“How could you let this happen?!” The thought raced through my head as doctors and nurses examined an ever-worsening Lewis Blackman in the series of events that led to his death. As the information was presented in the video, it was exceedingly clear that the prognosis was getting worse and worse. And yet everyone who cared for Lewis appeared to only see the snapshot of their interaction, decide that he was within normal post-operative ranges, and manage the symptom in isolation.
Watching the video, we can clearly see the heartrate trending upward, pain progressing to non-operative areas, failure to take in food or water. It is easy to see the result of months of chart synthesis and be alarmed that the warning signs were ignored.
Yet perhaps the warning signs were not readily apparent. The information was synthesized clearly for the audience, yet was unlikely to have been so organized at the time. And without that crucial information, we would not have been able to reach the clear conclusion.
Prior to medical school, I worked and conducted research an engineer in wind and water resources. Data might be collected for multiple years before decisions were made to move ahead with a project.
Working with a patient, the appropriate course of action is not always clear and major decisions must be made as the data is acquired. But from an engineering background, while it’s a challenging problem, it’s a problem that can be solved. We need to ensure that all the information – collected by the physician, by the nurses, and reported by the patient and family – is communicated and clearly available. We need to ensure that decisions aren’t swayed by fatigue, by time limits, by organizational demands, or by peer pressure. And we need to engage the team in solving the problem, because ultimately, this should not be another onerous top-down requirement, but an exciting opportunity to do better.