Care Theory

I have a theory. I believe that more people die in hospitals than anywhere else. Sounds obvious, right? The sick, injured and old go to hospitals for help and many times the help they receive, however heroic, is too little too late. But this is not what I am talking about. How often do patients suffer additional injury, are maimed or die due to simple human error.

We assume that our doctors, nurses, anesthesiologists, dieticians and the rest of the myriad of hospital staff are highly trained competent practitioners. This tenet is false and is severely limited by each individual’s area of expertise and the specific information that they have regarding each patient. In my wife’s and my recent experience there were several instances of what I am talking about. The first instance in question occurred in post op recovery. Our son Jordan had just received a spinal fusion with implementation and was in post op recovery when we first got to see him. He looked OK but his breathing didn’t seem right to us. We questioned the post op nurse about his breathing when we should expect him to wake up. Her answer was, “We like it when they sleep.” The truth is that in post op patients are supposed t wake up, after all that’s why they go there. Anesthesiologists use a complex set of calculations and intuition to maintain a level of sedation that is deep enough so the patient never feels any operative pain and yet doesn’t kill them. So when they get to post op the anesthesiologist should have a pretty good idea of when the patient should begin to wake. At some point the anesthesiologist came in and quickly realized that Jordan had been out to long. In my opinion this is something that the post op nurse should have identified. After all what else does she have to do? In post op it’s one nurse, one patient. This was mistake number one. It was an observational error on her part and a parental advocate error on our part. Basically what I am saying is ask questions and if the answer you get is flip, incomplete or an obvious blow off then ask again but don’t be so nice about it. The result was that Jordan wasn’t waking properly and required narcan, a drug that kills the effects of anesthesia.

Once awake he was moved to the Pediatric Intensive Care Unit, PICU, where he is turned over to the PICU staff. Their immediate task was to get Jordan’s postoperative pain under control. In Jordan’s case this became a balancing act. Because Jordan had narcan in his system the amount of morphine necessary to control is pain also caused him to become apnic. Basically, for the next 5-6 hours every time he fell asleep he would stop breathing. The farther he got away from his surgery the worse the problem got. The explanation from the PICU Dr. was that as he metabolized the narcan then the effectiveness of the morphine increased. The solution was to reduce the dosage of the morphine. He had a pump that gave him a continuous dosage while allowing him to selfadminister an extra dose every 8 minutes if needed. The apnic episodes were still there but were now minor and not of great concern. Then came shift change. This brings a totally new staff. One of the protocols with a shift change is to review the patients med orders. This is when the nurse noticed that his morphine dosage was half of what was in his orders. She was talking out while checking and she said, “His morphine dosage is incorrect I have to reset it.” This was mistake number 2. Hearing this we immediately let her know that the orders were wrong and that the dosage was supposed to be half of what was written. It turned out that the Dr. had not noted the dosage change. Had she simply changed the dosage to match the orders she could have accidently overdosed him. Now in her defense I believe she was talking out loud because she was questioning the dosage orders.

Following this there were 2 other mistakes. Number 3 was the dietician allowed Jordan to order a baked potato with his lunch. Potatoes cause gas when digested and gas is a very bad thing following surgery. Narcotics cause your intestines to slow way down and if they are barely moving you get terribly bloated. Bloating can be far more painful than the surgical wound. The dietician should know better so either he didn’t or he didn’t care. The 4^th was an X-Ray tech. She came in to perform an abdominal x-ray to make sure he didn’t have an obstruction. The problem was that she had no idea what kind of surgery had been performed and then began to handle him roughly and incorrectly. These instances were not life threatening but could potentially cause unnecessary discomfort for the patient.

Basically, anyone entering the hospital for any procedure needs an advocate not a yes man. The advocate needs to pay attention, ask questions and previous to the surgery do some research. What is routine to hospital staff in most cases is brand new to you. If something doesn’t seem right ask a question. If you don’t like the answer ask another. If you hear something that doesn’t sound right ask them to stop. For the most part hospital personnel are pleasant, cooperative and don’t mind answering questions. In the end the patient is your child, spouse or parent. The hospital staff is only there for one shift and you may never see any staff member more than the one shift. As a patient advocate you can provide continuity of care and you might just be the difference between a good outcome and a bad one.

