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Why Hospitals Make Great Killing Fields

Someone asked me about the connection between healthcare and serial killers. Well, if bank robbers rob banks because that’s where the money is, healthcare serial killers kill patients because that’s where the victims are. There are no locks on hospital doors. Anyone can enter at any time. Once inside the room, there’s an excellent chance a  patient won’t ask too many questions. particularly if the person who enters is confident and dressed in scrubs or a white coat. (Watch TV, people. Scenario after scenario shows the bad guy/gal throws on a lab jacket and does whatever they want).

A patient who is sedated by medications can’t question what is done to them. A patient constrained by intravenous lines, bed alarms, chest tubes, etc, can’t get away even if they suspect something is wrong. Hospitalized patients and their families quickly become used to a constant stream of people cycling through the room, playing with equipment, taking blood, giving medications. Be as suspicious at a hospital as you are at a hotel when an unknown person comes to your door. Ask questions, verify the answers.

Perhaps the one thing that most elevates inpatients to victim status is the innate desire to be a good patient. Good patients are docile, take direction, and don’t ask too many questions. For many people, there is the fear that questioning the doctors or nurses will result in substandard care. I can’t cite statistics, but I’ll say in many cases I’ve personally witnessed of people getting the wrong interventions,  (medication, procedure, vaccination) when the patient questioned whether it was appropriate, they were told the doctor ordered it. At those magic words, the questions and hesitation stop. Be a bad patient. Trust your healthcare providers, but verify what they tell you. Ronald Reagan had Alzheimer’s, yet he still knew the value of verification.

Still, most people would rather be subjected to an invasive procedure than upset the doctor. The healthcare system has helped to create a population of victims, and they know it. Make sure you aren’t one.

 An article in the Journal of Forsensic Science (2006 Nov;51(6):1362-71) provides some relevant facts on the particulars of healthcare serial killers.

Their method:  “Injection was the main method used by healthcare killers followed by suffocation, poisoning, and tampering with equipment.”

You’re in the hospital, someone approaches you with a needle. If you’re hooked up to an intravenous line or have a capped intravenous access, it’s not shocking to have someone come to your bedside and inject medication into the line or the intravenous bag. If a patient asks what’s going on or what’s going in, standard  healthcare response is it’s something the doctor ordered. Key point –  No one wants to argue with the doctor. Same if someone walks into your room with a syringe and tells you they’re there to administer a medication. Most patients won’t argue if the request to insert a needle is prefaced by saying it’s something the doctor ordered. I’ve been in healthcare long enough to know this is a dangerous practice even for a nurse who isn’t a serial killer. Patients should be identified, educated about the medication, and verify it’s something that’s been discussed with them by the ordering provider. I’ve heard and seen too many patients who have accepted medications meant for others because those magic words, “the doctor ordered it”, seems to override the common sense that would kick in under most situations. Doctors write down their orders.  Why shouldn’t the nurse let you see it?

Healthcare serial killers breakdown by role: “Nursing personnel comprised 86% of the healthcare providers prosecuted; physicians 12%, and 2% were allied health professionals.”

Of course nursing personnel are the majority of healthcare serial killers. They’re the ones spending the majority of time with the patients. They’re the ones who go in and out of rooms without anyone asking questions. They’re the ones who have access to the drugs and equipment to kill people. Why is the percentage of doctor healthcare serial killers so small compared to nurses? Doctors have less alone time with hospitalized patients and spend less hours with them. If your doctor showed up at your hospital bed at 3 a.m. with a syringe, you’d ask questions, wouldn’t you? Most of the time,  if a doctor shows up on a hospital floor, the nurses are right beside him trying to get orders clarified and their concerns addressed. Doctors aren’t rock stars, but they get plenty of attention. That doesn’t make them right.

“The number of patient deaths that resulted in a murder conviction is 317 and the number of suspicious patient deaths attributed to the 54 convicted caregivers is 2113.”

