When Residents Are Not Supervised—Part 2

When Lewis Blackman, a healthy, gifted 15-year-old, underwent elective surgery at the Medical University of South Carolina– one of the state's most modern hospitals–he was in good health. Over the next four days, he bled to death.
 
Lewis
~~~~~~~~~~~~~~~~~~~~~~

Lewis Blackman’s mother, Helen Haskell, founder of Mothers against Medical Error, sent me this article, first published in The State (Columbia, South Carolina). Her story serves as an extreme example of the dangers that hospital patients can encounter when residents are working without more experienced doctors supervising them. I’m posting the story and commenting on it  [in brackets] because too often, patients suffer when residents are working without a net.


The residents also suffer; they would dearly love to have a more experienced doctor help them with the most difficult cases. But, in some cases, they have been trained not to ask for help. That would be seen as a sign of weakness. 

I’m posting the story Haskell sent me, not to accuse anyone, but to remind everyone, if a loved one is the hospital, and something seems to be wrong, you should ask questions. “Ask to talk to the attending physician or the nurse manager,” says Haskell. “Unless it’s a true emergency, the attending physician may not be immediately available. But if the attending physician she doesn’t show up at all and the patient seems to be going downhill, you have every right to insist that an experienced doctor take a look at the patient.” 

This tragedy also may serve as a wake-up call about elective surgery. There is good reason to avoid surgery and hospitalization unless you and your doctor believe that it is absolutely necessary. Ask your doctor: “Are you saying that it might be a good idea for me go into the hospital and have this procedure–or are you saying that if I don’t, I’ll be making a serious mistake that could endanger my health, now or long-term?”  Often, this is not an easy question for a physician to answer. Doctors are dealing with many uncertainties. But if you put the question in a straightforward fashion, I’m quite certain that 98% of all physicians will do their very best to give you an honest answer.

Below Lewis Blackman’s story, written by John Monk, first published in Columbia, SC’s The State. [My comments in brackets; comments from people who knew Lewis are in italics.]
  ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
 “Nothing indicated 15-year-old Lewis Wardlaw Blackman of Columbia had four days to live when he entered the Medical University of South Carolina Children's Hospital in Charleston (MUSC)  . . .

 “That day, Thursday, Nov. 2, 2000, Lewis had the brightest of futures.

“The weekend before, Lewis' parents – Helen Haskell, 49, and LaBarre "Bar" Blackman, 52 – had taken him and his sister, Eliza, 10, to North Carolina. There, Lewis saw Duke University, which his parents had attended.

“Lewis was on track to sail into Duke, one of the nation's hardest schools to get into. He excelled in math, science, history and English. As a seventh-grader, he made the highest score in Richland County on a highly competitive Duke standardized test.

“Ten days before he entered MUSC, he took the preliminary college board exam at his school, Hammond. After Lewis died, his parents learned he had scored the highest of any ninth-grader at the private school.

"Lewis was truly the most gifted student I've ever had – not that I haven't had others. In second grade, he wrote a story of a butterfly and drew this amazing picture of a butterfly, with all the parts. The book won first place in the school district visual literacy contest. He was such a good all-around kid, too. I know he would have done something great with his life. Whenever I see a butterfly, I think of Lewis."

– Nancy Jarema, teacher at A.C. Moore Elementary School for 27 years. She taught Lewis in the second and fifth grades.

“Lewis had a ‘spark,’ says his mother, Helen Haskell.

“At age 7, he was chosen – out of hundreds of children – to be in a Sun-Drop soda television commercial with NASCAR great Dale Earnhardt.

“Ten months before he died, Lewis played the mischievous boy Mamillius in the S.C. Shakespeare Company's Finlay Park production of "The Winter's Tale."

“In the play, Mamillius says: "A sad tale's best for winter: I have one of sprites and goblins."

“In sixth grade at Hand Middle School, Lewis' teacher Caren Hazelwood told the students about a Columbia man who was trying to ban a book – "Mick Harte Was Here" – that the students loved. Lewis and his class wrote letters to the newspaper. The State published an excerpt from his letter.

"He who destroys a good book, kills reason itself," wrote Lewis, quoting 17th-century poet John Milton.

'LIKE GETTING BRACES'

"Lewis carried mirth around with him. He had this little light in his eyes, and he was very, very quick. As a teacher, I just wanted to work harder for him. When he died, my students and I were terribly upset. One girl didn't recover for months."

– Jeanette Arvay, Lewis' voice teacher, now at Dreher High School

“Lewis was born with a condition called pectus excavatum. It means a crease in the chest cavity. About one in 500 people has it.

For years, medicine believed the defect was cosmetic. But recent studies have suggested it can cause respiratory problems if not corrected.

“For years, Lewis' parents debated having an operation to correct the defect. But they decided it was too dangerous. The standard operation took as long as five hours. The whole chest was opened, and ribs and cartilage taken out. Then, a metal strut was put into the chest.

In 1999, Lewis' parents saw an article about a new operation at MUSC (Medical University of South Carolina) that supposedly was safer and quicker. In this operation, a metal bar is inserted through small incisions to prop up the breastbone.

The article, first published in The (Charleston) Post and Courier and reprinted in The State, was glowing. It described "a revolutionary type of surgery at the Medical University of South Carolina" for patients like Lewis.

“The article quoted MUSC's Dr. Andre Hebra as saying he performed the surgery in an hour through two small incisions. His patient would be playing basketball and swimming ‘in a month or two,’ Hebra said.”

[Speaking with the easy wisdom of hindsight, let me say that, as a rule of thumb, patients should be wary of news that they read in newspapers or hear on television about “medical breakthroughs.” Unless a patient has no other choice, it is probably better to wait until doctors have more experience with the new treatment. Even if a patient is seriously ill, he or she should be given the opportunity to decide for themselves whether they want to take the gamble with a new medical technology. This means telling patients how little we know about the new technique as well as any indications of side effects–mm.]

Monk continues: “Helen and LaBarre discussed the procedure with Lewis and with their Columbia doctor. They contacted MUSC doctors.

“Everyone agreed it was a good idea – and safe. Helen said she and her husband were comforted by MUSC's reputation as the state's oldest and largest medical school.

"We thought it was like getting braces," Helen said.

THURSDAY, NOV. 2, THE FIRST DAY

"Lewis was really funny. He would even make jokes about his chest – that he could eat cereal out of it. He was also more mature. In seventh grade, when we were all telling fart jokes, he was making fun of political things. One of his favorite songs was 'Typical Situation' from the Dave Matthews Band. He said, no matter what mood he was in, that would make him feel better. I think about him a lot."

– Michael Hood, 15, one of Lewis' best friends, now a junior at Dreher High; the song "Typical Situation" is about protesting and accepting life's injustices

“Lewis and his family arrive at the hospital at 6 a.m. The night before, the family—Helen, LaBarre, Lewis and sister Eliza—had driven to Charleston. Lewis chose where they ate, Poogan's Porch, a restaurant known for its Low country dishes.

“Lewis brings the book "Dune," the play "Julius Caesar" and a book on the Israeli spy agency, the Mossaad.

“He also has his proudest possession: his new learner's permit to drive. Since his 15th birthday, Sept. 6, he's taken it everywhere.

“The operation is set for 7:30 a.m.

“Before the surgery, Helen recalls, the nurses ask Lewis for his weight, instead of actually weighing him.

“That bothers Helen, who's not a nurse. An archaeologist by training, she nonetheless knows if drugs are to be administered, weight helps determine dosage.

"I insisted they weigh him," she recalls.

“The surgery is supposed to last 45 minutes. It goes 2½ hours.

“When lead surgeon Dr. Edward Tagge emerges, he says he had to reposition the metal bar in Lewis' chest four times to get it right. All in all, he says, Lewis did fine.

Lewis wakes in the recovery room. He tells doctors that his pain is about a "three" on a 1-10 scale.

At that time, nurses and doctors note in Lewis' record that he isn't producing urine.

“This is crucial because, after the operation, Lewis is given Toradol, a powerful painkiller to soften his chest pain. Good urine flow helps dilute Toradol's side effects.

“The Physicians Desk Reference gives clear warnings about the drug's side effects. Risks include perforated ulcers and internal bleeding. It says Toradol's use should be monitored. Roche, Toradol's maker, also notes the drug's "administration carries many risks."

“Doctors routinely give medicines that carry risks. Usually, risks are monitored.

One of the failures in Lewis' case is that after the doctors prescribed Toradol – with its clearly stated deadly risks – no one notices that Lewis is having a fatal set of reactions, according to his medical record.

“Lewis is taken to Room 749 in the children's cancer ward. There's no room in the surgery ward.

“FRIDAY AND SATURDAY, THE SECOND AND THIRD DAYS

“‘The things Lewis said! Like, he had a 10-minute Santa Claus joke…. He could memorize things like anything… We had conversations that mesmerized me, talking about, 'What if the evil monkeys are still here?' after watching a television show that had evil monkeys coming from alternate dimensions. Six months after Lewis died, I fell asleep in class and woke up thinking he was alive. Then I went, 'Oh, no.'"
– Alex Crawford, 16, one of Lewis' best friends, now a junior at Dreher High

On Friday night, Dr. Tagge, who operated on Lewis, leaves for the weekend.

“At 9 a.m. Saturday, surgeon Dr. Andre Hebra checks on Lewis.

“’No evidence of infection. Clear lungs,’ Hebra writes in Lewis' medical record. ‘May sit up and consider getting out of bed.’"

Hebra is the last veteran doctor to see Lewis for two days. [“The attending on call did not come into the hospital at all on Sunday,” Helen recalls. “Even the chief resident was not in the hospital—only the tired little intern. . . . Monday morning, the attendings would all be in surgery, too busy to see Lewis. By the time Lewis died (later that day) the intern had been on duty for 32 hours.”—mm]

Monk continues: “Lewis' doctors will be apprentice doctors, called residents. A resident has a physician's license but, because of limited experience, must work under a veteran doctor's supervision.

“Saturday night, Lewis begins to run a slight fever. His feet are cold to the touch. He is still on Toradol, taking it by intravenous line.

SUNDAY, THE FOURTH DAY

"On field trips, Lewis would be one of the kids to point out a spider. He would pick up on things other kids might miss or I might miss. He and his Writing Spider T-shirt helped inspire our school's writing excellence program very promising, and I often think, 'What if?' I'll never forget him."

