I always looked forward to Harold's visits. Harold knew that he had life threatening pulmonary fibrosis. He also knew that doctor's didn't have the faintest idea as to what was causing it and used quite toxic medications to try to keep it under control. Prednisone seemed to work the best for him.
Somehow he forgave me for all the shortcomings of medical science. He liked to chat about his life during office visits: how his grandson was playing football at Notre Dame; how a granddaughter was loving soccer; how the holiday celebrations were special with his family. Over time I thought I had gotten to know Harold pretty well. But did I really?
He would come in cheerful and bubbling with a tendency to minimize his shortness of breath. His lungs were progressively filling up with scar tissue thus blocking the oxygen in the air from effectively getting through into his blood. An oxygen tank helped and he actually accepted it with grace. We did have some serious discussions with his wife present and he had completed an advance directive stating that he wouldn't want to ever be placed on a breathing machine unless he could rapidly return to meaningful existence. His wife would be in charge if he couldn't make the decision.
One day, during a routine follow up visit in the office, I noted that his severe lung dysfunction had been quite stable for over a year. In the conversation I said, "Harold, you know you're really lucky to still be alive." I was referring to his tests and it was meant to be encouraging, but the result stunned me.
Harold burst into tears and started shaking. I rather helplessly said, "What's going on, did I say something?"
"You don't know how lucky I really am to be alive."
"What do you mean?"
"I was a paratrooper on D-Day. I came down behind the German lines like all my buddies. I didn't know where I was or where they were. It was pure terror. I saw a lot of terrible things and did a lot of shooting. It's never out of my mind."
I immediately understood how wrong I was. I really didn't know Harold well. Here was a true WWII hero, trying to live a normal family life, trying to fight a serious illness, yet suffering from disabling post traumatic stress disorder from 50 years ago!
Harold's defenses took hold fairly rapidly and he actually apologized! I tried to reach out and refer him for counseling but he would have none of it. In future office visits he would deflect questions about his WWII experiences, though he wife would confide to me that he would have night terrors with shouting and waking with drenching sweats.
Harold survived two more years until his pulmonary fibrosis finally caused his demise. I wish I could say that his death was peaceful, but as he weakened his terrors took hold. Our palliative care team fortunately used enough sedation and narcotics to take the edge off. But his PTSD didn't really die until he did.
Friday, October 30, 2009
Wednesday, October 7, 2009
A Body for the Morgue, please!
Cheryl and Susan arrived at the hospital at 6:30 AM. As was their routine, they stopped for their Starbuck's latte and shared family stories as they walked toward the ICU. The two were well known pranksters but were widely respected for being top notch ICU nurses. The whole crew there was like a family. They went to baseball games, picnics, and vacations together. Today was like most other days. They were laughing as they walked into the ICU to meet up with the night shift, but could immediately see something was wrong.
Room three was, in ICU lingo, a disaster scene. There was a crash cart with defibrillator in the room with all drawers open with multiple vials and kits removed. IV poles, procedure trays, towels, drapes, and instruments seemed to tell the story of a failed heroic effort to save a patient, now under a sheet on a gurney.
The night crew was really bummed out. Carol, the night lead, told the story. A 32 year old woman had been admitted in severe sepsis, probably from a liver abscess which ruptured. She had severe internal bleeding, went in to shock and all efforts failed trying to stabilize her for surgery. She died about two hours ago. The heartbroken family had just left.
Cheryl and Susan immediately shifted in to professional mode in order to help Carol and the other RN's, by saying "What can we do to help? Look, you have a bunch of calls to make and lots of charting to do before you can leave. What can we do for you?"
Carol responded, "The best thing you could do to help is to take the body to the morgue while we finish up here. We've prepped the body and it's on the transport cart. We hate to ask but ....."
"We'll do it."
Cheryl and Susan were glad the hour was early, that the family had left, and that they we're unlikely to bump into visitors coming up the back elevator. They could see the form of a fairly small woman under the sheet, but neither of them wanted to look. They were familiar with death, but this case was different. It felt close to home. They were silent in the elevator as they went to the sub-basement where the cold lockers in the morgue were located.
.
