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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