In September 2014, the Minnesota Department of Health (MDH) investigated a cluster of six patients diagnosed with Salmonella Enteriditis. Four of five case-patients reported eating Chicken Kiev, purchased as a raw, frozen, breaded and pre-browned chicken entree. Illness onset dates ranged from August 17 to September 26. One person was hospitalized. There were no deaths. All six patients were infected with an indistinguishable genetic strain of Salmonella Enteriditis as determined by Pulsed Field Gel Electrophoresis (PFGE). Isolates from all six case-patients were indistinguishable by whole genome sequencing.

Several patients told public health investigators they could not remember the brand name but described the packaging as “red and clear.” Other patients reported the brand as “Antioch Farms”. The Paulson family and another outbreak associated case patient had leftover product which was collected by health officials and tested for Salmonella at the Minnesota Department of Agriculture (MDA) laboratory. Of the home samples collected, 7 of the 11 were confirmed positive for Salmonella. Salmonella serotype Enteriditis was confirmed in 6 of the 7 positive samples. MDH conducted PFGE on isolates cultured from food collected from patients’ homes. Isolates obtained from patients and Antioch Farms brand Chicken Kiev collected at their homes were a 2-enzyme PFGE pattern match.

Minnesota Department of Agriculture (MDA) staff also collected samples of Antioch Farms brand A La Kiev raw stuffed chicken breast from grocery stores for testing at the MDA laboratory. In total 30 samples were collected and tested. Of these, 26 confirmed positive for Salmonella. Nine confirmed positive for Salmonella Enteriditis, and 17 confirmed positive for Salmonella serotype Schwarzengrund.

On October 23, 2014 MDA and MDH issued a joint press release alerting the public of the cases of salmonellosis and their link to Antioch Farms Chicken Kiev.[1] This was followed by a recall announcement by Aspen Foods Division of Koch Meats, a Chicago based establishment. The company recalled 28,980 pounds of chicken products with sell dates of October 1, 2015 and October 7, 2015.[2] These products were shipped to retail stores and distribution centers in Minnesota.

___________

[1] http://www.health.state.mn.us/news/pressrel/2014/salmonella102314.html

[2] http://www.fsis.usda.gov/wps/portal/fsis/topics/recalls-and-public-health-alerts/recall-case-archive/archive/2014/recall-073-2014-release

Well, actually, this in number five.

Minnesota state health and agriculture officials said today that seven recent cases of salmonellosis in Minnesota have been linked to raw, frozen, breaded and pre-browned, stuffed chicken entrees. Investigators from the Minnesota Department of Health (MDH) and the Minnesota Department of Agriculture (MDA) determined that the illnesses occurred in two separate outbreaks, involving two different strains of Salmonella bacteria in products from two distinct, unrelated producers.

In the first outbreak, four illnesses occurring from April 5 through June 8 were linked to Barber Foods Chicken Kiev. This product has a U.S. Department of Agriculture (USDA) stamped code of P-276. This product is sold at many different retailers, including grocery store chains. The four cases in this outbreak ranged in age from 19 to 82 years, all from the metro area, and two were hospitalized.

In the second outbreak, three people got sick from May 9 to June 8 after eating Antioch Farms brand Cordon Bleu raw stuffed chicken breast with a U.S. Department of Agriculture stamped code of P-1358. This product is sold at many different grocery store chains. The three cases were all adults in their 30s and 40s from the metro area, and two were hospitalized.

No deaths have been linked to either outbreak. MDH and MDA are working with USDA’s Food Safety and Inspection Service (FSIS) on the investigation. The investigation is on-going.

With these two outbreaks, there have now been nine outbreaks of salmonellosis in Minnesota linked to these types of products since 1998.

In 2014 Minnesota Public health and agriculture investigators in identified 6 cases of Salmonella Enteriditis linked to consumption of Antioch Farms brand A La Kiev raw stuffed chicken breast. Illness onsets occurred in August and September 2014. The outbreak strain was isolated in packages purchased at grocery stores.

In addition, Plant 1358 Aspen Foods was linked to Salmonella Outbreaks in 2005 S. Heidelberg, 2005-6 S. Enteritidis and 2006-S. Typhimurium.

Stewart, you and your counsel can complain all day that you could have proved the opposite, but that would not have worked.

BOBBY RAY HULLETT’S SALMONELLA ILLNESS AND DEATH

Bobby Ray Hullett, known to friends and family as Pete, and his wife Shirley lived in Maiden, North Carolina. The Hulletts were married for forty-five years and worked together at the Southern Glove mill for thirty years. Pete was a soft-spoken man who worked all his life. Early in his career at Southern Glove a huge press crushed one of his hands leaving him with one functional hand. Despite his hand injury, Pete continued to work uninterrupted at Southern Glove until his retirement shortly before his death.

