Like Two 747’s Crashing Every Day: the worst airline accident in history


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What are the three leading causes of death in the United States? Most people quickly identify heart disease and cancer, which in fact respectively account for about 750,000 and 550,000 deaths annually. The third leading cause of death is usually a guess: Alzheimer’s? Diabetes? Obesity? Traffic accidents? Airline crashes? With at least 440,000 deaths a year almost no one guesses the correct answer: medical errors. The practice of medicine, including diagnosis, treatment and surgeries, is the cause of deaths that approximate the number of fatalities of two full capacity 747’s crashing every day. If on one day there was such a loss of life due to airline crashes there would be massive investigations and media comparable to the March 1977 crash in Tenerife considered the worst airline accident in history: the search for black boxes, analysis of the weather, integrity of the equipment, the qualifications and behaviors of the pilots, and the airline’s quality assurance procedures. If two 747’s crashed on two consecutive days, there would be implications of terrorism, accusations of conspiracy. If two 747’s crashed on three consecutive days, the impact and reaction are unfathomable, but one could only guess that mass panic would set in nationally and internationally. Yet 1,200 Americans, twice the number of the casualties at Tenerife, die day after day, 365 days a year with the resulting death toll being that of the annual wiping out of the populations of major US cities: Atlanta one year, Sacramento the next, Miami the next, year after year. These tragic losses are not just numbers. They are our grandparents, mothers, fathers, siblings, our children and our friends. They are the victims of wrong site surgeries, the aorta sliced instead of the renal artery, over-medication due to a misplaced decimal point, a misdiagnosis of a hypokalemia leading to cardiac failure, a hospital acquired infection from inadequate cleanliness of supplies, equipment and hands, or a sponge left inside the surgical site.

How this is happening without public knowledge, panic and outrage is a simple question of multiple determinants. There are explanations when required, which is seldom. Hospitals are complex environments. To Err is Human, as the 1999 Institute of Medicine report citing the underestimate of 98,000 deaths a year was titled. In 2013, John T. James, PhD, a NASA toxicologist who’s own son was the patient who died from misdiagnosed hypokalemia, published his robust study based on findings using four different research tools, in the Journal of Patient Safety. His study results more than quadrupled the IOM number to 440,000 deaths a year. To err may be human, but in truth, all too often decisions for care are dictated by financial initiatives to benefit the hospital rather than the best care of a patient; hospital error reporting that is voluntary ; hospital quality assurance that is actually cover up ”risk management”; the autonomy of doctors who are never evaluated, tested or required to upgrade training and cannot admit that they have made a mistake. Atul Gawande, MD, in his book Complications stated, “There is a saying about surgeons, meant as a reproof: sometimes wrong; never in doubt.” Government, regulatory agencies and patient advocacy organizations have pressed for changes in reporting, hospital policies and procedures, and checklists ironically based on those used in the airline industry, but the number of deaths has not decreased, the needle on the scale of improvement hasn’t budged.

The Veterans Administration hospital scandal in June 2014, exposed the deaths of at least 40 veterans who died due to medical errors including delays in their diagnosis and treatment. But months and even years before the exposure, when lives could have been saved, employees in the hospitals had been raising concerns and reporting dangerous practices, inadequate care, and fraud. These whistleblowers were intimidated, threatened, harassed, transferred, put on administrative leave without pay and fired. Not unusual treatment for whistleblowers as recent high profile cases have been broadcast in the news.   The VA is now hustling to correct care deficiencies and provide remedies to the whistleblowers, but not enough to restore lives and repair permanent damage.

The Veterans hospital deaths as tragic as they are, are the tip of the iceberg of the 1,200 a day medical error deaths. Patients are dying in private hospitals, public hospitals, community hospitals and super-sized academic medical centers. Within these facilities whistleblowers have attempted to report and correct wrongdoing and system flaws that lead to the daily death count as well as almost 4 million errors a year that leave patients disabled, damaged and compromised. Like the whistleblowers in the VA hospitals these health care employees, nurses, lab staff, managers, and some doctors themselves, have lost their jobs, their health insurance, their retirement benefits, their professions, and ability to find other employment. Dr. Marty Makary states in his book, Unaccountable, which documents his experiences of patients suffering from medical errors, “if I was labeled as a whistleblower, my career would be shot.” Telling the truth in health care is risky business.

