Chapter 43: Never Events

January 19, 1987, McKinley, Ohio

Clarissa and I skipped our afternoon class on Monday after having spoken to Doctor Harding, who had given his blessing for us to attend the Morbidity and Mortality Conference. We arrived early in the auditorium where the usual Friday weekly conference was held and took seats towards the back, not knowing if doctors had 'usual' seats and hoping we weren't in a seat someone felt was 'theirs'.

"I've heard these things can be pretty rough on Residents," Clarissa said as we took out our notebooks.

"It's all about learning from our mistakes," I replied. "You just have to hope you never make a fatal error."

"I keep hearing the refrain that you aren't a real doctor until you kill someone."

"I call BS on that," I declared. "I'd agree that we'll all make mistakes, but most of us won't make a fatal mistake. As Doctor Gibbs and Doctor Roth have said, some patients can't be saved no matter how heroic your actions. If you had infinite time and complete information, you might save a higher percentage, but we won't ever work under those conditions.

"Doing your best with the information you have and losing a patient isn't the same as making a fatal error. I'll give you a perfect example where no doctor is to blame — the woman with the tumor during my stint in the ER. Every doctor did the right thing, individually, but the system failed the patient. And you know that changed my thinking about using computers, at least to track patient records."

Clarissa laughed, "So long as you don't have to touch it, right?"

"I'd make an exception in that case, I think! But back to the conference, the other thing they do here is discuss cases that stump the team attending the patient. I know they discussed the tumor case, but the problem is, as Doctor Gibbs and I discussed, continuity of care. The ER is decidedly not designed for that, and nor should it be. The problem, of course, is determining which patients are 'frequent flyers' or 'GOMERs' or drug-seeking, and which have legitimate complaints that do not appear obvious during an assessment in the ER."

"True. I was surprised that this conference is basically treated like a confessional."

"If you think about it, nobody would speak candidly or openly about medical errors if that wasn't the case. I know it might suck for a family making a malpractice case, but the greater good is served by allowing these conferences to proceed without concern that what's said will be used against us in court."

"You're more likely to get hit with malpractice in either of your potential specialties than I am in mine."

"And I'll pay the higher premiums, though the hospital carries the umbrella policy that will make mine affordable. But even surgery and emergency medicine aren't the worst."

"OB/GYN because no jury is going to deny a parent compensation for the death of their baby. A lot of compensation."

"There comes a point, though, when those costs are going to drive up the cost of medical care to the point where it's unaffordable. It's a tough balancing act — the needs of the many versus the needs of the few."

"Or the one," Clarissa added with a smirk.

"Spock and Kirk aside, that is how we're being taught to do triage — save as many patients as possible, sometimes denying treatment to a patient who has a remote chance of survival to treat several patients with much better chances of survival. It would suck to be one of the ones left untreated, but how many people do you put at risk to save one person? And before you answer, I have no clue what that answer is. And that's why there are triage rules — so we don't have to make that decision when every second counts."

"And you're OK with that?"

"Of course not, but I also don't see any way around it. Ultimately, there are limited resources available, and they have to be used in the most efficient way to benefit most people. Think about vaccines for polio, MMR, DPT, and so on. Are there some people who are harmed by those vaccines? Yes. But the overall good for society is so great that we accept those very limited bad outcomes. That's how the FDA operates as well — some drugs will cause severe side effects or even death in a small percentage of the population, and yet they're still approved because of the greater good."

"What do you think about parents who refuse to vaccinate their kids?"

"I think they're idiots, but it's not up to me to decide. Remember, though, I'm talking about the vaccines I mentioned before. If they manage to develop a vaccine for varicella, I doubt I'd give it to my kids unless they hadn't contracted 'chicken pox' by age ten or so. Before that, it's generally just annoying. After that, it can lead to loss of fertility and other problems. But my decision there would be based on the incidence of possible negative side effects versus the risks of complications."

"So, all stats?"

"That's all it is, in the end. If the risks from the vaccine are lower than the risks from the disease, which is the case for polio, measles, mumps, rubella, diphtheria, whooping cough, and tetanus, then it's obvious you take the vaccine. If not, then it depends on individual risk factors.

"Look at the disaster with the vaccine for Swine Flu back in 1976, and you can see the problem. The program was rushed, and as we learned in our epidemiology course, the vaccine was associated with an increased incidence of Guillain-Barré Syndrome. That can cause paralysis, respiratory arrest, and death. They stopped the vaccine because of that, after inoculating about a quarter of the population. The problem was that there was no actual risk because the outbreak was contained to a single military base."

"And that gave the anti-vaccine crowd more ammunition to oppose ALL vaccines."

"The source of the problem was the rushed development and rollout without proper testing. To me, that's a major red flag. The entire point of having an FDA is to ensure drugs are safe. If you can bypass that for what amounts to political expediency, well, that concerns me. I'm not saying there can't be a case where you need to approve emergency use, or even experimental use, but widespread use? That needs to be carefully considered."

