Coming in 2007:

The Deadly World of Medicine

by Joseph T. McFadden, M.D., F.A.C.S.

Introduction

Most people reacted with astonishment and doubt when the numbers were first made public more then five years ago. The reports claimed 100,000 to 300,000 preventable deaths every year in the medical system of the United States. As would be expected, the same reaction came from the public at large and from patients and doctors alike to this startling news. Impossible! Unbelievable! Surely these figures can't be right! And who says so, anyway? So you look to see who's talking and find the facts even more sobering. The tabulations were coming from reliable and important sources such as the Institute of Medicine of the National Academy of Science, and the New England Journal of Medicine among others, and continue to do so.

But wait. As a practical matter an accurate count would be impossible across the vast territory of the medical world. This you know and so does everyone. But now you realize something else, too. There very likely has been overlap in the various tallies, but whatever the real figures might ultimately prove to be, something really is amiss, the numbers entirely too big, and these initial reports are a warning of worse to come and a cry for action. Until these reports, the public had been unaware or at best only vaguely aware of this sleeping dragon. Unless one of these tragedies has happened to a friend or a member of your family, you might be quite skeptical. You have to be shown the real cases.

Here is an example. Mrs. John Simmons arrived at the hospital about nine a.m. in a happy mood. Her husband would go home today if his improvement continued as expected. She took the elevator to the fifth floor and greeted the huddle of nurses as she passed their glass enclosure, tiptoed down the hall to her husband's room, and slipped into the open door. A scream broke the silence of the ward and Mrs. Simmons ran down the corridor shouting, "Oh my God! No! No!"

The nurses rushed to the room and found Mr. Simmons corpse white without a pulse or signs of breathing, and lying terribly still in his bed sheets soaked in blood. Frantic resuscitation attempts were futile, and no one in the room could deny the awful truth. Mr. Simmons had bled to death. He had been alone for at least two hours without anyone looking in on him.

What happened? Mr. Simmons was not expected to die, but he was sick enough to require massive doses of antibiotics. Frequent injections damaged the usable veins in his arms and he had been given a subclavian line. "Subclavian" means under the clavicle, or collarbone. The line is a tube (catheter) sewn into a vein, its farthest end threaded down into the central venous system of the body almost to the heart. The insertion of a central venous line is for long-term treatment. Fluids containing drugs and nutrients are fed through it toward the heart. This saves having to puncture the patient for each dose of medicine or bottle of sustaining fluid.

Mr. Simmons had responded to the antibiotic treatment fed through his subclavian line, and the doctor had written an order the previous evening for the tube to be removed in the morning. Nurse N. came into his room before seven a.m., tired from a night on duty, and harassed by having too much to do and too many patients to watch. She shut off the pump, disconnected the warning beeper, and grasped the lower end of the fluid line to remove it from the hub of the apparatus. A voice from the intercom demanded her immediate presence back at the nurses' station. The night supervisor, the authority to ordinary nurses, was in a hurry to go off duty. The supervisor terrified Nurse N., who was a peaceful and somewhat whiffling innocent. She dropped the fluid line and ran to the desk.

Half an hour later, Nurse N. went off duty crying, the victim of humiliating verbal abuse. The night supervisor had discovered an infraction in record keeping and blamed the problem on the young nurse. Meanwhile, Mr. Simmons wiggled restlessly and the loosened tube end slipped out of its socket. He bled quietly from the open end of the line and lost consciousness. Mr. Simmons never called for help. He died at the worst time of the day, when the nurses change shifts. In this daily seven a.m. ceremony, nurses who have been on duty all night turn over the patients to the crew arriving in the middle of heavy hallway traffic. The scene is edgy in an air of confusion. He died because no one was watching him.

This unfortunate mishap is not recounted here to diminish the reputation of the modern medical system. We have the best the world has ever known, praiseworthy for its miraculous accomplishments. Attention to the flaws can only improve its services to humanity. But despite concerted efforts, no authority or organization has been able to eliminate the fatal faults in the system. If the doctors, hospital industry, insurance industry, and the drug empires can't control the damage, then only patients and their families are left to confront the problem.