Wow, 2113 suspicious deaths, but only 317 murder convictions. Why? Because people die in the hospital. They die for lots of reasons. It takes a lot for an institution to become suspicious that someone’s having too many deaths, and if the heat is on, the healthcare provider can easily go to another facility and start over. That’s the sad truth. Want a quick and easy way of finding out the caliber of your healthcare provider? Check out how many different facilities they’ve worked in. The more facilities a provider has worked at should mean the more the little hairs on the back of your neck should stand up. Trust me, hospitals don’t deal with problems, they move them along.

How do you protect yourself? Ask questions. Pay attention. Question what’s going on. Most patients are probably more suspicious of their local auto mechanic than they are of their healthcare provider. Guess what? Your auto mechanic might sell you something you don’t need, but your healthcare provider can kill you.

Still not convinced? Check out truTV’s series on healthcare serial killers, conveniently broken down into the doctors, the male nurses and the female nurses. The Angels of Death are out there. Protect yourself.
http://www.trutv.com/library/crime/notorious_murders/angels/index.html

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Zombies Wanted, But Are They Dead or Alive?

One of my favorite lines in the Wizard of Oz goes like this:  “As Coroner I must aver, I thoroughly examined her, and she’s not only merely dead, she’s really most sincerely dead.”  It has a measure of decisiveness and finality. If someone is dead, we’d like assurances that they’re really and truly dead.
In order to determine the relative deadness of a person, there are two different criteria that may be used.  There’s the always popular clinically dead, the medical term for when the heart stops pumping and the lungs stop breathing. Then there’s brain dead, based on neurological criteria, that allows for a beating heart and working lungs (many times artificially maintained by a ventilator or respirator), but a nonfunctioning brain. Brain death determination looks at cessation of cerebral and brainstem functions and demonstration that the changes are irreversible.
Some definitions of death include all three markers, meaning death is defined as the cessation of all vital functions of the body including the heartbeat, brain activity (including the brain stem) and breathing.
And that makes me think of zombies.
Unfortunately, most definitions of zombies include some reference to the supernatural or witchcraft. The Centers for Disease Control Preparedness 101 Zombie Apocalypse home page states: “Although its meaning has changed slightly over the years, it refers to a human corpse mysteriously reanimated to serve the undead.” New theories support the notion that zombies are merely humans infected with a parasite that spreads through saliva. No matter what definition is chosen, a zombie is a human form that has lost the ability to reason and is no longer reliant on a heartbeat or breathing to survive. He or she retains the ability to move, but their movements are slow and awkward (unless one believes in zoombies).  Zombies have brain function, and that is the trait that causes most of us to fear the Zombocalypse.  Luckily their brain function is very limited. Enough for them to stagger around. Enough for them to capture people. Enough to remember that brains are their choice of food. Mobility, lack of brain function, and a hunger for brains is a terrifying combination.
But traditionally zombies are not considered alive or undead.  They are categorized as dead, and though they fit the criteria because of their lack of breathing and circulation, what about their brain function?
Dr. Steven C. Schlozman, an assistant profession of psychiatry at Harvard Medical School, postulates that zombies suffer from Ataxic Neurodegenerative Satiety Deficiency Syndrome or ANSD. He contends that zombie brains have some function, as well as dysfunction, in their cerebellar and basal ganglia. He likens the amount of brain function in zombies to that of a crocodile. Their unpleasant behaviors, including their insatiable appetites, derive from the lack of activity in the parts of the brain that modulate behavior.  But does this make them dead?
Since, at this point in time, medical technology has not created a need for zombie organ donation, devising new definitions of dead are not at the forefront of medical science. If, in the future, a method to safely use zombie organs is developed, I have no doubt that a new definition will arise and it will include the presence of limited brain function in the absence of respiration and circulation. The process will follow the same path to definition and acceptable use that occurred when human organ transplantation became viable. Prior to the need of organs, one definition of death, absence of heart beat and breathing, sufficed. After organ transplantation, a new definition of death, brain death, arose. When the need for zombie organs is great enough, medical science will become interested in ensuring that the answer to the question, are zombies dead or alive,  will become “really most sincerely dead.”
Interested in reading more about zombies? Check out:
http://www.cdc.gov/phpr/zombies.htm
http://io9.com/5286145/a-harvard-psychiatrist-explains-zombie-neurobiology
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Defining Death

