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A Parents Nightmare
Ms. Sue Stratman opened with the observation that she had seen both the best and worst of the medical care system. She is the mother of Daniel, who was born with congenital heart disease but had done spectacularly well with 3 open-heart surgeries over the course of his first 11 years and in 1996 was well and vigorously active, successfully playing competitive soccer. He was found to have an inguinal hernia and the repair under general anesthesia was scheduled at the same very well-known large academic medical center where he had his heart repaired. There was a thorough discussion of Daniels history, cardiac status, and the anesthesia plan with the attending anesthesiologist prior to what was planned for a quick outpatient procedure. During the anesthetic, Daniel arrested and his heart was resuscitated, but he suffered permanent brain damage such that he today is blind, cannot use his arms, can walk only with the assistance of 2 people, can barely speak, and needs total 24-hour care.
Ms. Stratman stated that she was not aware preoperatively that a student nurse anesthetist would be involved in the anesthetic and would be left alone with Daniel during the case by the attending who was also supervising another room. The anesthesiologist was also distracted due to her own ongoing family issues. Ms. Stratman stated that the records had been altered to make it look like his heart had given out, but that eventual analysis of the original records and the printout from the monitor values suggested this scenario: Daniel climbed up on the table himself and was given an inhalation induction with 5% halothane; this induction dose was continued and not reduced to maintenance levels when the attending left the room; the non-invasive blood pressure machine (NIBP) had not been set to cycle at intervals, and the single initial blood pressure value was recorded 3 times on the record over nearly 15 minutes; an LMA was in place, but spontaneous breathing slowed so there was hand-assisted bag ventilation; the surgeon remarked on dark-colored blood upon incision; cycling the NIBP revealed profound hypotension and heart block, then arrest followed.
There was little communication to the family immediately after the event, and there was a delay in allowing them to see Daniel in the PACU, where he was intubated, ventilated, having seizures, and posturing. Beyond the panic, Ms. Stratman was crushed because she had promised Daniel no tubes or ventilator this time. After a week of little improvement and essentially no communication to the family, there was mention of the possibility of discontinuing life support. Daniels cardiologist demanded an investigation at the hospital. The attending anesthesiologist visited daily and was emotionally distressed, including about events in her own family, which she discussed with Daniels family. Ms. Stratman stated that the attending anesthesiologist communicated to her that she never really understood what had happened. Mrs. Stratman came to believe that the anesthesiologist did know what happened but did not disclose this.
Ms. Stratman stated that they were kept completely in the dark about the incident, and she learned that the hospital staff had been instructed not to talk with anyone (family, friends, coworkers, or other hospital personnel) while the investigation (initiated by the cardiologist) was conducted. She stated they were stunned to learn the truth about the event but, painful as that was, it was critical to know everything. The family did receive an out-of-court financial settlement. They did receive an acknowledgment from the hospital that mistakes had been made, but no acknowledgment from the anesthesiologist. Neither the hospital nor the anesthesiologist ever admitted that the records had been altered. Ms. Stratman stated that, even 9 years later, she would like the opportunity to talk with the anesthesiologist to help bring closure because she suspects that the anesthesiologist is not doing well with the burden of the situation.
Ms. Stratman clearly outlined what she believes should happen with the anesthetic for a surgery such as Daniels: 1) take it seriouslyas if it is the most complex major surgery imaginable, even though its a minor case; 2) the attending should never leave the patient [although it appeared that the function of anesthesia trainees in academic medical centers was not fully appreciated]; 3) be sure the equipment works and is used correctly; and 4) tell the truth. As seen in the previous presentation, there was a profound desire by this family to do something to help prevent tragedies such as this. The family has started the Daniel Stratman Foundation to help educate about patient safety. They are members of a medical malpractice survivors support group. Ms. Stratman stated they had served on a hospital parents board, but abandoned that when it was clear to them the hospital was not really interested in discussing substantive patient safety issues with families.
Again, the APSF Board was moved. Note was again taken of the potential disconnect between patient/family understanding of events during medical care, prospectively, and especially retrospectively, and the providers realities. The damaging impact of failure of disclosure after the event and overall failure of communication was unmistakable. Finally, as before, the drive by the survivors to do something, to make a difference so similar catastrophes would not afflict other families in the future, was heartfelt and strong, which is precisely the element sought by the APSF Board in these presentations and, more importantly, as stimulus for future follow-up efforts by the foundation.
