Repost: 'We all kill a few patients as we learn'

[Guest guest]

Frank <califpacific

Thu May 20, 2004 12:07 am

'We all kill a few patients as we learn'

 

 

This is the first time in my life that I have ever heard a doctor

admit to

anything. F.

 

http://www.guardian.co.uk/health/story/0,3605,1219003,00.html

 

'We all kill a few patients as we learn'

 

Everybody makes mistakes at work but what if you're a doctor and you

ruin a

patient's life - or even end it? Doctor-turned-writer Jed Mercurio

recalls a

catalogue of errors from his years as a medical student

 

Tuesday May 18, 2004

The Guardian

 

I made a mistake at work today. We all do it. But what if I said

that I was a

doctor? When a plumber gets it badly wrong, he leaves you with a

flooded

kitchen; when a doctor gets it badly wrong, he leaves you dead or

crippled for

life. One in every 10 hospital patients is harmed by a medical

error. As many as

70,000 people die every year as a result of doctors' mistakes.

While I was a medical student, I saw a young guy with a bad knee.

After the

patient left, the consultant explained that the surgeon who had

carried out the

operation had got it badly wrong, and this was the cause of the

patient's

disability. He would never walk properly again. I asked the

consultant why no

one had informed the patient. He answered that you don't blow the

whistle on

colleagues and they don't on you. I thought that he was wrong, that

the patient

had a right to know the truth so he could fight for compensation and

that the

doctor should be held accountable for his negligence.

When I qualified, I soon learned that there would be times when I

would be

called upon to conduct procedures I had never seen, let alone

practised. Airline

pilots learn to fly the plane before they have to carry passengers.

Due to

limited training opportunities, doctors gain experience by treating

patients. We

are carrying passengers before we know how to fly the plane. Even

newly

qualified consultants are under-trained: an average of 8,000 hours'

experience,

in contrast to the previous generation who gained 30,000. We all

kill a few

patients while we're learning.

I was responsible for a few cock-ups in my early days as a new

houseman - a

tardy diagnosis, a wrong infusion, some patients with bruised arms

from clumsy

attempts to take blood or insert an IV line - but they were mended

by a sincere

apology to the patient and an ad hoc tutorial from a senior

colleague. It was a

month before one of us made a contribution to the hospital's

mortality rate. A

close friend had been instructed by his consultant to monitor a

particular

patient's potassium level, but my friend's shift got wildly busy and

he put it

off. The patient suffered a cardiac arrest and died.

He confessed the truth to a couple of us that night, but to his

consultant he

claimed that he had carried out a potassium test but that the result

had got

lost in the system. He felt awful about the patient's death but he

could see no

way of being open about his mistake without his consultant deciding

that he was

irredeemably incompetent.

He trusted his fellow housemen with the truth, but he didn't know

his consultant

well enough to be sure he wouldn't blow the whistle. I think this

was the moment

I realised that not every doctor who makes a mistake is a bad

doctor. I knew my

friend was good at his job. He had made an appalling but

uncharacteristic error

of judgment. Two years earlier, I had been the moralistic medical

student in an

orthopaedics clinic outraged by the covering-up of a young man's

botched knee

surgery, and now I was a doctor who understood how many critical

decisions cram

the working day and how easy it is for a tragedy to unfold from a

momentary

lapse in concentration.

 

 

 

On closer examination, the cases I have cited from first-hand

experience don't

reflect the errors of a single individual. The surgeon wasn't the

only person

involved in the care of the young man with the wrecked knee; my mate

wasn't the

only person looking after the potassium patient. Nearly all medical

accidents

result from a chain of errors involving the misjudgments of a series

of

practitioners.

The systemic failures with respect to training, supervision,

communication and

cross-checking are more far-reaching than the malpractice of an

individual.

However, many people find it less disturbing to believe that medical

accidents

are due to the negligence of a lone gunman - the individual acting

alone and

counter both to his training and to the expectations of his

colleagues.

Furthermore, the people harmed by medical accidents are eager - if

they aren't,

their lawyers are - to prove negligence, because if they don't, they

don't

secure any damages. There are other factors, but I believe these two

are the

highest-octane fuel for the blame culture.

The punishments for getting it wrong are only getting harsher.