The first dead person I saw was my grandfather.  At first, I didn’t know he was dead. Lying on the hospital bed that filled the living room of his single wide, he looked the same. Cancer had turned him into an insubstantial man, gaunt and translucent. His eyes had sunk into his face and closed themselves off from the world. His mouth was open, like a baby bird begging for food, and his breathing ragged. Suddenly my sister gestured me to her side and said I think grandpa’s dead.  
I waited to hear him breathe, for his chest to rise, but nothing happened. I finally did the only thing I could think of, I went to the bathroom and found a small mirror. I carried it to his bedside, half hidden behind me, then held the mirror up to his mouth. No moisture appeared to indicate he was breathing.
We called the doctor. He came over to the house, briefly placed his stethoscope on my grandfather’s chest, and made the news official. He was dead. I remember the puzzled look on the doctor’s face when I asked, are you sure? You hardly listened. But he was sure. And I wondered what knowledge he had that I didn’t. How did my grandfather, who looked the same as he did when I first entered his house, go from live to dead with no fanfare and no striking change that signaled, dead guy here. Humans have no equivalent of a chicken’s pop up timer to show when their time is up.
The second dead person I saw was as a new nurse. At report I was told he didn’t have long to live. The wife was in the room with him and my job was to check in every once in a while, make sure they were comfortable, and give them privacy. Around two a.m. I went in and saw the man’s chest wasn’t rising. Walking quietly across the polished floor, I placed a stethoscope over his heart. I listened, and listened, and listened, but I couldn’t hear the reassuring thump of a heartbeat. Creeping silently back out of the room, I prayed the wife wouldn’t wake up and question me. I thought her spouse was dead, but I wasn’t 100% sure. Certainly not enough to break the news to anyone, let alone the wife. I found my preceptor and the two of us snuck back into the room. She placed her stethoscope on his chest and shook her head at me. He was dead. Back out into the hall we went and she coached me on how to wake the wife and break the news.
I remember shaking the wife softly, then harder, almost panicking wondering if she was dead, too, until she opened her eyes and peered at me in the dimly lit room. He’s dead, I told her.
I was ready for tears, for sounds of anguish, for cries to God. Instead she sat up, pulled her husband’s arm away from his body, and stuck her hand into his armpit. He’s still warm, she said, he hasn’t been dead very long. I didn’t know what to do with her reaction. Did it make a difference? Was it better to know right away rather than spending the night lying against a cold, dead corpse? Perhaps instead of a pop up timer, it would be preferable to have an actual timer that announced and marked the exact moment of death.
My third death was a lovely woman with heart failure and a host of other medical problems I have long forgotten. On the second day of her hospitalization, she decided she didn’t want any more heroic measures. She was ready to die.
Too bad death wasn’t ready for her. 
On the fourth day, struggling to breathe through the fluid that backed up into her lungs and slowly suffocated her, she looked in my eyes and said I never knew it would be so hard to die.
I wish I could say that at her death the pain and fear in her eyes was replaced with an expression of bliss, but the tortured look on her face never went away. The only change was the silence when the moist sound of her panicked breathing finally ended and her heart stopped.
All three deaths had something in common. Death was defined as the absence of a heartbeat. I don’t know if they continued to have thoughts or sensations. I don’t know if their soul leapt out of their bodies and went to wherever souls go when someone dies. All I knew was they no longer had a heartbeat. Therefore, they were dead.
Since then I’ve pondered the subject of declaring someone dead. For me, the bottom line is that I’m still the girl at my grandfather’s bedside asking the doctor, are you sure? As medical science develops different definitions of death in an effort to use the latest technology and interventions, I ask that question and find myself dissatisfied with the answer.
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Name and date of birth please

