Twelve Patients: Life and Death at Bellevue Hospital (34 page)

The call to me came a little after four in the morning. It was Larry, the night supervisor for twenty-plus years. He had called me more times in the middle of the night than anyone else. My wife knew him well; they would sometimes chat for a few minutes with a diagnosis and treatment plan of her own as she waited for me to get the phone. Tonight he wasn’t chatty. “Eric, we have a problem. You’d better get down here
prontissimo
.”

At four thirty in the morning the Bellevue buildings were lit up and empty, like a circus tent from
The Twilight Zone
. I gave the middle-aged Sikh driver, his graying beard tucked into his red turban, ten dollars, told him to keep the change, and walked quickly to the swiveling doors then down the long ramp into the central atrium toward the
bright-colored New York subway-style signs that welcomed you into the labyrinth of the F-Link, C and D Buildings, administration, and the main hospital building.

There were a few overweight hospital guards in dark blue uniforms chatting, a family leaving the building, and a middle-aged couple sitting on the stone benches desolate and tearful staring into the emptiness. I had no time to find out what loss they had suffered and kept half jogging into the labyrinth. I cut through the walk-in clinic outside the emergency room, swiped my card at the double metal doors, and headed past the ambulance bay to the slot. Larry was waiting for me in his pressed yet well-worn chinos, de rigueur L.L. Bean shirt with pocket flaps and perpetual
been there, done that
smile. He was a hard-core Vermonter at heart.

Cops and detectives were milling around outside the slot. An investigation into the shooting was already under way. The husband had been taken upstairs to the doctors’ lounge, a very quiet area with computers, lockers, a shower, and fifty white doctors’ coats hanging on pegs at the entrance. His mother-in-law had arrived to keep him company. His wife was in the PACU, the post-anesthesia care unit.

“What’s going on?”

Larry quickly summed up Trauma Detroit’s situation, her bleeding out, the emergency surgery. So far, standard. Why was I up in the middle of the night? Then came the kicker. “She received eight units of the wrong blood type.”

I was stunned.

“She was dying,” Larry continued. “We had to give her blood or she would fibrillate, a cardiac arrest.”

The nurse jumped in: “We gave her two units of packed red cells from the refrigerator in the slot that were O negative. We tubed her samples to the blood lab for type and cross.” Bullet-shaped hollow plastic canisters the size of seventy-five-millimeter howitzer shells hurtled through a vacuum system filled with specimens connecting the patient areas with the laboratories and pharmacy.

“That blood wouldn’t have hurt her. That’s the universal blood type for transfusions.” I still couldn’t understand what had gone wrong.

Larry added: “It wasn’t enough blood. She was bleeding out. Trauma Detroit had cleared the slot and was on her way to the operating room. Just then, another trauma came into the slot, Trauma Houston, a Brazilian lawyer hit by a cab, his leg held in place by a leather belt. The guy was still gripping his belt with both hands. We had to cut the belt off, he was so traumatized he couldn’t let go, like a rigor. The trauma B team attended to his needs and immediately sent off blood to be type-and-crossed for ten units of packed red blood cells. He had no identifiers so another premade chart was assigned, Trauma Houston.”

Jon, one of our top anesthesiologists on Trauma Detroit’s case, joined us. Tall, lanky, and self-confident almost to a fault, he was clearly rattled. He cut in. “The surgical team proceeded immediately with a cutdown at the left groin site, first controlling the blood loss with a clamp around the femoral artery and vein above the injury. The site was a mess and several nerves had been severed. As they worked away, the plastics team showed up. So did the vascular surgeon. This was going to involve several team members each providing their special expertise sequentially.

“At this point,” he continued, “I was totally focused on Trauma Detroit’s vital signs and resuscitation. Everyone in the room was concerned about losing her from overwhelming hemorrhagic blood loss from the gunshot wound. The room was tense and there was a profound sense of urgency in the atmosphere. We rushed an order for blood and sent one of the residents down the hall to go get it. When the resident returned with the first four units of blood I took them immediately and hung them to run in rapidly ‘wide open.’ Fifteen minutes later another four units of packed cells arrived and I ran them in sequentially. I know. I know. I didn’t check the labels.” Jon was distraught and so was I. Trying to avoid a death by cardiac arrest from life-threatening bleeding, he had skipped a key step in the
thou shalt
protocol for transfusions.

