Unfortunately, there were countless errors from before the start of Lewis’ surgery all the way through the handling of his death. The one systematic error I will comment on is physician-patient communication. Every patient undergoing a procedure needs to sign an INFORMED consent, which includes understanding the risks, benefits and alternatives to the treatment being offered. The situation continued to tailspin into a downward spiral as family was unaware of the expectations post op. There were multiple efforts made by the patient’s mother and nursing staff to notify the physicians that something was wrong. The physicians ignored the most valuable resource available to them, Lewis’ mother, who knows him better than anybody else. Her concerns were repeatedly disregarded or ignored because the doctor did not want to believe something was wrong.
Dr Levy eloquently stated, ” if you can’t see your mother/sister/daughter/son in your patient, you are not going to give them the best care”. It is our duty to recognize ourselves in our patients and do our best to keep families informed. What is often lost as we progress in our training as physicians is our ability to relate to others. While Lewis underwent a surgery that the resident had undoubtedly seen many times before, this is the defining moment in Lewis’ life and his family’s life. Understanding this, simply communicating what is happening, our thoughts, our uncertainty and asking the patient/family what questions or thoughts they have, could have made for a much better outcome.