Canadian Healthcare–Villains Amongst the Heroes

Who is to say who is the villain and who is the hero? Probably the dictionary. - Joss Whedon

Of the many gifts that my parents gave to me when I was young, two stand out.

From my mother, I received the gift of reading and the insatiable need for constant knowledge acquisition.

From my father, I received the gift of constantly asking questions, the need to understand the “why” of things and the need to never stop asking until I was satisfied with the answer.

Both gifts came together suddenly on Saturday past when my father was admitted to hospital in Eastern Canada in septic shock and renal failure.

It turns out that he was suffering from a retroperitoneal abscess, a massive, internal pus-filled infection that has a 75% mortality rate.

Thanks to the healthcare practitioners who quickly and correctly diagnosed this condition, my father is now recuperating, fortunate to be in the 25% and not the 75%.

I am very grateful to them for their quick thinking and the result.

But as my father taught me, after an event occurs it is important to understand why this happened so that it doesn’t happen again to my father or to anyone else.

Blame is not important but prevention is.

So a little due diligence produced this interesting trail of events.

Retroperitoneal abscesses are caused by a number of things including infections introduced via hospital procedures such as routine diagnostics or surgeries.  They are also caused by bleeding within the body, including bleeding from ulcers or micro ulcers.

A little extra digging revealed the fact that my father was on an anti-inflammatory medication for 17 years as a preventative measure against a bout of arthritis he had suffered years ago.

That’s like taking aspirin for 17 years on the off-chance that you might get a headache at some point.

I spoke to a couple of doctors about the use of this medication for this long as a preventative measure and they told me that it is simply not allowed.  One doctor, when I described the use of this medication for this long, replied with one phrase, that being (and forgive the language) “Holy Shit”.

One of the interesting by-products of this medication even in short-term use is the potential for the creation of micro ulcers and bleeding and the risk is especially heightened in the elderly.  For this reason, monitoring for bleeding is required although in my father’s case, no such monitoring was performed.

Hmmmmmm …. the plot thickens.

The documentation accompanying the medication indicates that it must be used in the minimum dosage possible and for as short a duration as possible.  I wonder what the risks are from taking it for 17 years.

Exploring the doctor’s background, one quickly learns that he:

- sought to put a 20 year old male on valium to slow him down because “he works too hard”

- once put a 22 year old male on Dolobid, Feldene and Orudis (all anti-inflammatory medications used for the treatment of osteoarthritis and / or rheumatoid arthritis) and aspirin simultaneously upon receiving complaint of a sore back and without any further testing to justify the use of the medications

- sent the same young male to the hospital a short time later with the diagnosis that he was having a heart attack (he turned out to be fine although the medical team that had been alerted weren’t too pleased with the doctor).  There are known complications from the previously named medications and heart and stroke risk although the connection was never made or explored.

- told a mid 40’s patient after placing him on cholesterol treatment medication that it would be easier to treat the patient if he weren’t an alcoholic.  The patient, a non-drinker, discovered that the initial baseline liver test that is required for this medication had not been performed and the subsequent liver test for monitoring abnormal medicinal impact indicated that the liver was seriously malfunctioning (a known side effect of the medication).  Without a baseline, the doctor was blaming it incorrectly on the lifestyle of the patient and the liver function returned to normal when use of the medication stopped.

- told a female patient that the pneumonia scars on her lungs as seen in a chest x-ray were in fact the signs of lung cancer and that treatment for such was imperative.

People are still emailing me their stories.  I think these are sufficient and are verifiable with doctor-written reports, hospital reports and prescriptions.

So, as a strategy guy who asks a lot of questions (thanks, Dad – it’s all your fault), I look at past performance as a predictor of current / future behavior.

And what I see appears to be much more than coincidence.

All that being said, we must not forget  ……………..

The Canadian healthcare system is filled with many heroes, people who go above and beyond to treat an incredibly diverse collection of diseases and injuries with ever-tightening constraints in the resources that they have access to.

Such are the heroes who saved my father’s Life this weekend and I am grateful to them.

In fact, I believe all Canadians should feel grateful to have such a healthcare system, one of the best in the world.

However, it is doesn’t help the heroes when there are doctors who are actually introducing patients into the system through carelessness or negligence that probably shouldn’t have been introduced in the first place.

