Victor “Buddy” Krumdick died of an overdose in the emergency department during his shift as a transcriptionist on Dec. 22
VISALIA – A medical transcriptionist’s overdose and death in the emergency department in December shocked Kaweah Health Medical Center and the community when the hospital announced the death in July. The event also sent shockwaves out to state and federal regulators to a potential pharmaceutical problem, delayed the opening of its expanded emergency department as COVID-19 cases began to push the hospital back to the brink of capacity, and threatened Kaweah Health’s Medicare certification which would have resulted in the closure of the area’s largest hospital as hospitalization’s were about to peak during the pandemic.
Described by the hospital and investigators only as a scribe, a contracted position which inputs physician notes dictated during rounds at the hospital, the transcriptionist’s name was not known until his family reached out to local media late last month to tell their story of the healthcare worker’s life.
Victor Krumdick, Sr. said his son was the fourth and last to carry the family name originating from their Welsh heritage but was affectionately known to friends and family as “Buddy.” Victor Robert Krumdick, 32, was described by his father as having “a soft, gentle side” and as “compassionate” and “mature at a young age.” He played the fiddle, loved to travel, and had landed a quality UPS job at just 17 years old. A bad fall on the job left Buddy with a nagging back injury for nearly half of his life.
“This led to a lifelong battle with pain medication, addiction, bogus alternative medicine treatments, back surgery and the like,” Victor, Sr. wrote in a message to the Sun-Gazette identifying his son as the deceased healthcare worker.
Life in the ED
Victor, Sr. said his son had moved home four years ago as a refuge to take on life’s challenges, which included his excruciating back pain, clinical anxiety, depression and sleeplessness. The first time Buddy stepped into the Kaweah Health emergency department (ED) was to take his father’s lifelong friend there after he had fallen in his home. While waiting with the man in triage, Buddy noticed the scribes following around doctor’s and inputting their notes on patients. Upon his father’s suggestion, Buddy inquired if there were any openings at the hospital for a scribe and found out there were in fact two job openings.
“Working in the ER profoundly changed our son’s life,” Victor, Sr. wrote. “He discovered his calling.”
After each shift, Buddy would come home to tell his parents about what went on. He talked about finding a whole new family in his field, hanging out with new friends and about his new dream of becoming a doctor of osteopathy in the ED. He had completed most of has associate degree, on his way to an emergency medical technician certificate and began helping ailing family members navigate the health care system and stay on top of their treatments and medications. He dreamed of his future success as a doctor and promised to personally care for his parents in their old age.
“From the most menial worker to honcho doctors and everyone in between, Buddy had a special way of communicating and making others feel their own worth and importance in the midst of their own life struggles,” Victor, Sr. stated.
The anxiety of school finals, helping an ill neighbor, working overnights at the ED and general stress of the holidays, both made worse by the pandemic, conspired to exhaust him physically, mentally and spiritually. Victor, Sr. wrote that just a few days before Buddy died that, “He was hurting in a lot of ways.”
At 3 a.m. on Dec. 22, Victor, Sr. wrote he and his wife Gillian received a phone call “that there had been an incident” involving their son at the hospital. When they arrived on that freezing night, they were told Buddy, who was working in the ED, had been seen on video taking medicine from an exam room. Staff searched for Buddy for about two hours before finding him dead in a locked employee bathroom. Victor, Sr. said officers and the coroner investigating the death repeatedly asked if Buddy was suicidal to which Gillian adamantly responded, “my son did not commit suicide.”
Weeks later, the coroner’s autopsy report revealed Buddy’s death as accidental and not a suicide.
“I do not condone my son’s foolish action,” Victor, Sr. stated. “He was of making some very poor choices and it cost him his life. But please remember the context of our son heading off to work that night.”
Death in the ED
Victor, Sr. took issue with Kaweah Health’s handling of his son’s death and the media’s callous coverage of the tragedy. This newspaper, based on its interview with Herbst, wrote Buddy had “snuck” into an empty ED exam room and stolen Propofol, a common sedative, from an IV bag still hanging from the pole where a patient had been sedated hours earlier.
