Twelve Patients: Life and Death at Bellevue Hospital (35 page)

“Alarm fatigue follows the same logic. Too many alarms and they are discounted, downgraded, and sometimes out of sheer frustration just turned off. A top nurse was trying to get his work done at his desk. The steady beeps and flashes for trivial occurrences, like a line falling off when a patient moved, were overwhelming. He turned off the beep status on the monitor. Guess what? The patient died. We plug and play and don’t understand what we have just spent millions of dollars on. There is no quick fix. There is no plug and play. There is no such thing. These are myths and legends I read to my grandchildren.” They all got it and hands went up. I said please hold on, I had two more examples, and then we would talk.

“A number of years ago, data on our infection rates was on the agenda for a routine meeting in my office over coffee and bagels, New York–style. Lots of data and flow charts full of information. I kept turning the sheets upside down. The curves made no sense. I was told by my expert that we were doing fine. Our infection rates were where they were supposed to be. Well, they might have been where they should have been if I held the paper upside down. So I said, ‘You mean to tell me the graphs are not upside down?’

“He explained to me, ‘The worsening performance is normal when you have our kind of patients. They are sicker and more complicated. We are actually doing better because it should actually be worse.’ Sounded like the phalanx of bankers and government economists talking about the recession aka depression. Infections and errors
were inevitable. Part of life. The way the planets circled the sun.” I paused and let the words penetrate. “This was flat-earth thinking. Pre-Galileo. Maybe we needed an Aztec calendar specialist, 2012 is here. Why do anything at all?

“I flipped the charts upside down and said that this is where we had to be without exception. No errors. No avoidable infections. Not one. Never. Period. I told him our patients were exceptional but not in the way he was describing them.

“Probably the biggest improvement in intensive care in this country has been the introduction of pencils and paper into ICUs. The now famous checklist. These are the five things you have to do twice a day to prevent infections. These are the five to prevent pneumonias on ventilators. Paper and pencils. The Luddites may win yet!” People rustled, smiled, and nodded. “Who was Dr. Luddite?” I heard from my right side. “And the real point of the checklists is to get people to talk together! It may not matter what is on the lists!”

The final case I presented had happened some years ago early in my career, but it still haunted me. “A patient was transferred from a hospital on Staten Island for specialty treatment. The woman had a benign brain tumor that was giving her migraines. Benign or not, anything in the brain can be deadly, trapped in this bony vise we call a skull. The only way to relieve the pressure was to press down into the narrow canal where the nerve fibers exit at the base of the brain, where the spinal cord begins. We examined her and repeated the CT scan and observed her in an intensive care area under close and careful observation by an experienced team.

“The nurses became alarmed when she started speaking in Mandarin, like speaking in tongues. She had always spoken in English before, although she was multilingual. They regarded this switch as an ominous sign. They paged the physicians in charge to move on the patient right away. Her exam was otherwise unchanged. After much discussion and review by the physician team, it was decided to continue to observe the patient. The nurses were not happy and continued to lobby for more aggressive intervention. To them, the language shift meant that the benign tumor mass was pressing on her brain stem. Too much
pressure would cause herniation—that is, it would force this most sensitive part of the brain against the canal’s hard bony walls. Two hours later, the patient was in the operating room, having lost consciousness. She died. The organ donor team was activated the next day. Many lives were saved, the woman’s legacy.

“These are just a few examples from hundreds. They are icons of what the core challenges are for all of us. So number one: A great team cannot make up for the lack of a standard set of procedures in a standard operating room. The only thing that had remained the same was the music in an old CD player they brought from their old OR to this new one. There is a lot to be learned from your next flight to Miami. Variation within the medical industry is inherently unsafe and potentially lethal.

“Second: Hardware and software are amazing. But they have serious limitations, and they introduce their own set of problems. We all turn childish in front of the promise of solutions from blinking lights in a shiny metal container. Our own electronic medical record has been rechristened at least eight times as the industry consolidates and it is purchased again and again. Once you think you own it, you are owned by the vendor, unless you know as much as or more than they do.