– Darrell Weston, retired science teacher, Hand Middle School

“At 6:30 a.m., a half-hour after another Toradol injection, Lewis gasps. He has horrible pain in his upper abdomen.

"It's the worst pain imaginable," Lewis says to his mother.

“Helen summons the nurse, who wants to know how intense the pain is.

Lewis says his pain is ‘five on a scale of five.’
“He speaks in wonder, almost as if amazed that a human pain could be so bad, Helen recalls later
.

“That is the first indication the Toradol is eating a hole in Lewis' intestinal area. When this happens, blood and toxic material can leak into the abdominal cavity, a sterile place where some of the body's most vital organs are located. Toxic leakage and blood can kill.

Ordinarily, Lewis' pain would be an indication to call a full-fledged, veteran doctor, known as an ‘attending physician’ or ‘attending,’ for short, said a medical expert who examined Lewis' case later.

“Lewis is three days out of surgery and should be getting better. And this pain is in his stomach area – not in his chest, where he had the operation.

The nurse tells Lewis and Helen the pain is gas. ‘There's nothing I can do for gas pain,"’ she says, Helen recalls later.

“In nurses' notes that morning, a nurse writes, ‘gas pains’. pt. (patient) needs to move around.’

“Another nurse suggests a bath. She and Helen put Lewis in the tub and sponge him off.
"Afterward, he sits in the chair for a few minutes. This is a tremendous expenditure of energy for him. He seems to be getting weaker and weaker," Helen writes later in a diary that reconstructs Lewis' death.

Nurses insist Helen walk Lewis. Lewis says his pain is getting worse.

“Over Lewis' feeble protests, mother and son lap the ward.

SUNDAY AFTERNOON

"We didn't insist Lewis have this surgery. It was his decision, but he did it because he knew we thought it was a good idea. He was scared to death to have surgery, and in that he was wiser than we were. When I think of the four of us tooling down the highway to our doom, the day after Halloween, I just weep. When I unpacked the car days later, after it was all over, I found it full of candy wrappers and drink boxes and CDs. Just like a family vacation. Just like always. Except Lewis never came home."

– Helen, Lewis' mother

Lewis' belly grows hard and distended, a sign of a possible intestinal perforation and internal leakage.

His temperature drops, his skin grows pale and he drips with a constant cold sweat. His eyes are sunken. He's exhausted, in great pain.

“All are signs of what is called "acute abdomen" – a collection of potentially life-threatening symptoms. Experts say that veteran doctors know to act on seeing these symptoms. They assume the worst, acting quickly to check out a lethal condition – to rule it out, if nothing else.

Helen calls the nurse a number of times.

“‘She seems convinced that Lewis is simply lazy and not walking enough to dissipate his 'gas pain,'" Helen writes in her diary.

“Outside the room, other nurses decorate the ward.

“As Lewis grips her hand in pain, "I could hear the nurses chattering and laughing in the break room," Helen says later.

“During Sunday, Helen repeatedly asks for a doctor. By that, she means a veteran doctor.

“Instead, Helen gets a beginning resident. She will later learn the resident is four months out of osteopath college. Osteopaths are specialists in bones and muscles.

“As Helen repeats her request, a nurse argues with her – offended Helen doesn't consider the resident a real doctor.

“The resident too is upset at Helen's insistence on a veteran physician. ‘She also is offended, and appears extremely downcast that I have questioned her judgment. . . I reiterate Lewis' alarming symptoms once again: the pallor, the dark circles, the cold sweat, the unremitting abdominal pain,’ Helen writes later in her dairy.

"She stands at the computer and nods glumly, but never says a word. My impression is that she is too angry to speak.

"Somewhere along the line, my request for an attending physician has been quietly shelved. I do not know who made this decision."

“At 6:26 p.m., Helen's insistence is such that a nurse writes in Lewis' record: ‘Parent requesting upper level M.D."

“At 8 p.m. Sunday, the chief resident, Dr. Craig Murray, comes to Lewis'  room . .

“Helen believes Murray is the veteran doctor she has been waiting for. If Murray has identification on him to the contrary, she misses it.

“Murray checks Lewis. He writes in the record: ‘probable ileus.’ That means: blocked intestine.

“Murray orders a suppository to ease the supposed blockage.

“Murray also writes that Lewis' heart rate is in the 80s, slightly above normal but no cause for alarm.

“However, at the same time, a nurse notes in the record that Lewis' heart is beating 126 times a minute – another sign something may be horribly wrong. The nurse also records that Murray has been made aware of Lewis' sweating.

“Murray has a confident manner, Helen recalls. He says Lewis' sweating and lowered temperature – 97.7 degrees, almost a full degree below normal – are ‘side effects’ of the medicine because Lewis is so young.

Later Sunday night, with Lewis' pain still enormous, Helen begins a vigil. “She stops trying to get a doctor. After all, the confident Murray came by. She believed he was a veteran physician.

"Neither Lewis or I sleep at all Sunday night. I have given up on the weekend staff and am waiting for morning when the regular staff and doctors will arrive."

“That night, Lewis' heart rate rockets. At midnight, it is 142 beats per minute and his temperature is 95 degrees. At 4 a.m., his heart rate is 140 and his temperature is 96.6.

MONDAY, THE FIFTH DAY

"Lewis knew about all kinds of things. If you introduced something to the class, he wanted to tell all he knew about it, but he wasn't obnoxious. He was hungry to share his knowledge. In later years, even when he was older, he would never forget to come by and give me a hug."

– Loraine Lambert, Lewis' first-grade teacher at A.C. Moore Elementary School

“More residents keep dropping by.

“Sometime Monday morning, Lewis' gut pain suddenly stops.

“In cases like Lewis', veteran doctors know sudden loss of pain can mean impending death.

“However, in reaction to Lewis' loss of pain, a nurse says, ‘Oh, good,’ Helen writes later.

“When Helen asks a resident about Lewis' pale color – his lips are the same shade as his skin – she recalls the resident says cheerily, ‘Oh, that's just that low blood pressure. It pulls the blood away from the capillaries to protect the vital organs.’

“An aide takes Lewis' vital signs. She can't find any blood pressure.

From 8:30 to about 10:15 a.m., Lewis' record reflects, others try and fail to detect a blood pressure.

“Lewis is bleeding to death internally.

“Instead of summoning a veteran doctor, residents and nurses believe the blood pressure devices are broken. They try various devices, according to Lewis' medical record.

“Nurses' notes say, ‘Unable to obtain B.P. (blood pressure).B.P. attempts on arms and legs unsuccessful.’

“Helen recalls, ‘The focus is entirely on the equipment. For two hours, aides try blood pressure cuff after cuff with no result. They try to take his blood pressure about 12 times.’

“Nurses' notes record Lewis' vital signs. At 8:30 a.m., his temperataure is 96.7–almost two degrees below normal. At 10:45 his heart rate is 155  beats per minute – almost twice as fast as normal. Lewis' heart is pumping so fast because he has lost so much blood internally; his heart is trying its best to pump what little blood is left.

“Still, no one calls a veteran doctor, according to Lewis' medical records.

“About noon, two technicians arrive to take a sample of Lewis' blood for tests. They get just a small sample.

"’Lewis is deathly pale,’ Helen wrote. ‘As they take his blood, his speech becomes slurred. He is trying to say something I can't understand. He says it again, very carefully and with great difficulty: 'Ish … going … black.' "

“It's going black.

“Helen calls for help. She thinks Lewis has had a seizure.

“Still, veteran doctors don't come. Instead, chief resident Murray walks in.

"Dr. Murray calls loudly, 'Lewis! Lewis!' He stands there for two minutes, then asks the parents and Eliza to leave the room," Helen writes later.

“At that point, 30 hours after Lewis has shown signs of a potentially fatal condition, hospital staff s
prings into action. Somebody issues a full alert – a code. Surgeons rush in.

"’We stand in the hall in disbelief, watching this scene from a bad TV movie. … A pastor appears. I turn away in horror. He says, 'Don't worry. I come to all the codes,’ Helen writes.

“Inside the room, doctors – this time, veteran doctors – work on Lewis. They do cardiopulmonary resuscitation. They shock his heart with electrical machines. They hook up intravenous lines, according to Lewis' medical records.

“They work for 60 minutes.

Doctors officially record Lewis' death at 1:23 p.m. Monday – 31 hours after Lewis first said he was having horrible stomach pains.

“At 2 p.m., Dr. William Adamson, the lead doctor during the attempt to save Lewis, writes in the record, ‘It is unclear why the patient expired at this time. We will pursue an autopsy.’

"’Someone comes to get us," Helen writes in her diary later. "The doctors want to talk to us. I am fearful they will tell us Lewis is brain-damaged. When we go into the room, there are five surgeons in green scrubs. One introduces himself as Dr. Adamson. He is the doctor on call. We have never seen him before. Dr. Adamson says, 'We lost him.'

"’This makes no sense to me. He is speaking as though Lewis has lost a battle with a long illness. He has to repeat it several times before I understand. They say they have no idea what happened.’

“Lewis' death is a mystery, Adamson tells Helen and LaBarre. Chief resident Murray found nothing wrong the night before, Adamson says.

“Helen now realizes that, despite her repeated requests Sunday for a veteran doctor, the hospital sent a resident, Murray.

Adamson asks Helen for permission to do an autopsy.

“She says, ‘No.’ Without knowing how, she feels the hospital killed Lewis. The only thing she can think, she later recalls, is: They aren't going to hurt my son any more.

“Within hours, Helen gets advice from relatives and friends with medical backgrounds: Get an autopsy. She requests one.

[It’s understandable when grief-stricken relatives are reluctant to agree to an autopsy. But in some cases, this is the only way that doctors can learn from their mistakes. Moreover, if you want some sense of closure about what happened to a loved one, an autopsy represents your best chance.–mm]

“The autopsy says Lewis bled to death internally because of a perforated ulcer. It shows his abdomen was filled with almost three liters of blood and digestive fluid.

“A child Lewis' size has 4 to 5 liters of blood. This means Lewis lost most of his blood supply into his abdomen.

“After the autopsy, Dr. Tagge calls Helen to tell her of Lewis' perforated ulcer and internal bleeding, Helen says.

“A month later, when Helen meets Tagge to discuss the autopsy, she tells him how she had tried Sunday to summon a veteran doctor. He apologizes. He says the residents should have called him, she says.

