Leadership is the
process of social influence in which one person can enlist the aid and support
of others in the accomplishment of a common task.” A leader drives the bus
(gives direction) to the team so a common goal can be achieved. At
Valley Medical the Hospitalist is the “driver of the bus (or so I was
told).”
Systems Thinking is the process of understanding how things influence one another within a whole. In the human body this would involve how a doctor orders and prescribes a medication for a medical issue (or disease) and knowing the impact of that decision and how it will affect other systems within the body. Example: if a doctor orders a drug for an infection, and the patient is receiving tons of other drugs, how that drug will react with the other drugs and the patients health and safety.
UW VMC ICU is not high energy or cutting edge – in fact, it is the total opposite. Complacency occurs on a daily basis – in an ICU. The shotgun approach to drug administration and ICU doctor’s practicing “Silo Medicine” leaves the patient vulnerable. The VMC ICU doctor health care planning for the patient is so appalling that I can’t describe it on this blog. VMC doctors lack basic project management skills, systems thinking methodologies and don’t even understand what a root cause analysis is.
I was regularly asked when a procedure was done.
November 17: Around 3:30 Dr. Suzanne Krell shows up and clearly appears agitated (because I asked where she was). The staff in Mark’s room look down (away from her like they are in fear) and scramble like mice. Dr. Suzanne Krell tells me she came by the previous day and I was not here. I explained to Dr. Suzanne Krell that I was here all day long; left to shower and eat dinner then came back. I mention my concern about Mark getting MRSA in his lung; it’s definitely from the respirator. Dr. Suzanne Krell tells me “that is the least of his problems. He also has an Enterobacter Cloacae infection in his lung.” This is the first I have heard of this. Dr. Suzanne Krell goes on to tell me (and she snips) that she has “26 PATIENTS” AND DOES NOT HAVE THE TIME TO GIVE THEM ALL 30 MINUTES.” And Dr. Suzanne Krell works in an ICU?
I explain to Dr. Suzanne Krell that maybe my expectations are way too high for VMC and the doctors that work there (because I expect clear communication – and daily). My expectation was set this high by the quality of doctors I have dealt with in the past, the doctors (all of them) dropping by daily to touch base with me when a loved one is hospitalized and when they miss me, they call my cell phone. Dr. Suzanne Krell clearly did not like this.
November 17: I take this photo because of the lack of tie-in with the staff and what I have to do for them to understand what my expectations are.
November 26: We talk to Bob Chapman, Rn about the lack of tie-in from Dr. Mary J Vancleave (the Hospitalist). We come up with a plan for priority reporting status from the doctors. This is only followed briefly by the VMC doctors; so I develop a daily “log/form” for me to document my questions and their responses.
Systems Thinking is the process of understanding how things influence one another within a whole. In the human body this would involve how a doctor orders and prescribes a medication for a medical issue (or disease) and knowing the impact of that decision and how it will affect other systems within the body. Example: if a doctor orders a drug for an infection, and the patient is receiving tons of other drugs, how that drug will react with the other drugs and the patients health and safety.
UW VMC ICU is not high energy or cutting edge – in fact, it is the total opposite. Complacency occurs on a daily basis – in an ICU. The shotgun approach to drug administration and ICU doctor’s practicing “Silo Medicine” leaves the patient vulnerable. The VMC ICU doctor health care planning for the patient is so appalling that I can’t describe it on this blog. VMC doctors lack basic project management skills, systems thinking methodologies and don’t even understand what a root cause analysis is.
I was regularly asked when a procedure was done.
November 17: Around 3:30 Dr. Suzanne Krell shows up and clearly appears agitated (because I asked where she was). The staff in Mark’s room look down (away from her like they are in fear) and scramble like mice. Dr. Suzanne Krell tells me she came by the previous day and I was not here. I explained to Dr. Suzanne Krell that I was here all day long; left to shower and eat dinner then came back. I mention my concern about Mark getting MRSA in his lung; it’s definitely from the respirator. Dr. Suzanne Krell tells me “that is the least of his problems. He also has an Enterobacter Cloacae infection in his lung.” This is the first I have heard of this. Dr. Suzanne Krell goes on to tell me (and she snips) that she has “26 PATIENTS” AND DOES NOT HAVE THE TIME TO GIVE THEM ALL 30 MINUTES.” And Dr. Suzanne Krell works in an ICU?