Pete was also able to take care of the house, garden, and car, which he loved to tinker with. A man of quiet pride, Pete never complained about his misfortune, and taught his sons to never make excuses for themselves. Pete liked football, bowling, and wrestling, but he loved NASCAR. Pete and Shirley were also devoted to their church, which they attended three times a week, and they especially enjoyed the gospel choir. Pete always provided for his family and was Shirley’s constant companion throughout the decades of their marriage.

Shirley Hullett had two young boys from a prior marriage when she married Pete. Pete helped raise the boys, Tony and Dale, and was the only father they knew. When Dale was only seventeen he had a son himself. Dale turned to Shirley and Pete to be surrogate parents. And so Shirley and Pete also raised Dale’s son Bobbie who is now thirty-five and remains devoted to his grandmother. Dale passed away from complications from chronic liver disease in his early 50’s.

At the time of his illness and death, though on high blood pressure and cholesterol medications, Pete was a very healthy person. He was also a frequent consumer of Austin-brand peanut butter crackers. In fact, in the days leading up to the illness that would take his life, Pete ate the crackers as a snack two or three times a day.

Pete’s symptoms began on November 23, 2008, with vomiting and severe dizziness that eventually caused him to lose consciousness and collapse on the kitchen floor. That night, he suffered from excruciating abdominal cramps and experienced multiple bouts of both watery diarrhea and vomiting. The next morning, the severity of Pete’s illness became dramatically apparent. Shirley recalls:

By Sunday night he thought he had a virus, he was up and down all night throwing up and with diarrhea. Monday morning he had gotten up and felt very weak, he took out the trash and came back into the house. He then collapsed on the kitchen floor, and I could not get him up. He asked me to call my son Tony to come help. Tony got off work and immediately came to the house. Tony did not want to wait for the ambulance, so he picked Pete up and put him in the car and drove to the hospital.

In the emergency room at Catawba Valley Medical Center in Hickory, North Carolina, doctors assessed Pete’s condition. After triage in the ER, Bernard Crain, MD, who recorded a blood pressure of 84/56 and pulse of 129, saw Pete. Pete was rehydrated, which brought up his blood pressure slightly, and was given oxygen by mask. Dr. Crain also ordered intravenous Phenergan for Pete’s severe nausea.

Despite being very ill, Pete was able to give a medical history, reporting no heart attack or diabetes, and no prior surgeries or other major health concerns. Dr. Crain ran an EKG that was compared to one done in 2004, and while no significant pathology was suspected, the strip did show sinus tachycardia with a heart rate around 130[1]. Pete had to suffer the placement of a Foley catheter and urine and blood specimens were sent to the lab.

Pete’s lab results were abnormal, indicating decreased kidney function by an elevation in his BUN and creatinine.[2] He was also acidotic, having an increased amount of carbon dioxide in his bloodstream.

Pete was in kidney failure, ill with severe ongoing gastrointestinal symptoms, and had to be admitted to the hospital for further care. Kenton Sanders, MD, saw Pete next, shortly after 5:00 PM on November 24. At this point, Pete was still coherent enough to offer Dr. Sanders a detailed medical history. He related that he had no recent history of antibiotic usage; that he had a vague history of multiple sclerosis for three years; and that he had recently been taking Lipitor, baby aspirin, and another blood pressure medication.

Upon examination, Dr. Sanders thought Pete appeared ill and “quite fatigued.” An abdominal exam revealed tympany to percussion[3], but bowel sounds were present, and there was no tenderness noted. Because of Pete’s severe and ongoing diarrhea, Dr. Sanders’s impression included the comment, “The room has the smell of Clostridium difficile,” and included the diagnosis of acute onset nausea, vomiting and diarrhea suggestive of gastroenteritis. He further indicated that Pete’s kidneys had likely failed as a result of “a prerenal component,” which is a reference to the severe volume depletion and dehydration Pete had experienced as a result of his gastrointestinal losses.

Dr. Sanders admitted Pete to the medical floor on telemetry and pulse oximetry, and he continued his IV fluids and oxygen. He began Pete on the antibiotic Flagyl, and ordered that samples of stool, urine, and blood be tested.

Less than an hour after seeing Dr. Sanders, Pete suffered additional bouts of green, foul-smelling diarrhea. The nurse checked on him periodically to make sure that he was as comfortable as possible under the circumstances. When rechecked around 8:00 PM, the nurse reported that Pete was lethargic, but very alert and oriented, and that he was responding appropriately to questions.

Shortly after 11:00 PM, however, the complexion of Pete’s illness began to change. A portable chest x-ray had been done, which showed no change, and afterward a nurse checking on Pete found him having notable shaking that had not been present just minutes before. His pulse was high—in the 140-150’s—and Pete began talking incoherently. He was also unable to follow the simple command of opening his eyes when prompted. A portable pulse oximetry read 54% on two liters of oxygen, so the nurse increased the oxygen to three liters. There was, however, no change in Pete’s oxygen saturation. The nurse immediately called Dr. Sledge, who ordered that Pete be transferred to the critical care unit (CCU).

