CHAPTER FIFTEEN

THE RECKONING

When something goes wrong in a hospital, the traditional response is the morbidity and mortality conference (the M&M). This picks through the minutiae of the case, trying to home in on the specific errors in the medical care. A broader approach to error is something known as root cause analysis, which looks not just for what went wrong but also for what weaknesses in the system made it possible for things to go wrong (and of course how to prevent this in the future).

Jay’s case exemplifies the fact that medical error is rarely just one specific thing. Instead—as also seen with Glenn and with Jack Adcock—most medical errors are the result of a cascade of actions that compound one another. Each of the small things, by themselves, might not cause a bad outcome, but together, they do.

To recap, Jay was a healthy 39-year-old man who was diagnosed with AML (acute myelogenous leukemia). He underwent his first round of chemotherapy (induction chemo) and had to be readmitted to the hospital a few days later with a fever and low white count (neutropenia). Over the course of three days, Jay grew progressively sicker. He was treated for MRSA blood infection but died of cardiopulmonary arrest.

“Please know,” Tara wrote to me, “that I realize that AML with trisomy 11 involvement is not a walk in the park, and I am well aware that the statistics were not in Jay’s favor. But the AML did not kill Jay; his poorly treated infection killed him.”

So let’s try to take apart the errors in Jay’s case that added up to the tragic outcome. In thinking this through, I’ve come up with several concrete errors, specific actions that are relatively straightforward to evaluate, such as the decisions about removing the central line or transferring Jay to the ICU. And then there are errors that are less tangible to describe, those that are more about human interactions and the culture of the hospital. These are much harder to fit into neat algorithms, but they contribute just as much to medical error.

It’s worth considering each of these errors in turn, because there is much that can be illuminated from each one. Moreover, these errors exemplify the relationship in medicine between the concrete aspects of care and the less tangible aspects. They also illuminate the challenges of preventing medical error: it’s easy to make a checklist for how to evaluate a fever or rules for when to remove an indwelling catheter, but you can’t checklist clinical thoroughness, good listening, effective communication, intellectual humility, or professional responsibility.

THE VACUTAINER

Two days after Jay was discharged from his hospitalization for induction chemotherapy, he had his blood drawn in the doctor’s office. The nurse drawing the blood struggled to get the Vacutainer to connect to his indwelling catheter. At one point, the Vacutainer fell onto the white paper of the exam table where Jay was sitting. The nurse picked it up, reattached it to the catheter, and proceeded to draw blood and then flush saline through the catheter.

Tara is convinced that the MRSA infection in Jay’s bloodstream was caused by this action, that the Vacutainer became contaminated upon touching the exam table and then went on to contaminate the catheter. MRSA can live for days and even weeks outside the body, so this could be plausible. (MRSA has been found living on stethoscopes, scrubs, bedrails, and hospital curtains, and there have been documented outbreaks of infection related to these.) Of course, Tara’s theory could not be proved unless that particular Vacutainer were to be cultured and then found to have the identical strain of MRSA present in Jay’s bloodstream.

However, even if the Vacutainer were not the cause of the infection, what that nurse did was still an error. Once any blood-drawing apparatus falls onto an exam table, it should be discarded (or properly sterilized before use). For patients with impaired immune systems, this step is particularly important. Nurses who work with immunosuppressed patients should know better.

It’s fairly clear, therefore, that the handling of the Vacutainer was an error, but it’s not possible to tell if that nurse’s action transmitted the MRSA infection to Jay’s bloodstream. This incident emphasizes the point that the presence of an error and the presence of a bad outcome don’t necessarily mean the two are linked. Furthermore, even if the incorrectly used Vacutainer did in fact transmit the MRSA infection, it would still be a stretch to say that this event was the cause of Jay’s death. As with most medical errors, it usually takes many more missteps by many more people for an error to translate into a death.

THE INDWELLING CATHETER

When I read through Jay’s case the first time, I remember feeling a nervous itch in my fingers as his clinical course worsened. They kept wanting to jump onto the page and yank out that catheter. If there is one thing that is pummeled into the brains of interns during medical training, it’s that as soon as any patient spikes a fever, all foreign bodies (central lines, urinary catheters, arterial lines) are immediate suspects. They all should be removed promptly unless there is a compelling reason not to do so.

For patients with suppressed immune systems like Jay’s, the urgency is even greater. There has got to be a persuasive and well-articulated reason to leave in any foreign body when it comes to a neutropenic patient with a fever. For example, if there is absolutely no other IV access and loss of that catheter would mean the patient couldn’t receive life-saving medications, the doctor might make the reluctant decision to leave in the catheter. But this was not the case. Tara commented, with no small amount of pride, that Jay had “marvelously gigantic venous access,” which of course would be expected in a fit 39-year-old who’d never been sick before. One other possible reason to leave in a catheter is that an alternative source of the infection was clearly identified and treated (e.g., a urinary tract infection), but even then most doctors would remove the catheter to avoid the possibility of it being “seeded” by the urinary organisms—especially with a patient who is immunosuppressed.

However, there is not the slightest shade of gray once blood cultures show definitive evidence of bacteria. Neutropenia, fever, foreign bodies, and blood-borne bacteria are a volatile mix. The only element in that tinder box that can be instantly rectified is the removal of the foreign body.

Admittedly, once bacteria are noted in the blood culture, it can still take another 24 hours to identify the exact bug (which is crucial for selecting the right antibiotic). Furthermore, “positive blood cultures” can occasionally be a false alarm, with the culture revealing nonpathogenic bacteria that just happened to be along for the ride (referred to as contamination). But in a febrile patient who lacks a sufficient immune system, you can’t wait the additional 24 hours to determine if it’s merely a case of contamination—the stakes are too high. So the first whiff of “positive blood cultures” is generally a mandate to pull the line, stat.

Midday on that Sunday, two days before Jay died, a nurse told Jay of his blood cultures: “There’s all sorts of stuff growing in there.” It would be another 24 hours before the microbiology lab could identify the bacteria as MRSA. Finding multiple organisms in the culture—if that’s indeed what the nurse was referring to—is more common in contamination, but it certainly doesn’t rule out a true infection. Jay had just received chemotherapy, his immune system was shot, and he had been persistently febrile for 48 hours despite receiving broad-spectrum antibiotics. I cannot come up with a plausible reason to leave in the catheter.

