May 20, 2009

Medical negligence, and the meaning of life

Posted in brisbane, health tagged , , , , , , , , , , , , , , , , , at 12:23 am by Margi Macdonald

A week is a long, infinite, tiny thing in the course of a life.
It is seven short days in which a life lived broadly, and joyously, can also become a compressed black hole; a through-the-looking-glass, spaghettified nightmare of anguish, horror and despair.

Recently, the public health system in my city almost killed my beloved Mother.

Twice.

The first attempt occurred in the emergency department of a smaller suburban hospital – briefly we’ll call that episode ‘failure to investigate’, ‘failure to diagnose’ and ‘failure to treat’.
We might also call it ‘assumptive thinking’, ‘ageism’, ‘laziness’, ‘inability to think logically’, ‘failure to take an accurate history’, and pricelessly and bleakly funny, were it not so damned horrifying – they named the fracture in my mother’s hand a fractured metatarsal.
Look it up, if you like.
Metatarsals are those things our toes are attached to.
The bone they were supposed to be thinking of, is a metacarpal.
Should we spell it out for them?

Is it any wonder they missed the brain haemorrhage?

Mum looked as if she’d been in a car crash, her face was so damaged. She was oriented, but her mental state was ‘odd’ and a bit ‘dotty’. She also had amnesia and her short-term memory was poor. Mum had been knocked-out due to a face-first encounter with a footpath. Her spectacles which she’d been wearing, were smashed and crushed beyond recognition, leaving her nose and cheekbones purple, and swollen. She had a cut inside her top lip, and a simple undisplaced fracture to just one bone in her hand. None of her injuries was consistent with Mum having effectively or consciously broken her fall; she is strongly right-handed, and all injuries were predominantly to the right side of her head and body, including extensive bruising to her right breast.

What had my Mum been doing when she ‘fell’? Letter-box dropping pamphlets for a local Bush-Care organisation, of which she is a fit, vital, and active member. Mum is also a keen, and formidably fit and sure-footed bush-walker. She still works as a successful CAM practitioner. Mum has never fallen in her life, and her intelligence sparkles. She’s also humble, stoic, kind, non-demanding, and endearing.

The original attending doctor, discharged Mum several hours after her presentation, with dressings to her head and face, a hand in a back-slab and sling, and the advice to me, that my Mum ‘had just had a little fall’. I specifically informed nursing and medical staff at this hospital that Mum never falls, and that the nature of her injuries indicated that she could not have been fully conscious when she hit the pavement. I specifically requested of them, that they Xray or CT scan my mother’s head, and to consider that there may be a more sinister reason for Mum to have ‘fallen’. They refused to do so.

Twenty-four hours later, at a major tertiary teaching hospital and referral centre, the system had another crack at killing Mum.

My Mother had been ambulance-transported to the larger hospital after I had her reviewed by her family doctor, who reluctantly arranged brain CT scanning [it was late in the day].This revealed the sub-arachnoid haemorrhage which the first hospital had failed to identify, least of all consider as a provisional diagnosis, or reason for Mum’s ‘fall’. The radiologists there, elected not to perform angiography using contrast, as Mum is considered at risk for anaphylactic shock. They – justifiably- did not want to take that risk, in a suburban clinic.
We went to the major hospital, having been advised that my Mother’s treatment and further investigations needed to be expedited. Kinda stating the obvious, isn’t it? The family doctor rang ahead, advising of Mum’s imminent arrival.
It took this hospital another 24 hours to perform CTA scanning, and another night and morning for suitably qualified and experienced staff to be available to definitively assess the results.

This is first-world, tertiary medical care at its best.

The unofficial rules for treating Elder-women with brain haemorrhages at this major hospital are:

1. After admission, spend two or three hours failing to notice that the neurology registrar has already seen the patient. Rely implicitly upon the electronic data-management system, rather than hard-copy case notes. This enables all members of the team to access vital information such as lab and radiographic results – stored and managed electronically- at least one hour later than ‘real time’.

2. Make no attempt to look for, or understand, what orders have been made – such as whether the patient can eat or drink, have toilet privileges, or needs medication.