There is a long history of retaliation against those who have spoken out against the medical status quo that puts patients at risk. In 2008, Dr. James was presented with the Semmelweis Award, named for Dr. Ignatz Semmelweis, considered now the father of patient safety.   The observational case control study conducted by Semmelweis in the mid 1800’s indicated that women and babies in hospital maternity wards were dying because doctors were not washing their hands after examining cadavers and then delivering babies. With a maternal and infant mortality rate of over 18% in hospitals where doctors delivered babies in comparison to a 2% mortality rate for deliveries at home with midwives or even poor women whose babies were delivered in tenements, Semmelweis wrote a treatise, The Etiology, Concept and Prophylaxis of Childbed Fever, on the imperative for doctors to wash their hands between patients. The medical community was outraged that he would state that doctors’ lack of clean hands was killing women and babies. Semmelweis was declared mentally unfit, and confined to an institution where 14 days after his admission he was mysteriously found dead, presumably beaten to death by guards. His work was not recognized as valid until two decades later after Pasteur and Lister presented evidence of germ theory. In 1965, to mark the 100th anniversary of his death, Semmelweis was honored with his image on an Austrian postage stamp. Doctors in the United States today are still less than 50% compliant in hand washing.

Despite current legislation in healthcare law, shooting the messenger is still the general practice in medicine. Retaliation is often couched in legal defense of protecting patient confidentiality, and hospitals misuse HIPAA as a way to attack whistleblowers. But more effective to deter whistleblowing, hospitals maintain cultures of don’t talk or else.   Special Counsel Carolyn Lerner of the Office of Special Counsel, a whistleblower protection agency, has stated that 125 VA hospital employees have filed retaliation cases. Three of the whistleblowers she has represented are Dr. Katherine Mitchell, Paula Pedene and Damian Reese. Mitchell reported understaffing and inadequate training of staff in the emergency department at the Phoenix hospital and was removed from her position as the co-director of the emergency care. Pedene, formerly the hospital chief spokesperson, was re-assigned to a job in a windowless basement office after she reported financial mismanagement in Phoenix. Reese complained about the data manipulation that covered up delays in care; he was given a negative performance review. Lerner stated in a PBS report, (September 29, 2014,) “Dr. Mitchell, Ms. Pedene and Mr. Reese followed their consciences and reported wrongdoing, and their efforts have improved care and accountability at the VA,”

The recent British National Health Service report on whistleblowing, Freedom to Speak Up? (February 2015,) by Sir Robert Francis QC, documented the retaliation that was mounted against staff in hospitals for reporting systemic problems, incompetence and medical errors that impacted patient safety. The report includes recommendations for a shift in culture to not only protect but value whistleblowers, and zero tolerance for retaliation.

Like whistleblowers in other fields, most healthcare whistleblowers say they would do it again even knowing what the consequences would be. Why would they engage in such high-risk behavior? A 2011 National Business Ethics report states that most whistleblowers are very committed to their workplace and they have been successful performers. An article by Vicki D. Lachman, Whistleblowers: Trouble Makers or Virtuous Nurses? (MEDSURG Nursing, April 2008,) bases whistleblowing in healthcare as driven by the ethics of the duty to tell the truth, the standards of professionalism (nursing Code of Ethics,) virtue, and that inexplicable courage that causes an individual to jump into harm’s way to safe the life of another. She also states that, “They (whistleblowers) are above average performers committed to the organization with a strong belief in moral principles.” Lachman however notes the potential retaliation:  “The list of negative consequences to whistleblowers seems endless: broken promises to fix the problem, disillusionment, isolation, humiliation, formation of an “anti-you” group, loss of job, questioning of the whistleblower’s mental health, vindictive tactics to make the individual’s work more difficult and/or insignificant, assassination of character, formal reprimand, and difficult court proceedings.”

The victimization of patients and the victimization of people on the inside of healthcare trying to save lives cannot be ignored. These tragedies are deserving of a hard look at where the bodies are buried, who is causing these deaths, and what needs to be done to protect whistleblowers so that when we access medical care we are not inadvertently boarding a plane destined to crash and burn.

 

 

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By Any Other Name: A Life Well Lived

The devastating epidemic that claimed the lives of 100,000,000 people globally and at least 600,000 in the United States caused the death of her young father, the family support and breadwinner when she was only 3 years old.  She was sent to live with her grandparents. Her sister died when she was about 5, from what was thought to be a heart condition, although diagnostics were limited then.  Children often died and the cause was a sad guess. The separation from her mother and two other sisters was emotionally difficult for her, but under the financial circumstances in the family and nationally, her mother knew it was her best opportunity.  Her grandparents had a small grocery store so no matter how limited their income was there was always nutritious food, for her, her family and the local community, her grandparents often taking a parrot, a zither, a paper IOU as payment from neighbors for their groceries.

