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Narrative Matters

No One Needs To Know

The voyage began with the care of a patient I will call Charles McNight. Just over sixty years old, he had come to the medical center to receive the care of our most highly skilled cardiovascular surgeons. They replaced two of his heart valves, put a graft on his aorta, and performed bypass surgery—all in one procedure. I do not recall the details of his cardiac pathology, but he sailed through the surgery, and his rapid recovery far exceeded our expectations.

I had gotten to know "Charlie" because I had been assigned to do his admitting history and physical, a typical job in those days for medical students. His thick, pure white, Santa-like beard and the warm smile beneath it instantly charmed all who met him. His wife and daughter were equally engaging. I became rapidly and intensely involved in his care, providing a human touch—a role that medical students often play on the hospital team in lieu of making medical decisions for which they are not yet prepared.

Crossing Boundaries

 
My care for Charlie was both fueled and complicated by my infatuation with his daughter, who was my age and unmarried. Her life as a single parent of a four-year-old daughter gave me ample substrate on which to build a wonderful fantasy. It was simple, it seemed, to help bring Charlie home, get him well, fall in love with his daughter, and be a stepfather to her little girl. These fantasies kept me returning to his hospital room.

A few weeks after surgery, Charlie was ready to be discharged. He went home with instructions to return weekly to the hospital lab for blood tests needed to adjust his level of coumarin, a medicine he was taking to prevent blood clots. A few days after discharge I received a call from his wife inviting me to their home for dinner—a small way for them to thank me for the extra care I had given Charlie in the hospital. I accepted, yet acknowledged to myself my level of discomfort in doing so. I had clearly crossed the line I had been taught to maintain between doctor and patient; I had allowed myself to become personally involved in Charlie’s life. Dinner took place almost a week after Charlie’s discharge, and I offered to bring the necessary equipment to take his required blood tests and to transport the blood back to the hospital lab. Charlie was grateful; he lived quite a distance from the hospital and was not looking forward to making the trip.

Dinner was great. Afterward, Charlie and I went into another room where I drew his blood. I then excused myself for the evening. The results of the tests were fine, and Charlie was doing well until a few weeks later, when he began to experience some sweats and weakness and the sensation that something was going wrong. Hours later he developed a low-grade fever that, within twelve hours, raged to 104 degrees. He called me at home that night. I was very worried for him and told him to go immediately to the hospital. His wife helped him put on a robe, and Charlie left home for what would be the last time.

I lived only a few blocks from the hospital and arrived almost an hour before Charlie and his wife. I was exhausted by my anxiety. My rotation in cardiovascular surgery had since ended, so I was there as a friend—a role I was not supposed to be playing as a medical student. Yet I was clearly part of the institution that was now responsible for Charlie’s life.

Charlie’s wife pulled their car into the emergency entrance. I helped him in to the hospital. Sweat was beading on his brow; he was so weak he could hardly stand. I took one of his hands in mine. It was cold and wet from perspiration. My other hand gently touched his back to support him; even through his robe and two shirts I could feel the thermal struggle his body was waging against some unknown infectious invader. Within moments it became clear to the cardiac surgery fellow on call that Charlie had an infection, and all too clear about its probable cause. "I am admitting you to the hospital in intensive care," he told Charlie, whose face looked close to death. "You have an infection, maybe on your aortic graft."

Slippery Slope

Top Crossing Boundaries Slippery Slope Entering The Dungeon Of... Unstated Obstacles To Openness

 
A shudder went through me. I had seen two similar cases while on the cardiovascular surgery service. In both cases patients had been discharged from the hospital, had returned with fever, and died. I had also heard that there might have been a problem with a batch of cardiovascular catheters that were in use in the hospital. Weeks after use, some had been suspected to have been contaminated, presumably by the manufacturer, with a fungus called candida. The patients who had been catheterized with these units were subject to postoperative infection with the fungus and seemed to be resistant to treatment.

