The following post is an excerpt from John Leifer’s recently published book, The Myths of Modern Medicine: The Alarming Truth About American Health Care, now available on Amazon.com
The Danger Lurking in America’s Hospitals
Perhaps the most startling revelation about hospitals is the degree to which they imperil patient safety. Allow me to share a few tales—including one that I personally witnessed.
Tragedy Strikes at One of America’s Finest Hospitals: Downing a Rising Star
Harvard-affiliated teaching hospitals symbolize the strength of American medicine.[i] Among these giants, one in particular stands out—Massachusetts General Hospital. It was here, in 1846, that the public witnessed the miracle of the first painless surgery performed under anesthesia.
There have been many firsts at Mass General—often bringing renewed promises of life where before there had been little hope for desperately ill patients. But like all hospitals, Mass General has witnessed its share of tragedies, including ones that were avoidable.
In the tough world of television production, there are also giants, and Trevor Nelson was well on his way to becoming one. Though only thirty-four years old, he had already made his mark in the industry as a producer of the award-winning program 60 Minutes. Though his job was demanding, he always found time for what was most precious—his family.
While on vacation with his wife, Maggie, and sons, George and Conrad, Nelson became ill. Though he tried to ignore it, he couldn’t shake the headache that accompanied his general sense of malaise, driving him to seek treatment at a local hospital. A short battery of test revealed little about Nelson’s condition, and he was discharged with medication. The medicine, however, proved to be of little help in ameliorating Nelson’s wracking headache. So, three days later, Trevor and Maggie drove to the Mass General’s ER.[ii]
With more than eighty-five thousand visits per year, Mass General’s ER bustles like a small city. The seasoned staff, who are accustomed to treating major trauma, not “mere” headaches, saw no reason for undue alarm. In fact, after a number of hours had passed, they suggested that Maggie return home to care for the boys. Reluctant to leave, Maggie finally acquiesced, accepting the staff’s promises that her husband would be fine.
But Trevor was not fine. Diagnosed with non-life-threatening viral meningitis, Nelson was admitted to the hospital. During the course of his visit, he was given a plethora of powerful drugs to alleviate his intractable headache—purportedly including more than twelve doses of narcotics in fifteen hours.[iii] Early the next morning, when nurses came to check on him, they discovered he had no vital signs. Though placed on life support, Trevor Nelson would never recover . . . and nor would his family from their epic loss. Was his death attributable to a fatal combination of drugs that suppressed the central nervous system, as the family alleges . . . and was thus avoidable? That question would be determined by a jury.
The Case of the Blazing Patient
There’s nothing esoteric about an electrocautery. The device has been a fixture of virtually all operating rooms for nearly a century. As its name implies, electrocautery can be used to stem the flow of blood during surgery through cauterization of tissues and blood vessels. It can also be used to make an incision. In most situations it is both safe and invaluable.
There are exceptions, however, as “Mary,” an eighteen-year-old patient undergoing emergency surgery for a ruptured appendix, was about to find out. As Mary was being prepared for surgery, her skin was treated first with iodine and then with an alcohol compound known as spirit. The initial incisions were made, and as the operation progressed, the surgeon began to cauterize the surgical site. Following is an account of what happened next.
As soon as the cautery was used, the cotton wound towels applied on the two sides of the incision caught fire due to a flame arising from the undersurface of the towel. It was extinguished using another sponge but not before producing deep dermal burns on two sides of the skin incision. The cautery was checked and found to be correctly installed. On careful examination, it was observed that the skin was still wet with the last coating of spirit, which was not dried up properly. The residual spirit film on the skin caught fire from the spark of the cautery leading to burns involving the lower part of the anterior abdominal wall. It took three weeks for the deep dermal burns to heal with residual scarring.[iv]
A research study published in the May 2013 issue of Anesthesiology examined the cause of OR fires using insurance-claims data. The researchers determined that the electrocautery was the source of ignition 90 percent of the time.[v] The most frequent cause was the ignition of oxygen being administered to anesthetized patients, though “alcohol-containing prep solutions and volatile compounds were present in . . . 15 percent of OR fires during monitored anesthesia.”[vi]
The Tragedy of Multiple Deaths Due to a Single Avoidable Error
Heparin is an extremely potent drug used to thin a patient’s blood as a preventative for strokes and other adverse events. It is commonly used in neonatal intensive-care units (NICUs) to keep the IV lines open in premature babies. The drug can be lifesaving when properly administered and lethal when given in the wrong dose.
On September 16, 2006, tragedy struck the NICU at Indianapolis-based Methodist Hospital, part of the Clarian health system (now IU Health). It began with a silent but deadly error—when vials of heparin containing adult doses of the drug were delivered inadvertently to the NICU by an experienced pharmacy tech.[vii] With tens of thousands of prescriptions being filled each day by Clarian pharmacists, it simply slipped through the cracks. Though there were numerous times when the error might have been identified, no one caught it before the drugs were administered.