Recently, the

courts levelled a charge of manslaughter against a doctor who

injected a drug

wrongly. The same mistake had occurred at least a dozen times before

in other

hospitals and by other doctors, all precipitated by administrative

blunders and

a lack of safeguards. The system lay at fault, not just the

individual. Yet, for

one momentary lapse of judgement while carrying out his normal

duties, a

respected professional who has dedicated his life to treating the

sick can find

himself facing the same legal proceedings as a knowingly drunk

driver who mows

down a pedestrian or a construction manager who with calculation

flouts safety

rules to maximise his profits.

Yet when things go wrong, many doctors still feel compelled to admit

their

failings. You hope a sincere disclosure will serve as an apology to

the patient

and also stop other doctors making the same mistake in future.

I was part of a chain of errors that led to the death of a patient.

I believed

my error was the most harmful one - more harmful than the nurses

saying the

patient was faking her symptoms, more harmful than the senior doctor

who saw the

patient the next day and agreed that we shouldn't do an x-ray or

blood tests -

and I confessed it to my consultant.

I was overcome with remorse. I wanted to apologise to the relatives

and stand up

at the inquest and say it was all my fault and I deserved to be

struck off. He

counselled me to brazen it out. Another colleague helped me buff the

notes (to

" buff the notes " is to make entries in the patient's records which

don't

actually lie but contain only the helpful elements of the truth). I

still feel

huge remorse both for the mistake and for never apologising to the

relatives,

but, instead of my career faltering before it had really begun, I

learned from

it, became a better doctor because of it, passed on what I had

learned about it

to many other colleagues, and I was only able to do those things

because my

fellow doctors covered for me.

A couple of years on, I was called to a surgical patient with an

abnormal heart

rhythm. A cursory examination of his notes revealed an ECG which

showed that he

had suffered a heart attack, but the houseman who had admitted him

had missed

the diagnosis. After we had stabilised the patient, I showed the ECG

to the

admitting houseman's registrar. The registrar was a mate; he was one

of us; I

could trust him. We agreed that he would pretend he had come across

the ECG

himself when reviewing the case. He would talk his junior through

the lessons to

be learned from the incident. The houseman would never know anyone

else was

aware of his error. Not for a moment did I have second thoughts

about this

course of action. The system had protected me and I owed a fellow

doctor the

same obligation.

Some doctors feel compelled to blow the whistle on their colleagues'

shortcomings. The medical profession invariably ostracises those who

broadcast

their concerns to outsiders, on the grounds that outsiders don't

know enough

about the job to fairly judge a doctor's performance. In my writing,

I have

chosen to concentrate on the darker side of hospital life. You might

argue that

I have acted like a sort of whistle-blower, but I feel that I have

endeavoured

to acquaint the lay person with the factors that contribute to

medical error

and, hopefully, the actions of doctors who close and cover will

appear more

understandable.

Turning a blind eye and closing ranks serves well all of us who made

the

isolated human error and learned from it and became good doctors. I

believe that

is how it served me and my friend who didn't monitor his patient's

potassium.

But I have to confess I don't know what kind of doctor the houseman

who missed

the heart attack became. It is only then that you realise the system

that

covered for you is the same system that wrongly protected GP Harold

Shipman and

gynaecologist Rodney Ledward for so many years at so tragic a cost

to so many

patients. But, because of the blame culture, many doctors remain

persuaded that

closing ranks and covering up are in their interests, because they

still fear

that they can be as much victims of medical accidents as their

patients.

· Jed Mercurio was a hospital doctor for four years before becoming

a full-time

writer. He wrote the successful TV series Cardiac Arrest and his new

drama,

Bodies, starts on Sunday at 9pm on BBC3. It will be screened on BBC2

later this

year. His novel, on which it is based, is published by Vintage.

_________________

JoAnn Guest

mrsjoguest

DietaryTipsForHBP

http://www.geocities.com/mrsjoguest

[Guest guest]

Hi, JoAnn.

 

Of course it's no guarantee, no complete failsafe, but your post is

THE REASON why no one who can help it should enter a hospital for

treatment on his own. Everyone who possibly can should have a

surrogate/advocate enter the hospital along with him---someone who

can be there to keep an eye on what's going on.

 

When my father was at the UC Berkeley Hospital in California in 1987,

I was at his bedside when a phlebotomist came in and took out a

syringe with dried blood in it with which he was going draw blood

from my father's arm. It was a good thing I was there.

