Making a difference out of her memory
The disease that killed his daughter was discovered too late to properly fight it. That spurred a Dunedin man to try to make sure it doesn't happen to anyone else.
By JAMIE THOMPSON
Published August 21, 2005
DUNEDIN - One hour passed, and then another, and he was still awake, still alone, still thinking.
He paced quietly, walking from room to room. His wife was asleep upstairs, but Carl Flatley knew he would not sleep tonight.
And so he walked, and waited, and played it through his mind once again, every mistake, every horrible moment of it. He could still see her face: Help me, dad. Please.
He had spent three years reliving his daughter's last seven days. He knew what everyone did and failed to do. He knew it all now, but could do nothing.
He had tomorrow, at least. Come morning, he would walk into the courtroom for her malpractice trial. He dreaded reliving it all out loud. But the whole story, at least, would be told.
Maybe then, he could rest.
Erin Flatley told friends she was having mouth surgery.
The truth was too embarrassing. She didn't like to talk about it, not even with her father, who already had the procedure done twice: a hemorrhoidectomy.
Doctors said it wasn't essential, but Erin, 23, had been having pain.
Her mother drove her to Morton Plant Hospital on April 24, 2002. The surgery was uneventful. After six hours, the doctor sent Erin home with a prescription for Vicodin. She would hurt for a few days. Everyone had told her: It was minor surgery, with major pain.
The doctor reminded Erin and her mother that he was going out of town. If they had problems, they should call his covering surgeon. They also had an emergency number for the hospital.
They weren't worried.
What could go wrong?
They returned to the family home, a two-story on a quiet, shady street in Dunedin.
The Flatleys have lived there for 23 years.
Carl and Barbara started dating in the seventh grade. He went to dental school. She got her master's degree in education. First came Jennifer, then Erin, then John. Dr. Flatley owned four dental practices. His wife stayed home with the kids.
Dr. Flatley was always coming up with corny ideas for family time - the Annual Flatley Fishing Tournament, or the Annual Flatley Bowling Tournament. He even had cheap trophies made.
"Making memories," he would say. "We're making memories."
Erin was perhaps the easiest to raise. She was a pleaser, sweet and mild mannered.
Erin was a junior varsity cheerleader and liked to have her girlfriends around her at all times. She surprised everyone when she decided to go away to the University of Georgia. She joined the Delta Gamma sorority, showed a talent for keg stands, and graduated with a 3.0 in child and family development.
She moved back to live with her sister in Palm Harbor and began her master's degree in education at the University of South Florida.
She talked about teaching fifth grade, getting married, having children.
Erin's mother helped her upstairs to her old room. A bulletin board by the bed held mementos from her days at Clearwater Central Catholic: prom pictures, dried rose corsages, a florist card with a note from her high school boyfriend, who was still her boyfriend: "Happy 7th month. Love, CJ."
Erin was in serious pain.
Her mother called the doctor's office, asking for a stronger prescription. Because the doctor was out of town, the office said she would need to go to another doctor in St. Petersburg.
Mrs. Flatley didn't want to leave Erin. She called her neighbor, Dean Fauber. The family had known "Dr. Dean" for 30 years, and considered him and his wife, Mary Anne, good friends. He also had been Erin's pediatrician.
Fauber called in a prescription for Demerol. Then his wife, a registered nurse, came over with a shot of pain medication, Toradol.
Erin had a restless night. The Faubers gave her two more shots, and the pain seemed manageable, until Friday morning, two days after the surgery. Erin seemed suddenly worse. Her mother was alarmed.
Mrs. Flatley drove Erin to Mease Dunedin Hospital. She wondered if she should have gone back to Morton Plant, where they had the surgery. But Mease was closer, a five-minute drive.
They walked into the emergency room before 8 a.m. That's when things began to go wrong, the Flatleys say.
The emergency room doctor, Amanda Feusner, noticed Erin's white blood cell count was high, more than double the normal level, according to court records. She thought Erin had some type of surgical infection.