Not only was the catheter not pulled; it was actively used during the ensuing 24 hours to administer fluids, transfusions, and antibiotics. If the catheter was indeed the source of infection, then using the line for 24 additional hours was simply infusing more bacteria into Jay’s bloodstream.

The next day, the bacteria in the blood cultures were identified as MRSA—a true infection, not a contaminant. Staph aureus is a skin-dwelling organism, so a catheter piercing his skin and offering a toll-free highway directly to Jay’s bloodstream would be the clear culprit. However, Jay’s catheter couldn’t be removed immediately because his platelets were dangerously low, so hemorrhage during the removal was a real risk. It took several more hours for Jay to receive sufficient platelet transfusion to allow for safe removal. One can quibble about the exact timing, but there’s no doubt that the infected catheter remained in Jay’s body longer than it should have.

TRANSFERRING TO THE ICU

Why wasn’t Jay transferred to the ICU? This question plagued me as I followed his progressive decline over the three days of his hospitalization. There were so many points where I thought, “Oh boy, this is where I’d be calling for help,” or, “This is where I’d grab the gurney myself and wheel the patient over to the ICU.” Admittedly, this partly reflects individual style. Every doctor and nurse develops his or her own clinical style, and one key requirement is knowing your own comfort level and being aware of your biases. I know that I tend to be conservative—medically, at least. I try, for example, to hold off on newly released medications until I see how the dust settles. The downside of my hesitancy is that my patients may miss out on some of the benefits that newer drugs offer, but hopefully I avoid some as-yet-unknown disasters. Other doctors view the benefits for their patients as far outweighing the risks and so prescribe these new meds as soon as they’re out of the gate. It’s not that one approach is right and the other is wrong—they’re just two different styles of practicing medicine.

Dr. Mueller and Dr. Peterson might have higher tolerance for acute illness than I do because they practice in medical specialties—oncology and pulmonary medicine—that experience a higher proportion of critically ill patients. Or their behavior could simply reflect their overall style of practicing medicine, something that is neither right nor wrong, just individual temperament.

On the extreme end are doctors who fall into the cowboy category, who would view transferring a patient to the ICU as some sort of personal failure, intimating that they aren’t macho enough to tough it out. Cowboy medicine has receded somewhat over the years, as tolerance for ego-driven alpha doctors has waned. If anything, I observe that medical teams these days have swung the pendulum in the other direction—calling extra consults when they don’t really need them, or pushing to transfer a patient to the ICU because they are afraid to care for a moderately sick patient on the regular ward. Usually this is from a risk-averse style of practice combined with a fear of a malpractice suit (though occasionally it’s due to laziness). Without having personally spoken to any of Jay’s physicians, I can’t know the reasoning behind their reticence to transfer him to the ICU. They may well have had valid clinical reasons. Nevertheless, I found it striking that the team allowed a progressively decompensating patient to stay on the ward when ICU care was available within the hospital. (In hospitals without on-site ICUs, one has to weigh the additional risks of transferring an unstable patient via ambulance or helicopter.)

In my experience, though, this is where the nurse stands up and declares, “This patient needs to leave my floor ASAP and go to the ICU.” Nurses are quite clear about the scope of medicine that can be handled in their particular clinical setting (ward, ER, step-down unit, CCU, etc.) and are usually reliably vocal when that scope is exceeded. For better or for worse, nurses usually err on the side of caution much more than doctors do. The critique of this, if any, is that some nurses adhere to an overly rigid interpretation of scope of care, and any patient who drifts even a hair’s breadth beyond that is bundled up and transferred before you’ve even unfurled the stethoscope from your pocket. Thus, the absence of nurses rallying to get Jay moved was quite surprising to me.

It’s true that some floor nurses aren’t comfortable confronting doctors (though a healthy hospital environment should encourage such back-and-forth), but they would surely alert their supervisor if they felt that they were in over their head with a patient. The head nurse is responsible for ensuring that there is enough nursing power on the unit to handle all the patients and cannot afford to have a single patient sucking up excessive nursing resources. It is often on staffing grounds alone that the head nurse will insist that a critically ill patient be transferred immediately to the ICU.

The first hematology fellow—Dr. Amir—thought Jay might have had ARDS (acute respiratory distress syndrome) after he ordered an arterial blood gas in the early hours of Tuesday morning. His speculation may not have been borne out by the CT scan done later that day, but ARDS is one of those five-alarm-fire words that nurses do not take lightly. If a head nurse hears “ARDS” from one of the docs—even a junior one—she is usually pressing the attending physician to get the patient moved yesterday. (As a side note, it’s worth pointing out that the typical X-ray and CT signs of ARDS may be absent in immunosuppressed patients. The black-and-white shadows that radiologists pick out as “abnormal” are a result of inflammation. If your white blood cells have been pulverized by chemotherapy, you are not able to mount the classic inflammatory response, so you could have ARDS despite “negative” scans.)

Looking at all of this together, what seemed to be lacking was a sense of urgency. The best that I could ascertain—admittedly from a secondhand source—was that Jay’s steadily worsening condition did not light a fire under anyone. The doctors did not appear to be reacting aggressively, nor did any of the nurses seem to raise an alarm on either clinical or staffing grounds. Was this from lack of awareness? Lack of knowledge? Lack of “big picture” thinking? Lack of time to analyze all the data points? I recognize that I have the unfair benefit of 20/20 hindsight, but I still find the lack of reaction concerning.

After Jay’s death, Tara learned an unusual fact about the bone marrow transplant unit in that hospital. It was a privatized unit. That is, the BMTU functioned almost like a separate hospital within the hospital. So a patient couldn’t simply be “transferred” to the ICU but had to be formally discharged from the BMTU (as though the patient were going home) and then readmitted to the ICU as if a brand-new patient.

Seems like a lot of extra paperwork, especially if all you are doing is wheeling a patient from one floor to another. Why would a hospital privatize one of its units and add all these extra bureaucratic hurdles? The nursing staff of the BMTU, Tara learned, all worked for an outside agency. Why would the hospital contract out the nursing services rather than use its own nurses?