In his letter, Victor, Sr. said Kaweah Health CEO Gary Herbst had made Buddy out to be a “patsy for the mismanagement of hospital medications and late opening of the ER. Needless to say, my family was enraged at both the distorted accusations, the pretense of anonymity with which our son was dealt, and the zero effort to communicate with us. I believe you [defamed] a good, but hurting young man and indirectly, our entire family. Shame on you.”
In a Sept. 24 interview, Herbst said he had talked with Victor, Sr. earlier that day and explained the situation to the grieving father. Herbst made clear, what many news reports did not, that Buddy was beloved by his coworkers and even though he was technically employed by Vituity, an emergency medicine group contracted to provide both clinical and non-clinical positions in the emergency department, he was considered part of the hospital family.
“I just wanted him to know how much we missed his son and loved and cared for him and how much he was a part of the Kaweah Health family,” Herbst said. “And I’m saddened that he didn’t get to hear that side of the story.”
Herbst said the hospital did not release Buddy’s name out of respect for his personal and his family’s privacy and that the hospital did not blame Buddy’s death for the delay in opening its ED expansion. In fact, Kaweah Health was unaware the death and delay were related until after its plan of correction for Buddy’s death and a physician’s theft of pain medicine for personal use, known as drug diversions, was rejected three times. Frustrated by the rejections and the state’s refusal to greenlight the hospital to open its new expanded ED, Herbst said hospital administrators were finally told the two drug incidents were holding up the ED’s opening over concerns there were not enough physicians supervising resident doctors, those gaining experience in certain fields treating patients at the hospital.
“I wasn’t blaming this on, Victor, but unfortunately, I was speaking the truth that the state told us the reason that they were not giving us approval to open the expanded ED was because of the Propofol event and the [Centers for Medicare and Medicaid Services] survey,” Herbst said.
In April, Kaweah Health unveiled its brand new, expanded emergency department, touted to bring their ED bed count up to 73 with state-of-the-art medical care and an expanded waiting room, said to be ready to start seeing patients within a week. The California Department of Public Health (CDPH) had completed its inspection of the new ED on April 1 and had only issued minor corrections, which Kaweah Health immediately implemented, such as an eye wash station being too high, but went months without hearing from the state when it could open the new ED. Around the same time, CDPH investigators, on behalf of the Centers for Medicare and Medicaid Services (CMS) completed its intensive investigation into the diversion events, called a complaint validation survey. On May 21, Kaweah Health received a 286-page report from CMS on the diversion events and the agency only gave the hospital until June 1 to respond with its 107-page plan of correction to prevent future medication thefts. After submitting three versions and answering a supplemental survey, asking questions already addressed in the plan of correction and where administrators cut and pasted from previous reports, CDPH’s regional director in Bakersfield finally told Kaweah Health the death and ED delay were related.
Herbst described the entire complaint validation survey as “torture.” Six CDPH investigators interviewed, observed and in some cases harassed hospital employees for up to 15 hours per day for nine straight days. He said one of CDPH’s investigators in particular made false statements, misquoted people and even brought some of the employees and coworkers to tears while they were still grieving the loss of Buddy.
“She is quoting people, including me, saying, I made these statements, which I never did,” Herbst said.
A month after Buddy’s death, Kaweah Health reported a second diversion event involving a physician who was stealing Fentanyl, a synthetic opioid, by ordering more than he administered to a patient and keeping the rest for himself to take home and use recreationally. Herbst said the physician, an anesthesiologist, had showed signs of possible impairment but there were never any witnesses or unreconciled medication use. A group of certified registered nurse anaesthetists, who had just returned from a drug diversion prevention webinar, filed some concerns with the chief medical officer and confronted the physician. After a week, the doctor admitted to having a substance abuse problem and confessed he had been stealing the pain killers since May 2020. He entered a confidential drug rehabilitation program, so administration was unaware of his addiction.
