Connected

I just returned from a trip to the beautiful Massachusetts where I was asked to present at the Healthcare for All conference. I was invited by Linda Kenney of MITSS, Medically Induced Trauma Support Services who lives in Massachusetts and founded MITSS after her own tragic event there.

I was deeply flattered that she invited me. After all, this was her community, but her expertise is the support following an unplanned outcome in care. I joined her at a meeting of the MITSS Task Force where a group of women discussed how they would work together to get the MITSS Mission out and help more people.

I loved the way each of these participants took ownership of MITSS. From the quietest person in the room, to the young animated chair of the committee, each participant seemed to feel responsible to the future of this organization. The energy in the room was wonderful and really very positive.

Something felt right there. We got to spend some quality time with two staff of theNational Patient Safety Foundation who were also on their way to the conference. Our late night dinner allowed us some time to chat and even laugh – something I realized I don’t do very often any more.

It reminded me how we are really all connected. And, if we aren’t, we should be. It is often our own sad experience, fear of having a bad experience or just the knowledge of knowing how dangerous, the present state of healthcare is today in this country that has made this movement grow at all. If we stay connected and pool together our work, knowledge and resources, surely we can grow strength across America to improve healthcare. But, like many of us, we need to have a voice in our own backyard first.

Case Gone to Trial

I ran into a woman this week at the supermarket that couldn’t wait to tell me about being on jury duty for a medical malpractice case. She is not in the “patient safety network” so didn’t know anything about medical errors or patient safety. It was fascinating to listen to her for 15 minutes describe her first, second and third reactions to the world of medical malpractice from her first time perspective.

The case was of a woman who had a mastectomy. She saw her original doctor a few times early in the year who watched the calcifications in her breast not change for repeated mammographies. She had many more tests for safety than would have been expected. Finally, the doctor said don’t worry, come back in a year. The following year, the patient changed doctors and it was found she had cancer and had a mastectomy.

Of course there is 2 weeks of information I am not filling in. They settled out of court for a fairly large sum of money.

The woman in the supermarket told me the entire jury was siding with the doctor. She was surprised they settled because they all really believed the doctor did all she could with the information she was given. It was a difficult case. The woman in the supermarket was in turmoil, clearly distressed but also amazed at what she learned in just these few weeks. She was glad she said “that the woman got something”.

I asked why since the money wouldn’t change anything. She didn’t know, it just seemed like it was the right thing to do for all her suffering.

Then I asked the question that could not be answered. “How do you know if the woman actually needed a mastectomy or if the doctor didn’t just do it because it was easier than treating the patient”? I went on to ask this woman in the dairy department “Did anyone interview the surgeon and ask what was the basis for the drastic surgery?”

There is no I in Tameka

I received a letter from the NY State Department of Health signed by Patricia Jones, RN,MN Deputy Regional Director about the complaints about the care of Tameka at a NY hospital while she suffered eleven months of infections following surgery. The letter is dated March 14, 2008 and reports that there were no violations of state regulations at any of the facilities that treated Tameka so no action is being taken. Tameka died March 13.

I can’t imagine that they looked very close or carefully since in my letter THEY DIDN’T EVEN SPELL HER NAME RIGHT!

Tameka

I went to the wake of Tameka today to see her husband Joseph and Tameka's very loving family. They displayed her wedding gown and wedding photos. Their young son ran around the funeral home oblivious to the pain that others held in their heart.

Tameka struggled for 11 months following a botched surgery and numerous other surgeries to repair the error. Tameka suffered from many, many infections. I have to wonder how things will ever change. How could this young, vibrant woman who had so much to live for die from something so preventable.

For eleven months this hospital became her home. Joseph spent as much time with her as humanly possible. I was privileged to be called in to help and get to know this family through Joseph's stories and memories of his wife.

In my conversation with the head of risk management a few months ago I was told that the husband isn't giving me the whole story. I never asked for stories or information. I wanted to make sure the husband had the information he wanted and his questions answered. Obviously, he had a right to be concerned. Now that Tameka is dead, I would like to tell them at the Long Island College Hospital "I told you so". But I wouldn't do that. It'S easy to find fault and demand answers following the treatment and yet another preventable death.

The Department of Health went in and found no violations. I went in and witnessed Tameka being treated by someone with no gloves and he never washed his hands. The nursing director pointed to her own photo on the wall when I asked her if she was in charge. When I asked each nurse their name, they scrambled for their name badges. One had to find it in another room. Not that any of this matters now.

I suggested that Joseph ask the doctor if we can find help for him to make better decisions. He told Joseph no, he was seeking advice from doctors within the same hospital. I reached out to the medical community for help. There was nothing they could do. Joseph was afraid to move his wife. She was too sick but that may have saved her. If she died because of the move, none of us could have lived with the guilt.

There is no easy answer. Joseph is warm, kind and a gentle soul with a lifetime of love left inside of him that he was supposed to share with his wife. Tameka, for many in that hospital she may be another statistic. But I will not soon forget her and what could have been if we were able to save her.

Joseph will go back to work in his hospital where he is employed to the loving community that surrounds and supports him. But love and caring just doesn't save lives. We have to start demanding better treatment or this will continue. We can not allow this to continue!

Mercy Medical Center Holds Press Conference

If you live on Long Island, unless you live under a rock, you have heard the charges by Dr. Anthony Colantonio, a Garden City surgeon, against Mercy Medical Center in Rockville Centre. LI Newsday covered this story as did the local News 12 channel for days until Mercy Medical Center held a 30 minute press conference to respond to the charges.