“My third example shows how vital it is to set our own bar high. When we start to rationalize mediocrity, then we are condemned to it. Mediocrity. Multimillion-dollar investments were not necessary to turn around that upside-down graph. The questions on the pads of paper or tree bark force us to talk to one another, to answer the same questions, every day without exception, face-to-face.

“And finally, I couldn’t tell a patient’s story in front of two hundred nurses in one room without including a doctor’s number one lesson: We all have to listen to our nurses. Listen to the people who spend all of their time at the bedside. You really don’t need gray hair to figure that one out. But you will get it prematurely if you don’t!”

I ended the conference in the twelfth-floor Rose Room conference center with a Circle Line boat making its way north up the East River, the deck packed with tourists as it cruised past the Waterworks Restaurant on a barge jutting into the river. The sun was glinting gold
off the UN directly to our north. A helicopter was landing. My colleagues were chatting in clumps, some waiting to catch up with me as we strolled to the elevators and back to work. Normally, I would have invited someone to have coffee with me back in my office. But not today.

First, I stopped to see how Diego Matta was recuperating from the amputation. The international phone calls had started as soon as he arrived at Bellevue. Matta’s mother had flown in overnight from São Paulo, a formidable matriarch. She informed me the rest of the family would be arriving today, and I promised to stop by later.

Then I checked in on Trauma Detroit. Her husband was in the doctors’ lounge just off the OR main entrance. The nurses had found a spot for him to sit quietly and where they could find him. He was sitting with his winter coat over his shoulders. He looked exhausted. His mother-in-law slept in a well-used armchair in the corner. He was on his cell phone when I walked in. He wound up when he saw me come in with my white coat and scrubs. “I will call you back. One of the doctors is here.” I introduced myself and gave him my card. “I’m Charles. Chuck Reed,” he said, standing up.

We shook hands. I gave him an update, leaving out the most glaringly important detail. That would have to come later.

I went through her injuries and what the surgeons had done. The major vessels had been repaired; the bleeding had been controlled for some time. They were making sure all the damage was controlled and a plastic surgeon with skills in microsurgery was looking at the nerves and doing a repair through a microscope. She was stable and we were hopeful. Youth had put her in the likely-to-make-it column. Hemorrhagic deaths were not common, but they did happen and we did not want one on our watch. Ironic, I thought, given what had happened.

I asked if I could spend some time talking about what happened in the Lower East Side. He gave me a
You too?
look. “The cops,” he told me, “have been at me for hours. Did I know the shooter? Do I buy or use drugs? Does she? On and on. Like I’m going to have someone shoot my wife? Fuck.” He looked over his shoulder at an older woman wrapped in a blanket, but she was still asleep. I let Chuck talk about
his interactions with the police, but then he said he didn’t mind going over the events one more time.

The crux of the story was that two men had tried to snatch the woman’s bag and she had resisted. They shot her, grabbed it, and ran off. The rest I knew.

“How long have you guys been together? Tell me a little about her,” I asked, quietly keeping Detroit’s mother in view and avoiding the detectives’ line of questioning.

Reed came around. “Susanne is a dancer. She came to New York City ten years ago from the suburbs. She worked part-time in different gigs. They went nowhere really. She used up her savings after a few months. Luckily she found an office day job at a private school to pay the rent and tutored high school preppies in French. Pretty much like everyone else we know in New York City. We live in a world of waiters, bartenders, special-event caterers, grave-shift doormen who are artists, singers, musicians, and dancers trying to hack it here.” Sounded pretty similar to my kids and a lot of our friends. The great immigration to the city to find yourself and pursue a dream, a fantasy until reality imposed itself—financial reality that is.

“So what’s she like?” I murmured.

He smiled, then remembered where she was. “Susanne is the quiet and introverted type. Super intelligent and sensitive. She shouldn’t have messed with those guys who were robbing us. Who cares about the money, a cell phone and stuff? It doesn’t matter. She responds, reacts first. That is how she is wired. She goes from hypervigilance keyed up to low, moody, pulling away. She cycles like that.”
Like what
, I thought.

