Collateral Damage: A Patient, a New Procedure and the Learning Curve

America’s Best Hospital in American Reporter

DAN WALTER

AMERICA’S BEST HOSPITAL
by Dan Walter

I have been reading recent stories about malpractice problems at Johns Hopkins Hospital with great interest.
I took my wife there for a relatively low-risk procedure last year and through a series of astonishing mishaps, she almost died. Since then I’ve spent a lot of time trying to figure out how such things can happen in one of the best medical facilities in the world.

Last monday (2/23/04), the same day Hopkins settled a lawsuit in the death of a two-year-old Brianna Cohen, the Maryland Office of Health Care Quality issued a report citing numerous safety lapses at the Johns Hopkins Home Care Group. The report concluded that Brianna Cohen died because an unqualified pharmacist supplied a deadly intravenous solution. Another case involved a seven-month-old who went into a coma after she was given the wrong formula. Last month a patient sued Hopkins because an intern cut an artery in her neck and then fled the room at the sight of blood. Other cases in the past few years include two deaths from contaminated bronchoscopes, two children getting overdoses of chemotherapy, and a volunteer who died in an asthma study.

Then there’s U.S. News and World Report naming Johns Hopkins “The Best Hospital in America” for the 13th consecutive year. After what we went through there, I contacted the person at U.S. News who makes these decisions and asked him how he arrived at such a conclusion. He described a fair and analytical process, then added, “For what it’s worth–very little to patients and their families who have had bad experiences–there isn’t a hospital in the country that hasn’t screwed up and/or treated patients callously.”

True enough.

When Johns Hopkins Hospital is named “Hospital of the Year” by U.S. News, the hospital’s P.R. staff enlarges a copy of the magazine’s cover to the size of a movie poster, which is then proudly displayed in the main corridor along with U.S. News covers from previous years. It gives a prospective patient a lot of comfort to walk by all those declarations of excellence. My wife and I felt reassured. I took her there for a procedure to treat irregular heart beats. Called a Pulmonary Vein Ablation, it involves manuevering a catheter through a vein and then up inside the heart chamber.

It was, we were told, a relatively new procedure, and as with any procedure there were risks involved. But the risks were minimal, and my wife was in the best of hands. They had done plenty of these and we had every reason to feel confident. We were given glossy brochures that described the procedure, told what to expect through the entire process. There was a picture of a woman who’d just undergone the procedure. She was recovering in a pleasant room, smiling and watching television.

Administration at Hopkins is very efficient. We were told to show up early in the morning. It was still dark outside when my wife was admitted. She was given an admission bracelet and put in a wheel chair. We were briskly processed through various checkpoints. We filled out forms and answered questions. The next to last stop was a brightly-lit cubicle. It was here under harsh lights in the early hours that my wife and I were handed clipbpoards with pages and pages of very fine print to sign and initial. It looks now as if we signed papers taking full responsibility for anything that went wrong.

And then, whoosh, she was gone behind the double swinging doors.

Later, to his credit, the doctor was very forthcoming about what happened. While the tip of the catheter was inside my wife’s heart, he’d turned away momentarily. The tip of the catheter got caught in the muscles of her mitral valve. Another doctor was called in to help. He pulled on the catheter. It sliced through the muscles that open and close the valve. Her heart was in “complete flail” as they described it, not much blood pumping at all. After several hours she was awake enough so that they could put her back under and crack open her chest in order to install a new man-made mitral valve. I will never forget the look on my wife’s face when she first came around expecting to be discharged shortly and I had to tell her things went wrong.

After the operation to insert the valve, the doctors were anxious to get her up and about. A little too anxious as it turned out because she wasn’t ready to be weaned off of life support. So when she started to die again, (acute congestive heart failure), they had to “re-intubate” her. It is an extremely difficult thing to have them shove a breathing tube down one’s throat. Difficult to undergo – and to watch.
She ran a fever, had a stroke and went into a coma. She spent three weeks in the Intensive Care Unit. I repeatedly asked the nurses if her eyes should treated somehow because she could not blink and stared vacantly at the harsh overhead lights for hours at a time. I was told to not worry. The result was scratched corneas from a syndrome called Exposure Keratopathy, a condition the eye experts at the Wilmer Institute later shrugged off as being something they “see a lot of ” in the ICU.