3. Assume that missing a once-daily dose of slow release antihypertensive medication – because the hospital allegedly doesn’t stock it – will have no affect on the patient’s already rising blood pressure. Upon discharge, dispense the very same medication; we do stock it, but just not ‘after hours’.
Leave the rising blood pressure untreated for the first 24 hours after admission, because heck, this really is best practice for chronically hypertensive folk who also have a touch of raised intracranial pressure. { Let’s get it straight: 24 hours previously, when first examined by ambulance para-medics at the scene of her collapse, Mum’s BP was noted to be elevated. It was high in the A&E department of the first hospital. At the tertiary hospital, one diligent RN did attempt to track down a single dose of the very common drug my Mother takes. He couldn’t find any. He informed me that he had then contacted ‘the registrar’ and had been told that it would be ‘ok’ to miss the dose. I have no idea if anyone explored the idea of administering a similar drug. I certainly requested that someone give this some thought. As it was, Mum’s hypertension was left untreated in this hospital for 24 hours. Subsequent to discharge, management of Mum’s BP has become the primary goal of treatment, due to the fact that small-vessel disease was ultimately identified.}

4. Disregard everything you learnt at medical or nursing school about the importance of managing hypertension in people who have a history of hypertension, acute closed head injuries, and blood in the sub-arachnoid space. Spend a number of hours 24 hours after admission,  giving IV-push doses of hydralazine, to get the BP down, because someone will finally notice and remember that elevated BP and a brain haemorrhage aren’t conducive to good health.

5. Rush through the basic four-hourly neurological observations, and consistently fail to notice when one pupil is larger than the other.

6. Replicate the mistake, by simply following what the previous observer has noted. Just for fun, when you come on at the beginning of your nursing shift in the A&E observation unit, tell the patient that though you’re conducting observations, you don’t know what her provisional diagnosis is.

7. Fail to provide anti-embolism pressure stockings for the first 24 hours, because the thrill of deciding how to potentially manage concurrent clots-which-can-kill and bleeding-which-can-kill is just too exciting for words.

8. Fail to ask about, or observe, bloody discharge – via nostrils or post-nasally – from suspected fractured noses, and ‘middle thirds’. Because the patient only has a mild headache, is a good enough reason to disregard the fact that the rhinorrhea may contain CSF. { My Mum encountered two A&E departments, one family physician, a neurosurgical registrar, and several resident doctors, not one of whom thought about the possibility of CSF leak, despite a face of contusions, haematomas and lacerations, an abnormal-looking nose, smashed and distorted spectacles, a history of ‘face-planting’ into a footpath, a loss of consciousness, and a belated diagnosis of a sub-arachnoid haemorrhage. Yes, they tell me someone examined the cribriform plate on CT, but that CT was not definitely assessed until Day 4. When I asked a resident about Mum’s rhinorrhea, he looked mildly shocked, stated it wasn’t “in the notes”, and then told me “we go by the clinical picture.” Pardon? Mum spent the first week after her collapse, mopping at the discharge trickling from her nose.}

9. At all times continue to assume that 71-year-old, little-old-ladies who fall over and smash their brains about in their heads, do this all the time. This saves the hospital many dollars in cardiac, and other general medical investigations, as the assumption is that falling and dying from it, is inevitable in this age group. Take another five days to finally listen to the family and patient, before looking for other reasons for falls – or loss of consciousness – which result in life-threatening brain injuries in Elders.

10. Be sure to pull the curtains around all patients in the emergency department observation unit for the night. This enables staff to spend the night uninterrupted by the tedious task of visually observing patients in various states of life-and-death. It’s anomalous with the constant, in-full-view-observations we subsequently make of folk in the neurosurgical High Dependency Unit for the next couple of days, but hey…

11. On no account attend to matters of hygiene or comfort whilst patients are in the emergency department observation unit for 15-16 hours. Not even a warm wet washcloth, or help with teeth-cleaning. This is not the Hilton, you know.

12. When you sense that the patient and her family are inexplicably outraged and aggrieved after such impressive, expedited care, send in the most charming, engaging members of nursing and medical staff to conduct damage control. It works most of the time, and usually saves everyone the mass of paperwork which a formal enquiry generates. Note to staff – having a senior RN in the neurosurgical unit personally clean an Elder’s dentures, after the communications between A&E, the Bed Manager, and the Neuro Unit have left a patient forgotten for 16 hours in a corner in the A&E observation unit, is a nice touch.

13. When conducting ward rounds, be sure members of the medical team stand at the end of the patients’ beds, chatting earnestly amongst themselves about the patients. Do not make eye contact or deliberately engage head-injured folk in discussions about their treatment, as this just makes them want to talk, and ask time-consuming questions. The essential assumption is that Elders with brain injuries are probably demented, not very intelligent, and well past their prime. Why bother with basic communication skills in this patient population?

