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

Pat Sydnor says:

My brother-in-law was killed in a local hospital a year ago. He was admitted with pancreatitis and put in a double occupancy room. He was out of his head in a matter of a few days as the sepsis had invaded his whole body while nobody watched. He was left dirty in his bed, unable to communicate properly, and severely congested. The doctor kept saying he had dementia and COPD which I can attest to that he never had. We talked on a regular basis. He was sent home after two weeks of hell in critical condition. After two days an ambulance was summoned and bypassed the hospital that had released him in critical condition. The second hospital took immediately to ICU and was astonished that he had been released to go home by the first slaughter house. He was found to have MIRSA in his lungs and it was too late to do anything for him other than make him comfortable. I am still in shock at losing a vibrant, healthy brother-in-law.
There are many horror stories and this is just one of them. I myself have had some very bad experiences but for the grace of God, I’m still alive. We for the most part, live in spite of the doctors. A degree in medicine, a God does not make.

LRR says:

Good grief. The valve was not torn out. You don’t know if the catheter would have gone where it went if Dr. C was driving. An anatomical predisposition would not necessarily have shown up on echo.

You get dealt a bad hand, despite the best intentions of a highly competent group of doctors. Collect your settlement and move on with your lives. Play the hand you’ve got now and don’t worry about what might have been.

I am done with your wheedling.

By the way, your repeated statements that Dr. C committed malpractice open you up to legal liability. If a trial finds that HE did not commit malpractice, then your statements are libelous. You could pay a financial cost. That would be irony.

Lather Rinse Repeat says:

> Would you say that continuing with the ablation
> procedure on a patient who is in congestive heart
> failure secondary to having her mitral valve torn out
> is “medically the right thing?”

See, this is what I mean. Her valve wasn’t “torn out.” When you’re that willfully inaccurate it makes it hard to take you seriously.

Also realize, as Hippocrates did 2500 years ago, that judgment is difficult. I don’t know if the decision to proceed was right or wrong, and neither do you, because we weren’t there, and because Dr. C did not have the perfect knowledge of the future that you do. I doubt Dr. C is a stupid man or a evil man, despite your cartoonish portrayal of him.

Your wife was in a world of hurt as soon as the chordae became entangled. She was destined to have her chest cracked at that point. You have no idea whether the same thing would have happened if Dr. C had been driving the catheter. Perhaps there is something about your wife’s cardiovascular anatomy that predisposed her to this complication.

You also don’t address the point that having the trainee perform part of the procedure is (I presume) standard operating procedure in every case at Hopkins. Your suppose that someone looked at her and said “Hey, she’s trailer trash, let Dr. Killwoman do the procedure.” If she were the Queen of Denmark, yeah, Dr. C probably would have done the whole procedure, but that’s a silly point to argue. He told you the part of the procedure for which he’d be there. You just didn’t listen.

And by the way, nice job on search engine optimization techniques by always spelling Dr. C’s name in full. Vendetta, no?

lather rinse repeat says:

You’re outraged, and you let it show, but it damages your credibility as an accurate observer. Example 1: you act as if warfarin being used as rat poison is somehow relevant — it is not. Physicians would love to stop prescribing warfarin, but there is nothing better. Example 2: You complain about getting consent from your wife while she is critically ill. What’s the alternative? She’s going into emergency surgery because nothing else is going to stop her from being critically ill. One does the best one can under the circumstances.

So, as a result of things like this, I’m not ready to trust what you say, and stopped reading after awhile. I think one reason you are so mad is that you apparently went to a TEACHING hospital (of your own free will) and apparently did not ask what the TEACHING bounds were for your wife. You guys have been around. Kind of an obvious question, no? I think part of your rage is guilt.

It was a horrendous outcome, no question about that. But understand that at every step people were medically trying to do the right thing, and trying very hard.

Steven Timmons says:

I don’t have to be in the medical field to disagree with such a lopsided discussion. No defense and no independent 3rd party review.

So what do you want? Money.

Or the surgeon should have his license revoked? At the cost of innumerable other people that will be saved? Slander his name like this becuase your wife was a statistic. That’s a slap to the hundreds of other people people he’s helped.

What is your goal?

What exactly is your goal?

Feel Your Pain says:

Excellent website,although horrific experiences. You may want to read the blogging of a nursing administrator who did blow the whistle, and after being attacked, resorted to blogging. There are lots of on point blog posts about empowering and protecting yourselves and your loved ones.

One more tool in your tool kit.