Ms. Sue Stratman opened with the observation that she had seen both the best and worst of the medical care system. She is the mother of Daniel, who was born with congenital heart disease but had done spectacularly well with 3 open-heart surgeries over the course of his first 11 years and in 1996 was well and vigorously active, successfully playing competitive soccer. He was found to have an inguinal hernia and the repair under general anesthesia was scheduled at the same very well-known large academic medical center where he had his heart repaired. There was a thorough discussion of Daniels history, cardiac status, and the anesthesia plan with the attending anesthesiologist prior to what was planned for a quick outpatient procedure. During the anesthetic, Daniel arrested and his heart was resuscitated, but he suffered permanent brain damage such that he today is blind, cannot use his arms, can walk only with the assistance of 2 people, can barely speak, and needs total 24-hour care.
Ms. Stratman stated that she was not aware preoperatively that a student nurse anesthetist would be involved in the anesthetic and would be left alone with Daniel during the case by the attending who was also supervising another room. The anesthesiologist was also distracted due to her own ongoing family issues. Ms. Stratman stated that the records had been altered to make it look like his heart had given out, but that eventual analysis of the original records and the printout from the monitor values suggested this scenario: Daniel climbed up on the table himself and was given an inhalation induction with 5% halothane; this induction dose was continued and not reduced to maintenance levels when the attending left the room; the non-invasive blood pressure machine (NIBP) had not been set to cycle at intervals, and the single initial blood pressure value was recorded 3 times on the record over nearly 15 minutes; an LMA was in place, but spontaneous breathing slowed so there was hand-assisted bag ventilation; the surgeon remarked on dark-colored blood upon incision; cycling the NIBP revealed profound hypotension and heart block, then arrest followed.
There was little communication to the family immediately after the event, and there was a delay in allowing them to see Daniel in the PACU, where he was intubated, ventilated, having seizures, and posturing. Beyond the panic, Ms. Stratman was crushed because she had promised Daniel no tubes or ventilator this time. After a week of little improvement and essentially no communication to the family, there was mention of the possibility of discontinuing life support. Daniels cardiologist demanded an investigation at the hospital. The attending anesthesiologist visited daily and was emotionally distressed, including about events in her own family, which she discussed with Daniels family. Ms. Stratman stated that the attending anesthesiologist communicated to her that she never really understood what had happened. Mrs. Stratman came to believe that the anesthesiologist did know what happened but did not disclose this.
Ms. Stratman stated that they were kept completely in the dark about the incident, and she learned that the hospital staff had been instructed not to talk with anyone (family, friends, coworkers, or other hospital personnel) while the investigation (initiated by the cardiologist) was conducted. She stated they were stunned to learn the truth about the event but, painful as that was, it was critical to know everything. The family did receive an out-of-court financial settlement. They did receive an acknowledgment from the hospital that mistakes had been made, but no acknowledgment from the anesthesiologist. Neither the hospital nor the anesthesiologist ever admitted that the records had been altered. Ms. Stratman stated that, even 9 years later, she would like the opportunity to talk with the anesthesiologist to help bring closure because she suspects that the anesthesiologist is not doing well with the burden of the situation.
Ms. Stratman clearly outlined what she believes should happen with the anesthetic for a surgery such as Daniels: 1) take it seriouslyas if it is the most complex major surgery imaginable, even though its a minor case; 2) the attending should never leave the patient [although it appeared that the function of anesthesia trainees in academic medical centers was not fully appreciated]; 3) be sure the equipment works and is used correctly; and 4) tell the truth. As seen in the previous presentation, there was a profound desire by this family to do something to help prevent tragedies such as this. The family has started the Daniel Stratman Foundation to help educate about patient safety. They are members of a medical malpractice survivors support group. Ms. Stratman stated they had served on a hospital parents board, but abandoned that when it was clear to them the hospital was not really interested in discussing substantive patient safety issues with families.
Again, the APSF Board was moved. Note was again taken of the potential disconnect between patient/family understanding of events during medical care, prospectively, and especially retrospectively, and the providers realities. The damaging impact of failure of disclosure after the event and overall failure of communication was unmistakable. Finally, as before, the drive by the survivors to do something, to make a difference so similar catastrophes would not afflict other families in the future, was heartfelt and strong, which is precisely the element sought by the APSF Board in these presentations and, more importantly, as stimulus for future follow-up efforts by the foundation.
