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In America we have the best medical system in the world (?) I am sure you've never heard that statement before. In the health care debate we heard lots of good stuff like that, mostly coming from our cash rich medical industry. I have also heard it stated that a lot of the high cost of medicine could be solved with tort reform. That means if we reformed our civil justice system in regards to how many malpractice lawsuits we have, set limits of awards and punitive damages against doctors and hospitals we would have less expensive healthcare. I wonder if that is a good idea because I am certain the issue will come up again. The following is a true story, it throws a little light on the subject and is I believe worthy.
Tammy is a registered nurse has been for over 15 years she worked for a time in pediatrics at a hospital in the western US. In pediatrics a nurse has less patients than a regular ward, kids are a little more needy as patients are concerned thus no more than 6 per nurse were allowed in the ward she worked. One day while working in the ward another nurse needed to take her lunch break and passed off a patient to her for the half hour she gets for lunch. (This is common practice at hospitals) The patient was a 9 year old little girl, pretty and brave she never once complained during what was to be the last hour of her life.
When a nurse takes a patient from another nurse a good one like Tammy takes the patients vital signs as soon as the hand off occurs. While taking her new patients vitals she quickly became concerned, a check of the chart showed that one hour ago the patients vital signs were much better than they were now, a marked deterioration in her medical condition. Further inspection revealed that the patient had just had medication administered before the hand off. That is not according to safe protocol, and is not acceptable at that work place. Tammy pulled out her cell and called the other nurse at lunch, reported to her that the patients vitals had deteriorated in the last hour. The other nurse sounding unconcerned informed her that the same thing had happened with the patient before with that medicine and she would be fine. She then informed Tammy that she would be late getting back because she had an errand.
Tammy had other patients (little ones) that needed care but she could not leave the little girl in the condition she was in. She took her vital signs again, they were worse, pulse weak and thready, face pale, difficulty breathing and lack of adequate blood flow. Her hands were like ice and her temperature was dropping. She pulled out the chart and called the number of the attending physician. He was on the golf course. When she informed him of the little girls deteriorating situation he told her what the other nurse had said. They had seen this before and she should come out of it fine. If there was any further deterioration of her condition or she showed no improvement in the next hour Tammy or the other nurse was to call him.
Thirty five minutes had passed since Tammy had taken this 9 year old girl into her care and she felt like she had done nothing to help her. She also had other patients so she called the doctor in charge of the ward. She informed him of the situation and asked that a team be sent to transfer the patient to intensive treatment. The head of pediatrics said that he could not go against the attending physician that she would just have to do what he said. He would not come, nor would he send another doctor to help her. Tammy was beside herself, she tried to call the other nurse to tell her to come take care of her patient because she did not want the responsibility anymore. The other nurse didn't answer her phone.
Tammy sat with the little girl for another 15 minutes holding her hand and telling her she was going to be ok before she coded (her heart stopped beating). It took almost 3 minutes for the code team to get there, they had to come all the way from intensive treatment. When they got there they were a mess, they were disorganized, couldn't find things, and failed to revive the patient. 55 minutes after taking the little girl into her care Tammy's patient was declared dead. She had lost patients before but not like this. This was a child, somebody's little girl, and she didn't have to die. The other nurse returned a minute after the official time of death looking rushed. Tammy told her, "You have to do the post-code on this patient because you killed her, and if I do the post code that's what I am going to say."
The other nurse did the post-code on the little girl. The well filled out reports detailing the extra-ordinary measures and lengths the hospital staff and code team had gone to to preserve the child's life. The family was devestated, but did not sue because they were never informed of what really happened. Tammy has a little girl and lives 5 miles from that hospital, when her daughter got injured the following year she drove her to a hospital that was 40 miles away.
My source could not tell this story herself for obvious reasons. Knowing this story and that it was swept under the rug instead of anybody taking a hard look at how things are and what can be done is troubling to me. It hurts me to think of the brave little girl who never complained while dying from the best health care system in the world. I had to write this.....I thank you for reading it.