I’ll admit I’m probably a bit cynical here, but when it comes to managerial rearrangements within the medical system, the reason is usually (though admittedly not always) money. Hospitals are always scrounging for cash, and some hit upon the novelty of privatizing certain services, often those that are already relatively self-contained. For example, radiology units typically exist in their own world within the hospital. Patients who need these services go there only for a brief period of time before returning to their home base (the medical ward, the surgical ward, etc.). Radiology is also an extremely expensive service to run because of the high-end technology.

Private companies saw an opportunity—they could set up private radiology units in multiple hospitals and pool radiologists to read the scans. The radiologists didn’t even need to be on-site; they could read the scans from home. Or they could read them from Estonia, where they would cost less to hire. For individual hospitals, contracting such a service might be cheaper than running the units and hiring the staff themselves. For the private companies, they can turn a profit by pooling services and even equipment. It seems like a win-win, at least financially.

I remember the first time I came across a setup like that. The rehab service in our hospital functioned like its own hospital, even though it wasn’t privately contracted. It always rubbed me the wrong way. First of all, it was a pain in the neck. Transferring a patient to any other service—surgery, geriatrics, OB-GYN—simply involved conferring with the respective teams and then wheeling the patient over. With rehab, though, you had to go through the entire discharge process—endless forms and busywork that fell on the shoulders of already overworked medical teams. The patient was only moving down to the fourth floor, but the paperwork needed for the transfer was the same as if it were for a full discharge from the hospital.

But even more than the logistical annoyances, something about this arrangement felt wrong to me philosophically. We are one hospital, right? All the different services—obstetrics, pediatrics, emergency medicine, neurology, internal medicine, oncology, psychiatry, surgery, radiology, anesthesiology, geriatrics, intensive care, ophthalmology, urology, neurosurgery, pharmacy, dialysis, laboratories—are critical facets of this larger and meaningful institution that we call a hospital. Even though some services (interventional cardiology) may bring in more revenue than others (gynecology), we are all part of this enterprise devoted to meeting the full spectrum of our patients’ medical needs. It feels plain wrong to me that some parts are cordoned off.

So when trying to figure out why Jay wasn’t transferred to the ICU as his condition steadily worsened, it crossed my mind—and Tara’s too—that there might have been competing interests at play. (Glenn’s wife, Nancy, entertained similar thoughts as she tried to figure out why her husband wasn’t promptly transferred to the burn center.) “Discharging” Jay from the BMTU would have meant losing the revenue generated by his admission. He’d now be in the regular hospital, which would take over the billing and the revenue.

As much as I try, though, I can’t bring myself to believe that money would drive the decision. I might be a bleeding-heart idealist, but I find it wholly impossible to imagine any doctor standing in front of a crashing patient and doing a calculation about revenue losses. Yes, I know that doctors can be as small-minded, greedy, selfish, vain, narcissistic (shall I go on?) as anyone else out there. But there is a baseline clinical instinct below which I cannot see any doctor or nurse falling: when a patient is acutely decompensating before you, you are not thinking about money. I would find it hard—and heartbreaking—to believe that financial issues could trump clinical acuity in the moment.

However, subtle pressures should not be underestimated. I wonder if the staff at the BMTU had been given the message from higher-ups that discharges to the ICU should be avoided unless absolutely necessary. Or they might have been informed that the BMTU budget was under severe strain, that staff might be laid off and raises deferred. Staff might be urged to improve documentation to appropriately capture the severity of their patients’ conditions (sicker patients merit higher payments). They might be reminded that the BMTU is a “comprehensive” unit that takes care of its patients at all levels of clinical need. They might be exhorted to “carefully consider the appropriateness” before discharging a patient to the ICU. Subtle pressures can be quite powerful. (If they weren’t, you wouldn’t see pharmaceutical sales reps showering doctors with pens, mugs, and sushi lunches.)

And even if financial issues—overt or subtle—didn’t get in the way of transferring patients from the BMTU to the ICU, the logistical issues certainly might have. Discharging a patient involves a lot of paperwork, especially for nurses, and it’s easy to imagine this as a disincentive to transfer.

About a year after Jay’s death, Tara was taking a weekend workshop in critical-care nursing (all nurses are required to maintain certification with continuing education programs). During the break, she noticed a nurse wearing a sweatshirt with the logo of the hospital where Jay had been. Not mentioning her own experience, Tara began chatting with this ICU nurse. The lecture they’d just attended had been about septic shock, so the conversation flowed effortlessly toward commiserating about hypothetical patients with neutropenic fever and sepsis, and how they always got transferred to the ICU too late.

“The patients who come to our ICU,” the nurse said, inhaling deeply from her cigarette, “don’t have a chance in hell.” She gave a sardonic laugh. “It takes forever to get these patients transferred to the ICU because we have a BMTU.” (“Oh really?” Tara inquired.) “They can’t come straight to the ICU,” the nurse explained, “because they have to be completely readmitted like a new patient. By the time they actually get to the ICU, they’re too far gone.” Tara asked if she ever reported these concerns to her manager. The nurse just rolled her eyes and then took another magnificent drag on her cigarette.

So far, we’ve reviewed three concrete issues in Jay’s care—reusing a Vacutainer that had fallen down, the delay in removing the indwelling catheter, and the reluctance to transfer Jay to the ICU. I’m going to assume there was no premeditated malice involved. Despite the jaded observations of this one ICU nurse, I honestly do not think that an entire oncology team thought, “Hmmm, we have this critically ill patient here. Let’s not transfer him to the ICU.” (Though there may have been subtle pressures at work.) To me, the real error was that it seems as though the staff simply did not recognize—or take seriously—how critically ill Jay was. This brings up the second category of errors, the ones that are less tangible.

POOR CLINICAL EVALUATION

The first time I walked through the case with Tara, I tried hard not to assume the easy self-righteousness of a Monday-morning clinical quarterback. But it was hard to restrain myself as I watched a textbook case of sepsis unfold.

