Medical Catastrophe

by Ronald W Dworkin

  even in the old days, because you always risk accidentally injecting some anesthetic into the spinal canal when placing an epidural. So even when

  they thought the drug was neurotoxic, they still allowed it,” he replied.

  “This is idiotic,” I complained.

  “You’re right. It is idiotic. But there’s nothing you can do about it.

  You see, the system is idiotic,” he said.

  “Wait, you know the system is idiotic. So then why don’t doctors

  change the system?” I asked.

  “They can’t,” he said. “But that’s okay, because the system is idiotic

  and I live under the system, but it doesn’t oblige me to be an idiot. And other doctors aren’t idiots, either. Everyone understands everything, but there’s nothing they can do.”

  Eager to elude the more obvious danger, and now flummoxed by a

  label, I surrendered to the power of the platelet rule and opted for general anesthesia.

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  C H A P T E R 8

  I gave Ms. O two puffs of her asthma inhaler and brought her into the

  operating room. While the patient breathed oxygen on her own, the nurse

  announced a time-out. Everyone in the room stopped what they were

  doing and paid attention, as required during a time-out. Afterward I began the anesthetic induction.

  Because Ms. O had eaten only a few hours before, I could not slowly

  breathe for her during the induction to get her deep on gas and in that way lessen the chance of bronchospasm associated with intubation. Mask ventilation risks churning up a patient’s stomach contents and causing aspiration. Instead, I rapidly injected the anesthetic drugs into her intravenous and intubated her. Then I connected the breathing tube to the anesthesia

  circuit and squeezed the bag.

  Tremendous resistance kept me from pushing air into her lungs. I

  listened to high-pitched squeaks in Ms. O’s chest with my stethoscope as

  I compressed the bag with all my strength. She was in bronchospasm. Her

  oxygen saturation dropped. The pressure needed to push air into her lungs was high enough to risk pneumothorax. I quickly turned on the anesthetic

  agent to dilate her bronchi, but it was hard to get air into her lungs, let alone anesthetic agent. Meanwhile, the nurse announced a second time-out.

  When time-outs were first introduced, some doctors and nurses grum-

  bled that they delayed the start of a case. Nevertheless, these providers adapted, especially when they realized the time-out’s safety benefits.

  Some hospitals, however, doubled down on the time-out, or even tripled

  down on it. They demanded staff perform two time-outs or even three

  time-outs before starting a case, thinking that if one time-out decreased the rate of medical error, more time-outs would do so even more. In other words, although doctors invented the idea of the time-out, administrators took control of the idea and ran with it. Doubling and tripling the number of time-outs is not illogical, at least theoretically. But it does push against the law of diminishing returns.

  The nurse announcing the second time-out demanded my attention.

  During a time-out all staff must stop what they are doing and listen. But I was busy managing Ms. O’s bronchospasm. The nurse asked me to stop

  and pay attention. I told her I was busy. The nurse hesitated over what to do next. Should she ask me again to stop? Should she skip the second

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  time-out? Should she continue with the time-out while making an excep-

  tion for me? She fidgeted for a few seconds, during which time I recog-

  nized the anxiety in her eyes. It was the same anxiety that I had about the platelet rule. A rule in medicine demands certain conduct; if you violate that rule, you risk getting into trouble. In my case, I feared a lawsuit; in her case, she feared being fired. The time-out rule was the rule at most

  hospitals, rigidly enforced, “up to a point,” but what that point was she didn’t know.

  I wanted to help her. I wanted to tell her that doctors had invented the

  time-out rule, and that because I was a doctor I knew the exact point

  when the rule could be overlooked. But we doctors had lost control of the time-out rule, just as we had lost control of the platelet rule. Hospital administrators now owned the rule, and there was nothing I could do.

  Fortunately, the nurse made the sensible decision and conducted the time-

  out without me.

  I broke Ms. O’s bronchospasm with inhalers and anesthetic gas. With

  difficulty we moved Ms. O onto her side, almost three-quarters prone.

  The nurse prepped the patient’s hip and the surgeon started to cut.

  An hour into the surgery I noticed the pressure needed to push air into

  Ms. O’s lungs rising again. I listened to her chest but heard no wheezing.

  The pressure continued to rise. I turned off the ventilator and manually

  squeezed air into her lungs with great difficulty. Thinking there might be an obstruction in the breathing tube itself, I passed a suction catheter

  through it. The catheter barely passed. Out through the catheter flowed

  thick yellow, gelatinous mucus. The breathing tube’s presence had likely

  precipitated these thick secretions.

  I needed an extra pair of hands to help me suction out the breathing

  tube. I looked over to the circulating nurse, but she was sitting on a stool, her back toward me, entering data on the computer. She had been entering data since the start of the case. It wasn’t her fault. New rules nationwide demanded that operating room nurses enter enormous amounts of

  data, to be collated later by administrators and policymakers to make

  more rules. The goal was medical safety. And yet time-consuming data

  entry often robs the operating room of a nurse’s observant mind and

  skilled hands at a crucial moment. Rather than decrease the risk of catastrophe, it sometimes raises it.

