36 Trial Lawyer • Fall 2023 Had facilities staff followed its safety protocol, the backup generator testing would have been delayed and Serkin would be alive. Instead of following safety protocol and communicating with the ER and OR, the facilities department proceeded with its monthly backup generator testing while Serkin was in the middle of a life-saving angioplasty procedure to insert a stent. When facilities cut the main hospital power to test the backup generators, Serkin’s surgeons had no warning and were forced to abort the procedure just as they were inserting the guide wire that would have led the stent to Serkin’s blocked artery. At that moment, the backup generators failed to start, and the Cath Lab lost power. Serkin’s surgeons were in the dark — literally. Fail safe failed One more fail safe remained that should have restored power to the Cath Lab and allowed Serkin’s surgeons to place the stent in his artery. Every cath lab and most surgical and ER departments must be equipped with an uninterrupted power supply (UPS). A UPS is an electrical apparatus meant to offer emergency power when all other sources of power fail. In the event that the main power fails, and the backup generators fail, the UPS is designed to kick in and restore power. But in Serkin’s case, the facilities department failed to test and replace the batteries that powered the UPS, and the UPS failed Serkin when he most needed it. The hospital’s multi-system failure ensured Serkin’s death. Only one of the three failed power systems was necessary for surgeons to save Serkin’s life. Combined with an egregious communication failure, Serkin was in the wrong place at the wrong time. This could have happened to anyone. The hospital Facilities Maintenance Impact Notification states: “Th[e] Harold Serkin died at OHSU when the hospital operating room lost power during a routine surgery to repair his heart. monthly generator test is our pledge to the…healthcare community that in the event of an electrical outage in patientcare areas, the quality and dependability of patient-care equipment will always be ready to meet your needs.” It is not lost on Serkin’s widow, Julia Serkin, and their children, that the very test designed to keep him safe and ensure the “quality and dependability of patientcare” caused his death. The hospital failed the surgeons who were trying to save Serkin’s life as well. The head of cardiology broke the news to Serkin’s family that he had passed. But they were fed an incomplete version of the events leading to Serkin’s death. At the time, Serkin’s family was not told why he died — they were told only that Serkin had died after suffering cardiac arrest during the procedure. Despite hospital fire alarms going off as a result of the power failure while Serkin’s family waited to hear the results of his surgery, the head of cardiology said nothing about power loss contributing to Serkin’s death. After Serkin’s death, Julia’s family never left her alone. Serkin was her soul mate, and Julia endured a profound and deep sadness. She spent much of the early days after Serkin’s death at home, just waiting for Serkin to walk through the door and come home. She was joined by Serkin’s dog Holly, who waited with Julia, expecting and hoping that Serkin would come home. The defense The hospital’s chief argument during this case was that Serkin was going to die anyway. Had he been lucky enough to survive the angioplasty procedure, the hospital argued, Serkin had a short life expectancy because of his ongoing cardiac complications. We presented the hospital with multiple peer reviewed studies suggesting that because Serkin had arrived to the hospital quickly and his vitals were strong (he was able to provide his informed consent to his procedure and was joking around about how long it would be until he could play ping-pong again), and because his procedure was nearly complete when the power cut, Serkin’s chances of surviving the procedure were between 72-87%. Those same studies, and others, suggested that Serkin was likely to have lived 5-10 more years without the need for further cardiac intervention. Had any one of the three safeguards not failed, Serkin had a good chance of meeting his Heart Surgery Gone Wrong Continued from p 35
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