Michele says:

This was a very well written, thought provoking story that I think you are doing a huge service by sharing! The truth is sometimes hard to swallow, none the less it is something that patients AND caregivers should not avoid, we should tell it, seek it and gleen from it.

As patients we all deserve and want to be treated right. We sometimes go blindly handing our lives over to others assuming that they will treat it as valuable, precious and worthy of their best effort. We should be able to EXPECT at the VERY LEAST honesty and a good attitude. However, more often than not it just doesn’t happen that way. Should caregivers take offense to this? YES- All the knowledge and know how in the world is worthless if you are incapable of giving your best effort, are dishonest or have a bad attitude. These are peoples lives you are dealing with! Their is a huge amount of pressure to be in this line of work, but you’ve agreed to it, if its too much you need to seek a new career.

We need to be a society where its ok to do what is right, without fear, as patients, as nurses, as Doctors, and as administrators, how did we get soo far off track? How is it that this story isnt unique, it is all to common, I myself have my own story(s) of healthcare ineptness, and who is to blame? Its time for accountability, and an expectance of higher standards. Doctors and Administrators get sick to and when it comes down to it every single person in healthcare should be treating their patients EXACTLY as they themselves would like to be treated PERIOD.

Best wishes to you and your wife! the pen IS mightier than the sword so keep it coming!

Michele

lifesavergirl says:

ICU nursing (which is where I began my nursing career) is my favorite for many reasons. I take great pride in saying that I am an ICU/cath lab nurse. It is our goal to make and achieve goals for our patient and their families. A plan of care should be developed by the nurse each shift when caring for the ICU patient (any patient for that matter). Many goals that are set for the patient will not or cannot be met for a plethera of reasons, but the most important and simply vital piece is that there are effective transitions to get to where the patient and family need to go next. Anything less than that just aids in wasted time, and ICU patients do not have time to waste. In my opinion, it seems as if those transitions were missing from your wife’s care. Pam was on detours from hell and that to me is not acceptable. “The Best Hospital” should have top notch critical care nurses taking care if its patients. My perception is that there was a serious lack of nursing leadership when Pam needed it most and that makes me very, very sad. All the more reason why each critical care nurse needs to read this. Your story defines “Murphy’s Law” (where if anything can go wrong it will/does) and I feel confident in saying that almost every nurse has experienced it with at least one patient in their career. I have several patients in my memory who were effected by it and secondary to it are the scars that are left in my mind. It is from situations like this that we should become a smarter and stronger nurse and patient advocate. After safety, compassion, advocacy and family education/empowerment are second. Sure sounds like you could have used just that.

Their are great doctors and nurses all over the world. Rest assured. Doctors need direction. The good ones know it and rely on the nurses and continuing education they trust to help them. That team effort gives each patient the best care possbile and details do not go un-noticed. The system failed you and Pam and I am so sorry. Sorries don’t buy back time though, do they?

I hope you win your case. I hope your story sends shock waves to doctors, nurses and hospital administrators everywhere. I hope it reaches the medical and nursing school deans. This is a problem in every city in the US. I hope Pam’s hard fight helps others to “do the right thing”. Good luck.

MP says:

WPW. I agree with your number one. It comes across as biased and vengeful, but I think he and his wife(who was an ICCU nurse for years) did research the surgery, the doctor and the hospital. What they didn’t research was the small print on the consent form. Unfortunately, most people forget that a teaching hospital allows interns, residents and fellows to participate in surgery. What most people don’t realize is that what they’re told doesn’t necessarily correlate with the documents they sign.

HM says:

Some parts of the story get boring.

k says:

Comment:
Deana: what we call what you are is a “TROLL”. Stop trying to hijack Dan’s website and get your own up & running again – and don’t abuse this one attempting to advertise it.

Dan: Thank you so much.

While my dad was dying of Amyloidosis in a celebrated Canadian hospital, I regularly saw petty humiliations and agonies perpetrated by un-empathetic, senseless stupidity. While dad and I were chatting in a common area one evening, a resident walked up, introduced himself, and asked dad how he felt. On being calmly told, “my hands feel like they’re on fire” the resident grabbed him by the hands and held on to them, commenting “they don’t feel hot to the touch” – I still shake, wishing I’d kicked that boy in the face.

My dad was from Buffalo, NY, worked at Bethlehem Steel like his dad before him, and served his time in the Army. My dad didn’t cry out and didn’t screm. His jaw went rock hard. The pain was blinding.