“Later, medical experts tell Helen that an experienced doctor, seeing Lewis Sunday, would have known to order routine blood tests that would have uncovered the problem.

“Lewis should be alive, the experts tell Helen.

'IT'S HARD TO KILL A HEALTHY 15-YEAR-OLD'

"Lewis was always laughing. From the time he was a tiny baby, we have picture after picture of him exploding into peals of laughter. ‘.‘.‘. I think the thing that so many people found shocking was that this could happen to someone who was so full of life. He just brimmed with energy. What they don't know – but I do – is how casual it all was. It was the easiest thing in the world. They just filled him with toxic chemicals and let him die."

– Helen, Lewis' mother

“MUSC sent Helen and LaBarre literature on how to go through the grieving process.

“Helen knew that suing MUSC wouldn't bring Lewis back. But she felt she had to do something. She looked for a lawyer.

“She found Richard Gergel, a Columbia lawyer who specializes in medical negligence cases.

“To Gergel, Lewis' case was a clear case of "wrongful death." That's the legal term for the death of a person caused by the negligence of another.

Gergel had medical experts study Lewis' records. Those records include more than 100 pages of doctors', residents' and nurses' notes, made on an almost hourly basis, as well as charts and the autopsy. Gergel said the experts concluded that the medical residents and nurses should have summoned a veteran doctor or – at the least – honored Helen's repeated requests to call a veteran doctor.

"This is about a boy who bled to death over 30 hours in a hospital with modern technology and vast technical resources," said Gergel. "Our experts' main point was that Lewis wasn't properly monitored."

“With Lewis' symptoms, a veteran doctor would have known to order a routine blood test – called a CBC – that probably would have shown Lewis was bleeding internally, Gergel said.

"’The test costs about $30,’ said Gergel. ‘Our experts couldn't understand why it wasn't ordered. It's one of the most common tests in hospitals.’

“Gergel contacted the hospital's insurer. Negotiations began.

“Helen also sent Lewis' medical record to an old friend, Dr. Gregg Korbon, a veteran anesthesiologist and former assistant professor at both the Duke and University of Virginia medical schools. Korbon has participated in thousands of operations, taught hundreds of medical students.

“Korbon said he was appalled by what he saw. "Even a Boy Scout could have done better."

Lewis probably could have been saved up through Monday morning, Korbon said. ‘It's hard to kill a healthy 15-year-old.’

“Eleven months after Lewis died, and without a lawsuit being filed, MUSC's insurer paid Lewis' estate $950,000. That's almost the $1.2 million maximum a state-operated hospital can pay under S.C. law that limits payouts.
[“We did not sue the hospital–we didn't have to,” Helen explains.  “Lewis's surgeon apologized and took responsibility for what had happened. The state-owned insurance company settled with us without a lawsuit. We have no confidentiality agreement. We got very unusual treatment.”–mm]

“Lewis' parents say the money will go for scholarships and to work for better patient safety. They are setting up a foundation.

“’It's public money,’ said Helen. ‘This is money we want to give back to the state of South Carolina. It's Lewis' legacy.’"

“In settlement documents, Helen laid out her claim:

"Petitioner. . . asserts that MUSC was negligent in failing to properly prescribe and monitor the use of Toradol, monitor, assess and treat postoperative complications, provide adequate, experienced attending physicians to monitor assess and treat Lewis, and conduct a timely and appropriate resuscitation effort."

'OUR SYSTEM BROKE DOWN'

"Lewis was just one of those boys who would have made a real difference in the world. He had this particular combination of intelligence and enthusiasm and essential goodness. People loved him."

– Mary Jeffcoat, Lewis' longtime drama teacher

Since Lewis' death, Helen has been to MUSC three times at her request to speak with doctors and administrators. She wanted to speak to them about the dangers of Toradol and her perception that MUSC put too much responsibility on inexperienced residents.

Helen also wanted to speak to the medical residents about how Lewis died.

The hospital denied that request. However, MUSC said it has instituted patient safety reforms since Lewis' death.

Nurses and residents now must call a full-fledged doctor if a family or patient requests it. Patients also will be given manuals explaining their rights. Joe Good, MUSC's general counsel, said he personally was shaken by Lewis' case.

"’Our system broke down,’ said Good. ‘It shook this place to the core. And, God knows, I hope we never see that again. This is the most tragic case I can recall in my 16 years here. We've got to do better.’"

“Dr. Murray did not return phone calls.

Dr. Tagge [the surgeon who performed the operation]] keeps a picture of Lewis on his desk at MUSC.

"’I can look directly at him every day,’ he said. ‘I don't want his death to have happened in vain.’"

“In hundreds of operations that he's performed over his 11 years at MUSC, Lewis is the only child to have died unexpectedly, Tagge said.

“Children's Hospital doctors and nurses were – and are – devastated by Lewis' death, he said. "It really sucks the life out of you."

“’Lewis' death has brought changes,’ he said.

The children's surgery unit has trimmed its use of Toradol. It also now utilizes a pre-surgical procedure that cuts down on intestinal blockages after operations. Those blockages were common, Tagge said. That's one reason residents didn't take more action; they believed Lewis had a blockage, Tagge said.

Although parents and patients always had the right to call a veteran doctor, that standard has been reinforced, Tagge said.

“Tagge said he accepts responsibility for what happened.

"’As a surgeon, if something happens to your patient, y
ou always accept responsibility. I'm the captain of the ship, and if something goes wrong, it's my responsibility. ‘It's all under our watch. Absolutely, we take responsibility. That's why we feel so deeply, and that is why we have changed.’"

“Still, he said, Lewis' case was not as simple as it might have looked. ‘This was a one in a zillion case,’ he said.

“Blood from a bleeding ulcer of Lewis' type normally passes into the gastro-intestinal tract, where it is vomited up or passed out the colon – giving a clear sign that something bad is happening.

"’He broke that rule,’Tagge said. ‘His blood went into his peritoneal cavity and just sat there, which I've never seen before.’"

“Perhaps, said Tagge, a veteran doctor seeing Lewis Sunday would have detected his serious condition.

“But many doctors – possibly including himself – would have missed it, he said. ‘I can't say what I would have done if I were on the firing line.’

“Lewis' complication was "so unusual" it's understandable why it would be missed, Tagge said. "I don't know if I can say much more than that."
[Even if the complication was unusual, it seems to me that what Lewis said about the pain should have raised red flags. Someone needs to listen to patients, especially when they are talking about unbearable pain. Other symptoms—the pallor and sunken eyes—should have raised alarms. –  mm]

'I WONDER WHY'

After Lewis died, Helen and LaBarre got his belongings from the hospital.

“Lewis' proudest possession – his new learner's permit to drive – was missing
It was never found
.

"I wonder why people have to die."

– Lewis, from a poem he wrote in the sixth grade
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I asked Helen what families and friends should do if they truly believe that a loved one is not getting adequate treatment in a hospital. This is her reply:

 “Ours was a story of a family that believed too much in the myth of medicine. The irony is that we were skeptical and, we thought, well educated. We simply did not realize how great the gulf could be between marketing and reality, not only regarding the procedure itself but also the conduct of patient care. In some ways, these problems seem to have gotten worse in the past ten years. Rosemary Gibson covers many of the details of Lewis's case in her recent book, The Treatment Trap.

“There is much that I would advise patients to do.  As you may know, my colleague Julia Hallisy and I have a little cottage industry in the production of (largely gratis) materials for hospital patients. They can be viewed at at this website.  Our operating principle is that patients need detailed knowledge about what can go wrong and what they can do about it. So here's my list.

“We advise people always to have an advocate and a person with a health care power of attorney, of course. . . . Every advocate should look at the patient's medical record regularly and should know what medicines the patient is taking.  They should know the signs of a deteriorating patient — rapid change in vital signs, breathing, level of consciousness, or urine output, for starters — and should keep a journal of what healthcare providers do and say and what treatments and tests the patient has.  (We have a journal on our website that includes forms for these and other purposes, but a blank notebook will also do.)

“It is also important to know how the hospital works: who is in charge of whom, and how to get help when you need it. Patients should know the name not only of their bedside nurse, but also the charge nurse and nurse manager for their unit.  They need to be sure they have a phone or beeper number for the doctor in charge of their care, and they need to know whom to call in order to get help in an emergency (in most hospitals, this would be how to activate the rapid response team).  In South Carolina we passed a law in Lewis's name that requires hospitals to give patients this information.  Massachusetts also requires that patients be given direct access to emergency care in hospitals.

 “Patients should know they can always ask to speak to a higher level caregiver. This is faster with nurses than with doctors, who may not be readily available. You can ask for the charge nurse, the nurse manager or the nurse supervisor. If you don't remember any of those terms, you can just tell your nurse you want to speak to her supervisor.

39 thoughts on “When Residents Are Not Supervised—Part 2

  1. Oh my goodness. Such sadness I feel. I have seen this before, been in the room to see the aftermath, the pain.
    This system, nationwide, must change.

  2. This hospital has had problems for years, in all departments. Back in the 1970’s I was a patient in the Pediatric Cardiology division. My parents would drive for two hours only to be told they did not have an appointment that day, regardless of what the appointment card in my dad’s hand said. Two weeks later the hospital would call and ask why we missed our appointment. This happened multiple times. We continued to go there because it was the nearest large hospital with a Ped. Cardiology department. As soon as we learned of another hospital, we went there.

  3. Oh…I feel bad too.. 🙁 This should really change. What happened is really awful. I hope situations like this will be given more attention. My heart goes out to the family of Lewis.

  4. I’m surprised that a CBC was never ordered. Unfortunately, treating his unbearable pain probably only got him MORE toradol. This big push to aggressively manage pain could cause more harm than it helps. One of the surgeons I used to work with was notorious for poor pain control, but he never had a problem like this or with someone getting too much narcotic. He would just bluntly state ” surgeries hurt”, which sounds callous but might have saved this kid’s life.

  5. Tragic story that represents all that can go wrong in a hospital. Having said that, it is easy in retrospect to always second guess those who have to make these types of decisions every day. In this circumstance, severe pain should have triggered a more vigorous response with checking of blood tests and an abdominal film.
    I will say that I have seen our more experienced surgeons less and less at the bedside post operatively. When your expertise and skill is centered in the operating room, then the post operative care appears routine and mundane. Why would one waste their time rounding on patients post operatively when they could be operating on another patient instead? These results are to be expected if these activities are now left to nurse practitioners, residents, and other lower level caregivers. It doesn’t happen often that such cases end so tragically, but I certainy recall many times that I have rounded on a post operative patient with a major complication that has been overlooked by the surgical team. This danger often increases on the weekends when the attending physicians are often not present and hospital services are less availible.