In the CCU, Pete was unresponsive when lifted into bed. Shortly thereafter, at just before midnight, the lab called Dr. Sledge to notify him that Pete’s lab values were grossly abnormal and consistent with severe metabolic acidosis.[4]

Just after midnight on November 25, 2008, an electrocardiogram was done that was abnormal, showing sinus tachycardia and signs of an acute myocardial infarction. Dr. Sledge made an addendum note:

I was called by 3^rd floor nursing staff due to decreasing level of consciousness and decreasing blood pressure. Patient has been transferred to ICU. ABG reveals severe metabolic acidosis. He was started on bicarb drip earlier tonight by Dr. Sanders due to shallow respiratory and unresponsiveness and will need intubation. I discussed code status with the wife. She wants everything done. Will ask anesthesia to insert ETT and central line.

In the early morning hours of November 25, Thomas Hill, MD, inserted a left subclavian central line and an endotracheal tube (ETT) for mechanical ventilation. Once these were in place, the results of another arterial blood gas study again showed severe metabolic acidosis. A short while later, Pete’s level of consciousness increased, allowing him to better appreciate what was going on. This frightened him badly and, ultimately, wrist restraints had to be used to keep him from pulling out the central line and ETT that Dr. Hill had just inserted. For Shirley, seeing her husband in restraints in the midst of his suffering was profoundly upsetting. Pete seemed to be getting worse by the hour despite the doctors’ efforts.

Physician notes around 2:10 AM indicated that Pete’s urine output was poor, despite receiving two liters of normal saline and ongoing fluid hydration. The differential diagnosis now listed shock, acute renal failure, diarrhea with white blood cells in the stool, and still questioning C. diff, although by history Pete had not been on any recent antibiotic therapy[5]. Respiratory failure was also now listed in the differential along with metabolic acidosis. Laboratory results at 2:43 AM showed liver dysfunction and continued kidney dysfunction.

At 4:00 AM on November 25, 2008, Pete was awake and looking at the nurse, squeezing her hands, and moving his toes on request. However, at 5:00 AM, blood gas alarm values were reported by the lab, again with significant metabolic acidosis, as reported to Dr. Sledge.

Pete’s family was in the room with him at 7:00 AM when the ICU/CCU physician came in to see him. He explained to them that Pete had suffered an acute myocardial infarction (MI) with cardiogenic shock and that his prognosis was poor. He was producing very little urine and was in acute renal failure. He remained on the ventilator, and the doctor indicated in his chart notes that Pete might not survive the day.

For Shirley, Pete’s hospitalization was a long nightmare. She never spoke to him again after Tony took him to the hospital because he was on a ventilator; she could only watch his torment as his life ebbed away. Her memories are vivid:

He had needles stuck in him, it seemed like there were fifteen to twenty needles total. I told him I loved him, I asked him if he loved me and with a pitiful look he nodded his head yes. It broke my heart to see him in this condition; the doctor told my family and myself that there was not a doctor in the United States that could save him. Every organ in his frail body was shutting down,

At 9:00 AM on November 25, Pete was awake but lethargic. The doctors gave him vasopressors to keep his blood pressure up. He still wore the wrist restraints so he would not pull out his breathing tube. The doctor came in to discuss Pete’s condition with the family again. Tony recalls that while Pete was unable to talk, his eyes reflected the pain of his overwhelming infection.

At about 9:30 AM, Sanjay Patel, MD did a cardiology consultation. Dr. Patel reviewed the history that had brought Pete to the ER and his subsequent admission event. He noted no prior cardiac history but that Pete had reported hypertension and hyperlipidemia. Pete’s cardiac labs were consistent with a recent infarct. Dr. Patel’s impression was shock with a possible cardiogenic component, but with his concurrent renal failure thought the cardiac component to be less likely. He agreed that Pete’s prognosis was not good.

At about 11:00 AM the same day, the laboratory called an alarm value to Dr. Kaariainen, which was to report that the blood cultures drawn the day before were showing positive growth of gram-negative rods. At about 12:25 PM, an IV with the antibiotic Levaquin was started. At 4:00 PM, Pete accidentally pulled out his arterial line, and respiratory therapy came in to try to place a new one without success.

At 10:00 PM that night, Pete was still alert enough to move his arms and feet a little when asked, but his hands were cold and cyanotic to exam. Serology for C. diff was negative. A stool sample was positive for occult blood, but negative for the protozoan parasites Giardia and for Cryptosporidia.

At midnight on November 26, 2008, Pete was still alert and oriented, but lethargic. But by 4:00 AM on the 26th Pete’s level of consciousness was declining. His eyes were partially open, but there was no response to verbal stimulation. The doctor discussed Pete’s grave and worsening condition with Shirley. Pete was no longer responding, although his eyes were open and he appeared to look around. His laboratory results reflected progressive organ failure.

