Back to Basics

During the roundtable’s first session, we had the opportunity to view the award-winning film, Faces of Medical Error…From Tears to Transparency: The Story of Lewis Blackman.  The film, produced by two of our faculty members Drs. David Mayer and Timothy McDonald, is part of a series of educational films focusing on managing medical errors and participating in honest, open communication with patients and their families.
The story of 15-year-old Lewis Blackman is tragic and completely preventable.  In short, Lewis underwent elective, corrective surgery for pectus excavatum (http://en.wikipedia.org/wiki/Pectus_excavatum), and his post-operative course was littered with numerous signs and symptoms of deteriorating medical status.  Over a five day course he experienced increasing levels of pain, a steadily, consistently increasing HR that topped out in the 160s, systolic blood pressures into the 140s, physical exam signs consistent perhaps subtle but then blatant acute abdominal pain, and severe hypovolemia.  All the while the medical team continued to hang their hat on a diagnosis of intraintestinal gas which was later revised to post-operative ileus.  Moreover, as his family tried to escalate their concerns, the medical team did not listen or acknowledge their worries…until it was too late.
What struck me most about this story was how the fundamentals of medicine and patient-centered care were clouded and all but suppressed by the “working” diagnosis of constipation and the hospital’s culture.  A mantra of medicine is that “vitals are vital,” and this case proved this to be true.  Between post-op Day 1 until the day he passed, his HR steadily climbed by 15 points each day, and his bp had a parallel trend.  Within the last 5-6 hours of his life, his oxygen saturation was in the 80s.  Furthermore, at post-op Day 2 he complained of abdominal pain which only increased with a worsening abdominal exam — distended, tense belly.  Lewis’ mother, to no avail, repeatedly raised her concerns and tried to move them up the medical hierarchy.
This story sets the stage for my week at Telluride, and it begs the following questions that I want to begin to answer: how do we, as medical professionals get this way… as allied medical professionals, PharmDs, nurses, and physicians, how do we get to a point in our career where we ignore the basics?  And as a medical system, with so many points of patient contact, how could this case have slipped through our hands?  Lewis’ course also makes me wonder about how much blame we place on understanding the basics of clinical practice and what portion of this was caused by systems/culture issues?
Throughout the week and beyond, I want to better understand the safety and quality theories and jargon that explain how medical professionals adopt these malicious habits so that I may better understand how to solve these problems.
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