Internal Bleeding by Robert M. Wachter and Kaveh G. Shojania

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Chapter 10 is divided into three stories of patients being passed around from physician to physician and the results of lost medical history.

The first story is of Tung Jan, an immigrant from Taiwan. He came to the United Stated looking for a better life. In his old age Jan was bound to a wheelchair or bed. Jan was a lifetime smoker and had end-stage emphysema. He carefully planned out his decisions of his care in his final years. Jan decided he did not want to be resuscitated, only to be given medication to ease his passing. One evening a nurse discovered Jan fighting for air but he could respond to what the problem was. The nurse was unaware that Jan was not to be coded and called 911. The paramedics did not know Jan was flagged as DNR because no had done so. After a failed attempt to put a breathing tube in him, Jan was put on oxygen and rushed to the nearest emergency room.

Once in the ER, Jan was still unresponsive and out of breath. The ER physician successfully inserted a tube into his lungs that was hooked up to a portable ventilator and he was taken to the ICU to be treated for his pneumonia.

After several hours, Jan’s son was finally tracked down and informed the physicians that his father was DNR. The son was faced with a difficult decision and did not know where to go from there. The doctors continued to support Jan. The doctors tried to lighten Jan’s sedation but he would become aggressive and try to “yank” the breathing out of himself. The doctors soon decided to see if Jan could breathe on his own and removed the breathing tube out. Jan was discharged back to the nursing home and his son made sure the DNR document was in his father’s file. Jan entered hospice care and died two months later.

The second story is of Joe Silber. Joe was admitted into the ER for chest pain that was not going away. His blood was normal and showed no sign of elevation in troponin and his EKGs were normal. His pain persisted but the he was ‘ruled out for MI’ (163). Silber’s ER physician also ordered a chest X-ray. The X-ray was taken but was quickly forgotten about because nobody expected anything to show up. Silber was discharged and went on to his life with the chest pain subsided.

The hospitals radiologist examined the X-ray and discovered a small lung nodule. The report was called in to the physician’s office and a paper version was sent back up. The physician’s partner received the report and he sent it to his colleague. Somehow the report of lost and the primary physician never saw it. Two years later, Joe was readmitted into the ER for a chronic cough. Another X-ray was done and large lung nodule was discovered. The doctor never knew about the first X-ray so they never acted on the nodule. Eighteen months later Joe Silber died of lung cancer. He life could have been saved by early detection but the first X-ray was never found and he was never treated for the lung nodule.

Both of these cases had one thing in common. Both suffered from handoffs between professionals. Handoffs occur each day across the country. The problem occurs at discharge. It is up to the patient to take care follow up appointments and medication. Most patients, especially the elderly, are “incapable” of these important steps.

The only ones who can prevent fumbles are the patients by making sure to keep updated information on medication and making follow up appointments. The system needs more rules and regulations on transitions and handoffs.

“ We need ‘bridge the gap’ training for caregivers on both sides of a transfer—to make out hypothetical health care system less virtual, more real, and better integrated. We need to talk to each other not just after we make mistakes, but before they happen” (179).

There needs to be a better way to handle handoffs and make it easier for patients to receive the care they need before a fatal mistake happens.

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Work cited

Wachter, Robert M., and Shojania, Kaveh G. Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes New York: Ruggedland Publishing 2004

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