 

In " Cancer As A Turning Point, " by Lawrence LeShan, there is a

chapter called " How To Survive In A Hospital. " LeShan not only says

anyone who can should have an advocate accompany them to the

hospital; he tells of one woman(I'll call her Alice Smith) who had t-

shirts made for her family and friends that they wore when they

visited, which read something like, " Alice Smith's Advocacy and

Medical Staff Inspection Team. "

 

After I read Dr. Timothy McCall's book, " Examining Your Doctor, " in

which he states that great numbers of medical personnel do not wash

their hands between examining and taking care of patients, my mother

had to enter a hospital for some ailment or other. I made a sign that

read, " Please be sure to wash your hands thoroughly before touching

the patient. " and put it on the bulletin board on the wall next to

her bed. The sign kept disappearing! I put it back up 3 or 4 times

before I gave up in disgust.

 

Best wishes,

 

Elliot

 

, " JoAnn Guest "

<angelprincessjo> wrote:

> Frank <califpacific>

> Thu May 20, 2004 12:07 am

> 'We all kill a few patients as we learn'

>

>

> This is the first time in my life that I have ever heard a doctor

> admit to

> anything. F.

>

> http://www.guardian.co.uk/health/story/0,3605,1219003,00.html

>

> 'We all kill a few patients as we learn'

>

> Everybody makes mistakes at work but what if you're a doctor and

you

> ruin a

> patient's life - or even end it? Doctor-turned-writer Jed Mercurio

> recalls a

> catalogue of errors from his years as a medical student

>

> Tuesday May 18, 2004

> The Guardian

>

> I made a mistake at work today. We all do it. But what if I said

> that I was a

> doctor? When a plumber gets it badly wrong, he leaves you with a

> flooded

> kitchen; when a doctor gets it badly wrong, he leaves you dead or

> crippled for

> life. One in every 10 hospital patients is harmed by a medical

> error. As many as

> 70,000 people die every year as a result of doctors' mistakes.

> While I was a medical student, I saw a young guy with a bad knee.

> After the

> patient left, the consultant explained that the surgeon who had

> carried out the

> operation had got it badly wrong, and this was the cause of the

> patient's

> disability. He would never walk properly again. I asked the

> consultant why no

> one had informed the patient. He answered that you don't blow the

> whistle on

> colleagues and they don't on you. I thought that he was wrong, that

> the patient

> had a right to know the truth so he could fight for compensation

and

> that the

> doctor should be held accountable for his negligence.

> When I qualified, I soon learned that there would be times when I

> would be

> called upon to conduct procedures I had never seen, let alone

> practised. Airline

> pilots learn to fly the plane before they have to carry passengers.

> Due to

> limited training opportunities, doctors gain experience by treating

> patients. We

> are carrying passengers before we know how to fly the plane. Even

> newly

> qualified consultants are under-trained: an average of 8,000 hours'

> experience,

> in contrast to the previous generation who gained 30,000. We all

> kill a few

> patients while we're learning.

> I was responsible for a few cock-ups in my early days as a new

> houseman - a

> tardy diagnosis, a wrong infusion, some patients with bruised arms

> from clumsy

> attempts to take blood or insert an IV line - but they were mended

> by a sincere

> apology to the patient and an ad hoc tutorial from a senior

> colleague. It was a

> month before one of us made a contribution to the hospital's

> mortality rate. A

> close friend had been instructed by his consultant to monitor a

> particular

> patient's potassium level, but my friend's shift got wildly busy

and

> he put it

> off. The patient suffered a cardiac arrest and died.

> He confessed the truth to a couple of us that night, but to his

> consultant he

> claimed that he had carried out a potassium test but that the

result

> had got

> lost in the system. He felt awful about the patient's death but he

> could see no

> way of being open about his mistake without his consultant deciding

> that he was

> irredeemably incompetent.

> He trusted his fellow housemen with the truth, but he didn't know

> his consultant

> well enough to be sure he wouldn't blow the whistle. I think this

> was the moment

> I realised that not every doctor who makes a mistake is a bad

> doctor. I knew my

> friend was good at his job. He had made an appalling but

> uncharacteristic error

> of judgment. Two years earlier, I had been the moralistic medical

> student in an

> orthopaedics clinic outraged by the covering-up of a young man's

> botched knee

> surgery, and now I was a doctor who understood how many critical

> decisions cram

> the working day and how easy it is for a tragedy to unfold from a

> momentary

> lapse in concentration.