Maybe a prescription of litigation such as is used in the US might cure the system of what ails it.  I’m don’t know as I’m not sure if the pandemic of litigation sweeping the US is actually solving anything or just making everything more complicated.

Meanwhile, the Canadian system won’t get better if we refuse to question the actions of a few bad apples merely because we don’t want to offend the heroes in the system, because we are told that we shouldn’t question anyone with more knowledge or authority or because we are told that we should feel so grateful for the entire system that to question anything is to be expressing a lack of gratitude for everything.

And it won’t get better in cases like my father’s when doctors will privately admit that this doctor made mistakes but will not admit so publicly for fear of losing their own jobs.

The bottom line …..

The best way we can help the healthcare system and ourselves is to follow the advice of my parents when they imparted these two key elements upon me many years ago:

1. Learn all that you can – in this case, about your health and any treatment options that a doctor insists you follow

2. Don’t be afraid to ask questions until you’re satisfied, even if it means offending someone.  A good doctor will welcome questions and dialog.  Open dialog brings knowledge and understanding, both of which strengthen the relationship and the results.  Only the weak-minded or those with something to hide will get angry or defensive when the opportunity for dialog arises.  Either are a warning that perhaps a second opinion should be sought.

I was raised to always be respectful of doctors and I am, recognizing the incredible knowledge that many have, the constraints that they work within and their raison d'être, their desire to heal others.

But I think one can have the deepest respect for someone and still not be afraid to ask questions of them.

What do you think?

My questioning continues …..

How about yours?

In service and servanthood,

Harry

Healthcare, Audits and Spinning Results

In my home province of Newfoundland and Labrador, an outbreak of c. difficile in the hospital system has prompted a review of appropriate hygiene practices within their facilities.

What caused me to sit up and take notice is the fact that a family member of mine passed away within that very hospital system Saturday before last and of all the complexities she had, one was the fact that she contracted c. difficile while in the hospital.  This no doubt made attempts to address her health concerns much more difficult (if not impossible).

Now in defense of health care facilities in general, when people do everything they can to provide good care, there is not much one can do about such infections.

However, a hygiene report just released by Eastern Health and Eastern Health’s interpretation of its data was what disturbed me.

Eastern Health Care President and CEO Vickie Kaminski said that:

“It is well-known throughout the health-care system that hand hygiene is the single most effective way to prevent the spread of communicable diseases and infections among our patients and our employees.”

Despite this well known fact, the compliance levels of hospital staff when it comes to appropriate hygiene are disturbing.  Here are some examples gleaned from the report:

Overall compliance with hygiene rules – 51%

Overall compliance when including ER – 49%

Compliance prior to patient contact – 40%

Compliance in acute care – 33%

Compliance in cardiac / critical care – 46%

Compliance in emergency medicine – 23%

Compliance amongst physicians – 34% (target of 80%)

Compliance in pediatric intensive care unit (PICU) – 39%

To use emergency medicine as an example, don’t forget that 23% compliance doesn’t suggest that everyone there follows proper procedure 23% of the time.  It suggests that there are individuals who are in varying degrees of compliance from 100% down to 0%, producing a 23% average.  Hopefully you won’t get one of the individuals closer to 0% compliance in any category.

What bothered me also is how the health authority downplayed the terrible compliance numbers (emphasis is mine).

The health authority said the audit results do not mean employees are not washing their hands. “It means they do not always wash their hands at the appropriate times, as measured in this audit: specifically, both before and after patient and/or patient environment contact.”

Frankly I don’t care if they wash their hands all day long as long as it is done during the critical times before and after patient contact.

This comment from Ms. Kaminski added to my disappointment (emphasis is mine):

“While I commend the employees at the sites where we have seen improved results, I want all of our employees to understand how important it is to practice proper hygiene for our patients, residents and clients and, just as importantly, for our employees and their families.”

I worry when healthcare workers need to be informed of the principles of basic hygiene, things we teach children before they are old enough to attend preschool.

The Centers for Disease Control estimates that 1.7 million Americans  contract infections within hospitals annually and of that number, 99,000 people die from hospital-acquired infections.

While this is a terrible statistic, hospitals are complex environments and it is impossible to keep the environment sterile unless everybody walks around in a hazmat suit.

But when I hear of an outbreak of c. diff and norovirus in a hospital where less than 50% of staff are following standard hygiene practices such as the simple practice of washing one’s hands, I think we need to demand better.