“So she can be pretty reactive, huh? Got to be careful in the city—like any city, I guess. Life can get pretty cheap depending on the situation. Two dollars and change during the crack scene in New York.” One of my doctor colleagues had been killed in the parking lot at Kings County at high noon for the change in his pocket.

He agreed and said, “Yeah, I do know all about that.”

“What do you mean?” I asked him.

“I am retired military, army, on disability now. Iraq and Afghanistan
multiple tours. Fucked me up pretty much. I’d been living with my parents in New Jersey when I met Susanne.” He seemed like he wanted to talk. I just listened.

“I spent four years overseas. I had been married before I was sent overseas, the stress of the two tours killed off the relationship. Can’t blame my ex. You sit and wait and you form other relationships. It was painful for sure but like the common cold everyone suffers from it over there or when they come home.”

“Were you injured?” I knew it was a meaningless question even as it came out of my mouth. So many vets came back with the invisible injuries. They were rewired by the experience.

“The command were running us really close to the Pakistan border. There were some advanced bases to support some ops going into the Northwest Frontier Province, the ‘stans’ as we called them. I was on a small base running patrols for the groups going deep on reconnaissance trips. We would even get stuff from Peshawar, the capital of the wild west.” I could start to imagine the isolation, cold, and fear from being way out there with a long helicopter ride back even to what passed for civilization in an armed camp.

“We got shot up pretty bad and had to evacuate the camp. Burned everything and blew it up. We lost some guys. I was burned on my legs.” He pulled up a pant leg where he had the telltale marks of third-degree burns and surgery. “Bad shit going down.”

“Did they ship you back to the States?”

“Yeah. I’ve been through rehab after the surgeries and grafts. They did a pretty good job. By this time I’d been out of the military for a year, had disability, and was back with my parents to continue rehab and psych treatments and try to figure out where my life is going. There were lots of times, sitting in my childhood bedroom, I had no idea if it was going anyplace.”

“Susanne?”

“I lucked out. Some friends dragged me into the city one weekend to just get me out of the house and from in front of the television set. There was a party for a friend’s friend who catered big expensive parties for
wealthy people. Music, drinks, a barbecue out back. Susanne was there alone and we just picked up a random conversation standing in line for smoked ribs dripping in chipotle sauce—which I promptly spilled on her.”

“So chipotle brought you two together?” I smiled at Reed. He was looser and slightly more relaxed.

“I was terrified of what she would think of me when she saw my legs and thighs. I ain’t pretty.”

“But everything is working okay, right?” I asked him.

“Most of the time,” he shot back. “She didn’t care. I looked like an armadillo. That’s what she said. But not making fun of me. I was like a wounded bird that she looked after. I did need looking after.” He added that matter-of-factly. And then continued without prompting.

“It hasn’t been easy at all. Not just my burns. Sometimes the complete meaninglessness of life in these dead-end communities sucks my soul right out. People getting blown to bits so suburbanites could sit in their SUVs waiting to go through the Holland Tunnel for under four dollars a gallon? Shop to support the troops? Nobody here has a clue what is going on and really doesn’t care. So much for the volunteer army.”

“Do you have trouble sleeping?”

He started with a list of complaints—anxiety, flashbacks, the fitful sleeping, hypervigilance. Clearly PTSD. He started talking about the treatment programs, the cost, the medical opinions and prognoses. The program that had worked the best was a virtual-reality one in which he had gradually been able to reenact the explosion. He explained about wearing the goggles as the therapist walked him through the scenario, again and again, slowly adding more and more realistic details. Increasing the dose of trauma a drop at a time while monitoring his pulse, his reactivity.

“Are you on meds?”

He stopped talking for a moment. Maybe the cops had asked him the same question.

He looked over his shoulder at his mother-in-law. She had opened her eyes briefly then dropped back into semi-consciousness.