Yes I became that guy. We became that crazy family that left the hospital ‘against medical advice.’ We had no choice though. Our daughter was four days old and completely helpless, and no one was listening to my wife and I while her condition deteriorated. I didn’t know where I was taking her, but there were half a dozen other institutions half an hour away. For her own safety – we had to leave. I carefully turned off the blue lights, took her out of the isolette, put her in her car seat, boarded the elevator, and eloped from the unit. The hospital staff was scurrying now… where the hell had they been all night?!

Newborn V.

I think about medical errors on a daily basis. As a practicing hospital medicine physician that has worked in multiple hospitals across four different states, I face the responsibility of providing quality care – while simultaneously trying not to become a factor in medical errors. The fear weighs heavily on me, and I often go home after a shift and log back in to the EMR to make sure I haven’t missed anything. Luckily there are many lines of defense to protect patients in the hospital; smart colleagues like nurses, pharmacists, consultant physicians and other team members have assisted me to avoid errors. Despite this, alarming reports detailing the terrifying scale of medical errors in the United States seem to be more frequent. Medical errors are now the third leading cause of death in the US (after cancer and heart disease). More than 250 000 deaths a year (likely more) are estimated to be due to medical errors, and countless more errors don’t result in death but lead to patient harm and increased cost to the system. Is our healthcare system truly alarmed, or have we become immune and indifferent, and perhaps more occupied with other ‘stuff’ that has been deemed to be more valuable than human suffering? Obviously all providers make mistakes (including me), but how we respond, learn and implement changes in the future is an entirely different issue.

Let me start at the beginning.

Our daughter was three days old and her eyes and skin were yellow. We went for our first pediatrician appointment, and a few hours later received a phone call telling us to go to a nearby children’s hospital because her bilirubin was very high. I hadn’t thought about neonatal jaundice since medical school – but apparently it can occur due to a host of factors; something to do with fetal hemoglobin breakdown, immature metabolic pathways of the liver, and sometimes breast milk. Some infants require phototherapy to break down the bilirubin and prevent brain damage (kernicterus results if bilirubin stains the brain tissue). After 2 minutes on Dr-Google we proceeded immediately to the hospital.

The first red flag was apparent on our arrival. No one knew who we were, despite our pediatrician supposedly arranging for a direct admission. When we finally were taken to the ward; the room was not ready, and the nurses seemed unfamiliar with how to use the phototherapy apparatus for treatment (which looked like four blue tube lights, and seemed dated like it was from the 1970s). My wife started to tear up even in those early moments, saying she had no confidence in the care being provided. The resident physicians seemed in no hurry to initiate time sensitive interventions – telling us bluntly they had no orders for treatment from their supervisor. I tried to allay my wife’s fears by joking about our own days with training wheels during residency. My wife called our private pediatrician, but she was powerless because she did not have privileges at this hospital. Finally the treatment started 2.5 hours after we arrived. Unsurprisingly the labs were worse.

Outdated equipment

Throughout the night we were left alone as new parents, to monitor our daughter and provide feedings. We weren’t seen by an Attending physician in 10 hours, and nurses came in three times, as did the residents. Her labs kept getting worse despite the blue light. At one point my wife asked about the seemingly incorrect setup with lights being placed far away from the isolette, and was told it was fine. People seemed annoyed at our line of questioning. I woke up blurry eyed at 1am to hear the fourth set of worsening labs as the nurse told my wife nonchalantly that the labs “hadn’t come back as expected.” Not as expected?! The words ‘brain damage’ kept reverberating in my mind, and I became even more alarmed when the residents explained to my wife that the plan was to ‘stay the course.’ I asked the nurse politely but firmly to please call the attending physician, reiterating that although not a pediatrician, I was a physician and was very concerned. When she deferred to the residents’ assessment, and told me there was no pediatric attending physician present overnight, I initiated our escape plan. I had enough – no more waiting.

V. in the isolette

Thankfully the ICU team showed up just after I escaped with my daughter and was walking towards the parking lot. I came back up to the ward reluctantly with our baby, as my wife relayed the hospital course to the critical care NICU attending. He expressed his horror at her management thus far, and wheeled her down personally to the NICU, and nurses placed an IV and initiated fluids, and began phototherapy with modern fiberoptic equipment. Thankfully she improved quickly and was discharged in 24 hours.

V at 2 weeks

After we had left the hospital I wrote a letter outlining our experience to the Patient Safety/QI Department of this hospital. The letter stated that the only goal of my correspondence was to prevent future episodes for other families. I expressed gratitude for the nursing and physician staff of the ICU, and understanding for difficulties new trainees face. I then outlined my observations including disorganized care from the onset, a lack of attending physician support for residents overnight, and finally the fact that all staff failed to listen to our pleading that something was wrong. The initial response I got was a polite and very concerned phone call from a non-physician administrator the very next day. After this, two weeks of silence followed, and then a legal letter denying any and all breach of duty. Oh and by the way, our bill was due in full. Were these people stupid? Do they think I was writing out of concern for a copay and deductible? Interestingly the letter thanked us for pointing out the outdated phototherapy equipment on the pediatrics ward and promised it would be changed. My wife’s subsequent conversation with the Chair of Pediatrics ended with him stating “we will have to agree to disagree – In my view everything was done appropriately.”

Well I don’t agree. Although my daughter seems to have suffered no permanent harm, in reality what unfolded was a potentially lethal mix of medical errors that led to a preventable NICU stay. My main concern is what are patients and families to do that have no formal medical education, or a poor health literacy? Clearly ‘staying the course’ would have been a horrible idea in our situation. Countless others face similar challenges in their hospital stays all across the world. Hospital staff are overworked, not supported by their administration in terms of appropriate staffing, and sometimes under-trained. It is a destructive cycle.

My advice to patients seeking to mitigate medical errors during their hospital stay is-

A: Ask questions, lots of questions – specifically about the Action plan. You as the patient are the only person that faces permanent consequences for medical errors. One of my mentors used to say ‘if you’re not asking why, you’re not doing your job.’ The same is true for patients and their advocates.

B: Be Heard. Voice your opinion if you think something is wrong. If you are ignored, ask to speak to a supervisor or the patient relations department. Hospital staff have multiple patients they are caring for, and their attention is divided between multiple complex tasks. Often patients and family members can sense when something is wrong.

C: Clarify. There are multiple team members responsible for ensuring quality care in the hospital. Clarify who people are when you’re talking to them. If you go to a teaching hospital make sure the attending physician (a fully trained doctor, the one ‘in charge’) has actually examined you. Residents and Fellows should be the first point of contact, but certainly not the last. They are still ‘in training’ for a reason.

D: Discuss. Although health outcomes are never guaranteed, if care has been compromised, there needs to be an open discussion. I’m not talking about lawsuits, or filling out stupid generic patient surveys – I mean a meaningful and specific outline of what you think happened and how it can be addressed in the future. Although the hospital sent back a letter denying any and all breach of duty – I know that my letter was seen by at least three departments; the administration, nursing department and residency program. Additionally the Chair of Pediatrics was forced to conduct a chart review of this case. On some small level the providers working that night will remember the crazy father who walked off the floor with his newborn, and the parents who outlined their concern after their discharge.

© 2018 Varun Verma, MD www.varunvermamd.com

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Dr. Verma is a board certified internal medicine physician. He believes that quality healthcare is a human right and has worked around the United States and internationally.