It was fairly dim in the long sterile hallway, the only noise being the rubber wheels of the squeaking cart. Then they heard the noise. It sounded like a moan, "oooohhhhh". They stopped, stunned and looked at each other. They knew that gases can escape from deceased bodies making noise on occasion, but this was weird.
After another 15 feet down the hall, the noise came again, even louder, "ooooooohhhhhhmmmmm". Then it was quiet. As they approached the morgue doors, again "ooooooohhhhhmmmmm" and the body began to sit up.
Cheryl and Susan had had enough! They both screamed and ran away leaving the body now sitting upright on the cart. They ran down the hall straight into the arms of their laughing colleagues. The "body" was a co-worker, an RN target of prior pranks. "Revenge" was sweet.
Comment: Gallows humor seems to have a place in high stress occupations such as nursing, medicine, fire fighters, police, teachers, etc. It seems that if we can laugh we can deal with stresses much more effectively. Freud, as might be expected, had a much more complex view: In his 1927 essay Humour (Der Humor) he states his theory of the gallows humor: "The ego refuses to be distressed by the provocations of reality, to let itself be compelled to suffer. It insists that it cannot be affected by the traumas of the external world; it shows, in fact, that such traumas are no more than occasions for it to gain pleasure". An interesting theory, but I personally view gallows humor as a only a temporary release and a momentary deflection with the reality of the traumatic situation remaining at the center.
Currently, gallows humor is surprisingly the subject of an academic conference and has surfaced in Presidential comments. It is also the subject of a review concerning its appropriateness in seriously ill cancer patients.
The above story I know is true. I walked into the ICU that morning just as the hilarity was underway. The RN's are still really good friends. The names, of course, have been changed. I hope you won't offended by this story which may appear disrespectful to some. But I'd agree with George Bernard Shaw who said, "Life does not cease to be funny when people die any more than it ceases to be serious when people laugh." I'd love to have you respond with your reactions and stories.
Room three was, in ICU lingo, a disaster scene. There was a crash cart with defibrillator in the room with all drawers open with multiple vials and kits removed. IV poles, procedure trays, towels, drapes, and instruments seemed to tell the story of a failed heroic effort to save a patient, now under a sheet on a gurney.
The night crew was really bummed out. Carol, the night lead, told the story. A 32 year old woman had been admitted in severe sepsis, probably from a liver abscess which ruptured. She had severe internal bleeding, went in to shock and all efforts failed trying to stabilize her for surgery. She died about two hours ago. The heartbroken family had just left.
Cheryl and Susan immediately shifted in to professional mode in order to help Carol and the other RN's, by saying "What can we do to help? Look, you have a bunch of calls to make and lots of charting to do before you can leave. What can we do for you?"
Carol responded, "The best thing you could do to help is to take the body to the morgue while we finish up here. We've prepped the body and it's on the transport cart. We hate to ask but ....."
"We'll do it."
Cheryl and Susan were glad the hour was early, that the family had left, and that they we're unlikely to bump into visitors coming up the back elevator. They could see the form of a fairly small woman under the sheet, but neither of them wanted to look. They were familiar with death, but this case was different. It felt close to home. They were silent in the elevator as they went to the sub-basement where the cold lockers in the morgue were located.
.
It was fairly dim in the long sterile hallway, the only noise being the rubber wheels of the squeaking cart. Then they heard the noise. It sounded like a moan, "oooohhhhh". They stopped, stunned and looked at each other. They knew that gases can escape from deceased bodies making noise on occasion, but this was weird.
After another 15 feet down the hall, the noise came again, even louder, "ooooooohhhhhhmmmmm". Then it was quiet. As they approached the morgue doors, again "ooooooohhhhhmmmmm" and the body began to sit up.
Cheryl and Susan had had enough! They both screamed and ran away leaving the body now sitting upright on the cart. They ran down the hall straight into the arms of their laughing colleagues. The "body" was a co-worker, an RN target of prior pranks. "Revenge" was sweet.
Comment: Gallows humor seems to have a place in high stress occupations such as nursing, medicine, fire fighters, police, teachers, etc. It seems that if we can laugh we can deal with stresses much more effectively. Freud, as might be expected, had a much more complex view: In his 1927 essay Humour (Der Humor) he states his theory of the gallows humor: "The ego refuses to be distressed by the provocations of reality, to let itself be compelled to suffer. It insists that it cannot be affected by the traumas of the external world; it shows, in fact, that such traumas are no more than occasions for it to gain pleasure". An interesting theory, but I personally view gallows humor as a only a temporary release and a momentary deflection with the reality of the traumatic situation remaining at the center.