    As in most of these cases, there needed to be several mistakes in judgement made. The patient was monitored by the nurse, seen by the intern, and then by a senior resident. All did not recognise the symptoms of an impending crisis.
    For the attending to state that this was unusual for no blood to be apparent is laughable. We are trained to recognise the unusual. The unusual presentation of the common complication is the norm. It certainly is not a diagnosis you will make easily from the comforts of home in any circumstance. There is just a gestalt you get only with experience when you know a patient is not progressing as they should after a surgery. The rule should be that if a surgeon operates on a patient, then he should be obligated to see them daily until they are discharged from the hospital; this duty cannot be delegated to other mid level providers or residents and in fact sends a dangerous message to our training surgeons that it is OK for you to ignore your patient after they leave the operating room. Is it any suprise that the disappearance of the surgeons post operatively has paralelled the bundling of surgical payment so that the operation and post op care are all paid as one? Now you can perform the surgery, leave the post op rounding to your nurse practitioner or resident. After all, you get paid the same either way!

  6. Keith, Jenga, Steve, Ed & homemade remedies —
    Keith, I’m not a surgeon, but it makes sense that the surgeon would be in the best position to spot a complication.
    In this case,however, the surgeon was leaving town the day after surgery. Unless we want to say that surgeons can’t perform any surgeries for the week before they go on vacation, surgeon won’t alway be available to check in on the patient daily.
    But as the surgeon iin this story said, someone should have called him. If he had been notified by phone, reports of such severe pain probalby would have alarmed him.
    It also strikes me that the pain should have made someone call in a palliative care specialit.
    They know how to manage pain better than anyone. And, a palliative care doctor or nurse would almost certainly have been away of the possible complications that toradol can trigger.
    And normally, I agree with you, surgeons should check patients daily post-op. As this surgeon said, if something goes wrong, they’re responsible for hte patient.
    I dont’ thingk surgeons should have to be paid extrra fee-for-service to do this. Even if they get a lump-sum payment, hospital rules should say they have to check in with patients post-op. If they are going to be away, they should delegate another exprienced doctor to take over the responsibility.
    But the surgeon can’t stay with the patient, day and night.. That’s why we have nurses, NPs and residents. In this case, it was their job to recognize that something was wrong.
    They didn’t have to diagnose it, just react to the symptoms and call for help from someone who should be able to diagnose it.
    Instead of listening to and looking at the patient, they were focused on the equipment.
    I agree that this is a case where an NP can’t substitute for a surgeon. There are no surgeon-NPs.
    But an NP can watch over the patient, run tests, and alert the surgeon.
    I suspect the resident was overly confident–and didn’t want to admit weakness by calling for help.
    If attendings are not going to be readily available on week-ends, then hospitals shouldn’t operate on Fridays.
    Maybe they shouldn’t operate on holidays.
    What you say should be a warning to patients: don’t let anyone schedule you for surgery shortly before a holiday, and avoid surgery on Fridays.
    Jenga– The surgeon who wan’t good at managing pain and said “surgeries hurt” shouldn’t be practicing medicine.
    I realize that’s a harsh statement coming from somone who isn’t a doctor. But one of my children could be his patient.
    As palliative care specialist Diane Meier points out: “Pain is a disease. Pain kills.”
    Pain that was this severe and this constant is also a red flag. The body is trying to tell you something.
    Steve– what you say about this hospital is important.
    I’m hoping that, going forward, Medicare will be tracking hospital errors.
    If a hospital with a history of high infection rates, medical mistakes,
    preventable readmissions and poor management, Medicare should alert the hospital that it is an outlier, and, if the administration doesn’t manage to correct the problem, recommend that hte administration be replaced. If that doesn’t worwok, ultimately, Medicare shoudl refuse to pay for Medicare patients at that hospital.
    The hospital would close. No hospital could stay open without Medicare payments.
    And I’m afraid that there are a number of hospitals in this country that just aren’t safe.
    Ed & homemade remedies–
    Yes, the system must change.
    Quite simply, Patient-safety should be the top priority at all hospitals.
    Too many hospital administrators have their priorities upside down.

  7. Maybe we shouldn’t train residents anymore. We can’t say without a doubt that lack of experience caused his death. There was no mention of continued monitioring of his urine output. Alot of balls were dropped, but that is a very big one. To the nurses and residents this should have been the biggest clue. Hindsight is 20/20 but you change the shape of the chest cavity it makes sense to get a CBC.
    I disagree with Diane, pain has never in the history of man been a cause of death. It does not kill people. I have never seen it listed as a cause of death on an autopsy. It’s unpleasant and it sucks, but it is not going to kill you. The side effects of treating it can however. That doesn’t mean it isn’t worthwhile to treat, but we can go overboard. That is my point. Treating pain causes more deaths than not treating it, complications such as this or respiratory depression, but we accept those risks. Just like we do to drive a car or play a softball game. This patient died from trying to control pain (Toradol). That surgeon that you said shouldn’t be practicing probably wouldn’t have lost that kid, cause he would have only given him Tylenol with codiene.

  8. Very tragic and disgraceful. But probably quite common.
    Whoever said this I agree “Is it any suprise that the disappearance of the surgeons post operatively has paralelled the bundling of surgical payment so that the operation and post op care are all paid as one?”
    I BEG YOU AND YOUR LOVED ONES-DO NOT GET UNNECESSARY SURGERIES!
    Dr. Rick Lippin
    Southampton,Pa

  9. In the times I’ve been in and out of hospitals one thing I’ve noticed is that nurses all have a big “RN” hanging off their ID badges. It’s pretty hard to miss if you’re trying to figure out whether someone is the laundry person or a nurse.
    Doctors have ID badges but you have to get close enough to read their name/title to tell if they’re a doctor.
    To a non-medical professional everybody looks the same. Why aren’t doctors badged in more direct ways? Why aren’t residents identified as such? Yes they are MDs, but no they’re not out training.
    I feel like it’s all set up to intimidate patients into following orders of anybody who shows up in a blue uniform.

  10. Ginger C.–
    Yes– you make a number of important points and ask some crucial questions.
    For example: Why are nurses identified so clearly as nurses? Why aren’t residents identified as residents?
    Common sense says that, in many cases, nurse, practioners (NPs) or RNS who have been the profession for many years, would be more knowledgable than a 1st year resident.
    Nurses are clearly identified becuase tradtionally, physicians (who were mainly male and much, much better paid) have wanted to make the distinction between doctors and nurses (who traditionally were women and earned far less) extremely clear.
    Resdidents, on the other hand, are on their way to becomign doctors. Doctors and hosptials have many reasons to present them as “Docs.” From the hospital’s point of view, residents represent cheap labor. From the attending’s points of view (an attending is an experienced physician who oversees resident) if patients and their families believe that much less expensive ressidents have the knowledge and training to cover them, attendings won’t have to leave home to come in to the hospital
    In this case it’s obvious that the nurse didn’t do her job. She never called the attending. or the surgeon, or any experienced physican who might have helped
    It could be, as Helen, the mother, suggests, that the nuse was offended my the mother asking for a “real doctor.”
    But a professional should never let her emotional reponse to a patient or a patient’s relative determine how she/he responds to the patient. Certainly not when the patient is in such great pain.

  11. What an incredibly tragic story. My heart goes out to the family, and I applaud their effort to prevent this kind of thing in the future.
    That said, I have to quibble with Mr. Monk’s focus on the absence of the attending surgeon as the cause of this event.
    By Sunday morning, according to the article, Lewis was tachycardic, hypotensive and hypothermic, with a distended and painful abdomen. It shouldn’t take an attending surgeon to diagnose this as shock, likely due to an abdominal catastrophe. An intern 5 months into his residency (they start in July, so Nov is the 5th month) and certainly a chief resident should easily make that call. The important question here, and I don’t claim to have the answer, is why they didn’t.
    I don’t think it is routine to call an attending surgeon about a patient with gas pain. So as long as that was the diagnosis, and the house staff was confident in that diagnosis (even though it was wrong,) their decision not to call makes perfect sense. I suspect they would have called if they had realized the severity of the situation.
    But why didn’t they? Was it because they had worked too long and slept too little? Was it because of too much focus on cutting costs by not ordering unnecessary tests? Was it because they had learned poor physical exam skills from their mentors? or were operating in a a cultural environment where listening to the patient isn’t encouraged?
    I think these are the bigger questions.

  12. They are presented as “Docs”, because that’s what they are. They have graduated from medical school. They are a physician. This was a horrible situation, but do you want to scrap the whole system? If you don’t want residents, don’t go to a teaching hospital. It is spelled out on every admission and informed consent that a resident will be involved with care. The only way you can dictate that you are never seen by a resident is to go to a private non-teaching hospital. If you want an attending to come into the hospital for every problem, there will be no attendings. That is why they often go to an academic program. There is plenty of blame to go around here poor nursing, poor doctoring, as Word stated an intern could have diagnosed this. This involved some missed basic concepts of patient care. There is zero way to prove that an attending would have made the diagnosis.

  13. Word
    Yes it woud seems that a nurse or a resident should have been able to realize that this was an abdominal catatstrophe.
    But they did’t.
    Why? My guess, based on m what Helen, the mother, says, is that the nurse and the resident were pretty angry that she was asking for a “real doctor” or “veteran doctor.”
    It’s not too hard to imagine that they saw her as a snob.. Ths could be why they stone-walled her.
    And this is why Helen (the mother ) should have had phone numbers for the attending and for the surgeon.
    One or both probably would have been alarmed by her description of what her son said about the pain, his pallor, sunken eyes, etc.
    The problem with residents working withut supervision is:
    a) they haven’t seen enough cases to have a good gut instinct that somethign has gone terribly wrong (even if an unusual way that they can’t diagnose what it is. ) and
    b)often they have been taught that they should b independent– they are “doctors’–and should’t lean on ab abatending for help.
    This is all tied up with the notion that an “M.D.” gives you magical powers.
    Residents are apprentices. In other professions and jobs no one expects people who were studednts yesterday to become seasoned epxerts the day after they recive a degree.

  14. If I’m not mistaken, surgical residents are usually “chief” in their 5th year of residency. Surgical residencies run 5-7 years, but usually its 5 years of clinical training, with the remainder being research. So, it may very well be that this chief surgical resident was in his final year of residency. If that’s so, then in July he’ll magically become an attending, just as he magically became “a doctor” after graduating medical school, and then there will not be anyone supervising him; he’ll be the most senior doctor on the team, the one Helen was asking for.