By morning the surgical team that originally treated Charlie was by his bedside. Only one hope remained: They loaded him with antifungal drugs and took him to surgery to replace the infected graft. I changed my clothes and went into the operating room to watch. The thought of being able to answer his family’s questions about the long and complex surgery was so powerful that it obscured the pain that developed in my feet as I stood, out of the way, on a tiny patch of floor in the OR.

The surgery went well and confirmed the infection. Charlie was back in the cardiosurgical intensive care unit, and I was by his bedside with his wife and daughter. The surgeon appeared shortly thereafter and briefly reassured the family that his team had replaced the infected graft and that Charlie had done very well in surgery. The surgeon walked away. I stood with Charlie’s wife and daughter and explained what I could about what I had seen in the OR, leaving out any mention that the infection he had suffered might have been caused by the contaminated catheters. Minutes later, a bell sounded, indicating the end of visiting hours. I left with them as if the bell was meant for me, too, and sat in the waiting area discussing with them my optimism about Charlie’s future.

As Pavlovian as the family’s response to the visiting hours bell, my response to the hospital’s emergency paging system was equally well programmed. I had learned since starting my clinical rotations that the moment a voice began to ring out on the pager, all other incoming auditory signals were instinctively shut out. The "code" was called for the cardiac surgical intensive care unit. I froze in fear, listening to the announcement. I told Charlie’s family I needed to respond to this, a total fabrication, and left. The crowd around Charlie’s bed confirmed my fears.

I was immobilized by not knowing what to do, by my emotions, and by the people running in every direction with medications and equipment. A few minutes later the surgeon who had just completed Charlie’s graft repair came to the bedside. There was no hope. All resuscitation attempts failed to restart his heart. As the code was called to a halt, a nurse hurriedly handed a STAT lab result to the surgeon. The patient’s serum potassium had soared to a level that would have made anyone’s heart stop. I looked over the surgeon’s shoulder as he held the slip of paper with the lab result, staring in disbelief. Charlie had died of a simple mistake. His potassium had been allowed to go too high after surgery. This well-known deadly event was caused by the release of large amounts of potassium into the blood from cells damaged at surgery. The event is so common in cardiac surgical procedures that close monitoring of the potassium was a routine part of postoperative care. How could such a small oversight undo the months of heroic medical care that Charlie had been given by the most skilled surgeons in the region?

Entering The Dungeon Of Deception

Top Crossing Boundaries Slippery Slope Entering The Dungeon Of... Unstated Obstacles To Openness

 
The surgeon looked at me and to my great surprise put his arm around my shoulder. I was unaware that he had given a moment’s thought to my role in Charlie’s care. "Son," he began, "I’ve been very moved by the interest and concern you have shown for this patient. I also know that you realize that nothing good would come out of the family’s knowing about the catheter problems or what happened just now. No one needs to know." He tapped my shoulder twice and walked away.

In those few seconds it happened. I had been invited to join the underworld of medical secrecy—that territory where doctors tread and where no others may look in; where secrets about mistakes and problems are brought and where they reside forever hidden.

I stood motionless. A stream of contradictory thoughts flooded my brain. Was I Charlie’s friend, and should friendship prevail? Should I tell his family everything I knew? Or was I a doctor, albeit in training, committed to keeping the secrets that lie beyond the patients’ and families’ grasp? Was I partially responsible for the future survival of the wife, daughter, and granddaughter Charlie had left behind? Had I done everything I could? I had little time to think, and I never really made a decision what to do. The surgeon left my side and went to the waiting room to tell the news to Charlie’s wife and daughter. I knew I had to follow but didn’t know if I should be standing next to the family or next to the doctor.

The surgeon offered his condolences to the family. He remained only briefly and then asked if I could stay with them for a while. He was deputizing me—an act that subconsciously sucked me deeper into the underworld. I was now responsible for maintaining the charade that "we had done everything we could." It was up to me to understand the importance of the statement, "No one needs to know."

I saw Charlie’s family only once after that, at his funeral. His daughter introduced me to everyone there as one of Charlie’s doctors who had taken such good care of him. I played the role well. Dressed in my only suit, I told them how much he had endured, how sick he had been, and how he kept all of our spirits high to the end.