Sepsis is one of those paradoxical medical situations in which the body’s protective mechanisms backfire and end up harming the patient. In response to an infection, the body normally unleashes a cascade of infection-fighting compounds. In the vast majority of cases, these do the trick and the infection is quashed. But occasionally this cascade can take on a life of its own, causing overwhelming inflammation that wreaks havoc on the body. Even with antibiotics to eradicate the bacteria, sepsis can power forward independently, leading to multisystem organ failure, as happened with Jay.

While sepsis can occur in anyone, it’s more likely in patients who either have a handicapping susceptibility or have the bad luck of getting infected with a virulent organism. Jay had the misfortune of both. And once he had a fever, the conditions were ripe for sepsis. While it is possible to have fevers from causes other than infection, it is standard medical practice to consider fever as an infection until proven otherwise. When Jay spiked a fever after his initial chemotherapy, his medical team did the right thing—admitted him to the hospital and started broad-spectrum intravenous antibiotics, along with antifungal and antiviral agents. (He’d been on oral versions of these medications while he was home, but now he needed stronger doses.)

The initial clinical evaluation of a febrile patient is critical. Since the identity of the pathogen is unknown at the outset, the clinical evaluation is akin to detective work. Urinary burning would suggest a genito-urinary source. Neurologic impairment or mental-status changes might suggest meningitis or encephalitis. Nausea, vomiting, diarrhea, or abdominal pain could suggest a gastrointestinal source, though these symptoms can appear, nonspecifically, in infections from other sources.

A good clinical history ferrets out the minute details that could suggest which microbes might be wreaking the havoc: where you grew up, what kind of job you have, who’s sick at home, whether you breed parrots, whether you’ve recently traveled to the tropics or been on the hajj, whether you’ve been hiking in the woods, whether you garden or keep an aquarium, whether you were recently hospitalized or incarcerated, whether you’ve been living in a nursing home or a college dormitory or a homeless shelter, whether you’ve had all your vaccinations, what medications you take, what illicit drugs you might have used, whom you’ve had sex with and whom they’ve had sex with.

A careful physical exam is also critical. A heart murmur could suggest infection of the heart valves (endocarditis). Abnormal breath sounds could suggest pneumonia. Joint swelling, swollen lymph nodes, characteristic rashes, enlarged spleen—these can all suggest particular types of infections.

I don’t know how thorough a clinical evaluation Jay was given on admission. I’ve certainly seen some doctors squeak by with the most cursory of evaluations. One attending I witnessed when I was a student used to plunk his stethoscope in the midpoint of the patient’s torso, taking in the cardiac sounds, breath sounds, and abdominal sounds all in one substandard listen. At the other end of the spectrum was the legendary Dr. Vincent McAuliffe, an infectious-disease attending who worked at Bellevue during the early years of the AIDS crisis.

One time when I was a resident, I found myself struggling with a complicated patient at 11 p.m. on a Friday. My attending had long since departed the hospital. I was alone and sinking fast. I paged Dr. McAuliffe and wasn’t surprised that he was still in the hospital at that hour. He came right over to assist me, even though I wasn’t part of his team and this patient wasn’t his. What is most memorable to me, even after all these years, was the full hour he spent evaluating my patient. He asked detailed questions and listened carefully to the answers. He then performed the most thorough physical exam I’ve ever witnessed, probing every crevice of the patient’s body, examining every fingernail, percussing and auscultating every organ. It was a medical tour de force. This was followed by a textbook-like note in the chart—single-spaced, red-pen script—methodically elaborating his evaluation, his reasoning, and his assessment.

Few physicians reach the pinnacle of Dr. McAuliffe in their examinations, but hopefully Jay received a reasonable initial evaluation. After that, it’s a waiting game—waiting for the cultures to grow—but it’s also a watching game, especially with neutropenic patients, who can decompensate faster than you can say MRSA.

If the culprit organism is sensitive to the antibiotics, the patient should start to improve in 24–48 hours. The fever should come down, and the blood pressure, pulse, breathing, and white-blood-cell count should begin to normalize. If not, it could be that different antibiotics are needed—that’s the best-case scenario. The worst-case scenario is that the antibiotics were correct but sepsis has surged ahead on its own. Despite all our phenomenal medical advances, once you are behind the eight ball on sepsis, there’s a good chance you’ll never catch up.

During Jay’s first 48 hours in the hospital, his clinical condition did not improve, and in fact it steadily worsened. Plotted out, his symptoms show that one organ system after another was being affected. His urine output decreased, a worrisome sign that his kidneys were failing. He had a swollen abdomen and right-upper-quadrant pain, suggesting that his liver was affected, possibly congested with fluid or (worse) harboring an abscess. His arms and legs swelled with fluid, suggesting that his vasculature was dilating and the vessels couldn’t contain the fluid inside the vessel walls. Jay’s hallucinations (his “altered mental status”) indicated that his nervous system was being affected. This could have been delirium from the fever or a medication, but it could also have represented meningitis, encephalitis, or the spread of leukemia. His progressive difficulty breathing was a sign of pulmonary involvement. This could have represented fluid or blood clots in the lungs, pneumonia, the spread of cancer, or, as the hematology fellow initially speculated, ARDS. Mottling and discoloration of the skin suggested diminished blood supply to the skin.

And of course, Jay remained febrile throughout his time in the hospital—a strong indicator that the medical treatment was not gaining ground on the underlying infection. I wasn’t present at Jay’s bedside, and I well know that even serious changes in medical condition can creep up insidiously. Sometimes they are obvious only in retrospect. But even with those caveats, I was startled that no one on the medical team seemed to be reacting to Jay’s relentless decline.

Dr. Peterson was a pulmonologist—the field from which critical-care specialists arise. The fellowship for pulmonologists (which they do after their medical residency) is, in fact, called “pulmonary/critical care.” So if there’s anyone in a hospital who should know when ICU-level care is required, it would be a pulmonologist.

Maybe Dr. Peterson didn’t believe Jay’s condition was serious. I recognize that it’s dicey to render an opinion without being there and seeing exactly what he saw. Maybe the recent dose of morphine had calmed Jay’s labored breathing just enough so that he appeared less sick at the moment that Dr. Peterson was at the bedside. But Jay was clearly gravely ill (he died five hours after the doctor’s visit).