"But they felt the risk was real."

"Well, they were wrong, weren't they?" I grinned.

Clarissa laughed, "Young Frankenstein, right?"

"Yes."

"You'd remember that because you do have an enormous «schwanzstucker»!"

"That goes without saying," I replied smugly, completing the exchange between Frederick Frankenstein and Inga.

Clarissa smirked, then sang, "Oh, sweet mystery of life, at last I've found you!"

I laughed, "You do NOT believe that at all!"

"No, but your pussy cat does!"

"Perhaps," I grinned.

Others began filtering in, and Doctor Gibbs sat down beside me.

"Who covers the ER?" I asked.

"Doctor Simons today. We rotate. But I was involved in treating the patient when he presented in the ER."

"Any chance you could have saved him?" I asked.

Doctor Gibbs shrugged, "I don't think so. Even knowing the source of the problem, he was already in septic shock by the time he was brought in. We ran the protocols for that by the book, but he was already too far into multiple organ failure. The M & M inquiry into the case will focus on how they managed to not be able to count to twenty-six in the OR."

"He should have come in sooner or seen his family physician," I said.

"And in the end, that's what caused his death. Yes, the surgical team made an error, but the patient ignored the warning signs until it was too late."

"How does that affect the near-certain malpractice suit?" I asked.

Doctor Gibbs laughed bitterly, "It's never, ever the patient's fault. No matter how poor their decision-making was, nor how long they delayed before they sought treatment, they'll win big. That little mistake will cost the hospital a million bucks or so. The guy was thirty-nine, so he had, according to the stats, another thirty years at least. That factors into the amount the hospital and insurance company offer."

"Would this have been caught?" Clarissa asked.

"Probably," Doctor Gibbs replied. "The symptoms would generally lead to an ex-lap, and that would have located the sponge. Even X-rays during diagnosis would have found it. Had he come in, there's a far better than even chance we'd have caught it long before it killed him."

"Not certain?" Clarissa inquired.

"No," I interjected. "It's always possible for symptoms to be masked, and unless a CBC was requested, it might be attributed to post-surgical discomfort. Even a CBC can't rule it in, because septic shock can have high or low white blood counts."

"Very good," Doctor Gibbs said. "You've been studying."

"I spent my extra study time on diagnosing sepsis and septic shock. We've covered it briefly in class, but I did more reading."

"Hi, Mike," Doctor Roth said, sitting down next to Doctor Gibbs. "What brought you here?"

"A learning opportunity! Specifically, Clarissa and I were in the pathology lab when Doctor McKnight found the retained surgical sponge."

"Learn that lesson well, both of you. Even with the best procedures, it happens. Somebody goofed here, and the goal is to find out what we can do to improve procedures."

"Is there any way to tag the sponges?" I asked.

"Numbering them has been suggested, but again, you're relying on human beings. Granted, numbering them would make it easy for a post-op review to find them."

"So, why not do that?" Clarissa asked.

"There are all sorts of concerns about sterility and introducing what amounts to ink into an open wound. Sewn-on tags might work, but they could come off or be so drenched in blood that you couldn't read them. Somebody wrote a paper about adding tags that fluoresce under radiological exam, which would help in identifying but not counting. We always count twice, but in surgery, especially if something unexpected happens, the count takes a backseat to saving the patient's life. Somebody will come up with a proposed solution that will help and can be implemented, but in every case, the human beings are both the strongest and weakest links."

Doctor Strong arrived with two medical students and sat down next to Doctor Roth with the medical students on his other side.

"Why are all of you sitting in the back?" I asked.

"We're not presenting today," Doctor Roth said. "Anyone presenting sits in front, so it's easier to go up to the lectern. We can sit here in the peanut gallery and kibitz."

Doctor Jerry Rhodes, the Medical Director, went up to the lectern and called the assembled staff to order. The first two cases were about difficult diagnoses, and the process was fascinating. The Resident who had prepared the first case began by describing how the patient had presented and what had been done. At that point, Attendings, Residents, and medical students began asking questions and offering suggestions as to what to look for and what might have been done, while others countered with other ideas.

Ultimately, everyone agreed that the right procedures had been followed and that the lengthy time to diagnose was not atypical. At that point, suggestions were made for improving the diagnostic process, though I was annoyed when Doctor Nels Anderson, the Hospital Administrator, pointed out the costs of doing some of the procedures on a routine basis. I then remembered my earlier comment about limited resources, and while I was still annoyed, I understood his point.

"How do we get more resources?" I asked Doctor Roth quietly.

"Raise prices or raise taxes," he said. "Both have tradeoffs; take your pick."

I nodded grimly because that really was the only solution. We'd been taught that preventative care could reduce overall costs, but short of forcing individuals to see a doctor, that could only mitigate the problem in limited ways. And in the end, there was a limit to how much you could charge and what taxes you could collect. Countries with national health systems, like Sweden and the UK, had limits on what procedures could be performed and what medications could be prescribed. In the end, something had to give, and because of that, some patients had worse outcomes.

