How to survive Christmas in the hospital, if you're unlucky enough to end up there
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Version 0 of 1. Three years ago on a long weekend, a little boy in hospital died of septicaemia. Victorian coroner Jacinta Heffey ruled that 15-month-old Leroy Scott would have lived were it not for the hospital’s tardiness in delivering antibiotics. The reason for the delay was debate over whether the illness was bacterial or viral. An important complicating factor was the public holiday that impeded the follow up of a positive blood culture, which would ordinarily have prompted urgent remedy. The coroner pointed out the need to improve collaboration and communication, especially during holidays when vital sections of the hospital operate at reduced capacity. For their part, the heartbroken parents seem incredibly gracious people who accepted the paediatrician’s apology and highlighted instead the “clinical and systemic failings” in healthcare. Leroy’s story pierced all my professional defences, and went straight to my heart. It reminded me of the time my daughter was rushed to hospital with a mystery illness. All my medical training evaporated as I put my faith in the hands of strangers to get it right. The paediatrician demurred over antibiotics and mercifully, was right in his suspicion that she had a nasty virus. Little Leroy’s parents don’t have the consolation of a happy ending and I feel for their loss. Imagining the event from a parent’s perspective was confronting. So was mulling over the report as a clinician who is regularly rostered to work public holidays, when we are reduced to a skeleton staff. The prospect of medical error is heightened as a result. So amongst the solemn recommendations it was actually an innocuous line that sent a chill down my spine: She nevertheless conceded in evidence that she should have followed up the results but had been very busy and forgot to do so. Unbidden images of patients came rushing to my mind, whose care was compromised by an intervening public holiday. The octogenarian whose dangerously high sodium level would have gone undetected had it not been for her vigilant son, who insisted that his mother had been playing golf until Easter Friday. The young man whose chest pain did not signal anxiety, but a broken rib missed on the original x-ray. The cancer patient who didn’t get home for Christmas because her swollen abdomen couldn’t be drained in time. The disabled man who kept receiving powerful antibiotics for days longer than was necessary. On my first day back from the long weekend, I sent the lady with the elevated sodium to intensive care. After she made a full recovery and credited us profusely for having saved her life, I felt compelled to follow the paper trail back to the admitting doctor. It was impossible to add to the doctor’s remorse but we both wanted to prevent future error. I knew she had worked a very long week and was also grappling with career worries. Furthermore, the hospital had been deluged with patients that weekend. I expected her to offer these as explanation. Instead, she wept. “I kept telling myself that it was odd the result was still pending. And then, the truth is, I simply forgot.” Shaken, she left the hospital that year. Over the years, I have observed and been involved in near misses, and yes, probably some deaths. “I simply forgot.” I can attest to the cold reality of these three words that have nothing to do with knowledge, experience or diligence, and everything to do with human nature. Once, we hoped that technology would take care of the problem. A red flag flashes when you contemplate prescribing interacting drugs. Addictive opioids require government authorisation. iPads on ward rounds obviate the need to queue up at a fixed screen to check results. Ubiquitous personal devices mean instant communication. Radiologists file reports around the clock and there is remote access for the clinician who worries what the midnight potassium test showed. Recognising that most medical mishaps happen due to “system errors”, hospitals have established protocols for everything from insulin infusions to clinical handover. The medical emergency team (Met) call is one widely adopted example. Triggered by factors such as a rapid pulse rate, low blood pressure and poor urine output it recognises early deterioration whose pre-emptive management reduces mortality. The thing is, no amount of systems refinement will ever replace the part of medicine that is simultaneously its greatest privilege and most daunting risk – the human element. The same human mind that presides over ingenuous discoveries is capable of faltering badly at times. I find that some medical errors happen because we know too much but haven’t figured out how to best harness that knowledge. Diagnoses and tests have mushroomed, not always to patients’ benefit and in fact, many times to their detriment. A typical inpatient receives several dozens of tests at the hands of doctors who don’t always talk to each other. Inconceivable as it may seem to the outsider, it is not unusual to have tests whose results are irrelevant or simply not checked. Mostly this is wasteful, but sometimes it can be downright dangerous. There is a second reason that is harder to acknowledge. Doctors, like everyone else, carry their personal issues to work with them. They have fragmented relationships and ardent affairs; nagging parents and dysfunctional children; problems with weight and self-esteem, fertility and career. Much as we’d like to think that the doctor at our bedside might tend us with a clear mind and an intact body, a doctor who is always and forever mindful and has never made a mistake exists only in myth. Yet, we get things largely right by working together. But the chance of error is multiplied when a system already under pressure finds itself short-staffed due to cost-cutting measures and bureaucratic decisions that fail to heed that serious illness does not care for a public holiday to pass. For this reason, I regard public holidays with some apprehension. In advising patients on how to survive Christmas in the hospital if they are unlucky enough to be there, I say the following. Staffing flux means less continuity of care. People rostered on a public holiday work under unique pressures. An intern might be the temporary social worker, physiotherapist and blood nurse. The surgeon may be covering two hospitals. The physician may be responsible for 50 patients. The speech pathologist may work the morning only. Bloods and x-rays take longer to process and a broken paging system takes longer to repair. Therefore, where possible, keep track of your own progress or have an advocate jot notes. It’s okay to tell the fourth doctor in four days that your breathing really doesn’t feel right, that your pain hasn’t budged, and that no one has sighted your leg ulcer in days. Check with your new doctor or nurse about your understanding of the plan. Ask about the test that was performed at midnight. Be polite but firm – understand that you have a say in your care. If you can, please wait for your needs to be met. Not every patient has the same acuity and you can be certain that the delay in your being seen translates into someone else receiving urgent care. However, if you think it can’t wait, speak up and raise the alarm. We would rather rush to your bedside than fill out an incident report later. Good medicine is a joint human endeavour. It is worth remembering that of the 53 million clinical encounters in Australia each year, the productivity commission reported that over the 2011-2012 reporting year only 107 cases of serious medical error occurred. Even if you take into account all the people who don’t have the energy to complain or whose injury goes unrecorded, this is a reassuringly small number. As another set of public holidays approaches, this will be cold comfort to Leroy’s parents. For doctors, it is not an excuse for complacency but a timely reminder that for all our successes, we are fallible and our fallibility can be fatal. |