Who killed my mother?

I read an interesting blog post this week by Mark Schaefer,  one of my favorite social media gurus. In it, he talks about a negative experience he and his wife had recently in a hospital. The question was, what should he have done, if anything, to correct the problem, and whether he should have used his popularity and influence within social media circles (Facebook, LinkedIn, Twitter and his blog) to "destroy" the hospital, when he received what sounded like a not-very authentic apology from the patient representative.

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I left a comment that basically said that the most important thing is that the hospital treat each such occurence as a learning opportunity and work on systems to keep such errors from happening. After all, anyone can have a "bad day" and if we want to provide the best care for all of our patients we have to ensure that one person's bad day doesn't translate into bad care for any patient. That is where check lists come in, and making sure that there are checks and balances in place to prevent a patient from being placed into a room filled with trash (and in this case blood) from a prior occupant.

So I thought I would relate to you an incident that occurred in my own experience as the family member of a patient in one of the "top ten" hospitals in the country (as ranked by US New and World Report). I would like to know what you would have done in my place. Not that I can change what I did, any more than the particular hospital could change what happened. But it still doesn't sit right with me, and I keep thinking I should have gone further with my complaints, because there was obviously something wrong with their system of care.

My mom was admitted to a local hospital with complaints that were not easy for the doctors there to put together into a comprehensive diagnosis. She was 85 years old, a life-long smoker, but in excellent health, and still able to work three days a week in a job that required a lot of walking and other physical activity. The local hospital discovered fluid around her heart (pericardial effusion) and transferred her to a higher level center where they drained the fluid and sent her home. She continued to feel poorly, and had to move in with my brother and his family. They brought her to a third hospital when it was clear she wasn't getting better. They admitted her, but felt she was "so old" there was nothing they could do. At that point we had her transferred to A-PLUS hospital for definitive care and optimal treatment.

She was pretty weak, and had trouble sitting up for more than about 10-15 minutes at a time. On the second or third day of her admission, she was scheduled for some tests, and I therefore didn't go to visit until I anticipated the last of the tests would be over. I arrived in her room, to find her bed there but empty. When I found the nurse, she told me that my mother had been "taken down to the department to have her test. " At that point the nurse realized she had been gone for several hours. She went with patient transportation in a wheelchair.

I was flabbergasted. I discussed with the nurse the fact that she couldn't tolerate sitting up in a wheelchair that long, and asked for directions to the department so I could go there and help if necessary. The nurse called the test site, and discovered that she had been picked up by the patient transporter 30 minutes before. So where was she?

As I began pacing in the room, the door opened and my mom was wheeled in. I went over to the chair, where she was slumped over. I started to ask the transporter what had taken them so long, but he just had a dumb look on his face and didn't answer. I thought she was sleeping. I shook her shoulder, but no response. Then it hit me: my mother was dead. I screamed for the nurse, and I ran to the nurse's station to tell the unit secretary to call the code team. She looked at me, thinking it was odd that a patient's family member would order such a thing. I finally got the attention of the nurse, she corroborated the lack of breathing and pulse, initiated CPR, and activated the code team alert. I was asked to leave the room (not very patient and family friendly) as what seemed like dozens of people arrived trying to resuscitate my mom. It didn't work.

I have to admit I was a bit hysterical at this moment. I called my husband. I called her physician. I was not coherent. As I calmed down a bit I started to think about what had happened. Who was the patient transporter? Where had he gone between picking my mom up and delivering her back to her room? Had anyone noticed she had trouble sitting up? Did she slump in the wheelchair after she died, or was she so weak she slumped in that position and couldn't breathe because she couldn't raise her head?

The nurse in the testing site corroborated that she was alert and talking with normal "vital signs" at the end of the test. She was even telling jokes to the staff. No one could find or identify the person who had done the transport. No one could tell me why it had taken 30 minutes to take a 5 minute trip.

I asked for answers. All I got were a bunch of "we don't know"s. Her doctor arranged for an autopsy which was unrevealing. There was no cause of death; no cause of her weakness and pain. Her physician told me " she was old." As if that was something I didn' t know.

In the weeks that followed I thought about what I could do. I thought about a letter to the editor of the city's newspaper. I thought about hiring a lawyer and suing. I had nightmares about standing by, doing nothing as other people died in my presence. In the end, I did none of those things. I received a nice letter from A-PLUS hospital expressing sorrow at my loss, and telling me that because my mom was in such a wonderful hospital nothing more could have been done to save my mom. REALLY?

The events I related above happened over ten years ago. They are still clear in my mind and my heart. I have lost the anger and no longer have nightmares. But I still feel some responsibility to others. Was there something intrinsic in the system that allowed a patient to die unwitnessed, or unrecognized? Was there some reason they would transport a weak, "old" woman by wheelchair and not in a stretcher for a two-hour test? Why could we not identify the person who transported her, and find out what the delay was all about? Was this even someone who truly worked for the hospital?

Could this happen to someone else? You betcha!

So, tell me. What would you have done? Should I do something NOW?  It's too late to bring a suit. It's too late for any additional investigation.

But is it too late to save another person's life?


About Dr. Ackerman

Alice Ackerman, MD, MBA, FAAP, FCCM is the Chair of the Department of Pediatrics at Carilion Clinic and Professor and Founding Chair of Pediatrics at the Virginia Tech Carilion School of Medicine. Dr. Ackerman is recognized nationally as an expert in pediatric critical care.

She has been at Carilion Clinic since June of 2007. Her primary goals are to enhance the health care of children in the Roanoke Valley and Southwest Virginia, and is actively working to do this both as physician in chief of the children's hospital, as well as through involvement with many state-wide initiatives.

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