At 8:00 AM nurse notes indicate that Pete was obtunded but did arouse to pain. Dr. Luney came in to evaluate him and reviewed his chart and labs, and confirmed his prognosis was grave. He continued to diagnose shock, hypotension, acidosis, and multiple organ system failure, now with lab evidence of liver failure as well as renal failure.

At 11:30 AM on November 26, hospice came in to consult with the family and to discuss the procedures they should follow when Pete experienced cardiac arrest, which they fully expected. They decided on a partial code procedure, as they were still awaiting other family members to arrive and did not want to terminate life support until later in the week.

Pete continued to decline throughout the day on November 26. His heart rhythm worsened and though his blood pressure held at greater than 100 systolic, he remained unresponsive and his skin continued to show mottling. At 6:20 PM, Pete’s blood pressure suddenly fell, and drugs to support blood pressure were given, but had no effect. Pete’s family was summoned. As Shirley and Bobby entered Pete’s room, Pete rose up slightly from his bed to look at them, fell back, and was gone.

With his family at his bedside, Bobby “Pete” Hullett was pronounced dead at 6:32 PM on November 26, 2008, the day before Thanksgiving.

Two days later, Pete’s blood cultures were finalized as positive for Salmonella group. In his “Death Summary,” of November 26, Dr. Kaariainen included the following diagnoses at death:

1. Multifactorial shock including cardiogenic shock, septic shock and hypovolemic shock
2. Respiratory failure with ventilator support and significant difficulty Inadequate oxygenation despite 100% FI02 saturation settings on the ventilator
3. Large acute myocardial infarction, troponin peaking at 45
4. Acute liver failure from shocked liver
5. Severe oligo-anuric acute renal failure from acute tubular necrosis from shock
6. Severe underlying metabolic acidosis including lactic acidosis, suspected likely ischemic colitis
7. Ongoing upper gastrointestinal bleeding with anemia
8. Hyperkalemia
9. Leukocytosis
10. Multiple other medical comorbidities contributing as noted In the admission history and physical

Dr. Kaariainen commented, “He was felt to be in shock from a multifactorial etiology including cardiogenic shock from his acute MI, hypovolemic shock from diarrhea and dehydration, as well as probable sepsis from an intra-abdominal source given his severe unresponsive metabolic acidosis and lactic acidosis.”

The “Death Summary” also explained that Hickory Cardiology Associates was consulted and that Pete was treated medically for his acute MI with the limitation that “we were unable to use significant doses of ACE inhibitors or beta blockers given his already pre-existing acute renal failure and hyperkalemia as well as his profound hypotension.”

On December 23, 2008, Pete’s stool culture that had been collected on November 25, 2008 was issued the final result: positive result: SALMONELLA TYPHIMURIUM – HEAVY GROWTH.

CAUSATION

It is clear that Mr. Hullett’s Salmonella infection and death are directly linked to his consumption of contaminated Austin-brand peanut butter crackers manufactured by Kellogg Company.

Specifically, Mr. Hullett consumed Austin-brand peanut butter crackers on a near-daily basis in the days leading up to the onset of his illness in November 2008. The crackers were purchased as a local Food Lion grocery. He began to suffer from symptoms consistent with a Salmonella infection around November 23, 2008, and a stool sample submitted on November 25, 2008 confirmed his Salmonella infection. Also, a blood sample collected on November 24, 2011 cultured positive growth of gram-negative rods, confirming that bacteria were in his blood stream.

Further testing revealed that he had been infected with Salmonella serotype Typhimurium. Pulsed Field Gel Electrophoresis (PFGE) fingerprinting of the bacterial isolate revealed a genetic match to the pattern linked to the nationwide outbreak strain of Salmonella associated with contaminated PCA peanut product used by Kellogg Company in the manufacture of its peanut butter crackers.

_____

[1]           There were also frequent premature ventricular contractions, but the doctors felt that was unchanged from Bobby’s prior EKG.

[2]           Creatinine is a breakdown product of creatine, which is an important part of muscle. A serum creatinine test measures the amount of creatinine in the blood. The normal range (NR) for creatinine is <1.2. A high level of serum creatinine is a marker of poor kidney function, because its presence at high levels shows that the kidney is not functioning properly to eliminate this by-product from the blood. The other such marker used is blood urea nitrogen, or BUN, which forms when proteins are broken down. The normal range for BUN is 5-17.

[3]           Tympany on a physical exam is a resonating sound typically due to intestines distending with gas.

[4]           Metabolic acidosis often occurs in the setting of acute renal failure as the kidneys normally remove acid from the body.

[5]           Clostridium difficile bacterial infections often occur in patients who have recently taken antibiotics with the resulting disruption of their normal intestinal flora which creates an opportunity for C. diff. to overgrow resident bacteria and cause diarrhea. Pete would test negative for C. diff.

Today, the Court in Georgia Federal Court in the criminal case against Stewart Parnell, et al., allowed the defense to question whether PCA and Stewart Parnell was responsible for the death of nine.  Yes, you were and here was one of them.