This calls for greater understanding of modern medicine, with its wonders and dangers, from earlier times to the present day. No one born since the end of World War II knows the grim limitations hampering medicine until well into the twentieth century. The introduction of sulfa drugs in the 1930s and penicillin in the early 1940s brought the first real defense against one of the greatest threats to life, infection caused by bacteria and other organisms. Since this beginning, the continuing advances in technology and drug research have saved countless lives and cured countless people.

The doctor at best only prolongs life and delays death. He diminishes physical damage and alleviates suffering and anguish. His effectiveness continues to grow as medicine adapts discoveries from the scientific community to the struggle against disease. But slow as the progress of Medicine has been over the centuries, the related social and economic issues have become by comparison a deadly failure. The intrusion of government into the social and financial problems of medicine, the big business tactics such as the HMOs, the dictatorial control of medical decisions by the insurance companies, all in the wake of revolutionary medical discoveries, have swept the doctor and his patients into a gigantic out-of-control industry where system failures are taking a terrible toll.

The wonders of medicine are brilliant life-saving accomplishments and the dangers are indeed deadly. We are familiar with the miraculous rescue of patients from disease and death, and we look to the doctor as someone much greater than ordinary, who can rescue us and can be trusted with our lives. But in reality the doctor is just one person in a gigantic system and he cannot protect any one patient from its dangers. Many patients look upon a well-chosen physician as a protector, and they consider the hospital a haven where nothing can go wrong. On the contrary, regardless of who your doctor is and how well trained he may be, the doctor alone cannot control the daily events where mistakes occur due to faults in the system. So, what happens when something goes wrong in our modern society? The usual reaction is to find a culprit, place the blame, and seek retribution. This attitude contributes to the enormous number of malpractice suits against doctors working in a system over which they have no real control. It encourages cover-ups, delays the rescue of patients in trouble, and interferes with changes necessary to prevent future accidents. It inhibits honesty and openness. People cannot be expected to admit mistakes if punishment is to be the reward. The military, the major industries, and other organizations are now recognizing the fallacy of blame-placing. When the hospital system makes these changes, prevention of mishaps will improve and the damage will decrease. This would require reasonable and just compensation to patients damaged in the system and in no way relieve the doctor of his responsibilities to safety.

What can you do for yourself or for a family member as a patient in this intimidating system? The answer is neither easy nor simple. You have to cross barriers, some ages old, and some almost forbidden by custom and tradition. You have to become an advocate and get involved, and expect to meet resistance. You have to look for the weak places in the system. For instance, the handling of medication routines carries one of the major risks to patients. The responsibility for drug delivery as well as general administering to patients in a hospital is passed down from the doctor to people with less training. In this system, every time a task changes hands, the potential for error increases. The doctor orders the medicine and the nurse gives it by whatever route. The nurses' aides and maids do menial tasks, like bedpans and food trays, to free the nurses for more sensitive duties. Orderlies carry the patients by wheelchair and gurney to various places in the hospital. Each endeavor leaves room for error. Who is in charge of an unthinking person doing menial tasks, and who is in charge of an unthinking person doing dangerous and important tasks? No one is in charge because no one in charge could possibly see everything done by the personnel. In the system as it functions, each person is in charge of his or her own activity, with commitment to an assigned duty, but no one is in charge of the patient. The person who can see the most and do the most to safeguard any one patient is the person with an active mind at the bedside. Only the advocate or the patient can catch the mistakes where they are most likely to happen.

If the system is to be brought under control, the major offenders such as errors, accidents, drugs, infections, and human foibles, among other faults must be corrected. In the modern system as it continues to develop, patients can no longer complacently regard the medical scene with the attitude, "It can't happen here." It does happen here, and patients and their families must learn to recognize the dangers and how to avoid them. In this spirit, Navigating the Deadly World of Medicine depicts a major human endeavor blessed with astounding success and still fraught with great risks. The cases and remedies are based on the author's years of experience in the medical profession.