Currently, gallows humor is surprisingly the subject of an academic conference and has surfaced in Presidential comments. It is also the subject of a review concerning its appropriateness in seriously ill cancer patients.
The above story I know is true. I walked into the ICU that morning just as the hilarity was underway. The RN's are still really good friends. The names, of course, have been changed. I hope you won't offended by this story which may appear disrespectful to some. But I'd agree with George Bernard Shaw who said, "Life does not cease to be funny when people die any more than it ceases to be serious when people laugh." I'd love to have you respond with your reactions and stories.
Thursday, October 1, 2009
Tragic Medical Mistakes
Scene 1: A medical student at a prestigious East Coast medical school, is doing a BSP test (now very outdated) to evaluate a patient's liver functions. The BSP clear fluid vials are in the same container on the cart as the epinephrine. The student accidentally administers a lethal dose of IV epinephrine to the unsuspecting patient - sudden excruciating headache, then cardiac arrest.
Scene 2: There's a diagnosis of recurrent lymphoma in the ICU. The oncologist gives a phone order for cytoxan, prednisone, and vincristine. The recorder, working a double shift, mistakenly writes the vincristine daily for 5 days similar to the prednisone order. The fatal dosage is given to the patient over the ensuing days. He dies in bone marrow failure.
Scene3:In a radiology department, a cleaning solution rather than a dye is accidentally injected into a patient's femoral artery leading to a painful death.
Scene 4: A pharmacist fills a prescription for a patient with asthma. Instead of prednisone, the pharmacist mistakenly counts out digoxin, a pill given for heart disease. Digoxin can have severe side effects even at a dosage of one a day. The prescription is followed by the patient: take 8 a day for 3 days, 6 a day for 3 days, etc. The patient calls the MD about the symptoms of severe nausea and notes the pills look different than usual. The medication is stopped and with treatment the patient luckily survives digoxin poisoning.
Medical errors frequently hit the headlines. Also, there are a number of published articles in the medical literature, even a report to the President. Magazine articles, such as "How the American Health Care System Killed My Father", can be both thought provoking, and provocatively accusatory. Stress and fatigue often play a role.
Medicine is not only a proud profession; it is also highly regulated. Currently doctors, nurses, pharmacists and others can face hospital sanctions, medical disciplinary boards, media scorn, and malpractice threats when they make mistakes. In most situations, a number of things have to go wrong at the same time in order for the mistake to occur. None of the above are my personal mistakes, but "I've been there, done that" and I guess I'm still reluctant to publish my own!
On a personal level it's humiliating and devastating to be involved in a serious mistake. I sat down with a psychiatrist friend after a significant mistake and it helped to talk it out, but the hospital's legal department had to be notified, affected family members met with, and eventual reports to the state dealt with (and this is in the middle of a 60+ hour week). Fortunately I was not sued, but the worry was palpable.
There's pretty good data now, that fessing up is the best thing to do from a legal standpoint and certainly from the moral view. But believe me, it's not easy when you'd rather hide. When one patient died after a procedure that I probably shouldn't have attempted because he was so sick, I sat down with the family and explained the whole sequence. The son had lots of questions, but then looked reflective and said "It must be hard to be a doctor sometimes. Look it's OK. Dad was going nowhere and he's in a better place now." Basically, he had let me off the hook.
On the prevention side, there's good data from systems engineers (like Toyota and Boeing) that critical mistakes can often be prevented with good quality management and systems surveillance. All hospitals and major clinics have extensive quality control and review. The answers can be simple or complex. For example, for some recent eye surgery I had, I was asked my name and birth date three times by three separate people (even though they all knew me) - along with what operation I was having and on which side. These quality/safety techniques require constant review, updating, and reporting.
There are quality ratings of hospitals by procedures that can be reviewed. The hospital that does large numbers of, for example, carotid surgeries will almost always have better outcomes and fewer mistakes than the hospital that only does a few. It brings into question the future role of the smaller hospitals. The issue is not so much mistakes as the inability to match the experience and quality of an institution that does large number of a complex procedure.