CLIFFORD TOUSIGNANT’S SALMONELLA ILLNESS

The Early Years

Clifford Frederick Tousignant (Cliff) was born in Duluth, Minnesota, in 1930, to Violet and Clifford Tousignant, Sr. He was an adventurous and fearless young man, known for his introspective nature and generous heart. At the age of 16, Cliff joined the Army in the Civil Air Patrol. He loved the military and serving his country, a duty he maintained for 22 years.

During that time, he fought in the Korean War and earned three purple hearts. The only thing Cliff loved more than his country was his family. He had six children—Paul, Marshall, Susan, Calvin, Jane, and Lou, and eventually became a grandfather to fifteen children, and a great-grandfather to fourteen children. As his family recalls, “He could often be seen with them crawling all over him. He loved every minute of it and loved being in photos with them as well.”

In addition to his loving nature, Cliff was also known for his generosity. One family story that is told often:

The night of his death I sat and spoke with my brother-in-law, Dan Herrick. He shared a story with me. When he and my sister, Jane, were first married, like many Americans times were tight. My dad would make up reasons to come over and fix things that were never even broken. He would give them money as a way to help them get by. He helped out many of us over the years, including his own parents when he joined the army as a teenager. As long as he had a few dollars in his pocket, he was willing to help others as best he could.

After leaving the armed forces, Cliff entered the security field, working for Frasier Shipyards in Superior, Wisconsin until his retirement.

When Cliff was diagnosed with diabetes, he took it seriously, and did his best to care for himself, but despite his best efforts he lost his right leg to the disease when it was amputated in 1985. He also lost four toes on his left foot. But ever the fighter, he did not let the loss of his leg and toes slow him down. After he purchased a motorized wheelchair, Cliff was as mobile as ever.

A Man Loved By Many

For those who knew him best, Cliff could usually be found enjoying a good football game or sharing stories about his past experiences with friends. As his brother, Robert, recalls, he was a “gentle, soft, loving person. That’s not to say that he was a push-over. Although he did not rile easily, when he did he could be very vocal.” Cliff had no qualms about standing up for what he believed to be right.

The memories and stories of those he left behind after his untimely death are the only true way to explain what an extraordinary man, father, grandfather, brother, and friend Clifford Tousignant was to those who knew and loved him. What follows are some of those family memories:

***

My parents divorced when I was 23 years old. My father never dated to much after that so he was pretty much on his own. Of course, that made me want to include him with my family much more at the time. At that time my husband and I had only 1 child our daughter Sarah. We spent one to two days a week with my Dad. Having him over for dinner or him always wanting to take us out to eat. When Sarah was 6, I became pregnant with my 2nd child. We were so excited as was my Dad. Close to my due date, my Dad came down to where I was working to take me to lunch. I had been having a backache all day. I remember him saying ” Maybe you’ll have your baby later today.” I did. My son Brian was born that evening. I called my Dad, he was so happy and showed up at the hospital early the next morning to meet his new Grandson.

As much as he always loved holding the babies and hugging all of his grandkids, he and Brian would just grow closer as Brian got a little older. Being a military man my father just related to guys better. He and Brian became very close, with Brian spending many nights at grandpa’s place. My Dad did so many things for him and with him. He took him on train rides, boat rides, sent Brian flying in a small airplane and just waited on the runway for his return. Brian loved to always go and spend the night at Grandpa’s. It was special, just the two of them. We spent every Thanksgiving with him for years. We always had a birthday party here with our kids on his birthday and on theirs.

It was never a surprise for the kids to come home from school and find their Grandpa here. Brian started to play football at age 12. Now football was my Dads most favorite thing. I’d always go pick my Dad up and off to the game we’d go. Brian’s games were on Saturdays and my husband was always working so my Dad was my loyal companion. He’d sit out there with me in the rain and cold and never complained. He loved that Brian was playing football. My Dad went to every single game with me for 4 years until he moved to Brainerd. My brother Marsh even brought him back here to attend one of Brian’s high school games.

When my brother Marshall retired, he moved my Dad to Brainerd. At that time I was working full time, had one child in college and one in high school. Life was very busy. My Dad spent about 3 years in Brainerd before he passed away. It was nice for my brother and his family to get to spend a lot of time with Dad. It was so different having my Dad not here in Duluth, but I knew my brother and his family were taking good care of him. We’d see him when we could get down there and call. Marshall brought him back to Duluth lots of times so we were still able to see him here in Duluth too.

The last time I saw my Dad was on December 31, 2008. My husband, Sarah, Brian and myself visited him in the hospital in Brainerd. It was hard to see him so sick. He was in the hospital being treated for food poisoning. He looked so happy when we walked into that room. We had a great visit with him that day. I will always be so thankful for that day. I left that day feeling so sad to see him like that but I knew my Dad would get though this because he had always bounced back from everything. I spoke with Marshall, getting updates, just waiting for him to get better. On Sunday January 11, 2009, Marshall called to tell me that he was putting Dad back in the hospital. The next morning Marshall called to tell me that our Dad was gone.