Dr. Feusner wanted to speak with the doctor who did the surgery. She was transferred to his covering physician, Mitchell Levine.
The elevated blood cell count was not uncommon after hemorrhoid surgery, Levine said, according to court records. And, he said Dr. Feusner might not want to start Erin on antibiotics, as they would give her diarrhea.
Dr. Feusner had another surgeon examine Erin. He agreed with Levine. Erin was sent home with a topical cream.
"This is going to be a horrible weekend," one doctor said, according to Mrs. Flatley. "So get ready."
Minor surgery, major pain, Mrs. Flatley thought, and headed home.
The Flatleys say doctors did not tell them about Erin's elevated white blood cell count, which can indicate sepsis. Nor were Erin's levels retested before she left. In three days, the number would be off the charts.
On a scale of one to 10, Erin rated her pain a 10.
She had trouble urinating. Her neighbor, Mary Anne Fauber, the nurse, offered to catheterize her. Erin and her mother agreed. It was either that, or call the home health care nurse at the hospital, Mrs. Flatley said.
Erin spent the weekend back and forth between her bed and the bathtub.
She lifted her shirt and showed her sister Jennifer her stomach, which looked puffy and distended.
"I wish I had never done it," Erin said.
Late Sunday, Mrs. Fauber returned to catheterize Erin again. Her urine looked cloudy.
"I think you need to take her back to the hospital," Mrs. Fauber said.
Their second visit to Mease didn't start off well.
After they arrived early Monday, the woman checking in patients insisted that Erin sit down, Mrs. Flatley said.
"She can't sit down," Mrs. Flatley said. "She's had a hemorrhoidectomy and she's in excruciating pain."
The lady kept saying, "Well, she's going to have to sit down and answer these questions."
Erin smiled weakly. She sat down. She was classified as a "non-urgent" patient.
Tests showed Erin's white blood cell count was at 40,000. The normal range is about 8,000. An emergency room doctor suspected a kidney infection and prescribed an antibiotic.
Despite the pain, Erin wasn't complaining.
"She's got this mind-set going: just got to get through this," her mother said.
By early afternoon, Erin was hungry and thirsty, but doctors said she couldn't eat until she had a CAT scan at 1:30 p.m. But that kept getting postponed because of other emergency patients, Mrs. Flatley said.
Hours passed. Erin was shaking, thrashing in her bed.
An infectious disease specialist, Dr. Don Bercuson, saw her about 3 p.m. He thought she might have an infection and ordered three antibiotics. He believed the drugs would be administered relatively quickly, according to court records.
But about five hours later, he received a telephone call from the Flatleys' neighbor, nurse Fauber, saying Erin hadn't been given the drugs yet and her mother was upset. Dr. Bercuson was surprised at the delay, according to court records.
Erin's white blood cell count kept rising, to 80,000.
When Mr. Flatley arrived at 5:45 p.m., he looked at the monitors near Erin's bed. The retired dental surgeon could see that her heart rate was up and her blood pressure was down. Something was wrong.
"Where is the doctor?" he said.
"That's him standing down there," nurses replied.
"Get him," Dr. Flatley demanded.
Dr. Anoop Goyal walked into the room. He had been called shortly after Erin was admitted to the hospital hours earlier. He had sent an infectious disease specialist to her room, ordered pain medication and a CAT scan, but hadn't seen Erin himself.
When he walked into the room, he did not know that she had hemorrhoid surgery, according to court records. He said no one told him.
Erin had been in the hospital for more than 15 hours, yet no one seemed to know what was going on, her family thought.
By that evening, Erin's boyfriend, C.J. Botsolas, was nervous.
"You need to calm down," one doctor told him.
Dr. Flatley was worried. He asked a doctor what was wrong.
"I think she's septic," the doctor said.
Erin's parents and her boyfriend went into a small room with a handful of doctors about 9 that Monday night.