A few months ago, I received a notice in the mail that a referral to a specialist had been generated in my name and my insurance company had authorized three visits. The letter was disturbing for two reasons:  the doctor that referred me wasn’t my primary care doctor (and never had been) and the diagnosis prompting the specialist visit wasn’t anything I had. My first, panicked thought was that someone was using my identity to get medical care.
When I called the clinic to follow up, I discovered it wasn’t a case of medical identity theft, rather poor patient identification. My account was pulled up in the electronic health record in error and the documentation and need for a referral belonged to someone else. I wondered how many people had been involved in this mistake, how much documentation was incorrectly entered in my medical chart, and why no one caught it prior to the letter being sent out. I mean, I had to be registered in the system in order for someone to bring me up in their schedule and I needed to have a note in my chart in order for the referral people and specialists to judge how quickly I needed to be seen. At one point in the process you’d think someone would have checked a name and date of birth, a simple task which could have resulted in the right patient getting the referral.
The current standard for identification of patients is to ask people to state their date of birth and full name at every stage of the process: when an appointment is booked, when the patient checks in, when the patient is put in a room, when the doctor sees the patient, and before any injections or treatment. A lot of work, right? But clearly, when the process isn’t followed, mistakes occur.  
In the world of electronic health records, multiple electronic charts can be open on a desktop at one time and it’s easy to err and document in the wrong one. Some of these errors are annoying, like my referral, some of them catastrophic, like the deaths of patients who received blood transfusions not meant for them.
How does this happen in a world where patient identification is mandated by accrediting agencies and where hospital inpatients wear identifying wristbands?  Wristbands can have incorrect information or fall off.  Hurried staff members may verify patient information by stating the patient’s name and date of birth and asking if it is correct. In looking at errors in patient identification, there are myriad ways in which people are misidentified in a busy work environment.  As a nurse, I’ve been in more than one situation where the patient in the room isn’t the patient I expected.
Even in patient simulation exercises (where healthcare workers are aware their actions are being filmed and scrutinized) patient identification errors persist. One study involved three simulated patients, two with patient identification data that matched the task paperwork and one that had a discrepancy in the date of birth and medical record between the patient identification data and the task paperwork. Thirty-nine percent of the healthcare workers performed the assigned task on the incorrectly identified, wrong patient (http://www.ncbi.nlm.nih.gov/pubmed/20031263.  It’s probably a safe bet that the percentage would be higher in the high pressure atmosphere of daily practice.
The solution?  There isn’t an easy one to this complex issue. Healthcare can’t force people to do their job correctly (at least they haven’t been able to so far). Electronic health records offer many benefits, but also more opportunity for error. Involving patients in their care is key, but anxiety, physical limitations such as dementia or hearing loss, and the persistent belief that “the doctor is always right” prevent many patients from asking questions about their medical treatment.
Instead of depending on an overburdened, mistake prone healthcare system to do the right thing, patients have to actively engage in keeping themselves safe. You’d argue with a mechanic who told you he planned to fix the brakes on your car when you came in for a new windshield wipers. Don’t be afraid to question the people who deliver your healthcare. It could save your life.
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It isn’t brain surgery

Daily life requires some attention to detail. When I drive my car, I’m expected to stay on the right side of the road. Doesn’t make a difference if I spent a month in Ireland driving on the wrong side or if the road isn’t clearly marked as to what side is the correct one. Once I get behind the wheel of a car I’m expected to follow this minimum expectation.  If not, well, best case scenario I’ll get a ticket, worst case a head on crash. Details do matter.
That’s why it’s puzzling that healthcare professionals have such a difficult time making sure they operate on the right side of someone. Cutting off the wrong leg, “fixing” the wrong hand, or operating on the wrong side of the brain is considered a “never” event by the Centers for Medicare and Medicaid Services (CMS) as in “this should never happen.”  Amazingly, a study published in the April 2006 issue of the journal Archives of Surgery estimates that wrong-side surgeries occur between 1,300 and 2,700 times a year in the United States (3-7 a day).
Horrified? You should be. The problem is not a new one.
A quick Google search shows in 1995 a Florida hospital had two cases of wrong side surgery. In one case the surgeon amputated the wrong leg, another surgeon operated on the wrong knee. In 1996 a surgeon removed the wrong kidney from a patient. In 2007 a California hospital performed three wrong side surgeries in the space of 14 months. In December 2010, a Boston hospital reported three wrong-site spinal surgeries in a two-month period.
Scary stuff.
You’d think a hospital would learn after the first never event and develop methods to ensure there isn’t a repeat. Wrong. In 2007 a Rhode Island Hospital reported three cases of wrong side brain surgery. If you expect the surgeons involved developed practices to prevent a repeat, you’d be wrong too. Rhode Island neurosurgeon J. Frederick Harrington had already performed a wrong-sided brain surgery in 2006 at another hospital. He repeated his mistake in 2007, even when someone in the operating room questioned whether he was on the right side.