This was devastating to us. This man who had been such a big part of our lives was no longer here. At first I couldn’t get past the shock of it. As more details of how he got the food poisoning came out I just got really angry. My father should not have died from eating peanut butter! How unfair is that? Someone precious to my whole family was taken before his time. We miss him so much.

***

My father raised me on his own from 7th grade on when he and my mother divorced. He and I drove out to Las Vegas together and lived there for a while while I was in Jr High. We then moved back to Duluth and lived there together all through High School. Every time I moved during college (5 times) he was there to help. When I was injured in a severe diving accident he was there. Often times I was asleep in my hospital bed and would wake up; he was there sitting next to me. Not saying a lot but by my side.

My father was a guy that was always helping someone. He did it when he was in the army in Korea, he did it when he came back here after the war and as a person on a very fixed income was helping his brothers and sisters. He wasn’t a man that needed much but was willing to help those that were in need.

He will not only be missed by his children but his siblings, his grand kids and great grand kids. My son will only have fleeting memories of him because he was taken from us at a young age. I purchased season tickets to the new open air Gophers football stadium. He will never be able to go and enjoy an outdoor football game for the team that he loved and that I love now as well. I was recently scrolling through my blackberry and came across his number. I can’t bring myself to delete it. I wouldn’t have to be making a decision like that if he was still with us today.

***

Cliff and I were 20 years apart. He was in the army and when he came home on leave he stayed with his family. His oldest son, Paul, is only one year younger than me so I remember a lot of hectic times. My parents always told me that when Cliff went in the service at 16 years old, he would send his whole check back home to my parents because of the tough times they were going through. Cliff owned a home in Duluth and when the youngest, Louis, was born, Luella (also known as “Toots”), Louis’ mother, had to go back to the hospital with blood clots. I stayed at their house for a month helping out. That’s when I really got to know my brother.

When his wife left him taking all the furniture, but leaving Cliff to raise Louis, I was very supportive of Cliff. I found him a lawyer and went to all court dates with him. Our mother was in a nursing home for 18 months and every weekend I would bring her home and Cliff would come over on Sunday for BLTs with her. When Cliff moved to Brainerd, I talked to him every week. My husband and I went to see him every spring and fall.

I have Rheumatoid Arthritis and ended up disabled. My husband’s company ended after 12 years. Cliff sent $50.00 to us every month for 2 years until my husband could get social security.

Cliff’s Exposure and Salmonella Infection

In late 2000, Clifford moved to Brainerd, Minnesota to live with his son, Marshall. He remained there until November 14, 2008, when he moved into the Good Samaritan Woodland Skilled Nursing Facility, also in Brainerd.

On Friday, November 14, Cliff arrived at his new home. At the time of his admission, Cliff’s health issues were limited to diabetes mellitus, which had caused nerve damage, pain, and numbness in his hands and feet, gastroesophageal reflux disease (GERD), high cholesterol, and autoimmune thrombocytopenia (low platelet count). Cliff’s thrombocytopenia was being well controlled with twice monthly treatments of platelet infusions. His baseline platelet count was determined to be 20,000—a number achieved immediately following a platelet transfusion. Over the days following the transfusion treatment, the platelet level would slowly drop. Once the number dipped below 15,000, another platelet infusion was given.

With regard to Cliff’s diabetes, Marshall—who lived just a short drive away—continued to see his father on a near-daily basis and took part in monitoring his insulin doses.

The move to Good Samaritan Woodland was a good fit. It allowed Cliff to explore his sociable nature while also be under the attentive care of skilled nurses. As was noted in an early intake:

He does like to visit and talk to people. When he is feeling good he likes to take his scooter outside and ride to the clinic or out to eat. Mr. Tousignant has a friendly and upbeat attitude. [He] appears to cope well with change. Resident has good support from his son who lives in the area and visits often.

Cliff got to know his neighbors well, and was frequently found chatting them up. He also enjoyed the meals at Good Samaritan Woodland, one of his favorites being peanut butter sandwiches, a meal he ate almost daily.

His new life at Good Samaritan Woodland continued without much excitement through December. Early in the month he did have a persistent cellulitis on his right arm that required a brief hospitalization at St. Joseph’s Medical Center, but he was otherwise doing well.

All was well until a marked change occurred on Sunday, December 28. That day, Cliff began to have diarrhea. When staff members at the nursing home were made aware of the development, they obtained a stool sample and sent it to the St. Joseph’s Medical Center lab to be cultured and tested.

Throughout the rest of Sunday and into the next day, the frequency of Cliff’s diarrhea episodes increased steadily. When checked on Monday morning, he had passed a large stool and was in distress over the situation. He demanded to be taken to the hospital for treatment.