As a result, six babies received a dose of heparin that was one thousand times more powerful than prescribed.[viii] Three of the babies died. Three were injured. As a consultant to the organization, I witnessed this tragedy unfold, albeit at some distance. I saw the ensuing anguish that cascaded through the organization. Everyone was heart-broken, as, of course, were the families of those tiny children.
The children were gone, and there was nothing the team at Clarian could do to change that fact. But, much to the credit of Clarian’s administrative and physician leadership, they immediately went public with the painful truth behind the tragedy, promising that these tiny lives would not be sacrificed in vain. The team then devoted themselves to identifying and fixing the systemic breakdowns within their hospitals so that such tragedies would not be repeated.
A Mother Loses Her Precious Daughter
Desiree Wade was full of life. As a four-year-old girl, she dreamed of being a ballerina—dreams that helped shield her from the difficult reality of life in Harlem and brought joy into her life. When doctors suggested to her mother, Beverly, that Desiree needed a tonsillectomy, she assumed it was a minor operation with few risks. And she was right, in terms of statistical averages, but not in terms of the one outcome that mattered most to her—her precious daughter’s health.
Desiree began to show symptoms of a problem the day after what appeared to have been an unremarkable surgery. Seventy-two hours later, Desiree was hemorrhaging massive amounts of blood from her mouth, dying shortly thereafter in her mother’s arms.[ix] A beautiful life, a mother’s hopes and dreams, cut tragically short by a surgical complication arguably due to a poorly trained provider.
A Kidney Goes Missing
In August 2013, CNN broke a story regarding the University of Toledo Medical Center.[x] According to reporter John Bonifield, patient Sarah Fudzcz was hospitalized for a kidney transplant. Her brother, Paul, was a perfect match. So on August 10 of 2012, Paul underwent surgery to remove one of his kidneys so that it could be transplanted into his sister.
The surgery went swimmingly. Unfortunately, though, a nurse inadvertently threw the kidney away. Hard to believe? It really happened. Dr. Jeffrey Gold, chancellor and executive vice president for Health Affairs at the university, offered a profound apology. The matter is now in the courts.[xi]
These Cases Are Not Isolated Examples
As outlined in chapter 1, hospital-induced injuries, illness, and death are a major problem in the United States. The extent of health care’s dirty laundry was fully exposed in 2000, when the Institute of Medicine (IOM) published, To Err Is Human: Building a Safer Health Care System. Headlines across the nation proclaimed that medical errors were now one of the leading causes of death in our nation.
The report was groundbreaking. The fact that such sensational findings came out of a methodical study conducted by the IOM made it difficult to refute, though plenty of pundits tried. Most importantly, though, “the report called for a fundamental transformation in the delivery of health care, emphasizing the culpability of the entire medical system rather than individual physicians.”[xii]
This report was akin to Upton Sinclair’s 1906 book, The Jungle, which exposed the ills of the meat-packing industry, resulting in dramatic industry changes over time. Sinclair was a muckraking journalist. The IOM is a distinguished scientific body. If Sinclair could catalyze wholesale change across an industry, could not the IOM?
Despite the concussive effects of its initial publication, the IOM report does not appear to be having a dramatic impact on the safety of American hospitals. High rates of errors continue to plague our hospitals, based on the current research.
Hospital-induced errors were the key focus of To Err Is Human, but such errors are pervasive throughout the delivery system—from the physician’s office to the ambulatory surgery center. Just how pervasive are errors within our health-care system? A 2002 study revealed that “35 percent of physicians and 42 percent of the public reported errors in their own or a family member’s care.”[xiii]
According to Walshe and Shortell, hospitals have a long history of sweeping problems under the rug, thus preventing improvement in processes across the system. “It is striking,” they say, “that major failures are not usually brought to light by the systems for quality assurance or improvement that are now found in most health-care organization in developed countries.”[xiv]
Walshe and Shortell reinforce their point by citing a somewhat dated but glaring example of this issue. “At Vermillion County Hospital in Indiana, where Orville Lynn Majors worked in intensive care and murdered patients, there were twenty-four deaths in the intensive care unit (ICU) in 1991, twenty-five in 1992, thirty-one in 1993, and 101 in 1994, but the quality-management systems did not identify a problem.”[xv]
Despite incredible pressure on hospitals to clean up their act, mistakes are still happening at an alarming rate. The May 5, 2013, online edition of the St. Louis Post-Dispatch reported the case of a fifty-three-year-old paralegal named Regina Turner.