Coming out of the coma, there were long stretches of time when she was drugged, scared and disoriented. She was agitated and thrashed about. The nurses tied her to the bed. Her right elbow rested on the bedrail for so long that it damaged the nerve in her arm. For months afterward her right hand felt as if it were on fire and she still cannot fully use it. One morning I went into her room very early. She had been semi-conscious for days. The nurse said that she’d had a difficult night and was very restless. While straightening out her bedsheets, I felt under her back and found a pair of curved forceps that she had apparently been laying on through the night.

The people who work at the hospital, of course, try to do their best to prevent such things and despite the pressure and hardships they generally do. The administration is always looking for ways to improve the system. One team of Hopkins researchers who were studying ways to better the odds for patients in intensive care units recently came out with revolutionary new findings: they determined that patients have a better chance of surviving the ICU if doctors and nurses and everyone else involved communicate and set specific goals for each patient’s recovery. I think those guys are on to something. After surgeons had permanently removed my wife’s pacemaker during the open-heart surgery to replace the valve that had been inadvertantly destroyed earlier in the day, a man in scrubs came in the room and began moving her bed sheets around and pulling on wires. The nurse and I looked at each other. I asked him who he was, but he ignored me and kept poking around. The nurse became alarmed and demanded to know who he was and what he was doing. He was there, he said, to adjust the settings on her pacemaker.

Last year a Hopkins resident complained that the hospital was pushing him to work more than eighty hours a week, violating new rules designed to promote patient safety. The hospital lost medical school accreditation over it for a time. The resident, I can assure you, was right to complain. During my wife’s stay, the doctor in charge was a hard person to find. When I finally got hold of the frazzled and obviously overworked resident about my wife’s deteriorating condition, I was told more or less that he was a very busy guy with lots of very sick patients and that he had a family too.

Her situation finally improved after I went to the chief surgeon and waited and waited in his outer office while he wooed a big money donor. When he finally granted me an audience I told him that if my wife died it wouldn’t be good for anybody and he’d better get down there and fix it. Which he did. With the Big Guy taking an interest, my wife’s care improved and she was eventually discharged. But I firmly believe that if her family was not there to insist on proper care, my wife would be either dead or the next thing to it in a long-term nursing facility. As it is, she has loss of equilibrium, short-term memory deficits and general cognitive problems.

Before her stay at Hopkins, she was a relatively healthy registered nurse and entrepreneur who ran two businesses. Post-Hopkins she can neither run a business nor practice nursing and has been officially classified by the Social Security Administration as being disabled . Under the large ugly scar on her chest, a titanium valve can be heard clicking away. The prosthetic valve means that she must take warfarin – a blood thinner – for the rest of her life, and “patients who take warfarin walk a tightrope between bleeding and clotting and a hundred things can tip the balance, it’s a difficult drug to use,” according to a well-known pharmacologist. She still suffers from the irregular heart beat that brought her to Hopkins in the first place.

The hospital’s view is that the damage my wife suffered is the result of “previously unreported complications”. Oddly, I have found three previous reports of this “previously unreported complication,” that is, a catheter tip becoming entangled in a mitral valve apparatus. The earliest report I found dates back to 1994. The hospital maintains that what happened to my wife did not violate their “standard of care”. We are left to assume then that the standard of care at Hopkins rises to the level of a drawn out, agonizing, near-death experience that leaves one disabled.

One last newspaper story about Hopkins: Years ago a doctor there wrote an article about what to do when medical errors are made. His said the hospital should come clean right away, admit its errors and offer to compensate the victim. Besides being the right thing to do, it would ultimately cut down on malpractice payments because victims and their relatives are not immediately thrust into an adversarial role, with all the attendent bad feelings and personal-injury attorney fees. Plaintiff’s attorney fees can be anywhere from one-third to one-half of a settlement.
High profile cases such as the death of a child are generally settled quickly and quietly for unknown sums, but most cases take years to resolve. The head “Risk Manager” (defense lawyer) at Hopkins, Richard Kidwell, said in an article for an in-house newsletter titled The Malpractice Lottery that “once people see juries making the big awards to patients, the number of claims often increases. It’s like the theory of sharks being attracted to blood in water.”

My wife doesn’t feel like she won the lottery.

When these things were happening to her, I told administrators that I couldn’t afford to fly relatives in from around the country, and did not have the money to put them or myself up in local hotels for the duration. I was told that the hospital’s “Risk-Managers” would not allow any such disbursements. It might indicate some sort of culpability in the unfolding tragedy. The best they could do was validate parking and offer me a voucher for a free cup of coffee.

Insult to injury from “America’s Best Hospital.”

_______________________________________