Cliff’s son, Marshall, arrived a short time later to visit and calmed him down a bit. But the diarrhea and abdominal cramping continued without relent. He was given Imodium, but it did little to slow the frequency of his loose stools.

Hospitalization One—December 30, 2008 to January 4, 2009

On Tuesday, December 30, he was again noted to have “loose brown stools” and additional amounts of Imodium were provided. Dr. Halverson became concerned, as dehydration can be a serious health risk with profuse diarrhea like that afflicting Cliff. He gave orders for Cliff’s transfer to the St. Joseph’s Medical Center emergency room for further evaluation. Marshall was called and notified of the decision. At approximately 10:40 AM, an ambulance arrived and he was transferred to the hospital without incident.

While in the ambulance, he was given IV fluids and a check of his blood pressure revealed it to be elevated at 149/80, along with a blood sugar level of 217. The ambulance arrived at the ER in about five minutes. He was promptly examined and noted to be suffering from diarrhea—at least three to five episodes per day—over the previous days that was described as “pure water,” with some mucus and very foul smelling. His platelet count had dropped to a low 11,000, and thus a transfusion was ordered to help with blood clotting. Of note, his right conjunctiva was bleeding at the time of the initial exam.

Cliff was moved to a room a short time after his admittance. His decreased short-term memory retention was noted, but it was not a problem. The results from his stool culture sample obtained on December 28 were still pending at the time, but the treating physician believed his diarrheal illness could be a Salmonella infection or possibly from a viral source. A blood transfusion was initiated at 1:00 PM, improving his platelet count.

Overnight Cliff remained calm, despite the intense pains and diarrhea. In the morning he was re-checked and found to be alert and oriented. His blood pressure was checked and had come down to 126/68, a significant improvement from the day prior. Later that afternoon the results of his stool culture were finalized and revealed the reason for his declining health—he was infected with Salmonella. He was discontinued on the antibiotic Rocephin and changed to Bactrim.

Although he remained connected to IV fluids, Cliff’s urine output began to decrease. He was therefore encouraged to sip juice and other fluids frequently. After nearly a week of profuse diarrhea, his rectum and scrotum were unsurprisingly red with irritation and bloody drainage. His treating physicians were worried about infection of that area, making frequent cleanings of the perianal area necessary, but no less pleasant for Cliff. He was noted to frequently “yell out” in pain during the cleanings, and would then become upset and frustrated with his caregiver.

The next day, January 1, 2009, marked the beginning of a new year, and also a slight turnaround for Cliff. He was in better spirits than he had been for the past few days, although he was still having “loose mushy green stools,” albeit a little less frequently. The pain medication was also providing relief from the stabbing abdominal cramps.

The seemingly unending blood draws and cleanings began to wear on Cliff, a man who was normally very sweet and gentle, but who valued his independence and privacy. He particularly dreaded the perianal cleanings, but due to the never-ending diarrhea it was necessary. The skin in that area was significantly compromised, causing constant pain and itching. To Cliff, it was pure misery.

Over the next three days, Cliff’s diarrhea continued to be a problem, as was the related skin breakdown in the perianal area. It eventually became ulcerated, with “bloody abrasions throughout peri area.”

Cliff’s body also ached all over and grew increasingly weak. By Saturday, January 3, he required almost complete assistance just to get in and out of the bed, a marked turnaround for a man previously mobile and independent despite his reliance on a wheelchair. That night, after yet another nurse woke him up and the accumulated frustration got the better of him, Cliff had an angry outburst. It was just too much. Between the blood draws, perianal cleanings, diarrhea, body aches, and required assistance just to get out of the bed, he could not contain himself.

Thankfully the next day, Sunday, January 4, brought some good news. The frequency of Cliff’s bouts of diarrhea had significantly slowed and he was feeling better. Other than keep him hydrated and provide assistance as needed, there was little else the hospital could do at that time to treat his Salmonella infection. He was thus discharged that afternoon to the care of the Good Samaritan Woodland Skilled Nursing Facility and transported by medivan.

Cliff was relieved to be back at the familiar surroundings of Good Samaritan Woodland. But over the next week, he continued to struggle with loose stools that simply would not abate.

Hospitalization Two—Sunday, January 11, 2009

In the afternoon on Sunday, January 11, Marshall stopped by to check on Cliff and visit for a little while. He noticed a shift in his dad’s demeanor, who turned lethargic and agitated before becoming completely unresponsive. Marshall had no idea what was going on, and in a panic went to the nursing station to request an immediate blood sugar check and an ambulance to take Cliff to the ER.

The ambulance arrived at 4:40 PM. Marshall and the nurses relayed the events leading up to their arrival, including that Cliff’s blood sugar had tested 99, then 106. While he was awake, he would not respond to anyone. The emergency medical technicians moved Cliff to the ambulance and sped off to St. Joseph’s Medical Center with Marshall not far behind in his own vehicle.