“Once the bleeding was controlled by the surgeons,” Jon continued, “we settled into our usual routine to assess and repair the damage to the blood vessels and nerves using magnifying lenses. The patient was being transfused, there was plenty of staff in the ORs,
and the patient was young. She would make it and they would do the repair, taking their time. After two hours the patient had received all of the units of blood and the group had settled down into a calmer routine. The nurses shuffled around the room tidying up from the controlled chaos of the first hour. A circulating nurse, in charge of supplies, cleanup, and getting items from other ORs and storage, asked to talk to the head RN in the room and one of the attending surgeons not involved directly in operating. She said it with some urgency. She showed them several empty bags of blood. They reviewed them and compared the blood type on the bags with the blood type on the patient’s chart, name, and medical records number. They got all the empty blood bags and asked to talk to me. The surgeons who were still operating asked what was going on.

“Trauma Detroit got the wrong blood, all of it. It is the blood from Trauma Houston.” Jon said it slowly and deliberately, allowing the full effect to sink in to the team.

Larry picked up the thread and explained that a second-year surgical resident had been sent from the operating room to pick up the blood. He ran to the window at the blood bank, agitated. The trauma patient in the OR was dying. He needed the blood. He had shouted through the old teller-style opening in the Plexiglas window. The two women who staffed the lab overnight asked to see the Blood Request Form. He didn’t have it. He became increasingly agitated. “She’s going to die,” he insisted. He started yelling at them to “fuck your forms! If she dies, it’s on your head.”

Even with their combined experience of thirty-five years, the idea of a young patient exsanguinating on their watch was too much. They had blood from a designated trauma patient they were working on at that moment. They got the blood for that case and pushed it through the opening in the glass window to the resident. They were agitated, angry, and felt demeaned at being treated so disrespectfully by a trainee the age of their children. They wanted this guy to get away from them as fast as possible. They took his name down from his ID and decided to report him to their chief in the morning when shifts changed. This was not rare bad behavior. But there was a zero
tolerance for abusive behavior of any kind. The tides had changed in medicine. Just how much verbal abuse were they supposed to take at their pay grade, at any pay grade?

“So”—I finally understood—“the lab gave the resident the blood. The wrong blood. Houston’s blood.” So many errors. The resident’s. The lab’s. The anesthesiologist’s. I felt very tired, and not only because it was four forty-five in the morning.

“How is Trauma Detroit doing?” I asked. The critical question now was whether she would have a major reaction from receiving the wrong blood—lung injury or renal failure and bleeding.

“We’re not sure,” said Jon. “Too soon to tell.”

“And please tell me Houston didn’t get Detroit’s blood.”

“No,” said Jon. “The mistake was caught while the surgeon was talking to Houston about the odds of saving the leg.”

“Thank God,” I said, too frustrated, even angry, to say anything else. “Let’s talk later today. I have to give a talk in a couple of hours. After that. Call Patty to find a time.”

Back in my office, I threw my coat on the table, flipped on the espresso maker, and collapsed into my chair in the dark. I was beside myself. I thought of calling Diana and then remembered it was only a little after five a.m. I flipped through my phone and then threw it back down. I stared out the window at the first streaks of morning light. If a mistake could happen, it would happen. The possibilities were endless, no matter how many systems and forms and cross-checks we had in place. I knew being angry would not be the professional way to proceed. And it wasn’t good for me, either. At moments like this, I wondered if my cancer hadn’t been produced by all the stress I confront every day. For many reasons, I had to calm down.

A long career is littered with cases of things gone wrong—“bad outcomes” or, in the most sanitized, medical-speak version, “adverse events.” Sitting in the control center of a hospital can be a very depressing experience. Sometimes it is like being a psychiatrist when all your patients have complaints, bad behaviors, and emotional angst. I could easily slip into the diagnosis that humanity itself is little more than an auto-induced or socially induced mess of unmitigated suffering. I
could forget the thousand and one acts of generosity and selflessness that go unnoticed every day. Enough bad things happen to reinforce a vision of a Hobbesian world both unforgiving and untrustworthy. It happens to police officers, corrections officers, social workers, judges, doctors. Why not medical directors?