I got in my car and drove home across the city in a pouring rain. That was the last time I saw Charlie’s family. I could not remain in contact with them while being filled with the secrets I had been implored not to reveal: the contaminated catheters that might have caused his infection, and the elevated potassium level that caused his heart to stop beating. I would be living a lie each moment I spent with his family. Even the closeness I had felt to them, my thoughts of his daughter, and my continuing sense of responsibility for them were not strong enough to overcome my discomfort. I knew I could not violate the laws of the secret society of medicine into which I had just begun my initiation. Being invited into the sanctity of this dungeon of deception was part of the honor of becoming a doctor. It made me feel special—an entrusted colleague, a real doctor. But many questions flooded my mind.

Had anyone else died before Charlie as the result of fatally high potassium after surgery? Had anyone explored the need to change the systems by which such monitoring took place? Did the company that made the catheters know that some had been contaminated? Would lawsuits have forced them out of business, making these devices unavailable to others who would benefit? Would the hospital be forced to pay millions to those who died as a result, eroding the services it was providing to other patients? Would doctors be afraid to assume the challenges of critically ill patients like Charlie? Did Charlie’s family deserve to be compensated for the errors that caused their loss? Would the benefits to that one family outweigh the damage that could be done to the physicians and the hospital?

I had no answers and thus did nothing. Today I am puzzled by how quickly I adapted to this new role of "keeper of secrets" and remain concerned that others entering medicine are still taught in the same way.

Unstated Obstacles To Openness

Top Crossing Boundaries Slippery Slope Entering The Dungeon Of... Unstated Obstacles To Openness

 
What keeps any doctor I have ever known from initiating discussion of medical mistakes with patients is a set of redoubtable barriers. First, there is tacit agreement among physicians that mistakes are an inevitable part of practicing medicine. I have made my own errors over the years, some with minor adverse outcomes, others with horrible results. When I discover another physician’s mistake, I only discuss it if the doctor is employed by me or is formally under my supervision. We physicians are afraid to turn up the heat on others, lest we fry in our own fire.

Then we have the specter of medical liability lawsuits. Who would reveal errors to a patient and initiate the years-long process of defending a medical liability lawsuit? The financial burden of such an action and the public humiliation involved are insurmountable insurmountable for most physicians and deter a more honest reckoning of medical errors among physicians and between physicians and patients.

Finally, like most doctors, I went into medicine to be a helper and healer. Scrutiny by colleagues and the process of discussing my mistakes openly with others compel me to relive, over and over, the pain of having played a role in injuring someone who entrusted me with his or her life. A prolonged probing of my errors would force a level of self-doubt that would affect future decisions and could prove immobilizing. With no grounds for comparing my abilities and practice skills with those of my colleagues, I would be left asking, "Do I make more mistakes than my colleagues? Would another doctor have done a better job taking care of this patient?"

The formal internal quality assurance discussions that have been implemented in some institutions take place in a protected environment and thus promote a more open review of the cause of medical errors. Such sheltered examination often results in fixing systemic problems and thereby protecting patients from a simple oversight like the one that killed Charlie McNight. But building a legal firewall between quality review processes and public scrutiny fails to create a mechanism for the legitimate compensation of patients who have been injured through medical mistakes. Studies have shown that only a small percentage of such injuries are compensated through legal actions, while most go unaddressed.

The process by which law and medicine have evolved to deal with medical mistakes must be drastically changed, both to compensate those injured and to encourage the disclosure of errors. At the same time, each of us, as physicians and teachers, must fight the continuing urge to hide our mistakes. We must teach the next generation of students to talk about medical errors as a part of medical practice that will always be with us. Most of all, we must teach each other that the biggest gaffe of all is to cover up our mistakes, thus perpetuating barriers to safe care.

Everyone needs to know.

Editor's Notes

 
Neil Calman, <ncalman{at}institute2000.org>, is a family physician practicing in the Bronx, New York. He is president and cofounder of the Institute for Urban Family Health and professor of family medicine at the Albert Einstein College of Medicine, Yeshiva University.

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