    I share your hope that the attending would have taken the situation more seriously if he had been contacted, but I don’t know if that’s the case or not. The attending’s reaction probably would have depended, at least in part, on who did the contacting, and what, exactly, they said. I can imagine that waking up the surgeon in the middle of the night to say, “Lewis Blackman is having some really severe gas pains” might have resulted in an angry outburst and offered minimal benefit for Lewis. On the other hand, a call saying something like, “Lewis is having severe abdominal pain; he is distended and tachycardic, he’s not producing much urine and he’s generally looking sick” would probably have resulted in some very helpful instructions. But in order to say that, the resident would first have to see it that way. It’s not unreasonable, especially in the case of a chief resident who will graduate and become an attending surgeon in a few months, to expect that he could see this situation for what it is. At a minimum, he should recognize that this is potentially serious, and investigate further.
    To be clear, I definitely do think that the attending should have been contacted in this case. Helen recognized the seriousness of the situation and tried to get the attending involved, but her concerns were ignored because the residents didn’t agree with her assessment that her son was in serious trouble. Since the attendings are not in the hospital all the time, they rely on their residents’ assessments to keep them abreast of what’s happening, and to decide when they need to be more involved. Maybe that should change; maybe there should be other ways to get the attending involved, as you suggest. But the residents, especially the chief, need to be able to get the assessment right. Any solution that doesn’t involve the residents getting this right is inadequate. They can, and should ask for help if they need it, but if they get through residency unable to do this, then they are not adequately trained, and may represent a danger to their patients for the rest of their careers.

  15. This is a very tragic story and I’m sad to hear of the family’s loss.
    I think that this was best stated when described as a system wide breakdown. Being a physician myself who was recently in residency, I did have a few thoughts on the article and case presented. And if you’re wondering, I’m not a surgeon (actually internal medicine) and I have no affiliation with this hospital.
    CASE: There’s a large number of questions I have surrounding the case itself. Why didn’t the nurse contact the intern sooner? Why was no lab or imaging done? Why was no imaging done when an ileus was suspected? Why was the patient not transferred to an intensive care unit when his vitals were becoming unstable? What were the lab results from earlier that day? Hindsight is 20/20 and since none of us were there doing the exam ourselves, it’s difficult to say. This may very well have looked like gas early on and an ileus is a very common post-surgical complication. Without a doubt, this should have been managed a lot more aggressively. There’s a pretty standard protocol in most training institutions: the nurse assesses the patient and notifies the intern if needed (in this case the onset of abdominal pain which was a new symptom and change in hemodynamics), the intern evaluates the patient who in turn either treat/work-up/or will notify their upper level if they are uncomfortable. The upper level resident will then do the same and will notify the supervising physician of record for that night if needed. Also, keep in mind that the upper level resident in this case was in his last year and 7 months from finishing. I understand that this is still considered training, but by this point in their career, they should need only minimal supervision. The comment made by the hospital that this was a 1 in a zillion case doesn’t make much sense. And there really isn’t a specific test that we can say would have definitively made the diagnosis sooner. CBC’s (specifically the hemoglobin and hematocrit) are known to lag behind acute blood loss as the hemoglobin equilibrates. An x-ray may have shown air under the diaphragm but it may have been obscured. I’m not defending or following this “secret code” someone mentioned, just providing a little information.
    PAIN MANAGEMENT: In this case you have to look at three things concerning his pain. The first is that he’s having abdominal pain not chest pain. The second is that he had a surgery involving his chest and not abdomen. The third is he’s getting worse when he should be getting better. It’s a completely new symptom that appears unrelated to his surgery and must be worked up first. If he were given Tylenol, it probably wouldn’t have worked, very few problems that cause acute abdominal pain require toradol (which at this point would not have helped the situation any), and this leaves us with Narcotics. This would have likely been able to control his pain, although probably requiring high doses, and masked his symptoms and dropping his blood pressure thus causing him to expire sooner. Using rather large generalizations, palliative care is a specialty who, as you say, is quite good at managing pain, but deal with the terminally ill usually. Pain Management Specialist for the most part are outpatient clinicians who deal more so with chronic issues (usually musculoskeletal). And you may be right that this would at least have an “experienced physician” examining the patient and he may have made the diagnosis. But since you’re going to be hard pressed to find either on the weekends, I think that a consult to pediatrics, internal medicine (depending on age), or critical care would have been more appropriate in this setting. It may not be a supervising physician coming by, but it would have been a different insight into his condition. And as for the guy’s saying “surgeries hurt”, he’s right. His statement is being transposed onto this case, where it seems cruel, but look at it this way. We don’t like to see patient’s in pain either, but we also don’t like to see the guy who post-operatively gets too much pain medication, won’t work with physical therapy, lies in bed all day, doesn’t use his incentive spirometer because he sleeps all day, aspirates his dinner, and then either ends up on a ventilator or dies. That’s a bit of an extreme, but so were your statements on the matter. It’s a bit more complex than it may seem. And pain doesn’t kill. What’s causing the pain may, as demonstrated here.
    IDENTIFICATION: We are taught to introduce ourselves when we enter the room. If we forget, just ask, we don’t mind. Not sure where the blue uniform thing came from but for the most part, we have long white coats with our name plus a badge, students have short white coats, and nurses have no white coats.
    POST OPERATIVE MONITORING: It sounds like supervision was handed to another physician that saw the patient Saturday. It’s unlikely he didn’t come to the hospital on Sunday. I can’t say exactly why he didn’t evaluate him personally, but it was probably dependent on the information presented to him by the team. As far as requesting the physician’s phone number and pager, I don’t think this is reasonable. If you could only fathom how much this would be abused, you would retract that statement. The nurses should have the information as well as the operator if needed. And in this case, if the nurse hadn’t agreed with the management of the upper level and felt it would harm the patient, she should have called. Physicians have to have time off too.
    ELECTIVE SURGERY: I absolutely agree with the statement that they should be avoided when possible. It’s risk versus benefit, as simple as that. And as for the comments on not having surgery before the weekend or holidays, if you come down with appendicitis on a Friday afternoon, I probably wouldn’t wait until Monday.
    SLEEP DEPRIVATION: About the 30 hour limit currently in place, that’s how my residency was as well. I could probably talk for hours about the subject, and I never thought I’d say this, but I’m glad I did it. I’m glad it’s over, but still, glad I did it. The patient autonomy, amount of knowledge, and experience you gain is invaluable as a developing physician. I do feel that a lot of changes are on the horizon, and quite frankly, the evidence supports it. I’m not too sure what the right answer is to the sleep deprivation problem. I’m not quite sure why this article was chosen to support the problem though. The intern in question is listed to have been there 32 hours at the time of death so wouldn’t that mean she had just arrived about the time his symptoms started.
    In closing, I’d just like to say that I’ve recently read quite a few of the articles on health beat and I think they are very pertinent issues. I’ve been quite shocked about the general feelings displayed towards physicians. Apparently, we’re all in it for the money, aren’t good with managing what we make, aren’t very intelligent if we have to try more than one therapy, don’t care about our patient’s or their families, etc. I’d like to think that I went into medicine for the right reasons because I could help people and make a difference in some of their lives. Money was never the driving force behind my decision. I didn’t come from money and no one picked up the phone for me and made a quick call to get me into medical school. I’m the first in my family to even finish college and I’ve worked hard to get to where I am. I’m not looking for a pat on the back but just for you put a little more thought into the impact your statements may have. Physicians are as varied as everyone else. And for those who feel that training programs should have a supervising physician standing beside the resident at all times, you can be the first to go see them when they finish and become a supervising physician because I won’t. It’s hard to explain when you haven’t been through it, but there is no way to replace experience, and having a life-line by your side at all times, isn’t the same. Try to imagine daddy taking the training wheels off and pushing you down a steep hill while he walks back inside.
    The major issue is that a kid lost his life when the diagnosis was missed by several members of the health care team.

  16. Nice post Todd, I guess one of the big issues here pain management wise is explained vs. unexplained pain. Tylenol wouldn’t have been great post op, but that surgeon I was discussing would have expected that and not have given Toradol in the first place. Narcotics and coupled with Toradol could have made matters even worse by dropping his BP and masking the true nature of his pain. Pain management is not a risk free endeavor. Pain is a disease, sounds nice, but as we have seen time and time again sometimes the treatment is worse than the disease. It is a symptom, it does not kill. It is worthwhile to treat, but it is not without risks. The surgeon that says “surgery hurts” may not be callous, just risk averse. If my kid is being operated on I want the person that does the best job, while subjecting them to the least risk possible.
    As far as identification, I guess I can have the number of years in practice and board certified sewn on the back of my lab coat like a football jersey. In my residency it was made clear that if you are not sure there are plenty of people to call. If these residents were more worried about making an attending mad by calling them, rather than taking the best care of the patient they are going to have to live with that, because it is inexcusable. Residents and Interns are giving free reign in hospitals to be involved in basic patient care, which is what this was. Monitoring vitals, looking at urine output, exam, labs, they are all allowed to do these things and they failed miserably.

  17. I think what my be needed here is for some doctors (particularly specialists) need to grow up, not Maggie.
    As seen many times in cancer medicine, oncologists are paid to treat. Many times in this overzealous need to treat, they overlook the side effects that can occur from particularly overtreatment. This is not what oncologists do. They don’t know how to treat the side effects of their treatments.
    Cancer patients need to add to their repertoire of spcialists for their disease. A Physical Medicine and Rehabilitation Specialist for neuropathy, a Pulmonary Specialist for radiation pneumonitis, a Neurologist for leukoencephalopathy or worse, radiation-induced necrosis, or an Endocrinology & Metabolism Specialist, depending on what actually could be wrong with the patient.
    I’ve just been recently reminded of these kinds of problems with orthopedic surgeons after they have performed a knee replacement (arthroplasty). Infection remains one of the most challenging complications of joint arthroplasty. For most orthopeds, only a detailed clinical history and physical, with xray, remain as their recognized tool for infection. Arthroplasty pays more than cleaning up after infection.
    Classic signs of fever, chills, inflammation and painful joint are ignored as simply low-grade infecton and/or aseptic loosening. Only when you make the orthoped actually go in an examing in detail do you find out what he presumed wasn’t the case. An Infectious Disease Specialist should be aboard after any joint arthroplasty.