  A few minutes later the breathing tube obstructed almost completely.

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  C H A P T E R 8

  “We have to turn the patient back on her back—now! I need to re-

  intubate her,” I said excitedly.

  “But I’m in the middle of the operation,” pleaded the surgeon.

  “I don’t care. We have an airway emergency. Just cover the operative

  site with a sterile drape,” I insisted.

  The surgeon reluctantly draped the site. The nurse turned her head

  away from the computer screen. She looked as though she had only just

  been awakened from sleep and opened her eyes wide, trying to grasp the

  situation. Quickly she refocused. Since the operating table was too nar-

  row for us to maneuver Ms. O back onto her back, the nurse ran out the

  door to get the stretcher we had brought her in on. The plan was to jam

  the stretcher next to the operating table to give us a larger platform on which to turn the patient over.

  But the stretcher was gone! I was furious. A rescue stretcher was

  supposed to sit outside the door for just this problem. The nurse panted

  out what had happened: a new rule in the fire code had demanded that all

  halls in hospitals be cleared of stretchers. I told the nurse to go find

  another stretcher. Ms. O’s oxygen saturation dropped lower. Her color

  grew dusky. I had no choice but to remove her breathing tube with her

  lying on her side and try to breathe for her with her face half-buried in a pillow.

  It was an almost impossible task. The pillow pressed up against the

  side of her face and kept me from securing a tight mask fit. Secretions

&nb
sp; poured out of her mouth, wetting both the mask and my gloves, and

  causing the mask to slip from my grip. Also, her tongue obstructed her

  airway. With my left hand holding the mask, I stretched out with my right hand toward the instrument table to grab an oral airway. It was there—but wrapped in plastic. A new rule required all airways to be wrapped in

  plastic bags. The rule seemed silly to me, as the airways were run through a sterilizer and therefore were more sterile than any patient’s mouth. But I had already been reprimanded once for violating the rule. A rule is a rule,

  “up to a point,” but what that point was I never knew, so I just followed the rule.

  I dropped the mask and grabbed the oral airway. Then I used my wet,

  gloved hands to tear open the plastic. This took time, during which Ms.

  O’s oxygen saturation dropped lower.

  I put the oral airway inside Ms. O’s mouth and breathed for her just as

  the nurse rushed in with the new stretcher. We tilted Ms. O’s body toward

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  the stretcher, making it easier for me to mask ventilate her. Her oxygen

  level returned to normal. Still, I needed to re-intubate her to keep her

  from aspirating her stomach contents. To do so I needed more muscle

  relaxant, which sat inside the new anesthesia carts that had mandatory

  locks. Before, such drugs had been available in open drawers. Adminis-

  trators around the country had decided this was wrong because it meant

  drugs could be stolen or go unaccounted for. Carts with locks took over. I always distrusted the locks for fear they would jam during the worst

  possible moment, as during an emergency, and so I got in the habit of

  keeping emergency drugs in my scrub shirt pocket. In particular, I would

  keep an ampule of Versed on me while working in obstetrics so that I

  could treat a patient suffering from an eclamptic seizure. The four min-

  utes needed to chase down Versed in a locked cart could be catastrophic

  in such an emergency. But the new rule didn’t allow for exceptions, and

  rather than test the rules by hiding one or two drugs in my pocket, I went bare. I had no muscle relaxant on me when the lock jammed in Ms. O’s

  case.

  A bureaucrat had written the rule on locked carts. And the rule did

  have the flavor of truth. Some drugs do go unaccounted for. The bureau-

  crat had written the rule in good faith. But there is often a divergence

  between words and things; a rule written down on paper fails to represent with sufficient exactitude the complexity of situations that might arise

  and invalidate that rule.

  Why would an anesthesiologist follow this insane rule and not keep

  emergency drugs in his or her pocket? Because a normal person under-

  stands it is dangerous and pointless to oppose universal insanity, and

  rational to participate in it. In theory I was a doctor, but in reality I was an employee who lived in constant awareness that at any time I could be

  discovered, discussed, and punished. Doctors sometimes do ignore insane

  rules. They observe the rules only outwardly, while in fact living a semi-underground life. For example, anesthesiologists will write drug names

  on syringes but sometimes skip writing the time and date on them, think-

  ing it silly to add such data when they’ll be using the syringes a few

  minutes later. They will also remove their mandatory goggles before

  trying to intubate a patient with a difficult airway, to gain a better view.

  Although they do not challenge the authorities openly, they refuse to

  observe all accepted rituals, believing that some rules need only be fol-

  lowed “up to a point,” with their judgment telling them what that point is.

