glove and asked, "What's this?"
"CSF [cerebrospinal fluid]," replied one of the surgeons, apparently Burns. "Give it to the anesthesiologists." Anderson carried the glove and bottle to another tray, where Harewood, having heard the surgeon's instruction, peeled off a "spinal fluid" label from a sheet of premarked labels and pasted it on the bottle.
12:30 p.m. -- Ghows returned, and Harwood told her, "We have additional fluid."
3:30 p.m. -- Ghows, needed in another operation, was replaced by nurse anesthesiologist Janet Laubenmann.
4:30 p.m. -- Surgeons called for the spinal fluid to be put back into the patient. Laubenmann attached a syringe to the labeled bottle.
4:45 p.m. -- Gyamfi, recently returned from a break, inserted the capped syringe, then the syringe that had been in the bottle, into a catheter that had been in East's spine since the start of the operation.
4:50 p.m. -- East's vital signs dropped quickly, prompting Gyamfi to peer over the anesthesiology curtain to see if surgeons had done something to precipitate the latest nose dive in a pattern than had looked like a roller-coaster much of the day. The surgeons, working on East's face, did not appear alarmed.
5 p.m. -- Chandler asked that Slomovic be called and told to return to the operating room.
5:15 p.m. -- Slomovic reentered the operating room and found the eye, with some cancerous facial tissue, in a container on the table, along with his tray, "exactly where I left it."
Slomovic noticed that his glove and bottle were not there, so as he prepared the eye for the trip to his institute, he asked nurse Anderson, "Where is my fixative gluteraldehyde ?"
With that question, for the first time, the operating room team realized there had been, in the words of Chandler, "a bizarre, tragic mistake."
"We froze," recalled surgeon Kronberg. "I was petrified."
"Oh my God, oh my God," screamed anesthesiologist Gyamfi.