Hospital depot: a victim of hospital error takes a critical look at the healthcare system

Humanist, March-April, 2005 by Sarah J. McCarthy

This is one person's story--from a belly-up viewpoint and armed with one of the best private health insurance policies available in 1999--about one of Pittsburgh, Pennsylvania's, best hospitals. An anecdotal story is useful only if representative, which I'm afraid this is.

Having lost control of my bladder and intestines due to an acute life-threatening attack of diverticulitis, which required surgery, and from an angle flat on my back, I saw a healthcare system so cash starved that most days there were no clean linens. I noticed the linen shortage right away because I needed so much of it.

Late one night I rang for help with the illiostomy bag attached to my intestines. The bag became unattached several times over the course of the day and night, leaking dark bile all over my abdomen and onto the sheets. "I'll be back as soon as I can," apologized the night nurse who answered my call for help. "Your problem right now isn't life threatening. I have thirteen other patients and I'm the only one on the floor."

I felt sorrier for her than for myself. We were both stuck here in this mess, managed by forces out of touch and beyond our control. At the nurses' station I saw a sign that read "Just deal with it." In the operating room I heard my surgeon say there was none of my blood type stocked. Just before I lost consciousness someone went for it.

This hospital seemed to be operating on a just-in-time inventory system, with the doctors and nurses having to be ever watchful and solely responsible for something not there or something going wrong. This was a health care system where even as you lay flat on your back you had to stay on your toes.

Robert Wachter in his recently published book, Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes, says there are about 90,000 medical errors committed annually in the United States and that hospital computerization functions at the level of circa 1980, about ten years behind the level of public schools and twenty years behind Wal-Mart. An updated version of this study, done by HealthGrades Inc., reported in August 2004 that 200,000 people die each year in U.S. hospitals due to "preventable medical errors." The Institute of Medicine in its report issued in 1999 says that the level of hospital errors is equal to that of a jumbo jet crashing every day. American medical mistakes are killing more people than al-Qaida. Most of these mistakes occur, says Wachter, during what he calls the "hand-offs" period when the patient is switched from one area of the hospital to another with few procedures in place to ensure that adequate instructions regarding care are given.

Twelve days after my surgery, my bag still popping off like an overheated radiator cap, the insurance company said time was up for the kind of surgery I'd had and it was necessary for me to go home. Just like Home Depot does with plumbing problems, hospital personnel were going to instruct me on how to take care of this problem at home. "How can I do that," I asked becoming panicky, "when you guys in here can't get it to stay on?" The insurance company relented a bit and decided I could go to a nearby nursing home for maintenance care.

It was a nicely decorated nursing home, bright and chipper, with no private rooms but a physical therapy room and good food. I was finally beginning to eat again. When I shuffled into rehab the first morning, the nurse said I looked so healthy I should be working there. Recovery was moving along nicely until the second or third day when my blood pressure fell dramatically to a level it had never been before, something like ninety or eighty over sixty.

I asked the nurse why I was still being given blood pressure medication when my blood pressure was so low. She told me to take it anyway but I refused. I told her to ask the doctor why I was still receiving it. The next day the nurse came back and said she had asked the doctor about my medication and he had said I needed to continue taking it. I did and a few hours later I was fighting for my life. Lucky for me Carol Matthews, an ostomy specialist from the hospital, paid an above-and-beyond-the-call-of-duty visit and saved my life.

"You look weak," she said. "Something is wrong." She ordered a potassium test that indicated I was in kidney failure that could soon lead to heart failure. Blood pressure medicine had built up in my kidneys due to dehydration and, as a result, my kidneys were shutting down. The nursing home, unlike the hospital I had been sent out of, doesn't do daily checks for urine output that would have immediately indicated dehydration and caught it before it became a life-threatening condition.

The nursing home called my husband to come immediately. I was put in an ambulance and sent back to the hospital. The ER staff attached a blood pressure cuff to me and called the code blue team, which surrounded me all night watching for cardiac arrest from heart failure due to low blood pressure. All night long I listened to the sound of the blood pressure cuff attached to my arm as it automatically inflated. My pressure kept going down. "I can't believe you never lost consciousness during all of that" the nurse told me the next day. Eventually, sometime in the early morning hours, my pressure began creeping slowly up. The code blue team left. I had almost been killed by my insurance company.