And that fool held on, not having seen dad’s chart, not having asked permission to touch him, not noticing he’d gone stark white – babbling nonsense until my dad could politely interrupt him and take his hands back.

Dad was surprised. I wasn’t.

I went in for annual checkups and always told the nurse and doctor I was a virgin. Unfortunately, I’m pretty. I’ve been stabbed by more cucumber-sized speculums than I care to admit, because nobody, inall the times from 16 to 26 that I visited the doctor, ever believed me. The small speculum was *every single time* the second one they used on me. I will admit, I’m loud, and on at least one occasion, I believe I bit a “caregiver” in the room.

Too many people don’t understand the *critical nature* of the mistakes that are made, and are too polite to speak up for themselves until they’re a bewildered “victim”.

Thank you for writing this – it’s necessary that patients become aware, and that caregivers realize there’s a reason that patients must protect themselves from caregivers with the best intentions.

Lori says:

Having been at our mother’s side for eight months after she contracted MRSA after surgery, and then a whole series of other (preventable) complications, we can personally attest to the very dangerous healthcare delivery system we are all at the mercy of. The bottom line is…the longer you are a patient in a U.S. hospital, the more at risk you are of facing an untimely death.

Our mother died four years ago, and we found out after the fact, that the circumstances of her death were never revealed to us. (We were simply told that she had a stroke from a massive brain hemmorrhage. What they neglected to tell us was they had given her the antidote for antigcoaulant overdose—and it was given 9 hours too late.) Blatant lying and lying by ommission are accepted behaviors in hospitals.

One crucial piece of bloodwork is missing from our mother’srecord: her CBC for that day (she had a CBC every single day for 2 weeks in this ICU—the only one missing is the one for the day she hemmorrhaged.) We also found out that her platelet count was so low 2 days prior to this hemmorrhage that she needed a blood transfusion. But no CBC was done 2 days later? …and we’re supposed to believe this?

After four years of dealing with the hubris, arrogance, and ‘there’s nothing you can do to us’ attitude of hospital administrators and risk managers, we have come to realize that hefty profits and complete lack of regulatory oversight/accountabiliy have led to corruption in our hospitals.

The Joint Commission is toothless.” They told us that “because we are not a regulatory agency, you should file a report with your state dept. of hospital licensing.” The Joint Commission is nothing more than a paid membership organization that hospitals use to market themselves as “SAFE.”

I believe every word of your 18 chapters—because we’ve been there. All we can do is continue to speak the truth until we have our last breath. One thing they can’t do is silence us.

Keep Writing Dan,

Another RN who advocates for patients rights.

ak says:

Thanks for sharing your story, which I am sure has taken quite a mental toll on your
family’s life. I am sorry to hear about all the mistakes made.

I am a physician ‘in training’ as a 4th yr fellow. I feel that I read other’s stories, in order to re-connect with that ‘perspective’ you discuss so often. I do gain some insight as well, about doctors, patients, and medical care

Although, I also feel attacked as well. “Great doctors” everywhere start somewhere as a trainee. Some of your commenters would not prefer any ‘trainees’ when it comes to them. To be fair, would have been ok if Dr. Wu be introduced as assistant? Do have any numbers to know how many of these procedures Dr. Wu has done? How about Dr. Calkins? What if you had heard that Dr. Wu had done 10 procedures in the past 1 month, Dr. Calkins has done 50, but his last one was 2 years ago, b/c now his fellows do the procedures? how about with this specific catheter?

Of course, I am making up numbers, and being somewhat ridiculous, although during my training, I have found that some procedures I do, I did it more often, and I was better at it than my superiors, since they leave those procedures to residents/fellows.

I read the case report. I am not a cardiologist. Is it possible that their maneuvering the catheter was the standard of care? (I don’t know that answer). If so, then how could they be blamed for this? Could you include where you found that the docs were in in the left ventricle? Their case report makes no mention of it.

You also make a point of saying that in the case report, they report that it is an unknown complication, but then reference 2 other cases. Its a little cheesy, but the distinction appears to be the reason for the procedure (your wife’s was for a-fib, while others were not).

I agree the medical notes disparity is maddeningly frustrating. It does sound fishy that the note suddenly appeared. May I reasonably argue that it was poor handling of medical records, and not ‘tampering’? Is it possible that the missing document was really written in ’02 but never got to the chart? the cynic will say ‘no way’ but the believer will say its possible. I think its easier to argue the missing chest tubes notes. In handling patient charts, I have often come across some that have easily >400 notes. It is very easy to find some of them missing for any reason. I have accidently dropped these charts, b/c the sheer nature of their size. Papers fly everywhere. Also, moving from one room to another causes things to get misplaced. I will bet some get missed. That is unfortunate.