She was told at some point in her adolescence that she might not be able to have children, and yet she married  and had three daughters.  She had a heart attack.  There was a diagnosis of breast cancer, a breast removed, chemotherapy.  A broken hip.  A thyroid condition.  Upper respiratory infections.  The long slow decline of Alzheimers.

My mother, Rose, died last week at the age of 96.  Despite the health and financial challenges, she thrived for most of those 96 years.  Last August my youngest daughter, Alex, and I visited her at the nursing home she lived in for about 5 years.  She was bright and happy to see us although at some point during the last few years I had realized that she might not really remember my name or which one of the daughters I was.  But she was all smiles and hugs that day, and she loved that we were there with her.  She particularly loved the granddaughters.  Once about 4 years ago, she was rushed to the hospital barely conscious.  My daughter Kierra and I met my sister in the emergency room and standing at her bedside we all believed that my mother was about to die.  Concerned that she might, even in that state, be thirsty, Kierra dripped some juice from a straw onto her lips.  She licked her lips and as the juice ran into her mouth she swallowed.  Her eyelids fluttered open and she smiled at Kierra.  “What are you all doing here, Sweetheart?” she asked.

Fortunate to have had her for so long and to have been able to spend her last two days of life with her, I am still grieving, but I also can’t help but wonder what it was that contributed to her long life.  My father died in 2001 at the age of 86 from a heart attack.  Most of my parents’ friends have died.

When I think about the generally accepted contributors to health, exercise, good nutrition, and keeping mentally active, I wonder how these affected my mother’s life.  She was always active gardening, cleaning, taking us kids to the beach, helping at the church, but she never went to a gym, never ran, never wore spandex.  Even at the beach she wasn’t a swimmer.  She and my father though would take walks around the neighborhood, holding hands.  And nutrition, well, she was an amazing cook and in the summer months was always gathering fresh fruits and veggies and then canning and freezing them to get us through the winter with those summer vitamins.  But, there was lots of meat (red and otherwise) in our diets:  Sunday roast beef, pork and dumplings and sauerkraut, fried chicken, bacon and eggs for breakfasts.  I remember that when I was in elementary school, the other little girls had these darling little sandwiches made of cream cheese, and peanut butter and jelly, maybe tuna salad, cute sandwiches with the crusts cut off.  I however, would remove from my lunch box, big hunks of homemade bread with a fried veal cutlet or slabs of leftover Sunday roast beef.  And by the way cutting off crust was considered totally wasteful and my parents subscribed to the philosophy that  eating “crusts makes you pretty.”  And of course there were not only the sandwiches…..my lunch box consistently contained a big slice of homemade lemon cake (with frosting) or apple strudel or a poppy seed pastry or chocolate chip cookies.  Well into my parents’ late 80’s, my mother was known as the “Cookie Lady” in their neighborhood because rather than giving kids’ candy bars for Halloween, she baked cookies that she and my father put in little baggies with ribbons to give out to the costumed callers.  They were renowned at their church for making literally hundreds of donuts (fried in hot oil of course!) for the Fastnacht celebrations every year the night before Ash Wednesday.  For all of this, neither of my parents were ever overweight, nor are or were any of their off-spring.

So exercise and nutrition in my mother’s life were not exactly by the public health book.  Keeping mentally active was.  When I was in high school, my mother, who was a very good student in high school but never went to (as if it would ever even have been thought of) college, became the assistant for a well-known sociologist in Stony Brook.  She took over his academic life as a gentle whirlwind, organizing his books, redeeming royalty checks that were long expired, editing his manuscripts, negotiating with publishers and handling all of his correspondence and travel plans.  Long after Dr. Nelson died in his sleep on a train in Italy, my mother continued to read academic articles and edited my sister’s doctoral dissertation and my masters thesis.  But that wasn’t all.  She sewed.  No, she didn’t just sew, she was the mastermind of three daughters’ and her own wardrobes.  Months before Easter Sunday, we would all make a pilgrimage to various fabric stores where we would study pattern books for the latest fashions, hunt through bolts and bolts of fabrics, and ferret out the best notions:  little fabric frogs, buttons, lacey trims.  And then over weeks my mother would work her magic with pins and those thin paper patterns and hours and hours at the sewing machine.  And those, long  “hold still!!!!” sessions of her pinning up the hems and adjusting waistlines, shoulder seams and zippers.  She knit us sweaters and scarves and  crocheted a dress for me that I still have.  She made millions of little craft items and baby sweaters and booties, and cloth dolls for church fairs.  When the grandchildren she adored came to visit she taught them how to make little Christmas mice, pot holders and seashell jewelry.  She always had the best craft supplies. My daughter Kristin loved those little Grandma mice.