One thing that struck me about Dr. Peterson was that he seemed to wear only his “pulmonary” hat; the “critical-care” hat seemed to have been left in the staff locker room. His evaluation of Jay appeared to have focused solely on the lungs, and when he had satisfied himself that those two sacs of air were not the primary drivers of Jay’s worsening condition, he exited the scene. It’s true that after fellowship in pulmonary/critical care, some doctors focus their careers on the pulmonary aspect and some on the critical-care part (these latter docs are often called “intensivists” and spend their time running ICUs). It’s likely that Dr. Peterson was of the pulmonary persuasion, which is perfectly fine, but you can’t “unlearn” your training in critical care. I don’t understand how Dr. Peterson could have filtered out the persistent fever, the abdominal pain, the dwindling urine output, the hallucinations, and the swollen limbs and made a beeline just toward the lungs with his stethoscope.

Which brings me to the conclusion that no one—not Dr. Peterson, not Dr. Mueller, not the nurses—seemed to be actually looking at the patient.

There’s a famous clinical pearl passed on to medical students. The question asked is “How do you know when it’s time to intubate a patient?” Medical students will typically reach for weighty data points for an answer—the oxygen saturation, the CO₂ level, the alveolar-arterial gradient. The answer from the wise senior resident is “none of the above.” You make the decision based on looking at the patient. You should be able to tell from across the room when a patient needs to be intubated.

It’s an oversimplified answer, perhaps, but it illustrates a key concept in medicine. It’s easy to get inundated—and distracted—by the vast amounts of data spooling out from our medical machinery. Hundreds of data points are churned out every shift, and wading through them can be dizzying. Even experienced clinicians can miss the forest for the trees. Not to mention that our shortcut-loving brains tend to cherry-pick the data that reinforce what we want to believe.

The importance of stepping back and taking a good look at the patient in totality cannot be overstated, especially in confusing situations. Jay’s case was complicated, no doubt: he had an uncommon and grave form of AML; he wasn’t responding to standard antibiotics; he was exhibiting symptoms that didn’t necessarily seem related. There was a bevy of medical people from different fields and different shifts involved, but it seemed as though each person on the team attended only to specific parts of Jay’s case—the breathing, the knee, the skin color, the restlessness. No one seemed to look at the big picture or, frankly, at him as he labored under the weight of the implacable metabolic disintegration taking place within him.

It is true that the symptoms and ramifications of sepsis are varied and complex, and often tricky to sort out. The situation can be murky, especially initially, but with sepsis you don’t have the luxury of waiting until things are clear—you have to act. The window of opportunity is not only slender but also ephemeral. Unlike some other diseases, sepsis does not wait until you’ve pinpointed exactly what’s going on.

Which is precisely what happened with Jay. No one added up the signs and symptoms from each of Jay’s organ systems. The nurses wrote off his symptoms as side effects of chemotherapy. The doctors didn’t seem to find anything alarming enough to raise their own blood pressure. The overall clinical evaluation struck me as oddly lackluster, especially when you consider the location of the patient. Neutropenic fever and sepsis might be oddballs on an orthopedic ward, but this was a bone-marrow transplant unit. Every single patient on a BMTU, by definition, has an impaired immune system, from the disease or the treatment or both. One would expect a BMTU to be especially attuned to the risk of sepsis, in the way that a geriatrics ward is attuned to the risk of falls or a psychiatry ward is attuned to the risk of suicide.

So my conclusion about the clinical evaluation of Jay is that the recognition and diagnosis of sepsis seemed more sluggish than it should have been. But what about the treatment of his sepsis?

Antibiotics are a must for treating sepsis, but they aren’t sufficient because the body’s immune reaction is now running amok, unmoored from the underlying infection that triggered it. The main “treatment” for sepsis, therefore, is to keep the patient alive (what’s demurely known as “supportive care”). You’re trying to outfox and outlast the body’s own self-damaging enterprise long enough for the antibiotics to do their thing. Keeping the patient alive, though, is a strenuous and fraught process.

The mainstay is aggressive hydration to support the collapsing circulatory system. As with burn patients like Glenn, aggressive hydration can easily backfire and cause fluid overload, because the blood vessels of septic patients are similarly over-dilated and inefficient at corralling fluid to where it needs to be. Finding the sweet spot between necessary, aggressive hydration and too much hydration requires deft medical management.

If fluid alone cannot maintain an adequate blood pressure, patients require pressors to artificially constrict the blood vessels to force blood supply to the critical organs. These medications, however, can strain the heart and cause arrhythmias. The over-constriction can paradoxically end up cutting off blood supply to the kidneys and other vital organs.

Septic patients are frequently in respiratory distress and often need intubation and mechanical ventilation. If the kidneys have been affected, emergency dialysis is sometimes needed. These supportive measures hopefully keep the patient alive until the antibiotics can work. But these treatments are immensely complicated and offer as many harms as they do benefits. As such, patients with severe sepsis are best managed in intensive care, which is why the best “treatment” for sepsis is early recognition and transfer to an ICU.

Would Jay have survived if he’d been transferred to the ICU earlier in the course of his sepsis? This is impossible to say. The mortality rate of sepsis ranges from 15% to 60% depending on how many organ systems have been affected. Jay’s profound neutropenia and his particularly pernicious form of AML were severe handicaps. Earlier recognition of the sepsis with aggressive supportive care in the ICU would have offered him the best chance, but Jay might have died even with the most scrupulous medical treatment.

NOT LISTENING TO THE SIGNIFICANT OTHERS

One of the perplexing aspects of this case is how little credence the staff gave to Tara’s observations. Doctors see a patient once or twice a day on rounds for just a few minutes, and so they depend on nurses, who spend more time at the bedside. Nurses also have other patients to care for, and so often they rely on the patients—or family members and close friends—to let them know if anything is amiss.

Interactions between medical staff and family members run the gamut. Sometimes the interactions are smooth—good communication, mutual respect, plates of brownies—and the staff and family work together to enhance the patient’s experience. But often it’s less than ideal. Personalities, priorities, and bodies jab into each other in the cramped space of a stuffy hospital room. Resentment and disrespect can lead to downright hostility.