The most egregious act committed by Kaweah, according to Herbst, was that when the chief of staff, a friend of the physician, confronted the anesthesiologist in July 2020, he chose not to report it to hospital administration nor the medical executive committee. Even after the second report in January 2021, neither Herbst nor the MEC received a report. Instead, they were notified a physician had a drug addiction and that he was enrolled in the hospital’s wellbeing program. When he exited the rehabilitation program, Herbst said the physician was placed on medical leave while the MEC deliberated on his case. Ultimately, the committee decided not to reinstate his privileges at the hospital.
Herbst said these were isolated incidents and the only two diversion events he could think of in his 30-year history with the Visalia hospital. The most disappointing part of the CMS survey, Herbst said, was that it connected the two isolated incidents, Buddy’s death and the anesthesiologist’s addiction, with two other events which happened outside of the hospital and years apart. In 2019, a certified registered nurse anesthetist (CRNA), a nurse trained to essentially be an anesthesiologist, who showed up to work impaired and quit on the spot after refusing to take a drug test. Not only did the CRNA take drugs before coming to work, she didn’t steal the drugs from the hospital, so it wasn’t a diversion event. In 2016, the survey noted two Kaweah Health CRNAs were at home recreationally using Fentanyl when one of them overdosed and died. Again, the drugs were not obtained from the hospital.
“What I didn’t like is, these surveyors tried to paint us as some literally drug-infested, out-of-control organization,” Herbst said.
Herbst went on to say the consulting firm Kaweah Health hired to assist in preparing its plan of correction noted they had never seen that level of ineptness and inaccuracies in a CDPH investigation despite the consultant’s 20-year history in the Los Angeles field office for the state agency.
“He said, ‘I’ve never seen a report that has been written more poorly than this’,” Herbst recalled.
Herbst said Evelyn McIntyre, Kaweah’s director of risk management, called CDPH on Sept. 24 and confirmed both of the plans of correction for the Propofol overdose and the Fentanyl thefts had been fully accepted and the investigations were not ongoing. However, Herbst said Kaweah Health has yet to receive letters from CDPH notifying the hospital that the matter in both Krumdick’s death and the physician’s theft of pain killers has been closed.
“The state would normally send us a letter,” Herbst said. “We haven’t received those letters.”
While he was critical of the CMS survey process, Herbst did say Kaweah Health is a better hospital today because of the report and the internal changes it has made. In the case of the physician, Kaweah Health will notify any new hires with past issues of substance abuse they will be subject to regular and random drug testing as a condition of employment, staff will receive additional training on recognizing signs of impairment in co-workers and the hospital is starting an extensive campaign to educate staff to issues of addiction in the healthcare industry. The hospital has also established a committee, which meets daily to review every incident report filed by employees or physicians.
“And now I’m highly confident that if this was ever to occur in the future, I would immediately be informed as with the Chief of Staff, as would the medical Executive Committee, and the Board,” Herbst said.
In Buddy’s case, Kaweah Health implemented several major changes to its policies. While Propofol is not a controlled substance, it will now be kept under lock and key like opioids. The hospital will no longer use IVs with ports, which means you would have to puncture the bag or line in order to draw the liquid into a syringe. Any unused fluid is now discarded within two hours of use. Syringes are no longer allowed out of locked drawers unless a nurse or doctor is in the room.
Herbst said both instances have taught the hospital a lot about watching for signs of addiction and depression among their medical staff, contracted employees and other staff.
“As you read in his father’s story, [Buddy] suffered emotionally, mentally, physically and we need to be more aware of that,” Herbst said.
Herbst cited a USA Today article reporting more than 100,000 doctors, nurses, technicians and other health professionals across the country struggle with abuse or addiction, mostly involving narcotics. Victor, Sr. said he hopes his death can help Kaweah Health prevent other deaths from happening among local healthcare workers and make the hospital a safer place for employees and patients alike.
“Then perhaps, Buddy Victor’s life and death in The Kaweah Delta Emergency Room will not end up all for naught,” Victor, Sr. concluded.