Tell you true, I’m not into the Super Bowl. But I am into analogy, and Bill Thatcher of Cautious Patient Foundation has come up with a doozy.
It’s said that the new Dallas stadium where Super Bowl 2011 will be played seats 108,000. Medical data has shown that that’s roughly the number of people who die each year from medical error in hospitals. My dad may have been among them back in 2005, with two separate infections—or so I thought at the time. He’d had a urinary catheter inserted that was too big, and the tech too lazy to go get the right size (my NICU nurse sister was present at the time although beyond the drawn curtain). He wound up with a MRSA bladder infection—a very big deal, especially for a man who’d never had any urinary tract difficulties at all in his 84 years. Dad also had developed a bulbous painful wrist which the docs initially (for two weeks) thought was a new cellulitis site (cellulitis is ballooning of the limbs caused by water retention, itself a result of certain heart medications for those with degenerative heart disease). The bulbous wrist turned out to be a blood infection that had lodged there.
Dad needed a non-heroic operation to drain the wrist. He specified “no intubation” due to witnessing Mom’s ~3 week terminal intubation fifteen months prior. The anesthesiologists refused on the grounds that failing to intubate should it prove required to save Dad’s life would be doing harm. But Dad was a DNR. Didn’t matter. No conversation, explanation, queries, or disclosure about the nature of surgical or post-op intubation ensued by any party. There was no where to turn (or so we thought at the time), so Dad admitted to hospice and died four days later. This 2nd hospitalized demise launched me into end-of-life reform and patient safety advocacy.
Fifteen months after Dad died I called the facility and tracked down the patient advocate employee whose card I’d taken and disposed of fifteen months earlier (my bad, and I own it). The snafu, the 3rd DNR-related snafu occurring during my parents’ demises, caused me to include in Notes a 33-page chapter entitled ‘The Complete Do Not Resuscitate Conversation.’ Anyway, the advocate—an RN—pulled Dad’s records and suggested that blood infections in the elderly usually wash up in one joint or another. I failed to ask back then where the blood infections come from. In any case, at that time and until recently, I considered the two infections as separate.
I recentlyh read Severed Trust by George Lundberg, MD, a former 27-year editor of the Journal of the American Medical Association. In it he cites now 10-year-old statistics about the number of deaths due to hospital error. He lists the main causes. Among them is catheterization. Now I’m not so sure that Dad’s two infections weren’t one, and regarding this aspect of medicine I am no longer sanguine (in either sense of the term).
So back to the Super Bowl. Bill suggests that we imagine all the people in the stadium dying in one year’s time (that’s about 12 every hour). Do that; I’ll wait… OK, you’ve just internalized the number of Americans who die needlessly every year, year in and year out, as regular as the Super Bowl itself, due to medical error while hospitalized.
That’s Bill’s analogy. I’ll extend it.
Since families are sort of like teams, multiply that number by, say 5 for close family members who will feel particularly impacted by their losses, their awful unfoldings and ramifications, until they too die, hopefully under peaceful circumstances. (Digression: if you want to die in peace, please believe that there’s a straight line connection between doing so and patient safety matters.) Now we have an impacted population of 540,000 annually. Keep adding half a million impacted people year after year.
This is just too much pain.
Now imagine this: Imagine that the stadium has 52 major sections seating 2077 people, and each section is divided into 7 zones seating 297. Each week, all the people in a zone—297 people, of all ages—slump over dead. After four weeks 2077 people are slumped over, and the entire section just collapses as if by implosion (kinda what a patient-family feels emotionally in hospitals nationwide). Week after week, regular as clockwork, starting at gate 1 and ending at gate 52, people slump over and another section collapses. By year’s end, no more stadium. Poof! Where have all the people gone?
Extend it further: make the stadium as large as the lower 48 states. So large that you really can’t see the slumping and collapsing; it’s too dispersed. All that you can sense, every now and then, is a momentary change in the light, a flickering. That’s someone dying who most likely ought not be dying. If your loved one is among them you’ll see the poofs of dust spread across your field of vision as you sit grieving in your armchair while another long day’s sun sets.
Toss all this around for awhile. We need a new playing field, don’t we?