How do we deal with all the parties involved in a mistake (the patient, family, providers, institution, legal, insurer, etc.)? Mistakes can be honestly dealt with. It is best for all involved to personally make a face to face apology! Sometimes one is forgiven, then sometimes not. But if animosity can be decreased, often a settlement can be reached after an honest admission of a mistake.. Involving the patient and/or loved ones in a case review with all present can be very powerful. It's very hard to stay angry or want to punish someone who can look you in the eye and sincerely apologize, plus actively listening to all your concerns. There comes a point that we all recognize that we're "only human."
Scene 2: There's a diagnosis of recurrent lymphoma in the ICU. The oncologist gives a phone order for cytoxan, prednisone, and vincristine. The recorder, working a double shift, mistakenly writes the vincristine daily for 5 days similar to the prednisone order. The fatal dosage is given to the patient over the ensuing days. He dies in bone marrow failure.
Scene3:In a radiology department, a cleaning solution rather than a dye is accidentally injected into a patient's femoral artery leading to a painful death.
Scene 4: A pharmacist fills a prescription for a patient with asthma. Instead of prednisone, the pharmacist mistakenly counts out digoxin, a pill given for heart disease. Digoxin can have severe side effects even at a dosage of one a day. The prescription is followed by the patient: take 8 a day for 3 days, 6 a day for 3 days, etc. The patient calls the MD about the symptoms of severe nausea and notes the pills look different than usual. The medication is stopped and with treatment the patient luckily survives digoxin poisoning.
Medical errors frequently hit the headlines. Also, there are a number of published articles in the medical literature, even a report to the President. Magazine articles, such as "How the American Health Care System Killed My Father", can be both thought provoking, and provocatively accusatory. Stress and fatigue often play a role.
Medicine is not only a proud profession; it is also highly regulated. Currently doctors, nurses, pharmacists and others can face hospital sanctions, medical disciplinary boards, media scorn, and malpractice threats when they make mistakes. In most situations, a number of things have to go wrong at the same time in order for the mistake to occur. None of the above are my personal mistakes, but "I've been there, done that" and I guess I'm still reluctant to publish my own!
On a personal level it's humiliating and devastating to be involved in a serious mistake. I sat down with a psychiatrist friend after a significant mistake and it helped to talk it out, but the hospital's legal department had to be notified, affected family members met with, and eventual reports to the state dealt with (and this is in the middle of a 60+ hour week). Fortunately I was not sued, but the worry was palpable.
There's pretty good data now, that fessing up is the best thing to do from a legal standpoint and certainly from the moral view. But believe me, it's not easy when you'd rather hide. When one patient died after a procedure that I probably shouldn't have attempted because he was so sick, I sat down with the family and explained the whole sequence. The son had lots of questions, but then looked reflective and said "It must be hard to be a doctor sometimes. Look it's OK. Dad was going nowhere and he's in a better place now." Basically, he had let me off the hook.
On the prevention side, there's good data from systems engineers (like Toyota and Boeing) that critical mistakes can often be prevented with good quality management and systems surveillance. All hospitals and major clinics have extensive quality control and review. The answers can be simple or complex. For example, for some recent eye surgery I had, I was asked my name and birth date three times by three separate people (even though they all knew me) - along with what operation I was having and on which side. These quality/safety techniques require constant review, updating, and reporting.
There are quality ratings of hospitals by procedures that can be reviewed. The hospital that does large numbers of, for example, carotid surgeries will almost always have better outcomes and fewer mistakes than the hospital that only does a few. It brings into question the future role of the smaller hospitals. The issue is not so much mistakes as the inability to match the experience and quality of an institution that does large number of a complex procedure.
How do we deal with all the parties involved in a mistake (the patient, family, providers, institution, legal, insurer, etc.)? Mistakes can be honestly dealt with. It is best for all involved to personally make a face to face apology! Sometimes one is forgiven, then sometimes not. But if animosity can be decreased, often a settlement can be reached after an honest admission of a mistake.. Involving the patient and/or loved ones in a case review with all present can be very powerful. It's very hard to stay angry or want to punish someone who can look you in the eye and sincerely apologize, plus actively listening to all your concerns. There comes a point that we all recognize that we're "only human."
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