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In the one-page text+video article, Is Healthcare Shaped by Industry? Of Course It Is! a leading physician in the patient-safety movement summarizes industry impact on healthcare and medical practice, concluding (emphasis added):

The old-prototype physician would not even have his little black bag with a thermometer and a sphygmomanometer if it had not been for industry...interested in...manufacturing devices and drugs that would be useful, even essential, in medical practice. We are stuck with medical industry. Let's hope that the big players try to behave more like a part of the learned professionalism they service rather than as pure capitalists.
Last November, Lundberg outlined the 1994 repercussions of publishing Lucian Leape's Error in Medicine in JAMA, igniting the patient safety movement. To AMA members' angry, "Whose side are you on?" Lundberg replied, "The side of science, truth, and all patients."



NEWS & USE-ABLES ON PATIENT SAFETY IN PROFESSIONAL SOURCES & PATIENT-ADVOCACY SOURCES: ■ Electronic Checklist decreases central line-associated bloodstream infections, a cause of illness & death hospitals battle everywhere   ■   Nearly 1 in 7 Hospitalized MediCare Patients Experience Adverse Events   ■   Misdiagnoses All Too Common: 1 in 20 US Adult Patients   ■   80-yr-olds benefit with senior-health group meet-ups and home-health visits   ■   PATIENT FACT SHEET: 20 TIPS TO HELP PREVENT MEDICAL ERRORS   ■   Guide to Patient and FAMILY ENGAGEMENT IN HOSPITAL QUALITY & SAFETY   ■   Society to Improve Diagnosis in Medicine   ■   SLIDESHOW: Top Patient Safety Strategies to Implement Now   ■   Examine the Patient   ■   What Not to Prescribe: APA List Aims to Make Patients Safer   ■   Consumer Reports Releases Top Hospitals for Safety List   ■   Warn Patients of Fall Risk Tied to BP Drugs   ■   NSAIDs: Not as Safe as Patients May Think   ■   E-Cigarette-Related Poison Center Calls Surge   ■ Antidepressant-Induced Liver Injury Underestimated   ■   National Patient Safety Foundation   ■   TIPSHEET FOR BEFORE, DURING, AND AFTER APPOINTMENTS   ■   Hospitals Make Steady Progress in Patient Safety but some lag behind   ■   Top 10 Patient Safety Concerns for Healthcare Organizations: Info-Tech/Electronic Med Record Flaws #1


             
Below the orangepeel: case study of a father's hospitalization.

KosAbility logoKosAbility is a Sunday 4pm(Pacific time) community series by volunteer diarists, as a gathering for people living with disabilities, who love someone with a disability, or who want to know more about the issues. Our use of "disability" includes temporary as well as permanent conditions, from small, gnawing problems to major, life-threatening health/medical problems. Our use of "love someone" extends to beloved members of other species.

Our discussions are open threads in the context of this community. Feel free to comment on the diary topic, ask questions of the diarist or generally to everyone, share something you've learned, tell bad jokes, post photos, or rage about your situation. Our only rule is to be kind; trolls will be spayed or neutered. If you are interested in contributing a diary, contact series coordinator postmodernista.

postmodernista's Dad's Case Study

 In 1998, I was one month into a master's program in higher education administration with 3 small children, 1 and 1/2 jobs, and a terrible, fraught thing was unfolding that I was not yet aware of. I lived in El Paso, Tx, and school was every other weekend at Texas Tech in Lubbock. It was Saturday, February 13th, I'd survived the 3rd weekend of my first semester, and Dad came by Mom's house (they were divorced in 1971) to deliver Valentine chocolates to me and the kids. Nice visit, but he looked a little tired- small wonder, as he'd done a car auction in Lubbock that morning, and then driven 50 miles to do a livestock/rodeo auction that afternoon.

I had to be back home Sunday, a 300 mile drive, to get everything prepared for the week, so at 5:30 that next morning, I was up and packing when the phone rang. Phones ringing at 5:30 in the morning are never a good thing, in my experience. I wasn't close enough to answer it, but it stopped and I supposed that my mother, her internal clock perpetually set to 4am, had answered from an extension or it was a wrong number.

Moments passed and Mother walked into the living room and said "J- ....". and I knew, I have no idea how. I said to her "Let me guess: Dad's having a heart attack and is at the hospital."

