Early in my career I was struck by how much I didn’t really understand about how hard it was for patients to access medical care. Long story short, this lead me to a career that has focused on quality and patient safety. I have worked at the national level in the VA and I have worked in large academic medical centers as a leader in quality and safety. And for all of this, despite everything I know, I could not save my father.
My Dad is a complex man. Very smart. A college professor who became frustrated that the nation didn’t always support PhD despite telling young people to go into science. But he was a remarkable teacher, a man fascinated with medicinal plants, a birder and the most amazing gardener. I can’t grow a tomato plant, he could grow anything. Like many 83 year olds he is slowing a bit, much to his frustration. He has cardiac disease, a scary bout with prostate cancer that ended happily, and well controlled rheumatoid arthritis. But he and my mother would take long walks, his garden was amazing, and he still loved reading, finding amazing minerals or a new artist, and holding a rare old book in his hands to see what was inside.
My father was out with my mother doing normal things and a strange sequence of events led him to a fall. He broke his left kneecap and his right wrist. The wrist just needed a cast, the knee needed surgery. The surgery was uneventful and I worked hard to get my dad into acute inpatient rehab to jumpstart his recovery. He was really looking forward to his 65th high school reunion and this seemed like a way to motivate him. A few days into his rehab stay he developed a hospital acquired UTI. It didn’t seem to respond to antibiotics though I was told it was not multi-drug resistant. He kept getting worse.He got confused one night though it cleared a bit in the day. He stopped eating. My mother asked physicians to call and so did my dad. One resident did….once. He said he would stay in touch, he didn’t. Nor did anyone else.
Last week he got worse and it was clear that I needed to get home. I didn’t make it in time. Though my mother had been asking for doctors to call me, the call I finally got was the one that told me they were doing CPR on my father.
So here I am. My career focused on improving quality and patient safety and none of it helped my father. He is in the ICU on a ventilator with multi-organ damage and no clear sense whether there is a brain left that is worth saving. My father was proud of his mind.
When I got home and spoke to the ICU team it was clear to me that they were caring for a man who had been gravely harmed by their health system. There was no mention that a patient safety report had been filed. No mention that what had just happened meets the Joint Commission definition of a sentinel event. After I spoke to them, perhaps they began to see the problem.
But here we are. A week later and no one from the quality office has reached out to us. I have had to reach out and push to see that things are being reviewed. There has been no disclosure. No contact. They don’t seem to understand their obligations.
So after all this time, effort and money spent on improving the quality of care, here we are. We must do better. We must stop seeing patients the way the medicare and insurance billing makes us….just a long list of medical conditions that we maximize in our charting so we can get paid.
That approach has a cost. It makes our patients into old people with diseases. Or young people with tragic diagnosis or accidents. I needed the team that should have been aggressively treating my father’s Hospital Acquired Infection to not see him as some old guy with some medical problems who got sicker. I needed them to see the gardener, the birder, the still inquisitive and active (though retired) professor who trusted them to get him back to who he was.
I hope things get better. I hope this facility recognizes and acknowledges what they contributed to. If they don’t I expect I will help them.