Apparently, a neurosurgeon operating at St. Clare Health Center in Fenton, Missouri, operated on the wrong side of Ms. Turner’s brain. As a result, according to Ms. Turner’s attorney, the patient “now requires around-the-clock care and cannot speak intelligibly.”[xvi]
A less malignant but nonetheless damaging form of error is the system’s failure to provide the requisite services for its patients. The IOM published a subsequent book on quality and error, entitled Crossing the Quality Chasm. In it, Sarah Bleich concludes that “the average patient receives only 55 percent of the services that would benefit that individual,” according to an IOM Report in 2001.[xvii]
In the automotive industry, there are extensive warranties on the product you are purchasing in order to provide a safeguard. In health care, not only are there no warranties, but providers stand to profit from the very problems they create through poor quality delivery.
[i] “Mass General Hospital Ranked No. 1,” Harvard Medical School, July 17, 2012, http://hms.harvard.edu/news/mass-general-hospital-ranked-no-1-7-17-12.
[ii] Olivia Victoria Andrzejczak, “Lawsuit: TV Producer Pumped Full of Drugs,” Timesunion.com, August 9, 2009, https://secure.timesunion.com/AspStories/story.asp?storyID=829318&category=REGION.[AU: The URL you offer is restricted and so shouldn’t be used as a citation for your readers. Is the following story perchance the same text? http://www.timesunion.com/local/article/Dead-by-mistake-547833.php]YES
[iii] Olivia VictoriaAndrzejczak, “60 Minutes’ Ace’s Death Echoes of His Own Investigations,” Houston Chronicle, July 30, 2009, http://www.chron.com/news/article/60-Minutes-ace-s-death-echoes-his-own-1747718.php.
[iv] Sanjay Marwah and Sham Lal Singla, “Spirit-Induced Cautery Burns: An Unusual Iatrogenic Injury,” Internet Journal of Surgery 22, no. 2 (2010): 1, http://ispub.com/IJS/22/2/9414.
[v] Sonya P. Mehta, Sanjay M. Bhananker, Karen L. Posner, and Karen B. Domino, “Operating Room Fires: A Closed Claims Analysis,” Anesthesiology 118, no. 5: 1133-39, doi: 10.1097/ALN.0b013e31828afa7b.
[vi] Mehta et al., “Operating Room Fires,” 17[AU: Please provide page number.]
[vii] Theodore Kim and Tammy Webber, “Third Baby Dies after Error at Indiana Hospital,” USA Today, September 20, 2006, http://usatoday30.usatoday.com/news/nation/2006-09-20-baby-deaths_x.htm.
[ix] Laura A. Fahrenthold, “4-yr.-old Dies after Surgery,” New York Daily News, March 23, 1995, http://www.nydailynews.com/archives/news/4-yr-old-dies-surgery-article-1.688316.
[x] John Bonifield, “Ohio Family: Hospital ‘Botched’ Transplant, Threw Out Kidney,” CNN, August 30, 2013, http://www.cnn.com/2013/08/30/health/transplant-kidney-thrown-away/.
[xi] Susan Donaldson James, “Toledo Hospital Threw Out Donor Kidney, Now Denies Negligence,” ABCNews, August 29, 2013, http://abcnews.go.com/Health/toledo-hospital-threw-donor-kidney-now-denies-negligence/story?id=20110334.
[xii] Sara Bleich, “Medical Errors: Five Years after the IOM Report,” Commonwealth Fund, last modified July2005,http://www.commonwealthfund.org/usr_doc/830_bleich_errors.pdf.
[xiii] Ibid., 9.
[xiv] KiernanWalsheand Stephen M. Shortell, “When Things Go Wrong: How Health Care Organizations Deal with Major Failures,” Health Affairs23, no. 3 (May 2004): [AU: Please provide specific page number.]107, http://content.healthaffairs.org/content/23/3/103.full.
[xv] Ibid., [AU: Please provide page number.]107
[xvi] Jim Doyle, “Blunders: Botched Brain Surgery Prompts Extensive Review at SSM Health Care,” St. Louis Post Dispatch,May 5, 2013,http://www.stltoday.com/business/local/botched-brain-surgery-prompts-extensive-review-at-ssm-health-care/article_df1f66b8-ba03-5ba1-8e93-ce0cc771f0a5.html.
[xvii] Bleich, “Medical Errors,” 9.[AU: Your citation is for Bleich, “Medical Errors: Five Years after the IOM Report,” but your paragraph text indicates it ought to be Committee on Quality of Health Care in America and Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, D.C.: National Academy Press, 2001). Please reconcile the seeming discrepancy The source is an Issue Brief from The Commonwealt Foundation (pub #830) published July 2005. The author is Sara Bleich).]