I explain to Dr. Suzanne Krell that maybe my expectations are way too high for VMC and the doctors that work there (because I expect clear communication – and daily). My expectation was set this high by the quality of doctors I have dealt with in the past, the doctors (all of them) dropping by daily to touch base with me when a loved one is hospitalized and when they miss me, they call my cell phone. Dr. Suzanne Krell clearly did not like this.
November 17: I take this photo because of the lack of tie-in with the staff and what I have to do for them to understand what my expectations are.
November 26: We talk to Bob Chapman, Rn about the lack of tie-in from Dr. Mary J Vancleave (the Hospitalist). We come up with a plan for priority reporting status from the doctors. This is only followed briefly by the VMC doctors; so I develop a daily “log/form” for me to document my questions and their responses.
1.
Pancreatitis. GI follows this
2. Lungs.
Intensivist follows this.
3. Renal:
Nephrologist/consultant follows this.
4. Liver
(hepatologist ~ at VMC the GI takes care of).
5.
Delirium.
6. Anemia.
7. Toe.
8. Misc:
Fever (Bob Chapman, Rn says this would be last; I’m thinking
it would be first because fever would represent possible infection)
January 4: I talk to Dr. Andrew Brokenbrough about CVVH DF and how Mark’s liver was improving. Dr. Andrew Brokenbrough is only focusing on removing fluids and doesn’t get the systems thinking (entire body). He is not sure why the CVVH DF had an impact on the liver enzymes. Dr. Suzanne Krell had mentioned it helping with the inflammation response.
January 14: We are having probably our last family meetings (because of Mark’s condition) with the VMC ICU doctors and staff. I am told right before our meeting that Dr. William Pearce (a GI that has been following Mark / communicating with us about Mark’s condition) is not available and that they are sending Dr. Duane Carlson (who has seen Mark and talked to me for 2 minutes [and that is generous] during Mark’s stay at VMC). We have serious questions to ask about Mark’s gastrointestinal issues and VMC sends the doctor that is the least intimate with Mark and what has transpired.
Right before this meeting I go down to get coffee - I see Dr. William Pearce in the lunchroom at 12:20 pm ~ he is standing behind me in the checkout line.
Dr. William Pearce wasn’t available because he was eating lunch and his patient, Mark, is dying?
Our
“Team” Quarterback – The Intensivist
December 20: In our group doctor meeting today Dr. Richard Wall uses an analogy of car repairs. Dr. Richard Wall says “you wouldn’t want an expert working on your tires or changing your windshield wipers would you?” Wayne strenuously reminds Dr. Richard Wall that we are not trying to fix the windshield wipers or the tires – WE ARE TRYING TO FIX THE ENTIRE CAR!!!
Dr. Richard Wall then says the intensivist will be the “Quarterback” for the team of VMC doctors. Dr. Richard Wall writes this order and from this point (December 20th) until Mark’s death a hospitalist never sees Mark again; no GI’s see Mark from December 20 until December 29 (and remember Mark has pancreatitis, gallstones, and his liver is shocked/failing from the medications).
How long do you think Dr. Richard Wall saw my son after these orders? FOR THREE DAYS MORE AND NEVER AGAIN – NO ONE VMC DOCTOR WAS MARK’S “QUARTERBACK” LIKE Dr. Richard Wall TOLD US THEY WOULD BE. Do you think I would trust this doctor again?
December 31: Dr. Vilma Quijada (nephrologist) tells me “I need to get all the doctors together to discuss a plan because Mark’s labs are all over the place with the new antibiotics and changes.” This was a fine concept however I am still trying to locate any medical record (that exists) to see the dictation from this meeting and what plan they came up with.