Erin was in septic shock, a surgeon said. She could die.
Die? After hemorrhoid surgery?
"Are you kidding me?" Mrs. Flatley said.
It had never crossed her mind that death was a possibility. It was supposed to be simple surgery - like getting your tonsils out, Mrs. Flatley thought. So many people in their family had hemorrhoid surgery - Erin's grandmother and grandfather.
Doctors urged the family to go home. It was going to be a long ordeal.
Mrs. Flatley had barely slept in the five days since the surgery. She and her husband went home for a quick nap after midnight.
Dr. Flatley couldn't sleep. About 3 a.m., he called the hospital. "You better come down," the nurse said.
Dr. Flatley walked into the room and looked at his daughter's monitor. He didn't know a heart could beat that fast.
His wife stroked Erin's face. "Honey, you just got to keep trying, get better and then I'm going to take you home."
Erin tried to get out of bed. She wanted to go home.
Erin looked so bad, Mrs. Flatley thought they might be fighting a losing battle. She called Erin's sister, Jennifer, and told her to come to the hospital.
About 7 a.m., Jennifer went to the hospital cafeteria with their neighbor, Dr. Dean. He picked up a tray for food. Then Jennifer heard the announcement: "Code blue in the ICU."
Dean Fauber dropped the tray and ran.
The nurses ordered Dr. Flatley out of the room.
He stood outside. He thought about his daughter's face. She had looked so afraid. Her green eyes had been pleading with him: Dad, can't you so something?At 7:30 a.m. on April 30, 2002, six days after surgery, Erin Flatley was dead.
They were supposed to be Dr. Flatley's golden years. He had retired in 1995. He still had John, 14, at home.
The girls had been close by, living together in Palm Harbor. Dr. Flatley, 61, was doing what he loved best: spending time with his family and fishing for bass.
Now he cried almost every day. He couldn't bring himself to visit Erin's grave or walk into her room.
He began spending hours on his computer, researching sepsis.
He learned that sepsis is a body's severe response to an infection. The immune system goes into overdrive, basically attacking the body. It can cause organs to become inflamed and shut down, causing death.
Dr. Flatley was surprised to learn how common and deadly it is. Septicemia, a form of sepsis, is the 10th-leading cause of death in the United States, according to the Centers for Disease Control and Prevention. Researchers estimate 215,000 Americans die every year from sepsis.
People are largely uninformed about sepsis because it often occurs in people with pre-existing medical conditions, said Marc Moss, associate professor of medicine at Emory University in Georgia. If someone who has cancer dies of sepsis, people remember the cancer, not the sepsis.
"I think it's very underrecognized in the general public," he said.
Doctors and emergency room workers need more training in sepsis, said Dr. John Sinnott, director of infectious diseases at the University of South Florida. The complicated syndrome claims a disproportionate number of lives, often because it is not diagnosed early enough. The symptoms - fever, rapid heart beat - can make it difficult to diagnose.
Dr. Sinnott said it is particularly important for doctors in intensive care units to receive additional training as they often are the first line of defense. He said he has, on occasion, been called in to see a patient who was well into sepsis.
"If we had seen them earlier, we could have made a difference," he said.
Quick recognition and appropriate antibiotics are key to treating sepsis. A delay of even four to eight hours for treatment can mean death, according to Emory University researchers.
Dr. Flatley read everything he could about sepsis. Working made him feel better.
He set up a foundation in his daughter's name to award scholarships at the University of Georgia. He created a Web site, www.remembererin.com with pictures of Erin.
And he started thinking about how he and Erin were going to conquer sepsis.
First, he needed answers about her death. No one could tell them what happened.
Only one doctor stopped by the house to offer condolences.
"You have to get a damn attorney just to figure out what went wrong," Dr. Flatley said.
He hired Miami attorney Mark L. Weinstein. The lawyer could take depositions, subpoena records, make the doctors pay.