Now, I’m not discounting the universally held, incorrect belief that “it won’t happen to me.” I am sure most surgeons and operating room personnel believe their superior skill, knowledge, and intelligence prevents them from making stupid mistakes. But after the first mistake, do they think lightning can’t strike twice?  No use changing the way things are done because it will never happen again? The statistics don’t support that notion.
Because this is an international problem, the World Health Organization (WHO) developed a surgical checklist, also known as a time out. A time for everyone in the operating room, including the patient, to agree on several key things, including the operative side. If properly followed, the checklist would catch errors before they happened and stop wrong site/side surgery for once and all. Unfortunately putting a policy in place, affixing some posters to the locker room, and filling out a checklist gives the illusion of patient safety, but the reality is, even in hospitals with the checklist and time out, wrong side surgery occurs.
Why? Studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout. Unfortunately, instead of expecting accountability from physicians, hospital strategies to prevent wrong side surgeries include assigning operating room monitors, installing video cameras, and telling the operating room nurse not to hand a knife to the surgeon until the time out is completed.  
Wouldn’t it be better if physicians complied because it is a minimum expectation that they operate on the right side of a patient? We can do it on the highway, it’s worth the extra effort in the operating room.

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Panhandling in Cyberspace

For a brief period during my teenage years, my family vacationed at Hampton Beach. After long, glorious days of lying on the beach, listening to the radio reminders to “turn before you burn,” and applying copious amounts of baby oil (yes, before anyone worried about skin cancer), my friends and I would spend our nights panhandling on the boardwalk.
The long promenade teemed with people on those hot summer nights. The smell of fried dough, saltwater taffy, and cigarette smoke filled the air. We’d move slowly through the crowd, searching for a place where we wouldn’t block the sidewalk traffic, where people naturally slowed down. Once settled, we’d smile at people as they passed, look them in the eye, and ask, “Do you have any spare change?”
 We didn’t need the money, not like the runaway teenagers or homeless men who lived on the fringes of our vacation experience. At the end of the night, we’d take our loot and give it away to the first person who asked us for spare change.  The thrill was in the boldness of asking strangers for cash, in looking people in the eye and asking the question.
Now there’s a new type of panhandler. One no longer has to fake cancer for handouts or stand on a street corner. Sites like gofundme.com and kickstarter.com provide a painless way to ask for cash. Got a book you want to self-publish? Why dip into your own savings account when you can put the touch on your cyber friends though Twitter. Want to spend a year in Europe? Saving money for your trip is a time-consuming drag when you can put out a plea to your Facebook friends to pay the cost.  The best part of cyberbegging is you don’t have to look anyone in the eye. Just hit send and wait for the bucks to flow in. Hey, we’re friends, aren’t we?
When I deal with real panhandlers, as opposed to virtual ones, I have choices. I can cross the street, avert my eyes, ignore them totally, or toss them a coin. Virtual beggars are harder to ignore. They send emails that evade my spam filter and clog up my social media feeds.  They use peer pressure in an attempt to pry cash out of my pocket and have an arsenal of guilt inducing tools at their disposal. Whether they list contributors on the site, giving everyone the opportunity to see who has, and hasn’t, ponied up, send personal emails, or use their Facebook or Twitter feed to individually thank those who have contributed and keep the begging project front and center (sort of like a panhandler that follows you down the street), it makes those who don’t contribute feel singled out.
But, what is the etiquette for those of us who don’t want to give? And what is the social cost for ignoring the beg? Do you owe someone an explanation for not contributing?
I say treat them like the panhandlers they are. Donate, tolerate it silently, or remove yourself from the situation. Remember we’ve opened our cyber doors to these people, we can shut the same door in their face.
Friends, if you want to beg, look me in the eyes and ask me once. I’ll appreciate your boldness.