January 4: I ask Dr. William Park when Dr. Frank Thomas will be making rounds because I would like to talk to him before the procedures (liver biopsy and G-tube insert – to be done by the GI or so I was told) are completed today on Mark. Like always, Dr. William Park says “I don’t know” I frantically look up Dr. Frank Thomas office phone (because I found out that Dr. Duane Carlson is on call ~ Dr. Duane Carlson has spent 2 minutes tops talking to me and following Mark at the hospital). I go downstairs and call his office. His nurse tells me to have the nurse in ICU page him; I tell her I can’t even flag an ICU nurse down and in rounds I was told to find Dr. Frank Thomas myself.
January 6: In rounds with Dr. William Park I ask about the rectal tube non-output, the blood in the G-tube and why the area on Mark’s right side (by his liver) is so hard; Dr. William Park tells me to “go ask the GI.”
Does Dr. William Park know anything?
White
Blood Cell Count (WBC):
December 25: I have a conversation with Dr. William Park. He is concerned about the pseudomonas in Mark’s lung – pancreatitis is in control (it was not). I tell Dr. William Park that Mark will fight the bacteria – the next day (under Dr. William Park’s command) Mark receives a drug called Dexamethasone (December 26 to January 7) which is contraindicated with the infections VMC gave Mark (MRSA, Enterobacter, Burkholderia and Pseudomonas). Dexamethasone alone caused the VMC bacteria to run rampant through Mark’s body and his LFT's (liver function) to run wild.
January 7: I ask Dr. Michael Hori why he thinks the WBC is so high. Dr. Michael Hori mentions that there are 3 types of WBC and there are tests to determine which type (says Neutrofils; etc.). Some WBC develop for bacterial issues; some for viral; etc. I ask if they have done any of those tests, he says he doesn’t know. Isn’t this his job?
January 7: My main question in rounds is (for Dr. William Park): which type of WBC’s are they seeing the most of (Dr. Michael Hori mentioned there being different types). Dr. William Park says “he doesn’t understand the question” ~ I have to explain my question to Dr. William Park several times ~ Dr. William Park then says “he doesn’t know.”
January 8: WBC is 64 today. I ask Dr. Amy Morris (per Dr. Michael Hori discussion) if VMC has run the test that determines what type of WBC it is; Dr. Amy Morris looks on her computer and says that the majority are Neutrofils which are usually seen after a surgery; she also mentions that there is a whole group of WBC’s (and mentions lymphocytes). Does Dr. Michael Hori or Dr. William Park know how to use a computer to look up information?
Too
busy to check in on an ICU patient when a severe complication arises:
January 7: The nurse and I go to turn Mark to his side so the wound nurse can change the bandages for Mark’s bed sores (which were preventable). Mark is on his side for about 5 minutes and by the time we turn him back over there is a huge amount of bile all over the blue sling that is beneath him and the large bandage that is over Mark’s G-tube (Tegaderm like bandage) is literally full of fluid. I ask one of the nurses to tell Dr. William Park; they don’t. I ask the nurse to page Dr. Daniel O’Neill; she does. I tell the nurse to talk to Dr. Daniel O’Neill first (to explain what happened in a technical manner) and then I would like to talk to him. Dr. Daniel O’Neill calls and talks to the nurse but says “he is too busy to talk to me even though something as critical as this happened.” Dr. Daniel O’Neill eventually calls me later this evening – when “he has time.”
January 9: Mark is in a lot of pain now and is belching massively. Jed goes to change the bandage on Mark’s G-tube incision and I see a light green bubbling/oozing fluid (bile) dripping down Mark’s side. At his same time I see Dr. Amy Morris and Dr. Daniel O’Neill in the hallway and ask them both to come in to Mark’s room and look. Dr. Amy Morris “is too busy;” Dr. Daniel O’Neill comes in (without gowning and putting on gloves) and removes the bandage. Dr. Daniel O’Neill looks very concerned. Dr. Daniel O’Neill says this is common and moves the G-tube around a bit; he may have to consider a pancreatic drain. Mark is in a lot of pain even after Jed gave him the Fentanyl. Dr. Daniel O’Neill says that to replace that G-tube Mark would have to be moved to some type of acute place. Dr. Daniel O’Neill suggests putting the suction (instead of gravity) on the stomach fluid drain. Jed does. I mention Mark’s abdomen and thighs looking like they will burst; Dr. Daniel O’Neill says he will talk to Dr. Amy Morris and see if there are areas that can be drained in Mark’s abdomen. I ask Dr. Daniel O’Neill where all the drainage is coming from (is it his stomach or bile in his abdomen leaking out?). I get no answer.