Have you discussed your case with another EP specialist? I think their perspective would be interesting as well.

It is unfair to characterize warfarin as rat poison. In medical management, its not the same. http://en.wikipedia.org/wiki/Warfarin

other questions that I don’t have answers for but would be interesting to know
1) are there conflicting reports that state this catheter is useful?
2) are there better techniques now for AF within interventional cardiology field?
3) complication rates for this procedure?
4) has techniques changed for the better?

Its a shame to hear that people lied to you and your wife, and the subsequent ordeal. Good luck in your endeavors..

Anonymous says:

I think your story is perfect as published. It is truth, and truth is what all of us need to see, and act upon. Medical incompetence is bad enough, but coverups and lying when medical imcompetence occurs, make the situation even more intolerable and hurtful and ANGER-MAKING. If a man makes a mistake, it is his ethical duty to admit it and attempt his very best to make amends — at the very least, in the case of your wife, all her surgical costs should be ERASED, and medical care to treat all complications of this BOTCHED PROCEDURE should be provided FREE FOR THE REST OF HER LIFE, and furthermore such care should be provided by ANYONEOF HER CHOOSING and then paid for by Johns Hopkins Medical School.
Someone asked me the other day, “Whydon’t you get a liver transplant” (to make it possible for me to be around fragrance chemicalsafter having experienced liver damage — primarily from chemicals in a lab I worked in and a building-in-renovation I worked in — that has made my liver incompetent to properly process/excrete chemicals ranging from air “fresheners” to perfumes to…). At the time I replied, “I would not want to be subject to being dependent upon a lifelong supply of immune-suppressing drugs.” And then, too, there is also the fact that “body harvesting” of spare parts for transplants, is not always characterized by the degree of quality control one would think should be fundamental to medical practice (in other words, the chance of getting a liver damaged in some way other than mine — perhaps even to the point of carrying nodes of cancer — seems a likely danger). Now, after reading your and your wife’s story, I am reminded of the third reason I attempt to stay out of the clutches of the medical system: incompetence and damage (much of which I’ve experienced, but not to the degree of your wife) and lying about said incompetence and damage. Oh, yes, there are some good doctors (I have had at least one in my family). But how does one know that the one s/he has consulted, is one of them?
Best of luck to you and yours.

Ashlei says:

I had a CardioSEAL ASD closure device placed at a Toledo hospital but the cardio oversized it by 2x and it punctured two holes in my atrium (So instead of closing the ASD, it created two more!) I had to have open heart surgery to remove it but one leg of the device is still lodged in my heart. We should have sued. Super scary.

mia says:

since you all seem to have so much distrust for doctors, nurses, and hospitals, please by all means avoid them! the next time you get sick, take your care into your own hands. clearly you know better than the so-called experts.

PVCWoman says:

As much as I am aware of things like this, I am truly speechless and so sorry! Thank you for sharing the story. It is such an important one.

I’m passing it along…

la says:

this whole thing is ridiculous–from the attending being in the dr’s lounge, to your sedated wife signing the consent(they would have had you do that) to drs owning the apts around the hospital and jacking up prices to take advantage of poor patient families–boo hoo you didn’t get to know the cardiac surgeon before he rearranged his schedule to perform life saving surgery–your wife would have died immediately anywhere else! and your quotes are completely irrelevant–the charges against JHH overworking residents occurred in august when the new guidelines were first in place, NOT in april when your wife was there. i’m surprised you didn’t somehow find hopkins doctors responsible for your wife’s car accident! maybe the drs were tired and scared because they work exceedingly hard hours and actually care and medicine is an inexact science with all kinds of complications and unpredictable outcomes. go find a shaman and avoid doctors all together if they are all so evil.

ps i am not a hopkins employee i just hate people who try to blame everything on someone, clearly the appeal of a lawsuit with big $$ is the underlying theme here

Joan Sadler, RN says:

What a horrible story. What a horrible experience to have to go through. I am a cert. med-surg. nurse and have seen hospitals cover up many things. Patients have complications caused by error. The nurses I have worked with are the best and have the knowledge and compassion to take the best care of the patient and of the family. The problems is we are all over worked. On a daily basis I have talked to my superiors about the dangers of high nurse to patient ratios. We nurses have no authority to change this problem, especially in areas where the facility company owns all of the health care facilities in the area. They have a monopoly on everything, staff are afraid of being blacklisted. My prior supervisor and vice-president of nursing told me I had a bad attitude when I went to them about my concerns for patient and employee safety issues. I assure you I spoke to them with great respect at the time. Facilities in some areas(Virginia) set their own staff to patient ratios. Although what they set may be good, in practice with the nursing shortage we have to take care of too many patients at a time and it is impossible to provide good care to all patients. If we stay late to complete all of our work we are told no overtime hours. It is scary to work in health care these days. When a family member of mine is in the hospital, I have stayed with them to make sure they get what they need, and I am not afraid to speak up and demand what they need.

Jim Walter says:

This story reminds me of Upton Sinclairs’s story of the meat packing industry “The Jungle.” Let’s hope it has the same dramatic effect!

Kobus says:

For some-one working in Medicine this is an eye-opener! I’m still a junior doctor, and have done a lot of procedures on my own, but in the beginning always under the supervision of my consultant.

Unfortunately we still have to learn, and sometimes the curve is “steep and rocky”, but remember the professor who heads the unit, and is world-wide recignised as a leader in a certain field, also had to start from the beginning, under supervision.

It’s like flying. Sooner or later you have to solo, with no-one to hold your hand.

But the one thing that we have to keep in mind is part of the Hippocratic Oath :FIRST DO NO HARM!!

Doctors need to ask themselves firstly: What is the best for this patient? And then, Am I able to provide this for the patient? If we are unable then we need to refer to a colleague who will be able to provide that option that is best for the patient.

Winne says:

All these arrongant SOB doctors have to face their Maker. Bad things happened to me via the hands of doctors. I have suffered physically and emotionally from uncaring doctors. I asked God to handle this. Every single doctor that has hurt me has had a tragedy strike them. Hmmm! God does work in mysterious ways! Almost like placing a voo doo on them. Watch out doctors. Walk the straight line and do what is right for your patients and admit to fault and error quickly so help can be forthcoming ASAP!

Ray says:

So Lauren it sounds like it was more important to get the kid trained than your well being. Thanks for sharing this. I will pay more attention now to details. Perhaps these teaching hospitals are not the answers to a patient’s prayer unless of course you are the King of Siam! Perhaps we all can add Ph.D after our name for times like this. Would that impress them? LOL

Runamok says:

Hmm sounds a little like when I had my gall bladder out. I spent 2 weeks talking to this doctor who had “done hundreds of these”. When I woke up some kid walks in and starts talking to me about how my surgery went. I looked at him and said “Who the F*** are you?” He replied. “Im Dr So-and-so, I did your surgery” Turns out he was a resident. Fortunately, I didnt get nearly as torn up as your poor wife did. But compared to what I was told to expect, it was definitely the job of an inexperienced surgeon.

Tate says:

Pam’s story sounds very similar to my third ablation done at Mayo Clinic Rochester, MN. I thought that I was going to the “best facility” with the best Dcotors available, if it was good enough for the kings and Presidents, it must be the best.
Being that this was my third attempt at ablation, I requested and thought I was assured of the most senior EP. I too was given the consent after initial sedation, back in the anti room prior to ablation.
My wife met a very nice woman while waiting for my ablation. It seems she and her husband flew in from Arizona on a “rush” basis being referred by a DR. at Mayo’s Arizona facility. In talking with her it appeared that this couple was very “well off”. My wife still had no clue that there might be a problem in being assured of the Doctor we had requested to perform the procedure.
After what seemed like an eternity, a Dr. we had never met nor knew of came in saying he had good news and bad news! He felt they had erradicated all the errant signals but that when they started to remove the catheters,one had punctured his ventricle and they were taking him to ICU. My wife was in schock.
While waiting in the ICU waiting area she overheard another family being told that during pacemaker placement, there had been a problem, also making her feel even more fearful of what kind of care was I receiving.
After another couple of hours, My wife had about had it and luckily my daughter was with her, she asked her to ask the nurse how much longer before we could see me, and if it wasn’t soon my wife was about to make a scene. I was very lucky to have survived with no permanent damage, that we know of. I went on to have a Cox maze in 2005 and feel better than I have in years. only wish I had done it a lot sooner, even though it is major surgery, there is less risk than with ablation.
Having read a shorter version of Pam’s experience on affibers.org, you have my best wishes for the best possible outcome, only sorry you did not have better luck with your court case. Where is the justice?
Best regards
Tate