Horseshoes and Hand grenades: Day 2 Reflection

Since the moment I first decided medicine would be my path, I began to prioritize education over so many other things. My family has always pushed an “education comes first” attitude and supports my medical journey completely. So I learned to prioritize school over all else, even when I felt guilty missing out on “life.” I would pass on dinner with friends if I had reading to finish. I remember spending time during a family reunion in the corner of the room writing essays. I even turned down a trip to a London because it interfered with my MCAT date. The examples fly by me and for many years I didn’t even think about these decisions because I was so laser focused on getting into medical school.

All of the times I missed out on experiences came into glaring light to me today.

Because once again I was missing out.

But this time was different.

While we were working on team building exercises today it makes me sad to admit that I failed as a team member when I bolted outside to take a phone call. Today, I was missing out on my mother’s heart surgery.

This surgery was originally scheduled for January and I was prepared to show up with my textbooks in tow and a checklist of questions to ask the team that would be operating on my mom. However, the surgery got moved and rescheduled for various reasons; including my mom’s petrifying fear of the procedure due to her past experience with a surgery causing permanent harm to her 26 years ago. After all of these schedule changes, a week ago we found out that today would finally be the day. Even with the new surgery date, my family still told me repeatedly that I should just go to my conference as planned because the doctors have been certain of my mom’s condition since January.

It was supposed to be “simple”.

It was supposed to be “routine”.

But today after their standard pre-op tests, all of the plans changed immediately when they realized everything they had thought was wrong. All sense of certainty suddenly dropped out of the conversation. And with the flip of a switch my family was alone in the room feeling blindsided by the new information.

This morning we watched a film about Michael Skolnik. One of my big take-aways from his story was that informed consent and decisions about a care plan should be realistic, honest, and collaborative. The doctor in his case rushed in with a big ego, put immense pressure on the family to act immediately, and ultimately lied about his qualifications. The actions of this one doctor, eventually lead to the death of Michael Skolnik.


Now, standing on the phone with my sister, I was terrified as my mind found similarities between Michael’s team and my mom’s surgical team. I could see his story through the lens of my own family. Was this surgeon telling my family the truth? How could we, the patient’s family, check how many of these surgeries he has done before? How could I know if the surgical team was collaborative? Would there be a nurse in that room that would be able to speak up if they saw a mistake being made? Or would every provider in the operating room be forced into silence by a hospital culture of intimidation?


I have never felt guilt so deep as I did in that moment; it seemed to cut me up from the inside out. I have worked all my life to serve others, but here I was failing to serve my own family.


I held my tears back—something I have done in patient rooms before too—because I knew that my sister needed me to be strong, reassuring, and calm in that moment.


I told my sister that I wished I could be there. And she responded with, “I’m just sitting in the waiting room, there is nothing you could be doing here.” My mind fired up with this dream of scrubbing in and diligently overseeing the operation just to make sure that everyone was giving my mom the best care ever. Of course me scrubbing in and overseeing anything is an absolutely preposterous idea for so many reasons that I can’t even list. But as someone who has always seen things from the provider’s side, this was my go-to. I am the person with a plan, the person who finds solutions to every problem. It was terrifying to feel so helpless.


Now that it is the next day and my mom is safe, I can feel the weight lifted off my chest enough to write about it. My family was fortunate. I don’t have to ask the “what if?” and “why her?” type questions that so many families have to ask after their family member gets harmed in a patient safety event. But how sad is it that going to get care in a hospital has become so unsafe that some days patients feel fortunate just to make it out alive?


We have to do better.


Today our faculty shared a few pieces of information that was genuinely shocking to me. Kelly shared that one hospital she worked with found that only about 50% of providers were washing their hands before entering a patient’s room (a fact which is disturbing by itself) but the team’s initial goal for improvement was to increase that number to 70%. We’ve all heard the expression that “close only counts in horseshoes and grenades” and when it comes to patient care 70% is nowhere near good enough. Why would an institution accept that only 70% of providers could wash their hands? The faculty here worked with that particular hospital and explained that the only acceptable number was 100%.


This is the attitude I implore all providers to adopt.


If it was your mom on the table, would you accept anything less than 100%?