So what else?  Certainly the literature supports the association of a long stable relationship with health.  Rose and Charlie were together in a loving mutually supportive marriage for almost 70 years.  My mother had a very strong network of family support, neighbors and church members:  a social support being a strong indicator of health.  My father worked for Grumman Aircraft and so we all had good healthcare benefits:  I actually remember as a child when my parents thought I might have polio, the doctor coming to our house with his little black bag.

And then there was my parents’ consumption of coffee, the health benefits now well documented.  From the Harvard Review: In 2011, researchers reported findings that coffee drinking is associated with a lower risk of depression among women, a lower risk of lethal prostate cancer among men, and a lower risk of stroke among men and women. Go back a little further, and you’ll come across reports of possible (it’s not a done deal) protective effects against everything from Parkinson’s disease to diabetes to some types of cancer http://www.health.harvard.edu/press_releases/coffee_health_benefits

And this in the Daily Beast:  A new study suggests that drinking coffee significantly reduces our skin-cancer risk. There’s a raft of other research that’s piling up evidence that regular cups of joe—six-ounce servings packed with antioxidants, polyphenols, and other health-boosting chemicals—can prevent everything from diabetes to depression to cirrhosis of the liver to stroke. (Intracranial aneurysms, not so much.) Scared of superbugs? Pour yourself another cup. http://www.thedailybeast.com/articles/2011/10/28/coffee-health-benefits-how-coffee-might-save-your-life.html

My parents didn’t know any of this and perhaps all the coffee health benefits were outweighed by my mother’s yummy buttery pastries and cookies and cakes that went along with the caffeine and antioxidants, but I do believe that the two of them sharing coffee at breakfast, the mid morning coffee, coffee with lunch, the mid afternoon coffee break, coffee after dinner and the late evening coffee (usually accompanied by ice cream,) contributed to my mother’s long and happy life.  Maybe it was the conversations they had while they were drinking coffee or the plans they would make or the hand holding that went along with the coffee.

My mother was not a public health professional, she wasn’t a nurse or a doctor although I do truly believe that she saved my life several times when I was a child by making me yum yum, a combination of hot milk, honey and butter, in the middle of the night.  She wasn’t a great philanthropist with a foundation that put her name on some medical center building or library, and she wasn’t the author of any great books.  Her long loving life is however a testimony to a life well-lived and perhaps the greatest lesson we can learn about our own health and improving the quality of life in the world:  Love the people around you.  Be passionate about everything you do, especially those the small acts of kindness.  Make the world more beautiful in your own unique way.  Love children, grow roses, knit a scarf, bake cookies, smile at strangers, hold a hand, share a cup of coffee, change the world.


Rose’s Czech Peach Dumplings

This recipe makes 8 dumplings

In a glass measure, pour 1/2 cup milk. Add 2 large eggs and whisk together to blend.

In a large mixing bowl, measure 2 cups all purpose flour, 1 teaspoon baking powder and 1/4 teaspoon salt. Stir to mix. Make a well in the center of the dry ingredients and pour in the milk and egg mixture. Use a wooden spoon to mix well. Dough will begin to get stiff. If it is very sticky, add a little more flour. The dough should not be sticky, but should still be soft enough to roll into a sheet.

Divide the dough into 2 pieces. Roll out one piece at a time into a thin sheet and cut (with scissors) into 4 square pieces. Place a half of a peeled, pitted peach on each piece of dough, and add a small piece of butter, sprinkle with cinnamon and sugar.  Fold in the corners of the dough to cover the peach half.  Be sure the peach is sealed well in the dough. Repeat with the other piece of dough.  Sprinkle some flour on a clean surface. Set the peach dumplings on the flour and cover loosely with a clean kitchen towel. Bring a large covered pot of water to a boil.  When water is boiling hard, gently drop the dumplings into the pot. Put the cover on the pot. Set the timer for 20 minutes. Do not take the cover off the pot until the timer rings. Transfer each dumpling to a large dinner plate. Prepare to eat by cutting into small pieces. Pour melted butter over the dumpling. Sprinkle with more sugar and cinnamon. Eat. Enjoy!!!