    Symatics aside (about whether pain kills or the treatment of it can), pain is debilitating. It is unpleasant and it sucks. Lack of treatment, as well as overtreatment, can be the beginning of a patient’s demise.

  18. Greg, how many total joints do you perform per year? I want to get your expertise in treating total joint arthroplasty infections, to make such a claim that will spend millions, possibly place patients at risk with futher testing and raise the infection risk by introducing possible unneeded joint aspirations, you need to show your work.

  19. A tragic story, but all too possible anywhere. And NO real consequences for the idiot who performed a risky procedure, prescribed a very risky medicine, and LEFT FOR THE WEEKEND WITHOUT MAKING SURE THAT THE PEOPLE WHO HAD TO HANDLE THE SITUATION KNEW WHAT THEY WERE DOING!!!!
    We had a similar experience with my 98-year-old father in a large teaching hospital in the DC area. He was rehospitalized for an erupting internal postop infection after his gall bladder was removed. He was admitted to a coronary unit, since there were no empty beds on other units. The morning after he was admitted (and NO treatment had yet been performed for the infection), a couple of newly-minted interns walked in, gave a cursory look at his chart (I think they looked at it, anyway) and decided he would be discharged since he had no problem with his congestive heart failure (which was under control, but somehow had been entered on his chart above the infection). The first my wife and I heard about it was from the discharge nurse who informed us of this (and that she was preparing his discharge) when we walked in that morning (a 2 1/2 hour drive from our home in southern MD). Only after we got rather loud talking with the floor nurse did we get anyone to listen to the fact that he was there for the infection, not the CHF. Never did get to confront the interns or the resident about the error. I shudder at what might have happened, since it took a surgically-implanted drain and 5 days to get the infection under enough control for him to be released to home health and a 10-day 24-7 IV antibiotics treatment (which is another story which I won’t detail here).
    Patients and their families have to be prepared to defend themselves at all times.
    Oh, and I think the link to Dr Hallisy’s website should be http://www.theempoweredpatient.com/, not http://www.empowered.patient.org/publications. The link you have in the article (the latter one) leads to a site with information on Alzheimer’s and diabetes.

  20. Jenga, Todd
    Jenga–You write: “Pain is a disease sounds nice.”
    As I noted, I’m quoting Dr. Diane Meier, a pioneer palliative care specialist. She isn’t saying this because it sounds nice. She has sat with many patients who were in pain and dying. She has learned how to manage that pain. She sits with them when they are dying. “Just sitting there. It’s hard,” she admits. Very few doctors do this.
    You might want to read her new book.
    Many U.S. doctors–and not just palliative care specialists– will tell you that far too many Americand die in screaming pain-as Lewis did.
    Todd–
    Thank you for your reponse. It’s clear you put a great deal of time and thought into it.
    First, let me just note, this post is not about sleep deprivation. Part 1 focused on that problem. This post (part 2) looks at the other problem that the IOM reports on– residents not being adequately supervised.
    I mentioned that the intern had been on for 32 hours as a small part of a larger story. She must have felt terrible, but she really wasn’t in a position to rescue Lewis.
    You ask some very pertinent questions: “Why wasn’t Lewis transferred to an ICU? Why wasn’t any imaging done?
    Because the nurse didn’t believe the patient. She thought he was experiencing pain as a result of “gas.” So she didn’t call a doctor or the chief resident.
    How a nurse could ignore the pleas of a child in great pain for so long is beyond me.
    But at least one other nurse supported her– suggesting to the mother that they bathe the child–that might make everything okay.
    The first thing that went wrong here is that no one (except the mother) was really listening to the patient. They don’t seem to have been looking at him either– ignoring pallor and sunken eyes.
    When they couldn’t get blood pressure, they focused on the equipment, not the patient.
    This all makes me think about an essay titled “What patient-centered should mean: Confessions of an Extremist” by Dr. Don Berwick, President Obama’s candidate to become head of the Centers for Medicare and Medicaid.
    In the essay, Berwick quotes
    “A New Professional: The Aims of Education Revisited,” by Parker Palmer:
    Berwick observes that “Parker argues against definitions of professionalism that separate human beings from their own feelings and hearts. He writes, in part:
    ‘The education of the new professional will reverse the academic notion that we must suppress our emotions in order to become technicians…. We will not teach future professionals emotional distancing as a strategy for personal survival. We will teach them instead how to stay close to emotions that can generate energy for institutional change, which might help everyone survive.'”
    Berwick continues: “Ask patients today what they dislike about health care, and they will mention distance, helplessness, discontinuity, a feeling of anonymity—too frequently properties of the fragmented institutions in which modern professionals work and train. Palmer is arguing for a reconnection of the feelings of health care professionals with their work, and he believes that violence is done when that connection is sundered by institutional norms and training. I claim that threats to the health of the professions come far more from denying our basic instincts to help than from embracing them.”
    I’m sure the nurse who didn’t believe Lewis had seen many patients in pain. After a while, no doubt one can become inured to witnessing such suffering. Traditionally, physicians have been taught to distance themselves.
    But Berwick and Parker argue that caregivers should stay close to their emotions.
    Are they asking too much of caregivers?
    Perhaps– Berwick acknowledges that in his title: “confessions of an extremist.”
    But in this case . . .
    After Lewis says his pain is 5 on a scale of one to five , the nurse says “there’s nothing I can do about gas.”
    Helen seems to have annoyed the nurse by asking for a “real doctor.” Perhaps this is why the nurse reacted in this way? I don’t konw.
    After 9 a.m. Saturday, Lewis was not seen by an experienced doctor–until he was dying Monday afternoon. That’s more than 48 hours.
    There was No One to order imaging or to transfer him to an ICU.
    The nurse refused to call the Attending.
    All day Saturday, Saturday night and throughout most of Sunday, no one sees Lewis except the nursing staff and the intern.
    The surgeon who saw Lewis Sat a.m. didn’t come in at all on Sun. (The insurance co. looked into all of this.) Also, none of the attendings came in on Sunday. This is a large hospital. Lewis is not the only paitient. None of them needed to be checked?
    Finally, Sunday afternoon, a first year resident comes in, barely talks, and seems angry that Helen wants an experienced doctor. Rather than being focused on the patient, she sounds pretty self-absorbed. She doesn’t enter anything in the record that would serve as a red flag about his condition.
    Sunday night– more than 36 hours after the doctor saw Lewis Saturday morning, the chief resident comes in.
    He decides this is an intestinal blockage. Doesn’t order any tests to hceck whether his guess is right. Also says Lewis’ heart rate in the 80s. At about the same time, a nurse records that it is 126. And apparently the chief resident doesn’t know anything about possible complications associated with this pain-killer.
    In retrospect one can only say that the chief resident appears to have been incompetent.
    Monday morning, the attendings come in but are too busy in surgery to check in on Lewis. No one—not the nurses, not the chief resident– try to alert them that Lewis is in trouble.
    I mentioned bringing in a pallisative care specialist because they are pain specialists and because they spend time with patients who are dying– and would be likely to recognize signs that someone is dying. As an experienced physician, I’m sure you know, there is a “look”, difficult to describe, but this is intuitive knowledge that physicians accumulate over time.
    Pallaitve care specialists also are extremely compassionate, are trained to believe the patient, and understand that pain must be managed. They don’t/can’t distance themselves from patients.
    A pain specialist who deals with chronic pain is coming from a very different place.
    The notion that it’s hard to find an experienced physician on a week-end is troubling. I understand that doctors have lives. But if it’s hard to get any experienced doctor to come into a hopsital to check on a surgical patient on a week-end, then perhaps hospitals shouldn’t do elective surgeries on Thursdays or Fridays?
    This case may well have been hard to diagnose. But as a lay person, I, like Helen, would have realized that he should be getting better, not worse, that the surgery involved his chest, not his abdomen. . . all of the points you make.
    These red flags suggest that the attending should have been called in. The original surgeon should have been called. If they couldn’t diagnose it, a consult with one of the specialists you suggest would have been appropriate.
    If they had started paying attention to Lewis on Saturday, when he began to go downhill, I have to think that they had enough time to diagnose this–if they asked enough doctors. This was not a rare disease from Africa. This was a reaction to a drug that we know about.
    One would think that by Monday morning, someone would have thought: “maybe it could be the pain-killer?”
    Even if no one had ever heard of the complications associated with the pain-killer, someone could have looked it up. In a situation like this, dcotors tell me that that you just check and double-check everything. And if the original surgeon who prescribed the painkiller had been called, I would think it likely that he would have been aware of the medicati\ons’ risks.
    On Pain: I’m not a doctor, but when I said “Pain Kills” I was quoting Dr. Diane Meier, a pioneer pallative care specialists. (Not sure how pain kills–probably it leads to a heart attack?)
    She also describes pain as a disease–and has seen far too many doctors more worried about over-medicating the patient than they are about the patients’ suffering.
    Of course hospitals and doctors vary in their attitude toward, and understanding of, pain.
    But Meier points out that med students learn very little about pain and pain management, and believes this should be required
    In other countries that are not as phobic about “drugs” as we are, pain is often better managed
    Meier is not the only palliative care specialist that I know and I greatly admire and respect all fo them.
    They do listen to and look at patients. That’s what their job is all about.
    The surgeon who saw Lewis Saturday morning did not come to the hospital Sunday. (This was all investigated by teh insurance company among others.) None of the residents came to the hospital Sunday. And the chief resident didn’t come until Sunday night.
    The only person there was the intern and a first year resident.
    On getting in touch with the doctor: I have a dentist who gave me his home phone number after an extractoin in case I get into trouble after I got home .
    My daugher’s dentist did the same when she had her wisdom teeth removed. I’ve never called either of them, but I appreciated having the numbers.
    Especially when the patient is a child, it seems to me the parent shoudl have a number for Someone– the attending who is on call, or perhaps the surgeon (who had every right to go on a vacation, but perhaps should have called in to make sure Lewis was okay.) Or perhaps the surgeon should have given Helen the number of the second surgeon who seems to have been covering for him.
    I realize some patients’ families would abuse this. And they should be told “please don’t use this except in an emergency.”
    If they call about what is clearly not an emergency, a doctor has every right to be curt.
    But when a hospital is understaffed on a week-end and the hospital bureacracy isn’t reponsive, what can parents do?
    Finally, regarding my “general feelings about physicians” — I have many physician sources who have become friends. I admire and respect them. By and large, doctors are very intelligent. I enjoy talking to them. Many are compassionate. Many went into medicine for all of the right reasons. Many find it difficult to practice medicine the way it should be practiced (patient-centered and evidence-based) in our fragmented and money-driven health care system.
