This makes my heart sad all over again. No family, especially a military family should every have to go through something like this when it could have been prevented. God bless this family and so many others that may have gone through the same thing. This is courtesy of Military.com.
December 29, 2010Virginian-Pilot
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PORTSMOUTH -- Lance Cpl. Ezequiel Freire got out of Afghanistan alive, but a stateside hospital stay proved fatal.
The 20-year-old Marine's death from a prescription drug overdose at Portsmouth Naval Medical Center has left his family reeling, outraged and frustrated by what they see as an absence of accountability for those charged with his care.
Freire died of a toxic cocktail of powerful narcotics and sedatives as he was awaiting chemotherapy treatment for cancer. The case underscores the dangers inherent in the many potent painkillers on the market today, which have helped drive an alarming rise in overdoses.
Overdose deaths from prescription drugs now exceed those from illegal drugs.
The Freire case also leaves unanswered the question of what, if any, consequences there were for the doctors involved in his care.
There were ample warnings available on the drug labels and in the medical literature about the risks of the multidrug therapy that was used in Freire's case.
But there is no record of any public disciplinary action against any of the doctors by the Virginia Board of Medicine.
A hospital official said the case has prompted several ongoing investigations that have resulted in corrective actions.
The final insult, in the eyes of Freire's family members, is that they have no legal recourse against his caregivers. That's because of a 60-year-old legal precedent known as the Feres Doctrine, which prohibits lawsuits when military service members are injured or killed by negligence.
"We trusted them, and they killed him," said Federico Freire, the dead man's older brother and a fellow Marine. "It just sickens me."
The Freire family moved to Bradenton, Fla., from their native Argentina when Federico was 10 and Ezequiel was 4.
From an early age, both brothers were attracted to the military life. They were fond of dressing up in camouflage gear and playing with paintball and BB guns in the woods.
Ezequiel Freire, the baby of the family, joined the Boy Scouts, a local rescue team and the Bradenton police explorer program.
"He was a good kid," said his sister Julie Freire. "He never had any enemies. He was always the mediator. He was always trying to help everyone."
Following his brother's footsteps, he joined the Marines in May 2008, going straight to boot camp from high school. Federico Freire, an infantry rifleman now stationed at Camp Pendleton, Calif., went to Iraq. Ezequiel, an anti-tank missile gunner, drew Afghanistan.
Ezequiel Freire was in more than 50 firefights during his six-month deployment in 2009, his brother said. Ambushes, roadside bombings and rocket-propelled grenade attacks were commonplace.
"He was knee-deep in it," Federico Freire said. "He had to pull buddies out of Humvees with their bodies cut in half."
Every day, he and his fellow Marines thought they were going to die, Julie Freire said, but he counseled his buddies not to be afraid, telling them: "You shouldn't fear death, because what we're living right now is hell. What better place to be than in paradise?"
When he came home at Thanksgiving in 2009, the combat clearly had taken its toll. He suffered flashbacks and blackouts. When he picked up his car, he kept making sudden stops on the drive home as if scouting for bombs.
When the family went out to dinner with his girlfriend's family, he repeatedly stepped outside, gripped by anxiety attacks. He told his sister: "Julie, I can't go in there. There's too much noise. They're starting to ask me questions. I just can't handle it. I feel like I'm going to go crazy."
When the family lit fireworks to celebrate the New Year, he locked himself in his room and put pillows over his head to muffle the noise.
"Nothing made him happy," his sister said. "He just wanted to be alone."
Back at Camp Lejeune, N.C., he was diagnosed with post-traumatic stress disorder.
There was something else wrong, too. Increasingly, he was troubled by chest pains.
His sister had noticed it over Christmas. When she joked with him, he'd say "Julie, stop making me laugh. My heart hurts."
X-rays at the base clinic revealed a large mass in his chest. He was taken by ambulance to the Portsmouth naval hospital, where a biopsy led doctors to suspect Hodgkin's lymphoma, a type of cancer.
Federico Freire arrived at his brother's bedside five days later after a 12-hour trip from California. It was after visiting hours in the evening, and after 20 minutes he was told he had to leave. He refused.
At that, "a gang of four security guards escorted me out of the hospital in the middle of a snowstorm," he said. "Then my brother had a panic attack. He thought I'd been kidnapped by the Taliban. He unhooked himself from his IVs and wandered the halls looking for me."
The doctors later apologized and let him back in, Freire said.
A port was placed in Ezequiel Freire's chest in preparation for chemotherapy. The plan was to deliver the first round of chemicals in Portsmouth and then transfer him to a medical facility near his home in Florida for the rest of the treatments.
