An Interdisciplinary Viewing
As a surgery resident, I had a different reaction to the the film “The Faces of Medical Errors…From Tears to Transparency: The Story of Lewis Blackman” than some of my fellow scholars. This is absolutely the value of viewing and discussing it in such a forum, as every perspective highlights specific opportunities for improvement.
As our interdisciplinary discussion highlighted, Lewis’ death was the unfortunate result of a broken system. Lewis was a 15 year old undergoing a new repair for pectus excavatum. The first systems issue brought up by his mother, who remains a strong patient advocate, was the informed consent process surrounding a new “low risk” surgery. The pectus repair was technically successful, but issues started intraoperatively. He was making minimal urine during the case and after. He received multiple doses of toradol, up to post-operative day #5, with minimal oral intake of food or fluids. He was not on a surgery floor post-operatively. He and his mother began to be concerned about his condition overnight and into a weekend when the regular team and attending were not on. Toradol did not then have the warning on the packaging it does now about gastrointestinal bleeds.
Focusing on the Failure to Rescue
Each of these is its own spark for an event review and an opportunity for improvement in the future. However, I had to highlight that a GI bleed does not have to end in death. It was the failure to rescue that caused me to tense up in my chair as the film progressed. The documentary lays out the sequence of events and vital signs as this teenager begins to complain of pain migrating from his chest to his abdomen.
One featured expert in the film highlights the danger of premature closure with a cross-covering team that was fixed on presumed ileus as the cause for his discomfort. I hoped that the medical students understood this point. A heart rate of 140-160 for hours with a tense and tender abdomen needs fluid resuscitation and an operating room – regardless of why the patient came into the hospital, what happened to him/her during the hospital stay or the prevailing theory when the patient initially complained of pain.
Lewis did not need to die of a complete cardiovascular collapse on the floor. His autopsy found a perforated duodenal ulcer eroding into a branch of the gastroduodenal artery. He needed resuscitation and an OR before his reserve ran out. Unfortunately, the system failed him, and did not rescue him.
Failure to rescue is an emerging quality indicator, representing the belief that health systems should be able to identify and treat complications – preventable or not. An analysis of almost 2 million Medicare beneficiaries found that hospital and patient characteristics only accounted for up to 57% of the variation in failure to rescue rates. This suggested that it was microsystem factors contributing to a hospital’s ability to rescue patient’s from the sequelae of complications (1). Our discussion touched on many of the issues of safety culture and hierarchy likely contributing to these inter-hospital variations.
For me, failure to rescue couples my interest in surgery and health systems. I want to work to improve surgical and medical culture to create safe environments that can prevent and rescue patients from harm. I also want to take the patient to the OR and fix the perforated ulcer in the moment so that the Lewises in our hospital currently have the chance live out their dreams.
“A failure often does not have to be a failure at all. However, you have to be ready for it—will you admit when things go wrong? Will you take steps to set them right?—because the difference between triumph and defeat, you’ll find, isn’t about willingness to take risks. It’s about mastery of rescue.” – Atul Gawande (2)
- Sheetz, K. H., Dimick, J. B., & Ghaferi, A. A. (2016). Impact of Hospital Characteristics on Failure to Rescue Following Major Surgery. Annals of Surgery, 263(4), 692-697. https://journals.lww.com/annalsofsurgery/Abstract/2016/04000/Impact_of_Hospital_Characteristics_on_Failure_to.9.aspx
- Gawande, A. Failure and Rescue. Retrieved from https://www.newyorker.com/news/news-desk/failure-and-rescue