    I also have met physicians that I don’t admire and respect. In Manhattan, in particular, some doctors are shockingly candid about why they became doctors. In a social situation, I once asked an eye surgeon why he chose that specialty. He turned to me and said “What are your eyes worth.?” He wasn’t joking. He went on to boast about his income.
    An oncologist who has become a friend wrote a post for HealthBeat that I titled “A Very Open Letter From An Oncologist” –you’ll find it here. He’s appalled by the degree to which cancer patients are over-treated.
    I’m a reporter dedicated to health care reform. This means that I think insurance companies, hospitals, drug-makers, and device-makers all need to change the way they do business. And a fair number of doctors tell me that doctors also need to re-think priorities and how they practice medicine. They also believe that we need to reform med school education. We’re “modeling” doctors in the wrong way.
    This may be why a few (and in my experience a very few) doctors respond sharply to any HealthBeat post where a doctor appears in a less than favorable light, and suggest that I don’t like docs
    Not true. I’m simply trying to spread the word–what doctors are telling me–about problems in the profession, and often, problems in our hospitals.
    As you say in your response, elective surgeries carry risks. Doctors should make this very clear to patients. Some don’t. It seems that the surgeon who operated on Lewis didn’t. I’m sure he believed that this new surgery was a medical breakthrough and much safer.
    I have no idea why he prescribed a potentially dangerous pain-killer, but perhaps, expecially because he was going to be out of town, he wanted to make sure Lewis wouldn’t be in pain.
    I’m a fan of the “shared decision-making protocol” developed by Dartmouth’s Dr. Jim Weinstein and others that gives patients a real chance to make an informed choice. It’s time-consuming, but I’m hopeful that Medicare will begin paying doctors and decison-making coaches for the time it take to take patients through it.
    Almost everything I know about medicine I have learned from doctors. See my book, “Money-Driven Medicine” and the film Alex Gibney made of the book– starring people like Doctors Jim Weinstein, Don Berwick, Dr. Junior, a wonderful doctor practicing at a clinic in the south, and other primary care docs. (You’ll find a link to the DVD on the front page of this blog–on the right.)
    . Todd, I totally believe that you went to med school for all of the right reasons. Many doctors did. But I have to believe that you mjet people in med school who were there for the wrong reasons . . . . . . . .
    Again, thank you for taking the time to think about and comment on all of this.

  21. Harry C.–
    I agree that the surgeon who operated on Lewis should have lined up someone to cover for him while he was away.
    Perhaps he did– a surgeon checked in on Lewis Sat. A.M.–but never came back. At that point, Lewis wasn’t yet in great pain.
    I’m more appalled by the nurse who refused to call the Attending. If the Attending couldn’t figuure it out (and apparently it was a difficult diagnosis) he should have called the surgeon.Or called d in other specialistrs to consult—as Todd suggests (see his comment on this thread).
    They had three days to diagnose what was happenign. . As I said in my response to Todd, this wasn’t a rare African disease. It was a known complication from a knoan medication..
    Over three days, if doctors were called to consult, it would seem that someone could have diagnosed it.
    In a situtation like this, I agree– all that a parent can do is do what you did– talk very, very loudly, causing something of a scene.
    Hospitals don’t like scenes.
    Admittedly, this can backfire.If the patient or family are perceived as “difficult” the patient may suffer.Still, I would take that risk. I’ve been a patient advocate on two occasions that were emergencies.
    Our hospitals need to be far more patient-centerd.
    Note to all M.D.’s– I’m not blaming the doctors in this story. . They didn’t know what was going on. The nurse(s) and hospital didn’t notify them. And the hospital doesn’t seem to have insisted that a doctor take responsiblity for Lewis over the week-end.

  22. Then Greg why are you making blanket statements that all patients with a total joint should be seen by a infectious disease physician, as if you are an expert on the topic. Total joints have an infection rate in the literature anywhere from 0.5 to 2%. That means your ID doc on average would see 99 patients before they saw one infected knee. Ninety nine more opportunities for lab tests, indium scans and joint aspirations possibly introducing an infection into a noninfected total joint. You also can’t say that most surgeons wouldn’t have diagnosed that one infection that the ID guy did, possibly doing more harm with increased cost and risk. No you are not a plumber, you are better suited to be digging outhouses.
    Maggie, she is saying it is a disease and it kills for a narrative. That is perfectly fine, she is dealing with dying, terminal patients and it is a good thing she is treating it like a disease. It shows urgency and compassion. Lewis is a completely different scenario. He had acute unexplained pain. Pain in the medical sense is a symptom. Lewis needed above all else a diagnosis, that would have saved him. If by sitting and listening to him they came to the diagnosis, great. If by getting ahold of someone with a fresh perspective they did,
    good. He needed a diagnosis, however they came across it as long as they did. That is what would have mattered. I think we are talking about to very different issues here.

  23. Jenga–
    I’m saying that acute, unexplained pain means that doctors should be called in to search, like detectives, for a diagnosis..
    Becuase he was a health y15-year-old, they had 2 1/2 days. He held on. But they didn’t investigate. They ignored him.

  24. Maggie,
    Just a couple comments. I know you were visiting two separate issues with this two part series. That was honestly my first post I’ve ever done, and since I read the articles together and figured most had read part one before part two, I decided to put it in there. Our program would give a lecture on the issue every year (usually at the first part for the new interns). I’ve read several articles on the issue and filled out a survey every year on the topic. My feelings on the matter is that the information is right in front of us and although I don’t agree with all the inferences made (ie 30 hour shifts are the equivalent to being intoxicated), changes need to be made.
    PAIN MANAGEMENT, I think Jenga is right. We’re simply viewing this from two different perspectives. You make a valid point that he should not have died in such severe pain. Well, he shouldn’t have died at all. Something should have been done. Someone should have walked in the room, introduced themselves, asked the kid where he was hurting, how long he’d been hurting, was it constant, was it increasing in severity, etc. They should have then turned to the mom and asked what she had noticed, what did she think, etc. Then they should have ripped off the sheet (figurative), and found out what the hell was wrong. The next thing (differing amongst level of skill and clinical suspicion) would have been to turn to the mother and answer in one of a few ways: “this is what I feel the problem is and this is how I plan to treat it”, “this is a list of the things I feel may be wrong and these are the additional tests I would like to perform to narrow it”, “I’m not sure and I’m going to call my upper level”. Then ask if they had any questions. You don’t have to be a doctor to notice that this mother was scared and who wouldn’t be in this situation. Her child was lying in front of her in agony and she didn’t know what to do. Communication is the key, and sadly, it’s very difficult to teach.
    PALLIATIVE CARE, I think I may have come across wrong in my views towards palliative care. I think that the work done by the health care professionals in this field is amazing. It takes a special type of person to enter this field and the care they provide is invaluable. All that I meant in my previous statement was that, I don’t think it applied to this specific case. The definition as listed by Wikipedia is “any form of medical care or treatment that concentrates on reducing the severity of disease symptoms, rather than striving to halt, delay, or reverse progression of the disease itself or provide a cure”. This patient was a child and didn’t have a terminal condition. I just don’t think it applies here, but I completely understand your point of view.
    CASE: just a few points
    If the insurance company is correct and a supervising physician or upper level was not in house all day Sunday, I think this speaks for itself.
    I think quite a few “red flags” (which may be the understatement of the year) were apparent. It’s clear when reading the article that the patient is going into shock. “That night, Lewis’ heart rate rockets. At midnight, it is 142 beats per minute and his temperature is 95 degrees. At 4 a.m., his heart rate is 140 and his temperature is 96.6”. I’ve personally never seen gas pains like this.
    On Monday morning attempts were made for 2 hours to take a Blood Pressure. Look, if the machine doesn’t get a reading the first time, check it again. If it doesn’t read the second time and you’re too lazy to do it manually, fine, try another machine. If it doesn’t work, do it manually. If this doesn’t work, check a blood gas with a lactate (which would have shown if he were getting enough blood to his tissues). I know we see in hindsight what is impending and for some reason “ileus” is the running diagnosis, but they can perforate too.
    And I understand your point about phone numbers. If she would have called the supervising physician in the middle of the night and told him half of what we see, she would have probably heard a loud “thud” as his phone fell to the ground and the tires of his car squealing off into the distance as he sped towards the hospital. I still believe the system that I proposed is adequate. This family needed a “real” doctor not necessarily the physician who did the surgery. And real doctor doesn’t necessarily mean someone who is finished with training, it means someone willing to ask questions and not take things at face value. This brings a saying to mind and I probably won’t get it exactly right, but here goes: “Being unintelligent is one thing, but being overconfident in your unintelligence is what gets people killed”. You’re told the day you start that if you don’t know, CALL. And I didn’t lump all experienced physicians into a single group. There should always be a “experienced” physician listed every night for each individual service that provides inpatient care (ie surgery, internal medicine, family medicine, ob/gyn, pediatrics, etc.) not to mention a supervising emergency physician sitting in the ER every night.
    MEDICATION: One would really have to know a lot more about the case to comment on the choice of pain medications such as how much he was urinating per hour, renal function, etc. Toradol has its place in the medical field. As for not knowing the side effects (even though I think this is common knowledge of this drug class any level physician should know), in the medical era of today where PDA’s, smartphones, computers, or even pocket sized drug manuals are so readily available, there is no excuse.
    For the post about specialist,
    I think this is a great topic for discussion and I’m sure Maggie could write several pages on the issue. I feel the opinion of the general population is that “specialist = better care”. This is often times going to depend on the situation. Take for example your suggestion about Infectious Disease being involved on every Total knee replacement. As Jenga said, the infection rate is already very low but is going to vary depending on hospital and surgeon. You’re right that the ID physicians should be experts in detecting early signs of infection but look at it this way. Orthopedist, as you say, will be more likely to “ignore” signs of infection. On the other hand, ID physicians are more likely to note non-specific signs of infection and over treat, and I hate to tell you what every ID guy is going to say; “Take it out”. The simple fact of the matter is that if a pathogen/bacteria is introduced into the area in question during the procedure, it doesn’t matter if you poor gallons of antibiotics into that patient. It’s simply not going to go away and the hardware has to come out.
    The current medical specialties can all be broken down into specific groups, but they all overlap to some degree. When a patient with kidney disease (say working 30% of normal) presents with chest pain. The cardiologist is more likely to suggest an early invasive procedure while the kidney doctor is more likely to suggest non-invasive testing because the contrast from the procedure could permanently injure his kidneys causing him to require dialysis. The right answer is to have your health care managed (both inpatient and outpatient) but a primary care physician who will be able to communicate with the consultants, discuss the information with you, and then make an informed decision together.