>

>

>

> On closer examination, the cases I have cited from first-hand

> experience don't

> reflect the errors of a single individual. The surgeon wasn't the

> only person

> involved in the care of the young man with the wrecked knee; my

mate

> wasn't the

> only person looking after the potassium patient. Nearly all medical

> accidents

> result from a chain of errors involving the misjudgments of a

series

> of

> practitioners.

> The systemic failures with respect to training, supervision,

> communication and

> cross-checking are more far-reaching than the malpractice of an

> individual.

> However, many people find it less disturbing to believe that

medical

> accidents

> are due to the negligence of a lone gunman - the individual acting

> alone and

> counter both to his training and to the expectations of his

> colleagues.

> Furthermore, the people harmed by medical accidents are eager - if

> they aren't,

> their lawyers are - to prove negligence, because if they don't,

they

> don't

> secure any damages. There are other factors, but I believe these

two

> are the

> highest-octane fuel for the blame culture.

> The punishments for getting it wrong are only getting harsher.

> Recently, the

> courts levelled a charge of manslaughter against a doctor who

> injected a drug

> wrongly. The same mistake had occurred at least a dozen times

before

> in other

> hospitals and by other doctors, all precipitated by administrative

> blunders and

> a lack of safeguards. The system lay at fault, not just the

> individual. Yet, for

> one momentary lapse of judgement while carrying out his normal

> duties, a

> respected professional who has dedicated his life to treating the

> sick can find

> himself facing the same legal proceedings as a knowingly drunk

> driver who mows

> down a pedestrian or a construction manager who with calculation

> flouts safety

> rules to maximise his profits.

> Yet when things go wrong, many doctors still feel compelled to

admit

> their

> failings. You hope a sincere disclosure will serve as an apology to

> the patient

> and also stop other doctors making the same mistake in future.

> I was part of a chain of errors that led to the death of a patient.

> I believed

> my error was the most harmful one - more harmful than the nurses

> saying the

> patient was faking her symptoms, more harmful than the senior

doctor

> who saw the

> patient the next day and agreed that we shouldn't do an x-ray or

> blood tests -

> and I confessed it to my consultant.

> I was overcome with remorse. I wanted to apologise to the relatives

> and stand up

> at the inquest and say it was all my fault and I deserved to be

> struck off. He

> counselled me to brazen it out. Another colleague helped me buff

the

> notes (to

> " buff the notes " is to make entries in the patient's records which

> don't

> actually lie but contain only the helpful elements of the truth). I

> still feel

> huge remorse both for the mistake and for never apologising to the

> relatives,

> but, instead of my career faltering before it had really begun, I

> learned from

> it, became a better doctor because of it, passed on what I had

> learned about it

> to many other colleagues, and I was only able to do those things

> because my

> fellow doctors covered for me.

> A couple of years on, I was called to a surgical patient with an

> abnormal heart

> rhythm. A cursory examination of his notes revealed an ECG which

> showed that he

> had suffered a heart attack, but the houseman who had admitted him

> had missed

> the diagnosis. After we had stabilised the patient, I showed the

ECG

> to the

> admitting houseman's registrar. The registrar was a mate; he was

one

> of us; I

> could trust him. We agreed that he would pretend he had come across

> the ECG

> himself when reviewing the case. He would talk his junior through

> the lessons to

> be learned from the incident. The houseman would never know anyone

> else was

> aware of his error. Not for a moment did I have second thoughts

> about this

> course of action. The system had protected me and I owed a fellow

> doctor the

> same obligation.

> Some doctors feel compelled to blow the whistle on their

colleagues'

> shortcomings. The medical profession invariably ostracises those

who

> broadcast

> their concerns to outsiders, on the grounds that outsiders don't

> know enough

> about the job to fairly judge a doctor's performance. In my

writing,

> I have

> chosen to concentrate on the darker side of hospital life. You

might

> argue that

> I have acted like a sort of whistle-blower, but I feel that I have

> endeavoured

> to acquaint the lay person with the factors that contribute to

> medical error

> and, hopefully, the actions of doctors who close and cover will

> appear more

> understandable.

> Turning a blind eye and closing ranks serves well all of us who

made

> the

> isolated human error and learned from it and became good doctors. I

> believe that

> is how it served me and my friend who didn't monitor his patient's

> potassium.