There’s an additional element in the brew, however, when the family member is a medical professional. Some staff welcome relevant medical input, though others feel uncomfortable and judged. Medical family members can be useful additional sets of eyes on the patient, but they can sometimes give unwanted—or incorrect—medical advice.

Tara described very comfortable dealings with the staff during the induction chemotherapy and the initial outpatient visits: “Jay and I were treated with respect. We had nothing but positive interactions.” But of course, things were going relatively well, medically, so there wasn’t much to disagree on.

During the hospitalization for the neutropenic fever, though, the interactions became strained. It seemed that every time Tara tried to point out a worrisome sign, the medical staff reacted negatively. Did they think she was insinuating that their care was substandard? Did they view her as competition? Did they just not like her as a person?

It’s impossible to know, obviously, if one hasn’t witnessed the encounters. But it is disquieting that they seemed to ignore, even disparage, Tara’s every concern. Many of her observations were objective—respiratory rate, heart rate, urine output (I’s and O’s). These hard data are a universal nursing vocabulary, and it seems strange that the staff nurses didn’t respond to them, irrespective of their feelings toward Tara as a person. Perhaps it was an issue of nurse-on-nurse territoriality. Maybe it was a hierarchical issue of a high-power cancer center pooh-poohing a nurse from a community hospital. Or maybe they just wrote her off, on day one, as a “difficult” family member and simply tuned out anything she said.

Tara is the first to admit that she knew nothing about leukemia. “I was totally ignorant,” she said. She checked out a textbook from the medical library hoping to get a good overview, but it turned out that the book was written for hematology specialists. (“I was out of my league,” she recalled. “The first chapter kicked my ass!”) Nevertheless, she soldiered on through the book, feeling that she owed it to Jay. It was that textbook that she was reading the first time she met Dr. Mueller, the Sunday morning after Jay was admitted with neutropenic fever.

“I saw her smirk when she read the title,” Tara remembered. “It was unmistakable. Only over the years has it dawned on me that it must have rubbed her the wrong way. Dr. Mueller could have made light of it, or maybe offered me an easier read. Instead, she smirked.” Tara quickly covered the book with her backpack and never brought it out again. But she noticed thereafter that the nurses were more curt with her, even though she was assisting them with much of the grunt work. “I was fetching Jay’s water and changing his sheets and cleaning his BMs. I was helping them to keep track of his I’s & O’s, but something had changed, inexplicably.”

Was Tara over-reading the situation? Was she being paranoid? Perhaps. In her view, they’d pegged her as “a frantic, overbearing, overanxious, bossy ER nurse from a podunk hospital in the middle of nowhere.”

Again, I can’t comment directly on this since I wasn’t present. But I do know that doctors and nurses are expected—rightfully, in my opinion—to tolerate a range of responses from patients and their families. Illness is a stressor like almost no other. Panic, helplessness, worry, pain—these are everyday issues in a hospital, and they can turn even those with the most staid personalities into raving maniacs. And of course we know—or are supposed to know—that it is not, in fact, raving mania that we are seeing but fear and intense vulnerability. In some fields, you get to choose which clients you take on. In medicine, you don’t. You take care of all your patients and their families, whether you like them or not. That’s the job.

Maybe Tara was indeed frantic, overbearing, overanxious, and bossy. She may have been the most annoying, unpleasant family member on the entire ward. But all of that notwithstanding, her observations about Jay’s progression to septic shock were largely correct. His cardiac arrest and death from sepsis sadly validated her clinical observations. The medical staff made an error—perhaps a fatal error—in not giving any credence to her words.

It’s hard to imagine a more punishing way to be proved right.

OVERCONFIDENCE IN CLINICAL ABILITIES

When Tara pressed Dr. Mueller about transferring Jay to the ICU, the hematologist responded, “Maybe in a smaller hospital he would be in the ICU, but not here.” There’s no doubt that a major cancer center has many capabilities that a community hospital can’t possibly match. But as Mark Graber—the researcher on diagnostic error—had commented to me, “Overconfidence is an enormous problem, both personal and organizational.”

One interesting study of overconfidence and medical error suggests that overconfidence is more of a problem in simple cases than in complex ones.1 With difficult or unusual cases, doctors and nurses feel the chafe of their limitations and so tend to seek out guidance and additional knowledge. It’s in situations that appear routine that overconfidence trips them up. The “meta-cognitive angst” caused by a complex case is absent, so staff members stop thinking and just perform rotely. I wonder if that’s what might have happened in Jay’s case. Dr. Mueller and the BMTU nurses kept viewing Jay’s symptoms as a typical response to chemotherapy, and so perhaps they stopped thinking actively about what else might be going on.

I have to admit, though, that I was dumbstruck when Dr. Mueller said to Tara, “We don’t electively intubate here at this hospital.” It’s one thing to say, “We don’t do heart transplants here at this hospital” when a hospital doesn’t possess such a facility. But it’s quite another to say, “We don’t do X,” when X is an available treatment in the realm of reasonability.

I could understand if Dr. Mueller had said, “We try to avoid elective intubation at this hospital,” given that elective intubation certainly has harms. But such a statement would have been followed by “So here is what we do when a patient is having trouble breathing,” with an elaboration of noninvasive respiratory methods such as BiPAP or a rundown of what respiratory therapists do.

The only circumstance in which I can imagine a doctor saying, “We don’t electively intubate here at this hospital” is when a hospital doesn’t own a ventilator. That might be the case in a rural hospital in a developing country, but it’s a clear impossibility in a major hospital that performs high-risk procedures such as bone-marrow transplants. In any case, elective intubation is not a policy (as in, “We don’t allow smoking here at this hospital”) nor is it a medical practice that was once accepted but now disproven (as in, “We don’t do blood-letting here at this hospital”).

To say, “We don’t electively intubate here at this hospital” would be like saying, “We don’t do emergency C-sections here at this hospital.” Nobody wants to deliver a baby under rushed conditions, but if the clinical situation warrants it, then you do it.

