Saturday, February 07, 2015

MEDICAL ERRORS: ONE MAN'S RECENT EXPERIENCE





MEDICAL ERRORS: ONE MAN’S RECENT EXPERIENCE

-- by Ken Godevenos, Toronto, 15/01/22

On December 29, 2014 my wife’s doctor advised us to take her to emergency because of how she was describing the pains in her chest.  She had suffered a heart attack.  The next day, she was transported to another hospital where she underwent an angiogram and angioplasty. Two stents were inserted into her arteries.  Then back to the admitting hospital for overnight observance and home by New Year’s Eve.  So far, so good.
Between then and Thursday, January 15, she had felt some chest discomfort three times and used her nitro spray to counteract it.  It seemed to go away, but not totally. That morning, she had a previously scheduled appointment at her cardiologist’s office to be equipped with a 24-hour monitoring device for her heart, a routine post-heart-attack procedure.  Thinking she would here cardiologist that day, she had made some notes of what she wanted to tell him.  When she found out he was still doing his rounds, she left the typed notes with the staff.  Upon his return to his office, her doctor immediately called and wanted to see her.  He had read the information she had left.  That action alone made a very positive impression on us. 
He sent her right back to the admitting hospital and arranged for a second angiogram at the other hospital the next day.  In the meantime, he had an echocardiogram done on her.  Thankfully, her cardiologist wanted to take no chances.  After all, this woman is still a young sixty-seven years of age and she is very spry, exercising regularly, eating well, and weighing around 113 pounds soaking wet.  The bottom line (after the second angiogram) for my wife at least was: her heart was as strong as a twenty-year’s old; her arteries were all clear; and the two stents were operating perfectly.  We brought her home later on that day.
So what caused the pains she was still feeling after her first angioplasty?  The excellent doctor who performed the second angiogram, although extremely busy that day with both emergencies due to procedures as well as in the recovery room, took the necessary time without being rushed, to explain two potential reasons for the pain.  The first was what he called “heightened awareness”.  A patient who undergoes such a procedure is often super-sensitive of any pain he/she experiences afterwards, often worrying if it could be a heart attack again.  Under normal circumstances, the same individual could well simply exercise right through the pain (and that in fact is what the doctor suggested in my wife’s case; all in due time, of course).  The second reason given was equally plausible.  Because the stents are stiff (made of stainless steel mesh), the arteries they are attached to are not accustomed to them yet.  So when the patient exerts some effort which causes more blood to rush through the flexible arteries, the irritation becomes more noticeable and thus the pains.  Again, these would decrease over time.  And sure enough, to the point of writing, a few days after coming home again, no pain at all.  We expect her to be her old self, showing the rest of us all up, very soon.
But in the five whole days she was in the hospital and I was with her for the majority of that time, in emergency, in recovery, and in a regular room (that wasn’t so regular as you’ll soon read), we observed and learned a lot about hospitals and the medical profession and how they work.  It was no surprise then when I read the leading article of the National Post on Saturday, January 17, 2015 written by Tom Blackwell entitled, “How Much Do We Know About Medical Errors?
First let me assure you that in the process, we met some very wonderful and very professional people – the doctors that took care of us, almost all the nurses, the ambulance teams, and even the cleaning staff.  These people work hard and they do a lot of good for a lot of people.
I remember once kidding a friend’s young teenage daughter about her dad not making it to what I considered was an important board meeting one night, to which she replied, “Yes, sorry, he was up all night saving lives.”  Her father, my friend, was a senior cancer surgeon at one of our well-known hospitals.  I learned my lesson as to what really matters that night and then again recently as I watched so many others doing the same thing – saving lives.
But I also learned some other things – things that if addressed would make these wonderful men and women even better and more valuable to all of us.  Here are just but some of my experiences.
Over the years, I have had my share of experiences with hospitals.  Some of them were great ones, and some a little worrisome.  Besides being born in one, I suffered peritonitis (a potentially fatal inflammation of the abdomen's lining) at eleven months of age.  My father hid under my bed (they weren’t allowed to stay overnight at that time) in the hospital in Athens so he could be with me.  I lost my mother in a hospital after she had gone into a coma on her 64th birthday.  My daughter was incorrectly diagnosed with a blood clot in her lungs, when all she had was pneumonia, because of failure to correctly interpret the x-rays.  In my own case, after they all thought I had three heart attacks, it was eventually concluded that I had pericarditis (an inflammation of the pericardium [the fibrous sac surrounding the heart]).  I lost my father in a hospital of advanced cancer when the doctors told me they could help him live for a few more hours, maybe a day or so, but then it would be over. Together, we decided to let him go earlier rather than later and I was thankful for their guidance and honesty.  More recently I lost my loving grandson after having him for six hours – just long enough to hold, hug, kiss, and pray with, and then return him to his Creator, even though everything went perfectly right through the delivery.  And that’s just the family; I’ve also watched others, friends and associates, die in hospitals.
In our most recent experience, we observed numerous problems that were more often than not clearly a result of process glitches and/or fatigue rather than inexcusable human error.
When my wife returned to her admitting hospital right after her first angiogram and accompanying angioplasty, she was returned to her previously assigned regular two-bed room on the appropriate ward in the hospital.  There was only one problem – when she had left it she was the only patient in the room but on her return that night, there was someone in the second bed with a bad cough.  By morning, that patient was put in isolation due to suspected MRSA (and actually had it as we found out later).  The Mayo Clinic says this about MRSA: “Methicillin-resistant Staphylococcus aureus infection is caused by a strain of staph bacteria that's become resistant to the antibiotics commonly used to treat ordinary staph infections. Most MRSA infections occur in people who've been in hospitals or other health care settings, such as nursing homes and dialysis centers. When it occurs in these settings, it's known as health care-associated MRSA (HA-MRSA). HA-MRSA infections typically are associated with invasive procedures or devices, such as surgeries, intravenous tubing or artificial joints.” And while this patient’s visitors had to wear masks, all we could do to protect ourselves was make sure the curtains surrounding her bed, that only went so far down, were drawn.  We were not even asked to wear a mask.  Fortunately, so far, neither of us has caught the infection, but its existence created another problem down the road.