> But I have to confess I don't know what kind of doctor the houseman

> who missed

> the heart attack became. It is only then that you realise the

system

> that

> covered for you is the same system that wrongly protected GP Harold

> Shipman and

> gynaecologist Rodney Ledward for so many years at so tragic a cost

> to so many

> patients. But, because of the blame culture, many doctors remain

> persuaded that

> closing ranks and covering up are in their interests, because they

> still fear

> that they can be as much victims of medical accidents as their

> patients.

> · Jed Mercurio was a hospital doctor for four years before becoming

> a full-time

> writer. He wrote the successful TV series Cardiac Arrest and his

new

> drama,

> Bodies, starts on Sunday at 9pm on BBC3. It will be screened on

BBC2

> later this

> year. His novel, on which it is based, is published by Vintage.

> _________________

> JoAnn Guest

> mrsjoguest@s...

> DietaryTipsForHBP

> http://www.geocities.com/mrsjoguest

[Guest guest]

, " breathedeepnow "

<aug20@m...> wrote:

> Hi, JoAnn.

>

> Of course it's no guarantee, no complete failsafe, but your post

is THE REASON why no one who can help it should enter a hospital for

> treatment on his own. Everyone who possibly can should have a

> surrogate/advocate enter the hospital along with him---someone who

> can be there to keep an eye on what's going on.

> When my father was at the UC Berkeley Hospital in California in

1987, I was at his bedside when a phlebotomist came in and took out a

> syringe with dried blood in it with which he was going draw blood

> from my father's arm. It was a good thing I was there.

> In " Cancer As A Turning Point, " by Lawrence LeShan, there is a

> chapter called " How To Survive In A Hospital. " LeShan not only

says anyone who can should have an advocate accompany them to the

> hospital; he tells of one woman(I'll call her Alice Smith) who had

t- shirts made for her family and friends that they wore when they

> visited, which read something like, " Alice Smith's Advocacy and

> Medical Staff Inspection Team. "

> After I read Dr. Timothy McCall's book, " Examining Your Doctor, "

in which he states that great numbers of medical personnel do not

wash their hands between examining and taking care of patients, my

mother had to enter a hospital for some ailment or other. I made a

sign that read, " Please be sure to wash your hands thoroughly

before touching the patient. " and put it on the bulletin board on

the wall next to her bed. The sign kept disappearing! I put it back up 3 or 4

times before I gave up in disgust.

> Best wishes,

> Elliot

 

 

Hi Elliot,

The post belonged to Frank originally, however I'd like to

respond. You are to be congratulated for caring for your parents in

such a unique and wonderful way. The sign was obviously an insult to

the hospital staff, although it may have caused them to think twice

about who they were dealing with and helped them to pay more

attention to business!

 

I believe we all need to pay more attention to what's occurring

whenever we have family members enter these facilities...

hopefully only in life-threatening emergencies, always praying and

hoping that everything goes well. This is even more reason to keep

in the best of health to ensure we don't need any of

their 'services'.

 

There is a nutritional 'cure' for every ill! The more I read and

learn and research I realize this. How on earth does anyone think

that our forefathers existed before the 'onslaught' of modern

medicine? Healing foods and herbs,... that's the way they dealt with

it. They knew exactly what to do and the right proportions of herbs

to brew.

One would think that there's a conspiracy out there, when we

consider everything that has been put in place within just a few

decades. I may be somewhat paranoid at times... and the paranoia may

very well have kept me alive.

I believe the very worst way to go would from a medical mistake.

Reminds me of a story I heard once of something that happened long

ago to my parents. One of their close relatives entered the hospital

to have a gall-bladder operation, passed away from the operation

eventually, however in the meantime my father just happened to be

passing by a room where they were opening a bottle of gingerale for

the patient.

The nurse wasn't very efficient it seemed,... couldn't open it, so

she just smashed the bottle top off and poured it out into the glass

for the patient. I don't believe this was an isolated incident

either, from what they said. It really makes you wonder how they can

live with themselves.

Someone should do a commentary on washing of hands in hospitals

similar to those they have been doing on TV regarding fast food

restaurants. I think the hidden camera would do the trick!

Of course, its just a fantasy. They wouldn't get past the front door.

 

Regards, JoAnn