I have to at least consider the possibility that Dr. Mueller was completely clueless about sepsis. I find that a stretch because any hematology attending, even a junior one, has been through a residency’s worth of clinical disasters and a fellowship’s worth of cancer disasters. You don’t have to preside over that many intubations—elective or emergent—to know this is something you do when you have to do it.

I can’t say for sure that it was overconfidence in the abilities of the BMTU that led to Dr. Mueller’s statement, but blunt fiat is a very limiting way of practicing medicine. Perhaps it was ego. Maybe having her treatment plan questioned—and implicitly doubted—by a nurse (or worse, a family member!) raised her hackles and she became defensive. We can never know exactly what prompted Dr. Mueller to write off elective intubation. But what we can see from the BMTU is that no one stepped up to take ownership of the situation, which to me is the defining error of Jay’s case.

LACK OF “OWNERSHIP” OF THE CLINICAL SITUATION

Caring for severely ill patients is never easy. And when the clinical condition is crumpling and the reasons aren’t clear, it can be nearly as terrifying for the doctors and nurses as it is for the patient and family. There’s a raw and ominous queasiness that creeps up on you when you sense the ground shifting under your patient and you’re not exactly sure why. The permutations of pathology seem endless—infectious, inflammatory, metabolic, autoimmune, vascular, traumatic, toxic, neoplastic, congenital, iatrogenic, idiopathic—and the clinical progression can feel like it’s spinning out of your control.

In the wake of confusion and decline it’s tempting to plug the small holes, to chase the minutiae, to temporize until someone else’s shift starts. This may net some gains on paper—the potassium level normalizes after supplementation; the fever is down after giving acetaminophen—but the underlying disease process hasn’t been identified or controlled. This won’t happen until someone takes ownership, both of the situation and of the patient.

Nowhere in the course of Jay’s hospital stay did anyone seem to say, “This is my patient. I’m not going anywhere until I figure what’s going on.” This is not to imply that it’s any one person’s sole responsibility to understand and solve every clinical problem—that’s not realistic, or even feasible. But it is the lead doctor’s role to take ownership of the case, especially when things are not going well. This ownership comes in many forms. For starters, it involves clearing the deck—in your mind and, if necessary, in your schedule—to perform a head-to-toe evaluation at the patient’s bedside. This should be followed by the equivalent amount of time sitting in the nurses’ station thinking, analyzing the case from soup to nuts. You need to start from scratch and work your way methodically through the data and the clinical course to make sure you haven’t missed anything. (Dr. McAuliffe was a master role model for this.)

Ownership might entail agitating the system to make things move faster—getting on the horn to CT and insisting on an abdominal scan stat. It might involve getting help, such as obtaining an infectious-disease consult, even in the middle of the night, because the patient remains febrile despite appropriate antibiotics. It might involve calling a colleague to get a second opinion, in this case maybe calling Dr. Everett, the outpatient hematologist who administered the chemotherapy and was familiar with Jay’s medical intricacies. Ownership might involve acknowledging that you are in over your head and transferring the patient to the more appropriate setting.

Sometimes ownership is the physical act of planting your derriere at the bedside and not leaving until you know what’s going on with your patient or your patient has stabilized or your patient has been moved to the appropriate clinical setting. But any way you slice it, ownership is taking full responsibility for your patient’s care and not passing the buck. It doesn’t mean you have to be a martyr who stays till 2 a.m. every night, nor does it mean you have to fly solo. But you do have to take on a leadership role and make sure the necessary things get done.

Whose job was it to take the leadership role in Jay’s case? Twenty years ago there would have been just one primary doctor for both the inpatient and outpatient care. In that model, Dr. Everett—Jay’s main hematologist for the AML—would have had the primary responsibility for Jay’s care, whether it was during office visits, outpatient chemotherapy, or inpatient admissions. With the increasing complexity (and pace) of medical care, it has become unsustainable for a single physician do all the outpatient as well as the inpatient care, so many medical centers use the hospitalist model, under which full-time inpatient doctors (“hospitalists”) assume the care when the patient is hospitalized.

But even this is an oversimplification. Patients are usually cared for by multiple consulting services who have commitments all over the hospital, and often at several different hospitals. Each of these consulting services might involve several levels of hierarchy—residents, fellows, attendings. The logistics alone make coordination of care a nightmare, but the real risk is diffusion of the sense of responsibility. It is very common, especially in complex cases, for each clinical service to “defer” to another service, leading to a serial punting of responsibility. No one takes charge.

In Jay’s case, Dr. Mueller—the inpatient hematology attending on the BMTU—was the person who should have taken charge of this situation. As the senior doctor on the ward to which Jay was admitted, she had primary responsibility for his care. This is not to say that she was responsible for every iota of Jay’s care or that every last fault in the case is on her shoulders, but it was her job to direct the care, coordinate the consultants, and make the final decisions. Most importantly, it was her job to take charge when the situation worsened. Instead, oddly, she seemed to pull back. This was the part that gave me the most pause.

In fairness, I did not have the opportunity to speak with Dr. Mueller, so I was not able to learn her perspective. In medicine—and in life—there are always nuances that don’t meet the eye on initial gaze. Neutropenic fever is certainly well within the realm of what a hematologist deals with but perhaps there were clinical elements of the case that I am not aware of that drove her to different conclusions. Perhaps there was a personal antipathy toward Tara that got in the way. (We’d all like to think of medical staff as perfectly objective, but of course they are not.) Whatever it was, Dr. Mueller did not step up to the plate either in evaluating Jay’s condition or in corralling the tests and treatments that he needed.

Dr. Peterson was a consultant, so he did not have primary responsibility for Jay’s care. But even a consultant has to take ownership relevant to his or her part of the medical care. Again, I did not interview Dr. Peterson personally, so I cannot know what he was thinking, but it seemed to me that Dr. Peterson shirked his duty by limiting his consultation to the pulmonary aspect of the case and not including his full spectrum of critical-care knowledge.