Yet as I sat brooding, it also occurred to me that constantly being aware how many bad things could happen was the best preventive medicine, a mental strategy that prompted a kind of hypervigilance. It wasn’t the only thing that was needed, but we did need it. I decided that would be the subject for my talk today to the hospital staff. One aspect of my job was patient safety, maybe the most important part of the job. I decided to talk about what I had learned from mistakes I had seen firsthand over my career. It would not be hard to find the cases. I ripped up my prepared comments, consigned them to the trash can. I quickly jotted down one through four with a couple of words after each number in block red letters on the back of an announcement for a fund-raiser with the Greater New York Hospital Association. I had given up on the ubiquitous omnivorous PowerPoint presentation years earlier. Stories told the tale better than multicolored Disney-style animation—all distraction and faux entertainment.

A couple of hours later, heavily fortified with caffeine, I got up in front of a conference room packed with four hundred people in uniforms from various areas of the hospital. Maroon scrubs, blue scrubs, gray scrubs, white lab coats, surgical booties, and gray double-breasted suits lined the walls around the edges. “I want to talk about things I have learned in my career from a few cases that I think about nearly every day, and some that have been uninvited guests in my sleep. I am sure you all have similar cases that you have known in your broad and varied professional experience.

“My first case involved a prominent surgeon. Let’s call him Dr. P. Dr. P had decided to do a case in an operating room that he and his team were not familiar with. They were an outstanding group who had worked together for many years and had a reputation for clinical excellence. A different hospital’s surgical program had expanded and P had volunteered to operate on the first case in the new environment,
to guarantee its success. The first patient was carefully selected, and the preparation was exquisite enough to make this a non-event. What had not been considered, however, was that Dr. P’s experienced team was not familiar with this particular operating room. Operating rooms are not like 747 cockpits. They are not all identical. A pilot does not need to know what kind of plane he or she is flying. Planes don’t have local nicknames or lists of peculiarities. But, unbelievable as it sounds, we know that each operating room is different. All the equipment is different, from different companies, different vendors, different arrangements, setups, electricity outlets, computer systems, supplies, and doors. So everyone’s rhythm and circulation in the room differs in each OR. The lighting and spatial arrangements all vary—and some variations are so subtle, they are beneath the radar, really invisible.

“So Dr. P and his hand-chosen, experienced team were working in a new OR. A tube got hooked up incorrectly. A tube that had been hooked up a thousand times before by a senior technician who could do it during REM sleep. A seemingly routine operation turned south in a nanosecond, and the patient began tanking. The banality of the error was so apparent and so inevitable given the circumstances. I was in the back of the OR that day in crisp blue scrubs and a sweatshirt—they like the temperature at sixty degrees—excited about expanding the new program. I was a fly on the wall. There to celebrate lots of hard work and hard-earned success. I learned more in five minutes about how and why things can and do go wrong than I had learned in decades of practice.” The room was quiet. I stood behind the lectern looking around the huge room at my colleagues individually and talking slowly.

“The second case is about magical thinking in medicine—the magic of technology. The prevailing national myth is that technology equals progress; that it can and will fix everything. Another dose of technology will eliminate all risk and eliminate the effects from global warming, food scarcity, water shortages, peak oil. Everything. The fact is, however, that every technological solution introduces another set of problems, and some are worse than the problems they are supposed to solve. It bypasses the need to work better together. The technology
often outpaces our ability to manage it, socially, politically, even practically. But I am jumping ahead.

“All of you have walked through an intensive care unit. If you’re like me, you’re struck by the complex and exasperating monitoring equipment sending real-time signals to the staff caring for a patient. Electronic signals via beep, blip, flashing lights, and monitors transmitting huge amounts of data inputs that continuously add information. If the computers detect findings outside normal limits, they set off an alarm. The constant noise, lights, and beeps are nerve-racking. Like the car alarm that rattles your sleep in the middle of the night and that the entire neighborhood ignores, safely assuming it’s a mistake.