When we returned to emergency in the admitting hospital on the second occasion, a number of things didn’t seem right.  Again the doctors involved were wonderful.  No problems there.  But other things happened that shouldn’t have.

At one point, the medication my wife was being given by a nurse was wrong.  We asked the nurse to check the records and we had to show her the problem.  She apologized.
At another point, while the doctor and one nurse had told her not to eat anything after midnight because of the procedure due early the next morning, the next nurse on shift in the morning offered her breakfast.  We had to remind her that my wife was not allowed to eat and this nurse also apologized.

One staff person came into the prep and recovery room for the procedures that my wife was getting and informed a patient that they were not going to do her procedure as scheduled.  Needless to say the lady was very distraught.  It turned out that the staff individual didn’t even know which patient she was talking to and had her mixed up with someone else.  That mistake not only upset the patient, but also embarrassed the rest of the nursing team who had been doing their best to keep things under control with a very busy caseload that day.  But that didn’t stop the ‘team’ being human, from talking about it in an obvious manner and volume, when the staff person had left.  The impression that resulted for those that could hear them was not good.

And then there was what I considered the biggest problem.  It happened on her second visit in this whole experience while waiting in the emergency room overnight before going by ambulance to the hospital where her repeat procedure would be done the next morning.   When we arrived the second time at the admitting hospital, I was told I had to wear a mask because, and I quote, “The whole emergency department is under isolation.”  I put one on, as uncomfortable as those things are, trying to be obliging.  But then I noticed that my wife didn’t need to have one on.  As a matter of fact, most of the staff walking around and other visitors and patients didn’t have one on.  That seemed odd.
A short while later my wife started to get up to use the bathroom.  A nurse rushed over and said, “I’m sorry but you have to stay in bed and we’ll bring you a commode.”  I hit the roof.  My wife was quite capable of using the bathroom as she had the last time she was in the same emergency ward two weeks previously.  We exchanged some words and finally they let her go to the bathroom.  They then explained that “she” was the one in isolation and that she would continue to be for her future visits until she was found to test “negative three times in a row” from having the MRSA virus.  So, that was it.  They unnecessarily exposed her to a patient with MRSA on her last visit and told her there was nothing to worry about.   Then they admit her again and lie to us about why I had to wear a mask.  And things got worse.  The doctor on duty clearly supported us and said there was absolutely no reason for her to be in isolation – there was nothing on ‘his’ files to that affect (which begs the question of whether all files are synced properly) and her blood results were negative.  She was perfectly capable of getting up and around.  The nurses argued that they had no choice; it was beyond their control because of the IPAC (Infection Prevention And Control, Canada) rules.  The doctor tried to change their mind unsuccessfully.  A hospital higher up was brought into the picture as well and he prevailed.  But, in the meantime, my wife had gone to the bathroom.  And again the impression we, and anyone who was watching, were left with was not good and unfortunately due to my frustration, I had a part in that.