At the hospital, Cliff was assessed for his unresponsive spell. Marshall had arrived by then and explained that his father was in the hospital just last week for a severe Salmonella infection, and that his diarrhea persisted. The decision was made to admit him again for further tests and motoring, including blood glucose monitoring, IV fluids, and another stool culture.

He was noted to be weak, lethargic, and “in such a state that he cannot carry on any useful conversation.” He also passed two loose, brown, liquid stools shortly after being admitted. A gastrointestinal consultation was requested. It was noted that Cliff was previously treated with Cipro after being diagnosed with a culture-confirmed Salmonella infection, but that he continued to decline. It was further noted that “there has been an outbreak of Salmonella at the nursing home.”

That night, he passed a bloody liquid stool, and began vomiting. The vomiting episodes came frequently, and lasted all through the night. A blood sample collected at the time of admission was cultured and confirmed to be positive for Salmonella—the bacteria had made its way from his gastrointestinal tract into his blood stream. The prognosis was dire.

By morning on January 12, he was completely unresponsive. A plan was made for the insertion of a central line catheter and for the transfusion of platelets to combat his plummeting platelet count, but unfortunately those plans did not amount to anything. At 11:08 AM, Cliff took his last breath and quietly passed away. The final diagnosis—Salmonella Gastroenteritis.

At the time of his death, Cliff left behind six children, fifteen grandchildren, and fourteen great-grandchildren.

CAUSATION

It is clear that Cliff’s Salmonella infection and death are directly linked to his consumption of contaminated peanut butter manufactured by King Nut using peanut butter product manufactured by Peanut Corporation of America (PCA).

Specifically, Cliff consumed peanut butter sandwiches on a near-daily basis in the days leading up to the onset of his illness in late December 2008. He began to suffer from symptoms consistent with a Salmonella infection around December 28, 2008, and a stool sample submitted on that date confirmed his Salmonella infection. Also, a blood sample collected on January 11, 2009 cultured positive for Salmonella, confirming the bacteria was in his blood stream.

Further testing revealed that he had been infected with Salmonella serotype typhimurium. Pulsed Field Gel Electrophoresis (PFGE) fingerprinting of the bacterial isolate revealed a genetic match to the pattern linked to the nationwide outbreak strain of Salmonella associated with contaminated PCA peanut product used by King Nut in the manufacture of its peanut butter.

Dean Norman, MD, a geriatric medicine specialist, reviewed Cliff’s records and provides the following opinion on the relationship between his confirmed Salmonella typhimurium infection and his death:

Mr. Tousignant was 78 years old when he was admitted to Woodland Care Center in November of 2008. His major medical problems included diabetes and diabetic neuropathy resulting in numbness in his extremities, right below the knee amputation and multiple amputations of toes of left foot presumably as complication of diabetes, polycystic kidney disease with high levels of protein in his urine, autoimmune thrombocytopenia (low platelet count and platelets are necessary for adequate coagulation), dementia and hyperlipidemia. He had undergone splenectomy in the past in an attempt to improve his autoimmune thrombocytopenia. Of note, he was on multiple medications including the immunosuppressant medications prednisone and mycophenolate mofetil. Despite these problems, Mr. Tousignant was usually alert, able to carry on a conversation. He required assistance for transferring from bed to wheelchair but was able to self propel himself in wheelchair. He enjoyed watching John Wayne movies and listening to music.

Mr. Tousignant developed mild cellulitis (infection of the skin) of his right upper extremity in early December of 2008 and was briefly admitted to St. Joseph’s Medical Center for intravenous antibiotics and discharged back to the nursing home on oral antibiotic therapy after he showed substantial improvement. However, he was readmitted to St. Joseph’s Medical Center on December 28, 2008 after experiencing several days of diarrhea. In the hospital it was noted that he had bloody drainage from his rectum and he suffered from perianal (around the rectum) discomfort. Subsequent stool specimens were culture positive for Salmonella species but negative for other gastrointestinal pathogens.

His symptoms improved on antibiotics and he was discharged back to Woodland Care Center on January 4, 2009. However, the following week, on January 11, 2009 he was transferred back to St. Joseph’s after his son found him to be unresponsive and he was subsequently found to have hypoglycemia (low blood sugar). A blood culture on admission was positive for Salmonella species with similar antibiotic sensitivities to the original pathogen found on his last admission stool cultures. Despite antibiotic therapy Mr. Tousignant’s condition deteriorated and he passed away the next day on January 12, 2009.

It is my opinion that, to a reasonable degree of medical probability, Mr. Tousignant’s illness resulting in admission to St. Joseph’s Medical Center on December 28, 2008 was due to salmonella enteritis (inflammation of the gastrointestinal tract). Usually this infection is due to consuming contaminated food and is usually self-limited. However, in the elderly and patients whom are immunocompromised as was the case with Mr. Tousignant the infection can result in bacteremia (bacteria in the blood) and overwhelming infection. His final admission to St. Joseph’s was clearly due to worsening salmonella infection as evidenced by salmonella bacteremia and this infection directly led to his demise.