14. Never, ever transfer head-injured patients up to the neurology unit promptly. Have no provision or protocols for specialist nursing staff from the neuro unit, to visit acute neurosurgical admissions who are in the ‘holding pattern’ of the A&E observation unit. Ensure that no medical review is conducted for at least fifteen hours after initial presentation and assessment. Even then, we only send neuro registrars back down to A&E to re-assess patients, when their families include relatives who are medical specialists with significant medico-legal expertise, and are irritatingly expressing concern that the patient has not been medically or surgically reviewed since initial assessment early the previous evening. If patients survive this crucial period unattended and untreated, we know we will have proven Charles Darwin was right about ‘survival of the fittest’ and ‘natural selection’.

15. Upon discharge, fail to return the patient’s original, privately conducted CT scans. In the ensuing weeks, be sure to book the patient into the wrong general medical out-patient clinic; we like the fun and games of booking patients who are not having surgery, into the pre-op medical assessment clinic. Fail to schedule any follow-up appointments with the neurosurgical team, and be sure to instruct the patient that they ‘missed’ their fracture clinic follow-up. { This one just makes us laugh – Mum was an in-patient on the day they say she missed the fracture clinic. She was seen by an orthopod that day – in that particular fracture clinic – of course }

15. A general rule for the whole hospital:  we have a fabulous new building, a  great art collection, a Starbucks outlet in the lobby, and impressive landscaping. Ensuring that cleaning staff actually vacuum and mop under beds, behind toilets, and in corners, is a very silly expectation indeed. We’re not talking about little balls of fluff here, we’re talking about used tissues, grime, tiny dressings from venepuncture sites, snap-off lids from ampoules etc. We instruct RNs to smile sweetly, acknowledge it’s ‘not the best’, but to ensure that detritus remains on the floors for at least 48 hours.

16. And a word about our IT. It’s amazing. It’s at least an hour behind real-time, which is of great assistance in situations where you need to make a prompt, well-informed decision, or get patients with life-threatening conditions out of A&E sooner rather than later. It’s probably why disinterested RNs in A&E can’t tell a relative if the patient has been seen by a doctor. It might also be why a patient with a sub-arachnoid haemorrhage is left unreviewed, and untrasferred to the neuro unit for so many hours. Not that we admit that, of course. { Though we might want to track down that young resident who did admit in a telephone conversation with a patient’s daughter, that the 16 hour period of neglect was ‘indefensible’.} We also don’t see the urgency in making any lab or imaging results available for ready access in the acute A&E setting, in the neuro unit, or after discharge. When the patient comes back for neuro rehab assessments, some three weeks after discharge, we pride ourselves on running a system which does not allow the neuro rehab team to access any of the CT scans or MRIs taken during the patient’s stay. It’s brilliant. It’s modern, and we especially like that our medical and surgical staff rarely pick up the phone and call a department to get a ‘verbal result’. If the computer isn’t going to give you the information, it’s probably not important.

My Mother survived this comedy of dark errors, and is expected to make a full recovery.

Here’s why I know Mum survived:
She is robust, youthful, and a cherished and active member of her community.
We are healers, and so too are many of our beloved friends and colleagues, each of whom sent healing, love, offerings, or prayers.
A family member with extensive medical, surgical and neurological experience in a similar hospital, knew that things weren’t right, and kept calling hospital staff to account.

Mum’s brain-bleed was the result of a heavy fall, not due to a ruptured aneurysm or AV malformation, so she is one of the lucky ones. The ‘fall’ has subsequently been identified by an independent general physician, as a loss of consciousness,  most likely caused by temporary kinking of a vertebral – or related – artery. Mum has an old neck and back injury, and visually evident changes consistent with osteoporosis and degeneration. This physician took the time to inquire about – and examine – Mum’s musculo-skeletal system. To my knowledge, only one of the innumerable hospital doctors she encountered, thought to examine my Mother’s neck – by palpation only – and only to exclude bony tenderness. To this day, we have no radiographic or other  evidence of the state of Mum’s cervical, or upper thoracic vertebrae, despite regularly asking. It is the physiotherapists in the neuro rehab unit, who are finally managing Mum’s neck and back concerns.

Mum lives a life rich with meaning, generosity, love and gratitude.
The world needs people like her.