The head nurse of a ward may not have the same legal responsibility as the attending physician, but that person is also expected to take ownership. If a patient is not getting the appropriate medical care, for whatever reason, it is the head nurse’s job to stand up and insist that it happen. And if circumstances make this awkward or untenable, there is a strong chain of nursing leadership to turn to. Like her medical colleagues, Constance also seemed to pull back. I do not know how she was viewing matters in the moment, but from an outside perspective, it seems as though she did not take ownership of the situation or the patient. To her credit, though, she showed up at the meeting with Tara and expressed true remorse. She was the only member of the team who did so.

After Jay died, there was an autopsy. The pathologist found extensive colonies of MRSA spread throughout his body, along with evidence of sepsis-induced clots and bleeding, known as DIC (disseminated intravascular coagulation). The official cause of death listed on the death certificate was cardiopulmonary arrest secondary to sepsis.

While sepsis is challenging to identify and treat, it is a quantifiable subject that is eminently teachable. What is far harder to teach is responsibility and a sense of ownership. These concepts—“responsibility” and “ownership”—may be pasted into mission statements or hospital brochures, but they can’t be taught in any meaningful way other than by example. When there are enough examples walking the halls of an institution, these values are infused into the culture and are absorbed by newcomers without any need for inspirational posters tacked onto the walls. They are among the rare things in medicine that we applaud for being contagious. Regrettably, lack of responsibility and ownership—as evidenced by Jay’s experience—is also contagious.

Of all the emotions Tara experienced, the one that lingers undimmed—beyond grief—is disappointment. She was so tremendously disappointed in her fellow medical workers. For someone who took such pride in her work, this letdown was—and remains—profound.

“How was there no one to have helped Jay?” she continually wonders. “Not one nurse to say, ‘Hey, this guy’s circling the drain? Not one blessed CNA [certified nurse assistant] to actually count Jay’s respirations for one minute rather than robotically write in the number 20? Not one oncologist to overrule the pulmonologist’s recommendation of morphine rather than ICU transfer to address Jay’s difficulty breathing? If I total all of the people who could have intervened on that day, I would include two physicians, two hematology fellows, one nurse manager, one case manager, two CNAs, and four nurses. My heart hurts to think about it.”

But Tara also wonders if a single outspoken nurse could have actually made the difference. The entrenched power structure in medicine could easily have overridden that one clarion voice. Would that one lowly nurse have felt empowered to call a “rapid response” against the advice of the attending? And if a team had rushed to Jay’s beside, might they have been turned away by a pulmonary specialist already at the bedside?

Jay’s story caught my eye specifically because his wife was a nurse. Medical error devastates patients and families from any background, but I was intrigued to talk to someone on the patient side of things who was herself in the medical profession. One reason is that I wanted to equalize the knowledge balance. For many patients and families facing medical error, the knowledge imbalance can be an impenetrable hurdle. Having a family member who is fluent in neutropenia, hyperkalemia, BMTU, trisomy, and MRSA would eliminate that issue as a confounder.

But the second, and possibly more important, reason was that I wanted to explore the experience of medical error with someone who understands the twenty-plates-spinning-in-the-air reality of modern medicine. Nonmedical folks often have the impression that checking into a hospital is akin to stepping onto a Boeing 747. We peek into the cockpit and see a dizzying number of buttons and levers, but we allay our anxiety because we assume that every pilot knows every single one. All can be accounted for on a checklist. The number of buttons and levers in that cockpit may seem frightfully large, but it is a finite number.

Nonmedical folks assume that the hospital is a similarly circumscribed, smooth-running machine. Medical insiders, however, know that it’s nothing like that. The number of variables—especially with critically ill patients—is vast, and the permutations and interactions of each are staggering. The variables don’t just include every possible thing that can go wrong with every possible organ but also the sheer number of people involved in the care—nurses, doctors, therapists, fellows, attendings, CNAs, supervisors, technicians, medical students—and the rotations of each of the people in each of these roles, since every role must be covered twenty-four hours per day, seven days per week.

For those of us on the inside, working in a hospital does feel more akin to circus juggling. The potential for major error feels ever present. We are amazed that more plates aren’t crashing to the ground. So I was interested to speak with someone who understood this dynamic.

Tara fit these two criteria. She was a clear-eyed realist who well understood the limitations of medicine and didn’t harbor any false expectations. Her rapid-fire intellect made it easy to dig through the reams of clinical minutiae with her.

But there was a third aspect that arose that I hadn’t really considered: the effect of the error on how that medical person would feel about her own profession and her own self as a member of that profession. I assumed there would be some frustration, even anger, but I hadn’t given much thought to the depth and totality of these emotions. In retrospect, I should have, because I know how deep to the core the identity runs. For many doctors and nurses, medicine is not just a profession; it’s a defining sense of self. In some other lines of work, you might hear, “I used to work in a bank, but now I’m in retail.” But you never hear someone say, “I used to be a doctor” or “I was once a nurse.” These professions define not what you do but who you are. A retired nurse never stops being a nurse, in her own eyes or in the eyes of the community. A retired doctor might say she’s no longer in practice but would never say she’s no longer a doctor. So I shouldn’t have been surprised by the intense and utterly visceral nature of Tara’s reaction.

“Betrayal” was the only word she could find to describe it. “The betrayal,” she wrote to me, “runs as deep as I imagine people who have been victimized by molesting priests feel. I trusted in the healthcare system just as any devout Catholic trusts in the Catholic Church. I believed that the doctors making Jay’s care plan were altruistic and adhered to their vow to ‘First do no harm,’ just as priests vow to be pious, chaste, and obedient. My healthcare profession was, to me, the way I felt closest to God. I had such faith in the work I was doing and in those who worked beside me.

“The nurses, in particular,” Tara continued, “were supposed to be my professional sisters and brothers. We shared an understanding, so I thought, of the trenches of humanity during the most vulnerable time in patients’ lives. We shared a belief—didn’t we?—in delivering skilled nursing care coupled with compassion. We prided ourselves in the missed lunch breaks and UTI-inducing, bathroom-free, twelve-hour shifts, all in the name of patient care. Is there anything more honorable?

“The absolute spiritual betrayal of my fellow healthcare practitioners has so scarred me that it has taken years of sheer determination to undo. For nearly ten years afterward, my mirror reflected a rage-filled stranger.”