In the space of a few minutes on the day she died, Joyce Echaquan went from an agitated and alert state to losing consciousness and slipping into a coma so deep an expert emergency room doctor thought she appeared to be dead.
After two weeks of testimony and reams of medical documents in evidence, it remains unclear how long it took staff at the Joliette, Que., hospital to notice she was in deep trouble and start life-saving measures.
The minimum answer is 17 minutes, but Dr. Alain Vadeboncoeur, the expert ER doctor who testified Thursday, said it was likely longer than that.
The inquest into the death of Ms. Echaquan, a 37-year-old Atikamekw woman, turned Thursday from examining the racist taunts and treatment she endured to the medical mystery of how the mother of seven died.
A video of hospital staff showering abuse on an agitated Ms. Echaquan brought her case to global attention and renewed scrutiny of the mistreatment of Indigenous people in Canadian hospitals.
But it was a second, private one-minute, 20-second video shot by Ms. Echaquan’s daughter about an hour later that shocked Dr. Vadeboncoeur, an emergency medicine specialist at the Montreal Heart Institute and expert witness at the inquest.
Those images showed Ms. Echaquan pale and still and should have spurred immediate action, Dr. Vadeboncoeur testified.
“I thought she was dead in that video,” the physician said. “At first, I thought it was taken afterward. There’s no reaction, no movement. I watched it several times and I’m still unable to say if she was breathing.”
It was another 17 minutes before Ms. Echaquan was moved to the resuscitation room where life-saving measures began.
Dr. Vadeboncoeur said any experienced emergency room staffer, from the head physician to an orderly, should have easily recognized Ms. Echaquan was in trouble and sounded the alarm.
Ms. Echaquan and other seriously ill emergency room patients were left in the hands of a nurse trainee. A medical resident saw Ms. Echaquan minutes before the second video and appeared to take no notice.
“The video doesn’t lie, and it speaks loudly,” Dr. Vadeboncoeur said. “The absence of reaction, of movement, is enormous. If anyone in an emergency room sees that, they call for help, they call a code.
There was also a 95-minute gap between blood-pressure readings, the second of which showed she was in desperate shape.
The Atikamekw woman would be pronounced dead about 50 minutes after resuscitation measures were launched, measures Dr. Vadeboncoeur described as adequate.
Dr. Vadeboncoeur and three other experts who searched for the cause of Ms. Echaquan’s sudden death found no simple medical conclusions. Ms. Echaquan had a serious cardiac condition and was living with heart failure, but she suffered no stroke, heart attack or other acute problem that would obviously explain her death.
Ms. Echaquan suffered from a weakened heart primarily caused by genetics, but possibly worsened by infection, childbirth and prior substance abuse, Dr. Vadeboncoeur said. Her heart had begun to fail several years ago.
She died from excess fluid in the lungs triggered by the sudden worsening of her heart failure that forced fluid back into her lungs.
Her heart failure should not have been acute enough to cause her death immediately and had actually improved since her first diagnosis in 2014, Dr. Vadeboncoeur said. She had recurring abdominal pain, including during her hospital stay, but the source was not identified or linked to her death, he said.
Pathologist Dr. Richard Fraser discovered she had heart damage from a rare, previously undiagnosed infection. Her heart was also enlarged. Neither should have killed her so suddenly, Dr. Vadeboncoeur said.
A toxicologist and pharmacologist testified she had amounts of morphine and the sedative Haldol consistent with hospital use. She appeared to have stopped taking some of her heart medication before going to hospital, but that shouldn’t have killed her suddenly either, Dr. Vadeboncoeur said.
A few factors may have combined to contribute to her suddenly worsening condition, the physician said. Ms. Echaquan was given a lot of fluid, which would increase pressure on the heart. She was also given large doses of her heart medication to make up for the fact she hadn’t taken it recently, which could stress the heart.
She had low blood sugar levels, which can worsen heart problems. Shortness of breath from heart failure can add to stress and worsen the heart condition also, he said. Her borderline personality disorder and the racist treatment she received would have added to her stress and agitation, which ended with her being sedated, which can then worsen heart failure. Medical staff then mistook her coma for the effect from sedation.
“There you have at least six possible causes. I don’t know which is predominant,” he said. “To do anything about them, first you have to recognize there’s a problem.”
Patrick Martin-Ménard, the Echaquan family lawyer, relayed a question directly from the family: “Could they have saved Joyce?”
“The answer is yes,” Dr. Vadeboncoeur said. “But it depends on what moment we ask the question.” Medical staff did their best to revive her, he said. She was stable for most of her stay. “Perhaps more could have done to prevent this earlier, but it mainly played out during the critical interval.”
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