Three guesses and the last two don't count. He was, and it was bad, and that was my entrance into a set of days that convinced me he might not make it, then that he would, and then the hospital really messed it up.

He was transferred by ambulance to the larger hospital in a city nearby, and I spent most of the day on pins and needles while he was put through all the diagnostics. In the early afternoon, they'd decided on bypass surgery but wanted to do it the next day ('You really want the surgeon rested and fresh' they said.) It seemed stable, so I took the opportunity to get the kids back home with their dad, so I'd be clear to tend to mine. Halfway back from that delivery, I had a phone call that they'd had to rush him into surgery.

Midnight-ish, he was out of surgery and in the SICU. A septuple bypass. They stop billing at 6, I later learned. Everybody went home and I commenced my indefinite stay in the waiting room.

For those of you who haven't had the pleasure of the SICU visitation, it involves a lot of sleepless, frightened people lining up every 4 hours to have a glimpse of their loved ones (5 minutes from the door buzzing open to being shooed away by the nurses). My dad is a big guy with a big personality- 6'4", and always the center of attraction in any given group. He looked so small and pitiful, wan and gray, and no wonder - he was having trouble maintaining a sufficient blood pressure, it was so low that he scared hell out of the experts, and there were meds being administered to keep it up enough to keep him perfused.

They finally got him to a level of blood pressure stability that would allow him to go to the cardiac care unit, not a great place, but better than SICU. So he and I commenced our time there. For just what feels like a little bitty minute, it felt safe not to think that he was going to die. I was so wrong to have thought that - it allowed me to feel hunger pangs, so I went downstairs to snag something out of the vending machines, and forgive me, have a cigarette. By the time I got back, roughly 15 minutes, the damage was already done, and here is what happened:

They woke him for his 3am assessment, and because it was standard procedure post-bypass, gave him a medication that lowered his bp into the major-big-problem range. They didn't know that he'd already had problems with that, so they went with standard treatment. And part of the reason that they did that, was that his chart and history was kept at the foot of the bed, and the medication orders were kept on the cart in the hall on the other side of the unit, and no one bothered to cross-check the two. The resultant drop in his systolic blood pressure (the top number) led to what is called narrowing pulse pressure (the difference between the top and the bottom number) which indicates generally nothing (monitor the condition vigilantly) or something quite lethal (all aspects are unpleasant).

So I come back upstairs, settle in to the room's chair, and doze fitfully until all the damned alarms go off on his monitors, and a bazillion people rush into the room.  What/why!!! Help me understand what the hell just went wrong? And their best explanation is that he has cardiac tamponade- blood or fluid accumulating in the sac around the heart, limiting the heart's ability to fully expand and contract. 'We're going back to surgery- call all your family' at 4am. Nobody likes to make or receive those calls.

So they sweep him off to surgery, and I make the phone calls, knowing how grim that condition can turn out to be. Presto-bingo, by the time he was out of surgery, the family was assembled and prepared to do the waltz of the SICU waiting room. The authoritative surgeon arrives to deliver THE NEWS!!!!- that they found nothing. Absolutely nothing. Which was not a sufficient explanation at all, and somehow, he found himself backed up against the closed door that he was desperately trying to open and escape, and treated to the combined thoughts of me, my mother, Dad's sister, and a couple of my cousins. I don't think that he found that pleasant.

He escaped as quickly as he could with a clear understanding that he did not want to have a meeting with us again, and we returned to the dance of the SICU visitation schedule, wherein I got the rest of the story. On my first trip in that day, the chirpy nurse decided to sympathize with me, now that I'm seeing him after having his chest ripped open not once but twice. The single relevant sentence told me everything I needed to know about why this happened: "The CCU staff probably should have checked his chart against the med orders before they gave him that medication!"

And that is where all the excitement of Dad's story stops. He lived. He recovered, he's still around and tells us all what he thinks, wants, how to something right (his way), and in general is very much the charming, bossy, sweet guy he's always been. The drama has to stop there, because the anecdote only scares you, and maybe only makes you more worried than you'd have otherwise been if something similar were to happen to you, or your loved one. Here's where we get to the categories of what went wrong, information broad enough to be useful should you ever need it. Here goes:

Human Factors:
—I'm the only child, and everybody wanted me to make the decisions. After all, I was a paramedic and all. I didn't mind that, but more eyes/ears increase the odds that you'll catch something before 'bad' happens. Something similar may occur when there are several family members who want their decision to be the one heeded.