The second case was similar, and when the discussion ended, Doctor Stuart Lyons, the Resident, stood up and walked to the lectern.

"Today, I'm presenting the case of Peter Quinn, thirty-nine, who succumbed to a post-operative infection caused by a retained surgical sponge. I'll take you through each step, from pre-surgical care to post-operative care. Doctor Carlton will present on treatment, and Doctor McKnight on pathology."

As he went through his presentation, there were very few questions because everything was textbook right up until the end of the surgery. And then the cause became evident.

"As we were closing, the scheduling nurse let us know that the OR was needed for an emergency appendectomy, which led to a failure to ensure the sponge count."

"Jesus Christ!" a doctor in the front swore. "We have procedures for a reason!"

"Tim," Doctor Rhodes reprimanded, "that's not helpful."

"I say it is," the doctor said, standing up.

"Who is that?" I whispered.

"Doctor Tim Baker," Doctor Gibbs replied. "New Chief of Internal Medicine."

"The team failed to follow the procedures," Doctor Baker said. "I don't give a tinker's damn about why they didn't."

Doctor Roth stood up, "Tim, you're new here, but we do not confront; we discuss. I'm not sure how it was done at your last hospital, but we don't allow anyone to be attacked, especially Residents and nurses. If you have a problem, take it up with Doctor Gardner in private. Here, the surgical team is admitting error. Our goal is to find a way to improve."

"Following procedures already in place," Doctor Baker insisted.

"That's true, but you know full well a time will come when it's a choice between procedures and a patient's life. We have to balance that. Now, if you want to propose changes to operating procedures, this is the place to do it, or, if you prefer, schedule a meeting with the surgical staff to discuss it."

Doctor Roth sat down.

"Why did you do that and not Doctor Gardner?" I asked quietly.

"Because it's his team, and it would look like he's trying to deflect blame."

I nodded, as that did make sense.

"In the end," Doctor Lyons continued, "the final count was not performed properly. But it is also the case that the in-progress count was off by one. In other words, from my review of the surgical notes, I believe a sponge was used and not recorded. THAT was the true source of the problem, not the failure to do a final count. In other words, the count as we closed matched the count of used sponges. A final count, if performed, would have matched as well. Our proposal is that the final count be compared to the actual number of sponges missing from the supply."

"Obvious," I whispered to Doctor Gibbs.

"Sitting here after the fact, yes, " she whispered back.

I nodded because one of the things we'd been taught was that changes to normal procedure came, more often than not, after errors. After all, if something worked, there was no real impetus to change it. We'd learned that change had its own costs, and those had to be factored into any decision to make changes. Of course, I thought back to my research on handwashing and understood that physicians were averse to change, even in the face of overwhelming proof. That was something I had to make sure didn't happen to me.

Doctor Lyons turned the lectern over to Doctor Carlton, who described what I felt, in my very limited experience, was a textbook response in the ER, and it appeared everyone agreed, as Doctor Carlton wasn't questioned by anyone. Doctor McKnight followed him and reported on the autopsy. He reported on several findings, but none of them, including a partially occluded coronary artery and initial signs of prostate cancer, had contributed to the patient's death.

"I do have one clinically significant finding," Doctor McKnight said. "The patient's lungs indicated heavy tobacco use, and his son confirmed that Mr. Quinn was a two-pack-a-day smoker and had resumed smoking not long after his surgery. It's my opinion that this contributed to the patient's death. As we know from Nesbitt's paradox, as dosages of nicotine increase, it changes from a stimulant to a sedative. With a sufficient dose, it dampens neurotransmission, and it's my opinion that is at least partially responsible for Mr. Quinn's delay in seeking treatment.

"Another factor might be his alcohol intake, which was fairly high, but liver enzyme tests before his surgery did not indicate alcoholism. That said, nicotine and alcohol combined reïnforce each other as sedatives and in depressing function of the central nervous system. I verified with Mr. Quinn's son that he regularly drank beer and often drank whisky. I conclude that these factors are at least partially responsible for the patient's death and that a patient who was not a smoker and who was a light drinker would very likely have survived this medical error."

"Are you blaming the patient?" Doctor Baker asked.

"I'm simply recounting my findings and giving my opinion as to the cause of death and the contributing factors. As you heard, I reported the cause of death as septic shock resulting from a retained medical device, and that is the official cause of death. My job is to point out ALL factors, so that the hospital review committee may make recommendations with regard to patient care."

"They should all stop smoking!" Doctor Sumner, who I'd had for my pediatrics Preceptorship, declared.

"Easier said than done," Doctor Lawson, who I'd had for my psych Preceptorship, said. "We advise all patients to cease smoking immediately and offer programs to help them. The same goes for alcohol consumption. Short of banning tobacco, I'm not sure how you completely stop it. Education is helping, but it's not perfect. And we know what happened when the government tried to ban alcohol."