The Reality of Risk

On average 1 out of every 20 people who are admitted to a hospital will incur a hospital incurred infection.  My father did, which contributed to his earlier than expected departure from this world. 

 It is estimated that 98,000 – 400,000 people die every year from preventable errors and accidents made within hospitals.  I am not sure what qualifies people to be included in these numbers, but last week I believe my mom could have been in that pool.

My mother on all accounts for her age was healthy.  Osteoarthritis in the knees, high blood pressure controlled by medication, restricted vascular flow in her lower extremities, and excess weight were the only medical conditions she had, none of which significantly impaired her daily life activities. 

On Saturday, August 23, she took a tumble which resulted in breaking her wrist and a hairline fracture of her pelvic bone.  She was admitted to the hospital on Tuesday, August 26, because she was not independently mobile.  She was put on heparin to mitigate the risk of blood clots and given pain medication for the pelvic bone injury.   She was stuck 7 times in an attempt to start an IV without success.  There was considerable bruising as a result.  A decision was made to insert a PICC line.  Surgery was performed on her wrist on Wednesday August 27, that required 3 pins to keep things together and aligned.  All seemed well post-surgery – except for her erratic blood pressure and pulse that measured from her legs.   One leg measurement consistently indicated inflated numbers, while the other leg yielded lower numbers (red flag #1).

I happened to be in Memphis during last weekend of her hospitalization. I visited her each day I was there.    On Friday, she looked pale and tired, but alert.  She had complained about not being able to urinate (red flag #2).  She was put on a medication that was to help relieve the arthritic knees.  She was concerned about the side effects of the medication.  Two weeks prior to her accident, she had received the final round of knee injections that provides lubrication for the joints.  My mom told me that medication had given her some relief.  She expressed fear about her current situation and made the comment “if I ever get out of here,” more than once.  On Saturday, she looked better and had gotten up with assistance to go to the bathroom and was able to empty her bladder.  She was looking better.  Things were looking better.  On Sunday, I went to her room before I left town and gave her a cell phone that I bought for her on Saturday.  This would enable her to get emails and re-engage with people on Facebook as well as call anyone as much as she wanted without any cost to her.  I told her my daughter would teach her how to become competent in using this device after she was discharged.  As I left, I felt a sense of fear from her, but I gave my best pitch of encouraging reassurance that all would be ok in the near term.  I had every reason to believe that she would be going to a rehab center to get her back on her feet again within the next week.

Fast forward to Tuesday.  I called her about 4 p.m. and we talked until after 5 p.m.  She sounded optimistic about being discharged to a rehab center within a mile from her home as soon as Wednesday, provided they could get her blood pressure and pulse rate under control (red flag #3).  She was apologetic for not having yet used the cell phone…that was my mom – concerned about everyone else’s feelings before her own.  She said her only concerns were being a bit short of breath and had a dizzy spell when she got up with assistance to go to the bathroom (red flag #4). 

On mid-morning Wednesday, September 3, I got a text that my mother was transferred to CV ICU because of her erratic heart rate and shortness of breath.  Throughout the day her condition rapidly declined to the point that they had to intubate her and connect her to a ventilator.  Around 6 p.m. she experienced the first of two codes and I told my sisters to forgo any more attempts since the inevitable was near.  Around 8 p.m. the priest from the parish she attended for over 40 years arrived to give the anointment of the sick (formerly, last rites) blessing and she died the moment he ended the prayer. 

In retrospect, as a non-clinician I identified 4 symptomatic red flags, all of which independently could be attributed to the stress of the injury, reaction to the new medications, pre-existing condition: vascular flow, obesity, arthritis, etc.  Together, these red flagged symptoms played a part in her overall health condition.

Could other things have been done to reduce the risk of her mortal outcome?  Certainly.  But, would the outcome have been any different?  We will never know.   In the end, is this death classified as universal fate, God’s will or a death that might have been prevented? 

Risk and Accountability

Do no harm,” is the core conduct of civility that allows some semblance of peaceful coexistence.  This ethical tenet is foundational to the human condition.  An event in the past week has violated this often unstated, but understood code of decency.

None of us ever knows with absolute certainty what will happen from one moment to the next.  As we leave the doors of our “safe” homes, just what is in store for us?  The world is full of potential harm.  Risk is inherent in everything we do.  Harm to self, harm to others, harm by self, harm by others.  Harm can be physical, emotional, financial, or relational.  I can be intentional or unintentional. 

Every time since 9/11/2001 when I board a plan, I participate in an effort to mitigate risk of harm by terrorist activity by going through a security checkpoint.  I don’t fancy the drill, but at the same time I don’t mind knowing my flight might be a bit safer. 

This week Malaysia flight MH17 was reportedly struck by a surface to air missile in the Ukraine that killed all 298 people on board.  I would imagine these passengers probably initially felt that same aforementioned degree of safety I do when they boarded their plane.  And then the unfathomable and the unexpected happened.   

The plane was generally considered to be in a “safe” zone from risk (> 32,000 feet) along this route even though there had been two military planes shot down in that area in the past week.  This was a gross miscalculation of risk.  This is one occasion where there was not any human error by the pilots or mechanical failure of the plane.  It was a systems issue.  Why was this air space considered safe in light of what had transpired the week before?  Was it negligent or reckless behavior to believe it was safe space?

In my work, I see the risk of potential harm in healthcare too often.  The potential of the wrong patient, the wrong procedure, the medication administration error, hospital-acquired infections, etc. is alive and well in all U.S. hospitals.   I read the transcripts of congressional hearing around patient safety held last week and had correspondence with one of the presenters after the hearing.  The patient safety advocate’s position is to increase efforts to reduce the risk of harm that kills up to 400,000 patients each year.  They believe the only way to effectively mitigate this risk is to get the government involved.  The airline has a national safety board sponsored by the FAA that has proven to drastically make commercial airlines safer and healthcare should have the same type of oversight. 

There are only so many finite resources.  Choices have to be made over which values are more important than the others which compete with each other for those resources.  To date, the U.S.  has allocated much in the name of safety.  Yet, we have a constant battle of political posturing over too much government versus no government oversight.  That’s not the issue…the issue is what is the right thing to do?”  The right thing is “do no harm.”  This should be the overarching value of our civil existence and our policy.    

So this is where the accountability comes into play.  Should there be a global organization that identifies at-risk airspace and restricts commercial planes from that area?  The events that have occurred since the plane came down have been criminal. There has been blatant disrespect for people (the passengers and their surviving families) and intentional efforts to mask the truth.  The fingers are pointing at the Ukrainian separatists who are allegedly supported by Russia.  It is a diplomatic firestorm that the world is now engaged in.  Which organization or country or countries will take the lead in attempting to reconstruct what just happened and punish those found guilty of the crimes committed? 

It’s times like these where the eternal optimist becomes a bit cynical and jaded about the internal goodness of his/her fellow humans.