    There are certain areas of medicine that have been proven to be better when managed by a specialist. Take critical care for example. When ICU’s were viewed as being open (individual patients managed by a primary care physician with a critical care physician consulted when needed) or closed (all patients managed by the critical care physician), it was noted that there was a significant decrease in mortality, days on a ventilator, hospital acquired infections, etc. when managed in a closed system.
    And I appreciate you’re statements regarding doctors Maggie. I actually went into a critical care fellowship after my residency. I know it may be hectic at times, but I’d like to think one day, my paycheck will reflect the quality of care if give and the time I spend with my patients. I know I may sound a little naïve, but I’m only 28.

  25. This has been a great discussion. I agree Maggie and Todd. There was a shocking lack of engagement and involvement on all levels with this case (nursing, intern, resident, attending) and a young boy paid with his life. It seems as if everyone forgot their job. As bad as it is, it is good that this story is out there. We don’t know, it may have already saved someone else. It won’t bring him back, but he won’t have died in vain.

  26. Jenga. If you know that you would also know the absolute number of patients with post-surgical infections continuously increases as the number of patients requiring (or being encouraged into) such implants grows. If <1%-2% would be true, what would be the odds that both parents with knee replacements would be hit with orthopedic device-related infection? With parents like that, perhaps I should go to the casinos and try my luck?
    Totally ignoring classic signs of fever, chills, inflammation and painful (hot) joint as simply low-grade infection and/or aseptic loosening by the orthoped is abhoring. Especially when upon arthroplasty there wasn't any loosening and (according to the ID) as many as 50% of cultures cannot even be identified.
    Todd. Although the treatment of such infections is poorly standardized, saying that every ID guy is going to say "take it out" is an overstatement. A subset of patients can be successfully treated with retention of the implant, as was the case for my dad. My mother experienced Biofilm formation to her knee device and had to have her device removed, debridgement, surrounding tissue cured of infection and then a second prosthetic device implanted months later. This time, she is going to retain her implant and go with oral monotherapy after some weeks with IV.

  27. You are using one personal anecdotal story to make recommendations for all total joints. Such statements contribute to the specialist tilt-o-wheel which often cause more harm than good. ID guys can’t operate, they can recommend, test and prescribe antibiotics, but they can’t do the most important thing in an infected total joint, the I&D. Whether it meets criteria to retain the implant or remove, a I&D is needed on all cases of a total joint infection.
    That takes an engaged Orthopod, which you may have not had, but it doesn’t require the massive costs, unnecessary tests and risks that your recommendation would require.

  28. I agree- a good discussion. There are a few more comments I’d like to make though:
    Regarding the diagnosis: There seems to be confusion regarding the difficulty of this diagnosis. We have a quote from Dr. Tagge where he calls it a very unusual presentation of an ulcer, and says its “1 in a zillion, ” which some of the commentary seems to accept. On the other hand we have Dr. Korbon quoted as saying “”Even a Boy Scout could have done better,” than these residents did, suggesting that this shouldn’t have been so hard after all. Some comments (including my own) seem to agree with this view.
    So who’s right?
    I think both are. To have figured out, especially early on when the only symptom was abdominal pain, that Lewis was having a Toradol induced ulcer with impending perforation and peritonitis, would have taken a very astute clinician. I can’t fault anyone for missing that, but this is a known risk with that drug, and perhaps there should be mechanisms to ensure people are mindful of this risk when Toradol is used. Perhaps Toradol wasn’t the best choice, as I’ll get to.
    But the other view is right too, because the residents didn’t need to make a complete diagnosis. They only needed to realize that he was having a new, severe pain, at a site different from where his surgery was, and that it needed further work-up. That’s all. It’s hard to argue that it takes a master clinician to have seen that when the one person who did see it (Helen) has no medical training. I think they should have recognized this on Saturday, but the really outrageous part came on Sunday morning when they failed to recognize and react to clear evidence of clinical decompensation, up to and including the syndrome known as “shock”. Again, they didn’t need to immediately deduce that he was having an NSAID induced ulcer with perforation, they just needed to realize that he was in shock, and that given the abdominal complaints, an abdominal catastrophe was possible.
    Regarding pain control: I completely disagree with Jenga’s position that adequate post-operative pain control should not be routinely attempted due to safety concerns. Jenga- correct me if that’s not a fair paraphrase, but that’s what I get from your comments.
    I agree with Maggie that many physicians are overly afraid of opiates and many patients suffer with uncontrolled pain as a result. PCA (patient controlled analgesia) pumps, for example, are quite safe when used and monitored appropriately.
    Bolus dosing of opiates is also safe when done properly, and if you are really that worried about causing respiratory depression and death, than use the old adage “start low and go slow” when titrating the dose. If you stop increasing the dose when mild symptoms of sedation develop you won’t kill anybody. You won’t even have to break out the Narcan. You might take longer than you need to getting their pain under control, but it’s better than not trying at all.
    Tylenol is a useful drug, but it’s only a mild analgesic and not adequate as monotherapy to deal with severe pain. Like opiates, it can kill people who take too much of it, and unlike opiates, there’s no antidote to a Tylenol overdose.
    There are some patients with difficult to control pain, and there are patients who begin to develop sedation while still having uncontrolled pain. And there are patients (especially the elderly demented ones) that just don’t tolerate narcotics well. But none of those caveats seems to apply to the present case.
    It’s not clear to me why Toradol was chosen in this case instead of opiates but there is, in general, a reluctance to use opiates among many doctors. I think if we’re going to be honest with ourselves this reluctance has more to do with the stigma of narcotic analgesics, and with past experiences in which patients have been manipulative and confrontational with us about these drugs, than it does with legitimate safety concerns.
    That said, I completely agree with your position that what Lewis needed more than pain control was a diagnosis, and the work-up and interventions that would have resulted from it. I’m not sure that “inadequate supervision” is a fair summary of why he didn’t get that, but I’ve already tried to make that point twice, so I won’t try again. Weather “inadequate supervision” is the big, systemic cause of this or not, I do applaud the efforts on the part of Lewis’s parents, and the reporter (Mr. Monk) and Maggie, to try to find the big structural, systemic issues at work here. Because as decades of malpractice litigation and an ongoing patient safety crisis clearly show, pointing the finger of blame doesn’t make the system safer.
    Thanks for the discussion.

  29. Actually, I guess there is an antidote to Tylenol overdose: Mucomyst, but it doesn’t always work, and the point stands that both drugs can be dangerous.

  30. Word, I never said that attempting post op pain control shouldn’t be tried. If that’s the impression I left, it is not what I meant. The point I was trying to make that aggressive postoperative pain control is not a risk free endeavor. There is more risk with treating pain aggressively than not. That does not mean it is not worthwhile. Toradol is a safe drug, to use postop, with the right indications. I’ve seen it used a thousand times with good effect. What is not safe is a disengaged staff. I think that more accurately states what happened, not inexperience. You are right all that needed to happen is someone to realize that something is not right and further workup is needed and eventually come to a diagnosis. Someone needed to get the ball rolling, but it didn’t happen on all levels.

  31. Word, Todd, Jenga and others–
    This has been a great thread. Over the course of the back-and-forth comments, I felt that we got closer to the real problem.
    This evening, I spent about an hour responding to the most recent posts, and then, suddenly my computer crashed :”Fatal Error, System Closing Sown.”
    Computer is fine, but of course, I lost my reply.
    (When will I ever learn to write replies on Word, then cut and paste to the blog???)
    Anyway, very briefly I think that Jenga’s diagnosis—caregivers were “disengaged” –may be the best description of what went wrong, better than “residents not supervised.”
    This is what I was trying to get at when quoting Berwick.
    Though I have to think that if a more experienced doctor had seen the patient, he would have done what Todd says someone should have done–
    asked the patient questions, asked the mother questions, and realized that if he couldn’t diagnose, he had to call an upper-level. Something had to be done.
    Though as Word points out, a resident didn’t have to diagnose. He just had to recognize that this patient was in real trouble.
    So I would amend what I said in the post. Helen needed a “real doctor” not necessarily a “veteran doctor.” She needed someone who would focus on the patient and be confident and mature enough to say: “I don’t know what’s going on here, but I have to call someone NOW.”
    I also think that Dr. Diane Meier is right about pain. Pain can be managed–even very extreme pain, but she points out that pain management is “very very diffcult.”
    As Jenga has suggested, pain-killers represent serious risks. The doctor has to get the dosage just right–which may mean “starting low.” This is time-consuming. She must constantly check on the patient. The doctor must understand the patient.
    Also, pain management is not something that you can just “look up.” You can look up certain parameters, but every patient is unique. As I understand it from listening to Diane, pain management is an art.
    This is why I think that patients in great pain need to see a palliative care specalist. These specialists treat patients who are very sick, not necessarily dying. (As you all no doubt know, Hospice is for patients who are dying. Palliative care is for patients who are very sick, might die, might recover. Palliative care specialists continue to offer them treatments that might let them walk out of the hospital–while also managing pain, and explaining treatment options to the patient.
    It’s an extraodinarily complicated job.
    Jenga, I know we often don’t agree, but I greatly appreciated your ongoing contribution here.
    Todd and Word– –Welcome to HealthBeat!
    I very much hope that you will continue to comment.

  32. Maggie
    “Jenga’s diagnosis – caregivers were ‘disengaged’ – may be the best description of what went wrong.” I believe could also apply to my mother’s orthopod. He was certainly was “disengaged.”

  33. Greg- they may have already checked this, but are your parents MRSA carriers? That is something that might need to be looked into.
    Maggie- thanks for the kind words. It also sounds like everyone was going through the motions doing their job, but in all accuality nobody was doing their job. I don’t know Maggie, I bet we agree more often on things than either one of us would care to admit. I’ve learned alot here, one because it’s a great site and two because I absolutely relish differences in opinion. It’s easy to find people and sites that parrot back your same views. Where is the fun or growth in that?

  34. Dr Korbon is an ANESTHESIOLOGIST. He has treated exactly ZERO acute abdomen patients. For him to state that a “boy scout” would have picked up the diagnosis here is a joke.
    Dr Korbon should stick to his own specialty. He is NOT a surgeon.

  35. Osteopathic physicians are physicians. The D.O. degree is equivalent to the M.D. degree. They both go through 4 years of med school & learn mostly the same things. They can even take the same Board exams.

  36. I think mistakes like this happen when idiots get into a field that they don’t care about and only care about the money. Just lazy people out to make money.