"The only thing they understand," Dr. Flatley said, "is an economic loss."
He knew what some people would think, that the family was trying to cash in.
"Yeah," he thought, "go say that over my daughter's grave."
Months after Erin's death, Nevada state Sen. Sandra Tiffany stumbled across her Web site.
Tiffany was interested in sepsis, too. She got a bacterial infection from a kidney stone in 2002 that turned into sepsis. She was in intensive care for seven days. Doctors treated her with Xigris, the only FDA-approved medicine for severe sepsis.
Tiffany contacted Dr. Flatley and they quickly became friends, deciding to work together.
Around the same time, the Eli Lilly drug company, which produces the sepsis drug, wanted to form a group to educate people about sepsis. It would provide roughly $100,000 in start-up money.
Dr. Flatley and a half-dozen people met at a Chicago hotel in 2003 and formed the beginnings of the American Sepsis Alliance. He was elected chairman.
The drug company later pulled out, but Dr. Flatley and Tiffany were joined by some nonprofit groups concerned about sepsis - the American Association of Critical Care Nurses, the Paralyzed Veterans of America.
The groups didn't think doctors knew enough about sepsis and wanted the CDC to launch an education campaign. They wanted to raise national awareness of sepsis. They hired a legislative consultant in Washington, D.C., to help.
It would be expensive.
Dr. Flatley began carrying Erin's picture to Tallahassee and Washington to ask for funds.
The trial was getting closer.
Dr. Flatley sat through almost every deposition. He became convinced that doctors should have discovered Erin's sepsis earlier and if they had, she would have lived.
Dr. Flatley wrote updates about the legal fight on Erin's Web site, visited regularly by her friends. He wrote as if he were speaking to Erin:
Your trial has been set for August 8. It will be terrible to go through but they (the ones who failed you) need to be accountable.
Mease Hospital and four doctors already had settled. Two doctors remained. The Flatleys had not sued the only doctor who stopped by their house. They felt he had done everything he could.
After a sleepless night two weeks ago, Dr. Flatley and his wife arrived at the Clearwater courthouse before 8 a.m.
Weinstein and his team began selecting a jury, but the doctors wanted to make a deal.
Dr. Flatley had mixed feelings. It seemed too easy for the doctors and their insurance companies, but they were offering what he believed was an adequate sum. Enough money to keep the sepsis alliance going for a long time.
The Flatleys accepted the offer late that day.
Dr. Flatley viewed the confidential settlements as each doctor saying: I messed up.
In truth, the doctors admitted no wrongdoing.
In pretrial depositions, one doctor's lawyer suggested that the repeated catheterizations of Erin in her home, rather than a sanitized environment, could have led to her infection. The Flatleys said they were grateful for their neighbors' help and do not blame them.
Can he rest now?
Dr. Flatley is trying to get Florida's U.S. senators to back a proposal to give the CDC $2-million to better educate doctors and emergency room workers about sepsis.
He will continue carrying around his daughter's picture, telling anyone who will listen about sepsis.
At some point, he will try to visit Erin's grave.
For now, he dreams about her. He sees her pulling into the driveway, stepping out of the car, her blond hair shining in the sunlight. It's always the same dream. Erin, coming home.
Jamie Thompson can be reached at firstname.lastname@example.org or 727 893-8455.About this story
This story is based on interviews and court documents. The Flatleys declined to discuss the specifics of each doctor's medical treatment of their daughter, citing a confidentiality agreement that was part of the lawsuit settlements. They offered details of their own actions in the days before Erin's death and general impressions of her medical care. Details of Erin's treatment, including the role of individual doctors, were taken from court documents. Lawyers for five of the doctors did not return calls from the Times for comment. Christopher Schulte, attorney for Dr. Don Bercuson, said he could not discuss the case because of the confidential settlement but added: "Our sympathies go out to the Flatley family." A spokeswoman for Mease Dunedin Hospital declined to comment, citing the confidentiality agreement.