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  C H A P T E R 8

  However, most rules they do follow. In the past, doctors would not have

  been punished for exercising their judgment. Indeed, there was no one to

  punish them, since most doctors were self-employed independent profes-

  sionals. Nowadays, most doctors are employed, and so they are punished.

  For an employed doctor to openly flout the rules is arguably insane.

  I banged hard against the cart with my gloved hands that were wet

  with Ms. O’s secretions. A new rule obligated me to change my gloves

  before touching the cart to prevent the spread of germs. But I didn’t have time to change gloves! Worse, my hands were sweaty, and every experienced health care worker knows that putting gloves on wet, sweaty hands

  is a difficult and time-consuming process. The glove rule had no known

  exceptions. Nevertheless, I said to hell with rules.

  I retrieved the drug from the cart. After giving Ms. O a few puffs of

  oxygen, I dropped the facemask and used both hands to draw up the

  muscle relaxant in a syringe. Then I dropped the syringe to give Ms. O

  another puff. Then I exchanged the mask for the syringe and removed the

  needle. I looked for a port in the intravenous line to inject the drug. A small secondary intravenous line occupied the port. I tried twisting it off, but the nurse had wedged it in too securely. I put the needle back on the syringe and looked for a port that would accept needles. There was none.

  A new rule had banned such ports, thinking such ports encouraged the use

  of needles, which were said to be unsafe. A nurse rushed over with a

  hemostat to help me twist off the line stuck in the lone port. In the

  meantime I gave Ms. O a few extra puffs. Unfortunately, as the nurse

  twisted, the line broke off just above the point of insertion, rendering the port blocked and useless. I gave Ms. O another puff. The nurse and I

  rushed to replace the intravenous line with a new one. I gave Ms. O two

  more puffs. When the new line was in place I injected the muscle relaxant and re-intubated Ms. O.

  I should have done a spinal.

  The rest of the case proceeded uneventfully, until, as we wheeled Ms.

  O to the recovery room, I realized that I had failed to relock the an-

  esthesia cart. A rule demanded that I do so, and if an inspector had caught me abandoning an unlocked cart, I risked my job. I knew the inspectors

  from a hospital accreditation agency were due for a visit. Were they here now? I wondered. I stopped in the middle of the hallway; the nurse at the foot of the stretcher stared at me quizzically while I pondered what to do.

  If I abandoned Ms. O for the one minute needed to go back and lock the

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  cart, I risked violating a rule. If I kept going toward the recovery room and left the cart unlocked, I risked violating another rule. In the end, I decided to drop Ms. O off in the recovery room first, and then circle back to lock the cart. My hand-off to the recovery room nurses was much

  faster than usual, though, as I kept worrying about whether the inspectors were around.

  Rules in medicine are the creations of the doctors’ inner selves. Doc-

  tors devise them in labs and research centers. They do so to improve

  medical safety. But doctors have lost control of their creations. Their

  creations have risen up against them. Malpractice lawyers own them.

  Hospital administrators own them. Accreditation agencies own them.

  Government agencies own them. As a result, doctors today fear their own

  creations. When they see a book of rules and guidelines, a mysterious

  voice whispers in their ears, “That’s where ‘up-to-
a-point’ lives.” The

  rules must be followed, except when they should not be followed; only

  that critical inflection point is never revealed to them.

  More rules and guidelines are written all the time. Almost every activ-

  ity in medical practice has been carefully tabulated. Nothing has been

  overlooked; nothing has escaped the eye of researchers. There are de-

  tailed instructions for everything. But the new owners of these instruc-

  tions have less feel for them than the doctors who created them do. They

  wrongly see them as information, something with a clear right and wrong,

  like an irrefutable math demonstration, something that comes with a sure

  path toward success. They do not see that rules and guidelines are only an approximation of truth, and that at every step they need a doctor’s considered judgment to make them more exact.

  Doctors, for their part, follow the rules, especially employed doctors

  who fear being sued and fired. The rules guide their decisions. Yet the rules also stand in the way of their decisions. Doctors love their rules, but at the same time they feel as if something terrible has been imposed on

  them. It has.

  The inspectors from the hospital accreditation agency arrived a week

  later. Because hospitals would go out of business without recertification, doctors and hospital administrators fear them. Doctors are warned not to

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  C H A P T E R 8

  argue with them, to be polite and friendly, and to accept all their recommendations.

  The inspectors entered my operating room while I set up for my case.

  Although neither inspector was a doctor, both looked confident in the

  operating room. They were the kind of people who are appointed to

  inspect and without a twinge of doubt will inspect firmly and decisively

  whatever it is they have been appointed to inspect, whether it be an

  operating room, an industry, or a school.

  They studied my workspace. A laryngoscope blade lying half outside

  its package caught the main inspector’s eye.

  “What’s this?” he asked in an icy tone.

  “I always keep a blade half open, so as to be available in case of an