We intend to initiate formal processes with each of these hospitals, so that no others may have to suffer the slow-moving chaos, ineptitude, disinterest, and age-bias which my Mother experienced.
We trust that medical and nursing directors will endeavour to implement change, rather than hide behind the catch-cry of insufficient funding, resources and staff.

Few of the oversights and omissions endured by my Mum, can be attributed to lack of human and other resources.  The culture of a large teaching hospital, and the over-education of young doctors and nurses, has eliminated basic precepts of common sense, and respect for the inherent stoicism, stamina, intelligence and courage of so many Elders. An over-reliance on IT at this hospital, as the most credible and timely conduit of information, is life-threatening.

Sadly, I know that had my Mother been a famous young sportsman, the course of her treatment would have been very, very different.

And some words about basic human decency:
Pressuring the anguished relatives of an unconscious, elderly woman – in the A&E obs unit – into transferring her back to her nursing home at 9-10pm is just plain cruel. Refusing to give her any IV fluids ‘because her system won’t cope with it’ is not a rationale I’ve ever heard used with clinical legitimacy. There was no conversation between that attending doctor and the patient’s family about advanced health directives, or ‘DNR’ orders.
If you’re elderly, unconscious, and not expected to survive, this hospital doesn’t really want to help you. Grudgingly, the attending doctor allowed this lady to stay the night in the A&E obs unit. Her family had to plead for some time, before that decision was taken. I’ve subsequently been told that this hospital was ‘at maximum capacity’ on the night of Mum’s admission, and that 17 beds in the hospital were ‘closed’ due to ‘an infection.’ Is trying to bump the dying elderly back into the community late at night, how they attempt to manage a critical bed-occupancy issue?

Nurses who intimidate and threaten vulnerable neurosurgical patients:
Yes there is one in particular at this hospital, who menaces and threatens patients who regularly pull out their naso-gastric tubes. I have no argument with legitimately and compassionately using restraints to prevent folk from injuring themselves. I know how hard it is when as an RN, you have a heavy patient load, and many of your patients have complex needs. I’ve been there.
I am appalled that this staff member derogates these patients quite openly to other patients and staff, and talks ‘over’ these patients – about their behaviours and misdemeanors – whilst attending to their needs. Mainly, I’m appalled that this nurse sternly and emphatically states “if you keep pulling your tube out, I will restrain you, and don’t think I won’t, I’ve got the legal right to do it.”
Is it any wonder these patients became agitated when they were in this nurse’s care?
I raised my concerns about this nurse with one of the Liaison Officers at the hospital, who suggested I talk to one of the case-managers in the neurosurgical unit where we witnessed and heard these exchanges. I informed a case manager there, who ducked into the office of the Nurse Unit Manager, and informed someone there. I was told “the NUM will come and talk to you about this”. By that stage Mum had been bumped out of the neurosurgical unit to an adjacent medical ward, and was suddenly discharged later that day. This nurse’s behaviour is a serious matter, which has never formally been addressed.

That medical, nursing and clerical staff are so deeply resigned to the way things are done at this hospital, worries me immensely. That there are some I encountered, who believe this hospital is doing a great job, is even more concerning.
To be unconcerned and disinterested, to buy into the belief-system of the model of care at this institution, is to practice tacit complicity.

Things will never get better for staff or for patients, if acquiescing is the preferred method of enacting change and progress, in hospitals such as this one.

Addendum: August ’09. Subsequent to all of this, ‘health care reform’ has become big news in the US, and for a few days, was the main news story here in Australia. Go here for an exploration of  ‘healthy self-sufficiency & grass roots health care reform’.

July 2010: What doctors should do – but don’t – when their colleagues are “impaired or incompetent to practice medicine”. Go here to find out

April 24, 2009

“Bad Heart Linked to Depression”

Posted in health, life, love tagged , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , at 12:34 pm by Margi Macdonald

sw03

So stated The Courier Mail last week.

Hmmm

What is a ‘bad heart’ anyway?

What makes a heart go ‘bad’?

Cholesterol?

Adiposity in excess?

Love gone wrong?

Existential crisis?

Being bitter?

Check back in a day or so for a Traditional Chinese Medicine, Care of the Soul, and Tarot-based interpretation of this important issue.

Today, and any other day, if you feel something is amiss with your heart, your mind, your body or emotions, please see an appropriately qualified and experienced health professional.

Margi Macdonald

A note about ownership of today’s image: the Three of Swords from the Tarot.

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