My anger, especially with the charge nurse who seemed to wander in from nowhere and started telling me off because I got somewhat excited, had to do with the fact that they had lied to me in the first place, and secondly that they weren’t agreeing among themselves over what they claimed to be a “common practice”.  Thirdly, I felt we had a right to know that we had been exposed to on the last visit at that time (not just now) and that IPAC would require my wife to be in isolation each time she came to the hospital until she tested negative in her blood tests for MRSA (apparently even if that took five years or more).  We should have been told that before we left the hospital the first time.  And we certainly should have been told it when we returned the second time rather than the lie to us and tell us the whole ward was in isolation.  They must have thought we were blind or that we’d never stick our head out beyond the curtains around her bed.  Holding her defensive position, the charge nurse would admit to no fault on her part or that of her nurses and failed to recognize any of my points.  All she was concerned about was my raising my voice.  That “holier than thou” attitude ticked me off even more and unfortunately often reminds me of how some other positions of authority defend themselves (but we’ll save that for another story).

And remember that nitro spray?  It was originally prescribed by one doctor and concurred with by another, for when she felt pains.   But the truth is it does not work for all pains accompanying heart or coronary problems.  As it turns out, we find out later that nitro spray works well when the pains are caused by narrowed arteries (so wisely prescribed in my wife’s case), but not when the pains are due to the two potential causes described above, one or both of which were possible in my wife’s case.  Now we know.  Perhaps that would not have been as big a surprise had we been told about other possible causes of pain, albeit it would still appropriately require the “checking out through a second angiogram” to be certain.  And good knowledge of possibilities also helps minimize fear or worry.

My heart goes out to all those who are not fluent in English; to the very aged; to all those who have been taught that doctors and hospital staff are gods (like lawyers) and one is never to question them; and to all those who do not have an advocate who looks out for them constantly while they are in the hospital.  (There must be a business opportunity there somewhere.)  I say this because mistakes do happen.  And while taking the wrong medication, being fed when she should not have, or putting her unnecessarily under isolation may not have physically harmed or killed my wife, the data indicates, according to the National Post’s investigation, that “the true number of preventable deaths is likely in the realm of 35,000 annually.  That’s four (deaths from medical or in-hospital errors) every hour.”
I don’t want anyone’s head.  These are all good people working hard and doing their best.  Some of them are phenomenal and go out of their way to do all they can to help their patients. But the system has weaknesses.  No one is learning from the mistakes.  No one reports, let alone records, the errors as the National Post piece pointed out.  Many patients just can’t wait to get out of hospital and get on with their lives.  Mum’s the word.  If they get out, like my wife, they are among the many fortunate ones.  But what about those that don’t get to go home – not because they died from their wounds or illnesses, but because the system failed them?

A newspaper exposé series like the one that got me thinking about our recent experiences with hospitals is a very valuable tool for the public.  But clearly, it also can have a negative impact on how the public feels about the medical profession.  It is with some justification.  But it is not something we want.  I remember the days when my own parents would never think of asking for a “second opinion” and I remember many a doctor back then actually getting angry if one of their patients did insist on one.  Hopefully, those days are gone – at least for good doctors.  They welcome a second opinion.

But there’s more work to be done in minimizing the errors that do take place.  Let’s hope that the good doctors (and there are many more of them than the other kind) will take it upon themselves to demand their hospitals start keeping records, without blaming those that make them once (we all make mistakes), so that improvements can be built into the processes we all so very critically depend on.

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