A little later Mark starts foaming at the mouth massively and burping quite a bit. I now hear the suction/gurgling coming out of the incision. Mark keeps rubbing his stomach and is in a lot of pain.
Do VMC doctors read the tie-in or anything? NO
January 8: Dr. Michael Hori comes in and says he has never seen a person on “4” pressers (for blood pressure) in his career (Dr. Michael Hori obviously didn’t read the tie-in or review the current drug library). Dr. Andrew Brokenbrough comes by and because Mark is on “3” pressers he wants Mark to begin CVVH-DF tomorrow.
January 16: Mark’s Death and VMC Discharge Summary: Dr. Wynne Chen states on the summary “However, subsequently during the course of his (Mark’s) hospitalization he did develop a pseudocyst; this fluid collection was drained twice, initially sterile. Subsequently, however, this as well grew Pseudomonas consistent with sepsis.”
Mark did not grow Pseudomonas in a pseudocyst – see labs on December 8, December 15 and January 6. I read the lab work; Dr. Wynne Chen didn’t. I wonder if any of these doctors read anything.
What really happened?
December 2: Dr. C. Gabriel Alperovich places tracheotomy and Peg tube for nutrition – CROSS CONTAMINIATION OCCURS (the surgeries happen in this order).
December 4: Pseudomonas is now found in Mark’s lungs
December 14: Pseudomonas is identified in Mark’s stool (I’m not told about this and the Burkholderia that is found later in the G-tube incision. Both performed by Dr. C. Gabriel Alperovich – this is not in any Focus Notes).
January
9 – the massive belching begins:
January 10: Bob Chapman, Rn announces that it is official that Mark has respirator assisted pneumonia (according to some measurement). Bob Chapman, Rn, any idiot knew this right after VMC intubated Mark.
I ask Mary to page Dr. Christopher DiRe. Dr. Christopher DiRe shows up at ~12:30 and tell him about Mark foaming at the mouth, massive gas, belching, rectal tube bag being full of gas, the gurgling feces between Mark’s legs (on the bed) and about the G-tube incision discharge gurgling (you can hear air in there). Dr. Christopher DiRe says this all has to do with the complex nature of fluid collection and that it is possible that the stomach fluid got into his abdomen. I told him this all started right after the Bronchoscopy performed by Dr. Amy Morris. I ask about the stomach fluid sample that Jed took the day before and Dr. Christopher DiRe says it has amylase in it. I also mention gallbladder stones (Dr. Christopher DiRe has no idea that these showed up back in November). I have to show Dr. Christopher DiRe the lab (and Dr. Christopher DiRe looks up on the computer).
January 11: The G-tube incision continues to leak; it’s now brown and foul smelling (per Cheryl, Rn). I also notice that a lot of the fluid retention in the stomach is going down; however Mark’s thighs have double in size. I also write this on the white board.
Mark’s mouth is foaming quite a bit today (also doing the spit balls) and he is rolling his head back and forth most of the day. Come to find out Cheryl, Rn gave him Ativan to “keep him calm.” Cheryl, Rn, likes giving patients a lot of drugs.
January 14: I go over (in our group doctor meeting with Doctors Dr. Wynne Chen, Dr. Michael Hori and Dr. Duane Carlson + staff) the events from January 7 to present (G-tube incision leakage to the foaming of the mouth, massive gas [belching and the rectal tube bag being full of gas]). I ask what happened to Mark. Michele Bohl, Social Worker, tries to circumvent what happened to Mark and re-asks the question pointing to this all being caused by feeding/nutrition (and why the nutrition was stopped).
Dr. Duane Carlson says “no” to Michele’s response, that would not have caused those symptoms and he begins to explain that a bacteria population could have caused this (as the bacteria are eating through Mark’s digestive tract they produce gas). At least Dr. Duane Carlson didn’t lie and told us (finally) the truth about the hospital acquired bacteria.
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