By then, Freire's chest pain had become chronic. He was given a series of high-powered drugs for the pain -- first morphine, then oxycodone and its time-release variant OxyContin, supplemented by Dilaudid. Simultaneously, he was receiving a series of sedatives for anxiety -- first Ativan, then Xanax, and finally Klonopin -- plus Ambien and then Lunesta for insomnia.
"He had so many doctors, and every one had a different opinion about his treatment," Federico Freire said. "Every day, it became more frustrating."
As many as 20 doctors were involved in his care over the three weeks he was in the hospital, according to his medical records.
Around midday on Feb. 12, the doctors switched his pain medication again -- this time to fentanyl, a narcotic 100 times more potent than morphine, delivered directly to the bloodstream via a patch placed on the skin.
On the theory that the fentanyl would not take effect for 36 hours, Freire was also given his scheduled doses of oxycodone and OxyContin that evening.
Family members say they expressed concern to Freire's caregivers about the number and levels of drugs.
"My sister and I spent two hours with the nurses, telling them, 'You guys are giving him a cocktail of death,' " Julie Freire said. "And the nurses agreed. They said, 'You're right. One Advil will put him over.' He had so much buildup in his system. That fentanyl patch is what did it.
"His last text message was to his best friend. It said: 'Hey, dude, I just took a bunch of pills. I'm about to pass.' It was like he could feel that his time was coming."
Around 4 a.m. on Feb. 13, a nurse found Freire unresponsive and was unable to revive him. He died in his brother's arms.
The cancer was not the culprit. In fact, Freire stood a good chance of recovery. The five-year survival rate for Hodgkin's lymphoma is close to 90 percent.
In a meeting with the family soon afterward, one of his doctors acknowledged that an overdose was to blame, Federico Freire said.
Later, the autopsy report confirmed it: The cause of death was "multidrug toxicity."
Freire had a level of fentanyl in his blood and urine "within reported toxic ranges," according to the report. In addition, 10 other drugs were found in various levels.
The powerful combination of drugs caused him to stop breathing, the report concluded.
Capt. Darin Via, deputy commander of the naval hospital, said the staff was "very saddened" by Freire's death. He said the case prompted an ongoing quality assurance review whose goal is "to identify areas where we can improve health care delivery to all patients."
Already, he said, the hospital has taken steps to "ensure that all of our providers and patients are aware of the risks associated with the use of fentanyl patches."
There was a separate investigation by the Naval Criminal Investigative Service; its findings have not yet been made public.
The available warnings about multidrug therapy such as was used in the Freire case are explicit.
For example, the website of Johnson & Johnson, manufacturer of the fentanyl patch sold under the trade name Duragesic, warns that the simultaneous use of the patch with other central nervous system depressants, including sedatives and other opioids -- a medical term for narcotics such as oxycodone -- may cause respiratory depression and a coma.
"When such combined therapy is contemplated, the dose of one or both agents should be significantly reduced," the warning states. "Overestimating the Duragesic dose when converting patients from another opioid medication can result in fatal overdose with the first dose."
John Horn, a professor of pharmacy at the University of Washington and an authority on drug interactions, called the dose of fentanyl prescribed for Freire -- 75 micrograms -- "a fairly robust dose."
"The first thing that would occur to me is, is that too much?" Horn said. "Is that too big a patch?"
Even if it was, Horn suggested, Freire's death might have been avoided with better monitoring.
"Typically, people don't go from normal respiration rates to dead," he said. "They have slower and slower respiration rates until they get down to a rate that's not compatible with life. If you catch it early, it's pretty easy to reverse it. But all of that requires monitoring.
"Something like this is not supposed to happen in a hospital. It does, of course. It can happen anywhere. But it's much more common at home, where nobody's monitoring the patient."
Horn said an increase in narcotic-induced deaths over the past few years has prompted heightened scrutiny of hospital procedures by accrediting agencies.
Freire's relatives have consulted lawyers but have been told that even in a case of demonstrable malpractice, a lawsuit would be hopeless because of the Feres Doctrine, a legal precedent based on the ancient common-law principle of sovereign immunity -- the idea that the government can do no wrong.
The precedent bars lawsuits over injuries "incident to military service."
Critics say the doctrine has created a culture of impunity in military medicine, resulting in substandard care.
Attempts to repeal it have surfaced periodically in Congress for more than 20 years, but all have failed.
"There's no accountability," Ezequiel Freire's sister Julie said. "For him, the most dangerous place was the hospital."
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