Waiting

Everybody handles the stress of waiting differently. Some people read, some pace, some eat, some pray, others pace back and forth from their chair to the information desk asking for updates every 2.375 minutes. I am a fidgeter. I do not sit still. I will try 17 different identical chairs all the while complaining about each and every one of them. They are identical and I should be able to figure out that they suck after the first 2 or 3 but not me I keep searching holding out for the slim possibility that mass produced Chinese manufactured chairs might somehow be hiding a unicorn. This time to add to other people's level of irritation, compliments of me, I carried a ukelele. At a party it's a great prop, at a surgical waiting room I am not so sure. I don't actually play songs yet but I can string together chords and do some interesting roll patterns. My philosophy is every person has to manage their own stress in a way that best suits them and if that happens to be running around naked in heals with a feather duster stuck in your butt squawking like chicken and as long as it doesn't physically hurt anyone so be it. Now irritating people to the point of an impromptu UFC match breaking out is always a possibility and from what I understand a really great stress reliever. One other point is that if your stress relief behavior actually turns into a battle royal what, better place for this to happen. The whole place is full of degreed corner men.

At some point the expected waiting time is exceeded. The Doc said 3 hours, not 3 hours and 15 minutes. 15 extra minutes doesn't sound like much but waiting for news from an operating room is miserable. Minutes feel like hours. It's like the movie scene where the kid is waiting for the class bell to ring and he's staring at the clock and the minute hand moves in the wrong direction.Then all of a sudden, from out of nowhere, the Doctor is standing there, ready to talk. The Doc give the basic run down of how the surgery went and what we can expect when we finally get to go back and see our loved one in recovery.

Then we get to wait some more.

Waking up at 4:30 AM

Waking up at 4:30 AM to go off shore fishing can be pretty exciting, getting up at 4:30 AM to take one of your children to the hospital for scheduled major back surgery is also exciting and will definitely send your anxiety level into orbit. On the other hand, My 17 year old son Jordan, was ready to go. He was bouncing off the walls and at one point announces” Come on let’s do this thing.”

July 12, 2010 at 4:30 AM my wife and I woke our 17 year old son, Jordan, to take him to a 5:30 AM check in at Wake Med hospital in Raleigh, NC. He was scheduled for a spinal fusion with implementation that was expected to last 2 ½ hours. This procedure was necessary because Jordan has severe scoliosis. Scoliosis is an abnormal curvature of the spine. In most cases children are treated with physical therapy and a sleeping brace. In Jordan’s case his curve progressed to 60 degrees with a rotation. Surgery isn’t even considered until 40 degrees of curvature. Because Jordan had both the curvature and the rotation he experienced chronic back pain and little to no lung capacity in his left lung. Often times with severe curves internal organs are affected.

Once signed in they took us back into the pre-op area pretty quickly. Jordan got a fashionable backless gown, a gurney and an IV. His Mom and I got chairs. The set up nurse asked several basic questions. When was the last time you ate? Are you allergic to any medications? Do you know what you are here for? At 6:00 AM Jordan got a surprise, his girl friend, Jesse, joined us. Now instead of talking our ears off there was a lot of kissing. Jordan ad Jesse not Jordan and his parents. Then the anesthesiologist came in to speak with us. He asked several basic questions. When was the last time you ate? Are you allergic to any medications? Do you know what you are here for? Then he asked if we had any questions and he was off. Then the scrub nurse came in and she too had some questions. When was the last time you ate? Are you allergic to any medications? Do you know what you are here for? There was a pattern developing. Then Dr. Mankin came in. He is Jordan’s surgeon, he too had questions. When was the last time you ate? Are you allergic to any medications? Do you know what you are here for? One begins to wonder if these people ever speak to each other. Dr. Mankin went over the procedure one more time and said basically 30 minutes to prep him and 2 ½ hours maybe 3 for the procedure, 3 to 3 ½ hours total and then off to recovery. 5 minutes later they took Jordan away and we went to the waiting area. Nothing left to do but play the ukulele.