Throughout this conference, I have been reminded many times of stories from my friends and family members about times when they have been victims or near-victims of medical error. Today’s discussions about disclosing medical errors and maintaining honest and open communication between providers and patients particularly made me think about my grandmother’s death. Just as with the Lewis Blackman story and many other examples that we have heard about at this conference, there was somewhat of a cascade of small mistakes and communication lapses that lead to her death. I think that writing it out here may be helpful to me because it will help me understand what happened to her and how all of the conversations at this conference can prevent these problems in the future. I heard all of the details of this from my grandfather a few years ago, so I might be slightly off on some of the facts.

Sometime in her 70s, she had a knee replacement and had developed a hospital-acquired staph infection. Nobody knows if there was some lapse in hygiene that lead to this infection, but we do know that it instilled a fear of hospitals in my grandmother, better known to me as “Grammy.” From that incidence onward, she insisted that she hated taking medication and wanted to avoid surgeries and hospitals at all costs. She maintained this stubborn attitude even when her primary care doctor recommended that she have her other knee replaced so that she could have greater mobility. She refused to have surgery, she had progressively worsening pain in her knees, and her mobility gradually declined.

When she was 82 and spending the summer months in Wisconsin with my grandfather, as they always did, their springer spaniel named Lucky was a little too enthusiastic and knocked her over one afternoon. Grammy stayed in bed for 2 days afterwards, claiming that she did not feel well. My grandfather eventually took her to both their PCP in Wisconsin, and the small hospital nearby. They were told a number of different things about my grandmother’s condition, including that she had Lyme Disease, that she did not have Lyme Disease, and that she needed to have a doppler scan to evaluate the swelling in her legs. At one point the only medical professional who would speak to them in the hospital was a PA who told them that she had been delivering babies all day and was therefore exhausted. They were told that she needed a doppler scan on a Friday afternoon, but that she would not be able to have the scan until the coming Monday. Knowing that not much would happen in the hospital over the weekend, my grandfather took my grandmother back to their cabin that evening. Come Monday, Grammy claimed she was too sick to get out of bed to go see the doctor and get the doppler scan. I remember thinking to myself that someone who is too sick to go see the doctor should be taken to the hospital by ambulance.

My uncle drove to their cabin in Wisconsin and somehow convinced them to let him drive them back to their home in a suburb of Chicago so that Grammy could receive better quality care. Her doctor back near Chicago told her that she did not have a positive blood test for Lyme but that she probably had “late Lyme’s.” He sent her to have the doppler scan to evaluate the swelling in her legs. The doppler showed clots in both legs and she was told to go to the local emergency room. In the ER, she was started on IV fluids with the plan of having her admitted and the clots treated with medicine and the insertion of screens to block them from traveling to her lungs. The local hospital had no available beds by that evening, so she was told that she would have to be transported by ambulance to nearby Evanston hospital. Her first reaction to that was “I don’t want to go there. My father died there. Am I going to die?” The ER doctor told her that she was not going to die, but that this was the only option.

She stayed at the hospital in Evanston for a few days while the doctors have her blood thinners and ran more tests. She did not feel well the entire time and had no appetite, but was still lively enough to talk with my family members when they visited or called. My cousin Jamie called her room one night to check in with her while nobody was with her. He said that she told him she could see the moon from her room and that is was a beautiful moon that night. The next morning, she was taken for some sort of scan or x-ray. When the transporter brought her back to her room, he noticed that she wasn’t breathing and a code was called. They were unable to revive her.

While it is possible that nobody on the medical team knew what was going on or what happened that killed her, it is also possible that something was overlooked or ignored in the course of her care. Either way, nobody in my family knows any more than the details above. We have no valid explanation for why she died. While she did have a long, wonderful 82 years of life, I think it would have given my grandfather, my mother, and my mother’s siblings great comfort to get to speak with the medical team at the hospital to know why she died. Instead, nobody would speak with my aunt when she tried to find out more information. There were so many points in this story when patient safety or communication was an issue. It makes me sad that there are so many stories like my Grammy’s. It also empowers me to be a better physician. It inspired me to speak up and to do my part to make our healthcare system a safer place for people in their time of need.