Sunday, August 9, 2015

The Hospital Experience - What Happened to the Checklist Manifesto?

My friend was recently diagnosed with colon cancer. As usual there is a lot of confusion about which doctor, which surgeon, which hospital. A doctor friend helped out and finally he decided on one famous cancer hospital and an equally famous surgeon and oncologist. No probems till now.

Until my friend is advised by an authority in a competing hospital to undergo an open surgery and not the laparoscopic one. My friend is fine with this idea. But the surgeon convinces him that a laparoscopic surgery is best. My friend agrees. After all doctor knows best. All set. The surgery is scheduled for a fine Monday morning. Patient has been asked to go on fasting from noon the previous day.

Next morning the patient is told that the surgery has been postponed. At the very last minute - after he has worn the gown etc. There is a Board meeting and many Board members are coming including some celebrity directors. So? Do people postpone major surgeries at the last minute because of a board meeting which he is 'supposed' to attend? What happens to the 'immediate surgery' advise? I thought it was rather unprofessional on the part of the doctor to cancel the surgery at the last moment and walk off to attend a board meeting. Of course he came back later and performed the surgery at 2 in the afternoon and it went on till 6.

The doctor friend went to speak to the surgeon. He is satisfied with the surgery. But, the cancerous mass turns out to be much bigger than he thought. He hoped he had removed most of it. Now why does hoping come into the picture I don't understand. After all the tests, probes, scans, x rays - how much of a surprise can one expect? And if one were to expect surprised - aren't open surgeries a better option? Anyway, the big surgery over, everyone heaved a sigh of relief and moved on.

Next morning we hear that there were fluctuations in the BP. The doctors feel that this should not have happened. But they don't seem to have a clue why its happening. The patient says he kept telling the doctors and nurses on duty that he could feel some mass to the left of his stomach and it was hurting. They ignored him.

However as the BP kept falling to something like 80/40. The morning doctor pokes a needle into the affected part and draws - blood. There's a bleed. He asks for a blood test. Haemoglobin levels were at 8 (where they were previously at 13 the previous night). The doctors got into a huddle and the surgeon calls our doctor friend and says that they needed to open up again. There appears to be an 'ooze' he says. An ooze? Why would there be an ooze?

Haemoglobin falls by half, BP falls by half. Logical conclusion - some bleeder has been left open and it bled half the blood in the system out into the stomach area from where the doctor drew blood. That is the only logical explanation.

This time they hack into the affected area like butchers - all the delicacies of laparoscopes are left behind - leaving a foot long scar. They are in the theatre for another four hours again - after having casually remarked that this was an hour's job. In two days the patient goes through two major surgeries and comes out. I'd think it must have been a close shave for my friend.

Not much is forthcoming from the doctor team save the 'ooze' theory. I liked the word 'ooze'. If its 'oozing' the problem obviusly lies with you. If its 'bleeding' the problem lies with the doctors. Right?

There is no talk of what happened, what type of surgery, nothing. Until the bandages come off no one can see the extent of the scar. No one knew about it. No one talked about it.

The discharge report was not signed by the surgeon. The report did not mention the second operation except for a sentence about the ooze which was attended to. The surgeon came, smiled and said its all ok. God help you.

Fine. Mistakes happen. But when something like this happens in full view of a team, should there not be a record of what happened. At least to correct things later. What happened really? Who left the bleeder open? Why was it not detected? Why were these things not recorded? Why are these things not discussed? Why are they not revealed to the patient?

More importantly why all this hush hush behavior?

In all circumstances the doctors would have congratulated themselves on the close shave. But the junior doctors would also have learned some important lessons. That its ok to mess up as long as you can cover up and not speak about these things. Have someone write, someone else sign. They can, in a room full of professionals, stand by one another and let these mistakes happen again and again. Some patients get lucky, some don't.

Here we are talking of well-educated, urban professionals who have no recourse really save to go legal or file a complaint and risk antagonising the doctor. No one wants that. What one wants is that the system has enough checks and balances, enough integrity to catch such odd circumstances and address them as hey happen. But in the absence of such a system, or the practice of such systems, people either have to fight and be heard or merely put up. Most put up quietly. Some beat up doctors and trash hospitals.

The question certainly remains - how many surgeries are really warranted? One can imagine what happens with rural populations?

Atul Gawande's book 'The Checklist Manifesto' speaks of the horrors that happen when checklists are not followed. Have they been followed? What are the procedures? Who has to be reported to when such things happen? Who is accountable for the second surgery?

In hospitals, government offices, police stations where the common man has so much at stake, there is zero transparency and zero control. What they say holds and that's it. There is no accountability - at best a 'clerical error'. But even in case of a clerical error the guy at the top is responsible. He should be made accountable. What kind of a ship is he running?

Our problem as a country lies there. That we have people enjoying unlimited power with no sense of responsibility, accountability. And they enjoy god - like status that they do not deserve. Unless they are willing to be accountable, they do not deserve the position and the authority. 


Hmmm said...

If reading your post makes me restless and helpless wonder how it must have been for the patient and his family. Do say if the patient and the family are going to do something about it? Of course it is completely understandable even if they don't, but the hospital's and the doctor's negligence seems to be simply unacceptable, even though from what I heard from a friend, colon cancer surgeries most probably lead to another one immediately.

Strangely, reading this piece, after recently attending a pooja at a hospital cabin - allocated to an oncologist friend on the occasion of him joining a famous hospital. The pooja had all the indulgences where it looked like the hospital was glad that a new business set up was being opened! My friend was embarrassed, and for a guy who never attends poojas, curiosity got the better of me and I have come to realize that something was so not right there... Clearly the intention is to make great business (sadly at the cost of patients). Can't help but wonder about the state of the hospitals here.

Harimohan said...

Hmmm. It mostly happens in a daze. The patients surely are not at ease at any time - so there is no question of confronting. Who has the patience really?

What really is the recourse? Is there a procedure for seeking such information or will the entire system clamp down and side their people? Most likely that is what will happen.

More than anything else, its the lack of checks and balances in the system (that such things can quickly go under the carpet instead of being studied, addressed and corrected) that bothers me. Mistakes happen - but what happens after mistakes happen reveals the system for what it is. That is where we are found wanting.

In the grey areas.