—My stepmom, sweet though she is, was even then in the early stages of Parkinson's, and was in no way fit to be the on-site patient advocate alone. The health and well-being of family members makes a difference, and that includes from the effects of their own illnesses, stress, fear, sorrow.

—What y'all might call a hospital stay is what my people call a family reunion. Everybody shows up, visits, and leaves. They may do that every day, and day is the keyword They didn't abandon me altogether- (hell my mother drove 30 minutes to bring me fresh drawers, and my stepdad's brother came to sit with Dad while I went to his house for a nap once). My stepsibs tended to my stepmom's needs, my aunt handled day-to-day stuff like bills and dog food, however:

—The dynamics and distances, and everybody's own life demands effectively left me alone with him for days and nights. We all thought I could do it-stay awake 24/7 and never leave the room- we were all wrong, I had to pee occasionally, eat sometime, and I wanted a cigarette now and again. What we created was a situation where I was the single point of failure at the hospital without regard the certain fact that I was absolutely going to be stressed, exhausted, and not in tiptop shape to catch an error, even if I could have been physically in the room with him 24/7. Being honest about the physical, mental, and emotional limitations of each of the family members is absolutely essential in helping keep patient AND the family safe.

Assumptions

—a single diagnostic measure was the trigger for the entire 2nd surgery episode. It could have been nothing or lethal, but there was no attempt to confirm through any other assessment either way.

—medical folks have a certain mindset, at least in my experience and I tend to have it myself, that when things are about to go to hell in a handcart, that person in front of them becomes 'the patient who must be saved', and they act, sometimes almost on autopilot. They are generally very good at this, but they are very focused and swift, and information that might be relevant but isn't in the first 5 minutes of their assessment and algorithms may be discounted. In this case, a cardiac ultrasound or similar would have confirmed or denied, and could have been had in less that 15 minutes. But somebody panicked, and it was all decided from that moment.

—medical people from the ground up assumed lethal and made the situation much worse.

Systemic

—Hospitals, large or small, are distributed systems that even with the most excellent attempts at coordinaton, things may go awry.

Physical aspects like the patient charts on this end of CCU, current med orders elsewhere are things that had never been viewed as a problem before (that particular thing got fixed after this episode)

Customs and interpersonal stuff- nurses know which docs are going to chew them to shreds for a middle of the night phone call. so they don't call. And you don't know what those dynamics are.

This was one of three major hospitals in that city. Being extra-special unhappy with this one, it crossed my mind to demand a transfer to one of the others, neither of which were more than a mile away. However, hospital criteria is generally to refuse to discharge, transfer, or accept a patient who is unstable, and since his instability was part of my chief complaint, there was no getting around that to effect a transfer.

Everybody is afraid to piss off the hospital staff at all levels. Surgeons, nurses, lab techs, for fear that care will suffer, likewise, your loved one. Also, if you get really out of hand, they'll just throw you out and then what? So instead, you've got this dynamic going on where you know that they know that you know that they are in charge, and there isn't a damn thing you can do about it.

Conclusion:

In the end, when you're dealing with a medical situation in a medical facility, for you, it is personal. And it is. But your part of it is also part of larger systems, be they family or hospital systems. It is difficult to think about any of that, because your primary focus is right there in the space between you and your loved one, but to try to keep in mind the larger systems gives you additional insights into where things might not go right, and an opportunity to address that before it happens.

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MEDSCAPE is a mostly-plain-English news & research report service geared for healthcare professionals but FREE to all who register - we caregivers, patients, friends, & family can pick Consumer on the PROFESSIONS list in the registration process when first using a Medscape link. A tremendous number of medical journals worldwide contribute to Medscape, so picking multiple topics for email notification may flood your inbox — trying starting with very few topics.

Many Medscape articles are commentable -  if you use a screen-name for privacy, it's worth devising one that won't undermine your impact. Some articles are slideshows with explanatory text added to illustrations and photographs. Where articles start with videos of speakers, turn sound off if you'd rather just read the transcript below the vid window.

Keep in mind that the competitive nature of publishing can skew writing to imply certainties not fully supported by findings, and there are always the basics to watch out for, such as: "Many Studies Have 'Elementary Statistical Errors'". Medical science, like every realm of human endeavor, is a work in progress.  Read critically for best results.

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