The response was by a group of doctors in crisp clean lab coats and staff in suits telling the listeners and viewers how wonderful Mercy Medical Center is. I am sure there are thousands of people, patients and families who also think Mercy Medical Center is a wonderful facility. I have heard great stories come out of there. What I didn't hear them say, is that when patients or health care providers are dissatisfied with their care, there is a way it is handled, there is a place for them to take their concerns and how they are handled.

The press conference participants had some strong words about the doctor who reported complaints. Dr. Anthony Colantonio does not have the cleanest record as reported at this press conference. We have to wonder why, Dr. Colantonio was continually working at the facility and only recently given a "leave of absence" pending an investigation and hearing. Unfortunately, it seems that Mercy as well as other hospitals have doctors who they feel may be unfit to work at their facility still seeing patients.

Unfortunetely, the public only knows what we are told by the media and with continued lack of any transparency the health care system and the doctors reputation are handled secretly while we, the public are left to get treatment at our most vulnerable time not knowing what kind of squabbling is going on possibly jeopardizing all of us.

It is only a matter of time until another story breaks at another hospital and we have to wonder if this one is preparing to work with the public before it happens or are they cleaning their lab coats for the next press conference?

Russian Roulette

Another Patient dies from surgery but even worse, the patient never needed the surgery? https://www.news12.com/NewCDA/articles/media_pop?region=LI&id=207015

I would like to think that this is a terrible accident but I don't think so. I think that hospitals can play Russian Roulette with our lives. Hopefully you, or I won't become the one who falls into the hands of the untrained, unqualified, overworked staff or understaffed "system" that is cutting corners to save money jeopardizing our lives.

The hospital is sorry? Of course they are sorry. They are sorry they got caught and a patient and their entire family have to now pay the lifetime of emotional pain that will go with this incident. They can be sorry but the patient is dead and it never should have happened!

Go Red

February 1, 2008 was Wear Red Day to heighten awareness in heart disease in women. The Go Red for Women movement is aimed to encourage women to change their lifestyle in order to avoid heart disease in order to live better and longer. By wearing red, they are bringing attention to and encouraging women to pay attention to their heart.

Watching the news that evening, I learned heart disease is the number one killer in women. But, stories I heard that made it to the local news were about the misdiagnosis of heart disease. Every woman said her heart disease was misdiagnosed. It sounds like the misdiagnosis should also be being addressed. Maybe then it wouldn’t be the number one killer!

It's the Patient Safety Hour

On January 29, 2008, late in the day, I received an e-mail that the NY State Health Commissioner and my state senator were holding a “round table” discussion the next morning about the infections on Long Island. Specifically, the event was related to the recent press about multidose vials after the recent spread of hepatitis C.

I was a bit surprised to see how this roundtable was actually meant to be a media event http://www.newsday.com/news/local/suffolk/ny-lifink315558189jan31,0,4710641.story

There were no handouts for the general public, only the reporters who attended. And the information was the same as it usually is, these are the problems and this is what we should do. So do it!

Why do our elected and appointed leaders feel that it is the media’s job to report what is being done in the field of patient safety? There are still no groups who are supported to do patient safety education yet in the community. Could you imagine if the only education about breast cancer came from media? We would have never moved forward to battle the disease. Imagine if doctor’s offices or clinics didn’t discuss diabetes with their patients? How would diabetes ever be tackled?

Unfortunately patient safety is still, in my humble opinion an opportunity for healthcare institutions to ask for money and hire people to exam issues within their systems. Until patient safety becomes more transparent, it will stay a secret and not move forward to real change.

What's a Patient To Do?

I wonder what our "rights" are as patients when I read again about another Long Island doctor who reused syringes and had to notify patients about his poor infection control practices. http://www.newsday.com/news/printedition/longisland/ny-lishot165539598jan16,0,1907627.story

In this case, the report is informing the public about the doctor's unprofessional practices when it comes to infection control.

So, what's a patient to do? Tell your doctor(s) to wash their hands? Well obviously it wouldn't have worked in this case. His hands may have been clean but guess what, there are plenty of other ways patients are at risk when it comes to the spread of infections.

Until patient education is taken seriously - before using the healthcare system, we, the public have no clue what we can be doing to get inolved in safe, quality care. I have been teaching patient safety for ten years and the syringe subject would have never come up. Still, I see no reports on what we should be doing to protect ourselves from reused syringes.

Reporting to the public is the medias job but we also must educate!

Hospital Visits

Sometimes, I like to visit people in hospitals or take them to their doctor’s appointments. It helps me stay well connected to the system I find often flawed beyond repair. By staying connected to the real world of patient safety and healthcare systems, I can truly report back, to the people who have the power to make changes, what is really happening. Unfortunately, it can be at the risk of losing someone’s life.

I recently met a patient who was in the intensive care unit of a New York hospital. I won't say where even though I probably should. This woman has been hospitalized for 9 months with infections. I witnessed 2 nurses treating her while she lay unable to move on a respirator and swollen beyond belief from fluids. Each nurse grabbed gloves from a box but never washed their own hands first. No antibacterial lotion, no washing. The radiologist came to take x-rays and he shifted the patient, moved her arms and prepared her for x-rays and he never washed, used lotion or put on gloves!

The husband, who I was there to support, did not want me to say too much. He is afraid they will let her die. This sort of thinking is what has gotten today’s healthcare system in trouble to begin with but I have to respect him and what he wants from me as a support to him.

Yes, I wanted to tell them to wash their hands first but I think I was too shocked that it didn't occur to me that what I was seeing was accurate. The simple words "Can you please wash first" that we want so desperately to say just don't come out as easily as we think. If it were my family member, you bet I would say it but it just seemed so irrelevant at the time when there were so many other "issues" I was witnessing at this facility.