I think we also need better transparency in the reporting of c. diff and other hospital acquired infections, since oftentimes a cause of death is listed as the original ailment even though the existence of c. diff prevented that ailment from being treated (with the focus being on treating the c. diff itself).  If medical staff are not distracted by the need to treat a c. diff infection, patients may be able to have their original ailment treated successfully.  It’s like being handcuffed and thrown into a pool.  If the person drowns, the cause of death is listed as drowning whereas if they hadn’t been handcuffed, there would have been a greater possibility of them avoiding a fatal end.  The existence of c. diff literally handcuffs the medical staff in regards to the priority of their efforts.

In regards to transparency and considering how every airline accident is reported publicly, if the airline industry had as many fatalities as the healthcare industry in this regard, the hue and cry for better air travel safety would be overwhelming.  For this reason, it appears that transparency and public accountability is essential to motivating the healthcare industry to do better.

I also think that the hygiene report may be a warning of something to come or a warning of other concerns not as yet exposed to the public.  What Eastern Health leadership and the NL Government do with the warning is a reflection on how seriously they take their job to protect Newfoundlanders and Labradorians.  What they say is less important than what they do and the results that they produce.

What do you think?

In service and servanthood,

Harry

Addendum: March 19, 2013

Eastern Health has faced criticism in the past, in particular for the breast cancer testing scandal that cost the lives of some patients a few years ago and the debacle a little over a year ago when Eastern Health employees tied up the hospital telephone lines participating in a local radio station call-in contest.

In regards to the latter, The Telegram reported the following interesting note:

The spokeswoman said the matter is being treated “very seriously” in light of the fact blocked phone lines can potentially endanger a person’s life.

According to Eastern Health, policies and protocols are in place relating to the use of communication devices at work for personal use.

It appears that in the case of Eastern Health, there are a lot of protocols in place to protect human life that are not being followed.

This suggests that the problems outlined in the hygiene report are more than just issues of laziness, awareness or being hurried.  It suggests a lack of focus, a lack of process and a lack of self-discipline.

This in turn suggests a lack of appropriate leadership.

What do you think?

On a side note, I remembered that I had written about Eastern Health in the past.  Here are some older musings on leadership concerns at Eastern Health.

Eastern Health – Leadership in Crisis

The Bread Recipe Rule

Addendum – March 19, 2013 – It’s the Patient’s Fault

As a sign of “strong” leadership, CEO Kaminski is now telling patients that they should be reminding staff to wash their hands (with the word “should” implying that if a patient doesn’t remind them, then the patient shares or owns responsibility for any issues that arise as a result). 

Many patients (especially young people, the elderly and the critically ill) will not be comfortable or able to do this and many healthcare staff (especially the ones already in compliance) will probably resent being told every time they see a different patient.  And besides, while there is such a thing as shared responsibility, it is not the patient’s responsibility to ensure that Eastern Health workers are following their own standard operating procedures.

Such off-the-cuff, awkward, ineffective solutions are not a sign of effective leadership and merely deflect or redirect attention somewhere else rather than where the responsibilities truly exist – within the leadership itself.

I think it takes a lot of courage to brazenly look people in the eye and push one’s own lack of responsibility and accountability onto the patients one is responsible for taking care of.

Or maybe it takes ignorance and / or arrogance.

What do you think?

Addendum – March 20, 2013

My interview on CBC Radio Noon today can be found here and a partial recap of the interview can be found here.

Addendum – April 12, 2013

Eastern Health has released findings indicating that the c. diff outbreak was spread through in-hospital transmission as noted here.  I guess washing your hands IS important, isn’t it? (Note: the original link was to a VOCM article here but it appears that VOCM removed the article, using a common technique that overrides classic Internet archiving techniques, making it more difficult to find the original article).

Addendum – May 22, 2013

CBC’s Mark Quinn investigates the occurrence of hospital acquired infections in Newfoundland and discovers some interesting facts.  My interview with him can be found here.

Addendum – March 14, 2014

Almost a year to the day since I wrote this post, it was announced that Vickie Kaminski is taking over Alberta Health Services.  Will she be able to save a healthcare service that has ten times the budget of the Newfoundland system and has ten times the staff or will we see more of the same confrontational approach that she was criticized for in her last assignment?

Will we see better results than I noted in this and other posts?

Time will tell.