Vernal family’s tragedy prompts legislative action, research

VERNAL — Overwhelming.

That’s the word Yvonne Gardner uses to describe the emotions she felt last week as she watched Gov. Gary Herbert sign a ceremonial copy of a legislative resolution dubbed “Parker’s Bill.”

“When I hear it called ‘Parker’s Bill,’ I feel like my son didn’t die in vain,” Gardner said. “Because of this, hopefully someone else won’t have to suffer this pain.”

Parker Stewart, a 21-year-old newlywed from Vernal, died in his sleep three days after undergoing a tonsillectomy on Dec. 1, 2016. The state medical examiner said pneumonia caused his death. The surgeon who removed Stewart’s tonsils, however, doesn’t believe that’s accurate given his knowledge of Stewart’s physical condition before and after surgery.

Instead, Dr. Michael Catten believes Stewart died from respiratory depression brought on by the opioid painkillers Catten prescribed for postoperative pain.

“The medicine I prescribed at the right doses — and he took half of the prescribed dose — killed him,” Catten said. “I don’t use the word ‘killed’ lightly or spitefully when I talk about this. It’s reality. We need to say that word out loud so we can address this issue.”

Catten and Gardner talked candidly about what he believed caused Parker’s death shortly after his funeral. The doctor said the grieving mother had one message for him.

“She told me, ‘I want to know what happened because I never want anybody else to have to go through this again. I want you to find out what happened,’” Catten recalled. “I promised her I would research it and find a way to stop it from happening again," he said.

Stewart’s mother and his wife, Madilyn, also approached Sen. Kevin Van Tassell, a former neighbor who knew Stewart as a boy. “Parker’s Bill” — formally known as Senate Concurrent Resolution 4 — came out of that conversation. Van Tassell would sponsor it in the Senate, while his Republican colleague from Vernal, Rep. Scott Chew, carried it through the House.

“Sen. Van Tassell and Rep. Chew are amazing, wholehearted men,” Madilyn Stewart said. “When we presented our idea, I know they recognized the deep thought (we put into this) and how personal this was.

“We live in a small town and when something like this happens — something this big of a deal — it hits everyone’s home," she said. "It’s a personal thing and they helped us make it even more so to more people than we could have ever thought by standing behind us.”

SCR4 received unanimous support in every committee meeting where it was presented, and on the floor of the House and Senate. It was officially signed by the governor on March 15.

The resolution urges the state Health Department, hospitals, doctors, and medical researchers to examine and identify a possible link between prescribed opiate painkillers and respiratory depression following surgery that could lead to death. It also encourages doctors to send postoperative patients home with an oxygen monitoring device when opioids are prescribed, if appropriate.

Catten, who practices at both Ashley Regional Medical Center and Uintah Basin Medical Center, began sending pulse oximeters home with postoperative patients almost immediately after Parker’s death.

“It is easy to monitor them, and it’ll save lives. It already has in our community,” said Catten, who is collaborating with Shay Uresk at Uintah Basin Medical Center's sleep lab and Kim Bennion, Intermountain Healthcare director of respiratory care, to research the effectiveness of pulse oximeter use by postoperative patients at home.

In a case documented during the trio’s early research, a 15-year-old tonsillectomy patient in Uintah County took pain medication as prescribed, then went to bed wearing the pulse oximeter she’d been given. At 4 a.m., the device alerted her parents that there was a problem. Their daughter wasn’t breathing. She had no pulse.

CPR was started and ambulance crews administered four doses of Narcan. They were able to revive the girl, who recovered fully and attended the governor’s ceremonial signing of Parker’s Bill.

IHC is now piloting a program that will allow medical staff at its hospitals to remotely monitor pulse oximeter readings of patients when they’re at home, providing an extra layer of safety, Catten said. Uintah Basin Medical Center is expected to follow suit shortly, he said.

For Catten, though, simply monitoring pulse oximeters isn’t enough. The critical component of Parker’s Bill, as he sees it, is the direction to the Health Department and other medical professionals to collect data on the postoperative effects of opioid painkillers on patients.

“Right now we’re not collecting the data we need to,” Catten said, noting that unexpected deaths within one week of surgery are not reported as sentinel events in Utah.

“They need to be so we can make them never events,” he said.

In medical terms, a sentinel event is defined as “any unanticipated event in a health care setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness.”

“We need to make these deaths sentinel events so that reporting is compulsory,” Catten said. “Then we can actually get hard numbers about how often this is happening and look for commonalities in these cases to identify causes.”

Madilyn Stewart described her husband as a “selfless” person who cared deeply about the feelings of others and loved to make people happy. The process of working on Parker’s Bill has been both heartbreaking and rewarding, she said.

“I’m happy that this (was done) in my husband’s honor and we can save others by pressing for answers, but it will never bring him back,” she said. “He would be proud that something good has come out of his early passing.

“People will never truly understand (our loss) until something tragic happens to them,” she added. “That is why we have pushed this so hard, because we don’t want other wives, fathers, mothers or siblings to have to understand.”

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