Stan's Story Redux

“You’ve already heard most of this story, Jaded Julie, but not the ending. In January of 2007 I visited Stan (not his real name), a very close friend from my college days. When Mrs. Curmudgeon and I entered their house, Stan recognized me and said, ‘hello,’ but I couldn’t understand much else that he said.”

“I remember our posting the original Stan’s Story on October 30, 2008. I guess more has happened in Stan’s life since then. In any case, because of its lessons on patient safety, the story merits retelling. Please repeat the original Stan’s Story and bring us up to date on what occurred after it was posted.”

“Shortly after his retirement, Stan, who lived very far away from here, suffered a stroke. While he was recovering in the hospital, he sustained a tragic fall that injured his brain much more than the stroke had. After the fall, Stan, always a gentle giant, could not speak a coherent sentence. Although he was cared for by his devoted wife, this was not the way Stan planned to spend his ‘golden years.’

Here are some of the details as provided by Stan’s wife: Stan experienced a severe stroke early one evening a few years ago, and his wife rushed him to the hospital a few minutes away. She anticipated that Stan would be treated with thrombolytics within the ‘golden three hours.’ (However, I never did learn whether the stroke was ischemic or hemorrhagic.) Stan was first seen by a physician in the ED two hours after they had arrived; he apparently did nothing. At 2:00 a.m., a cardiologist appeared, and he pronounced that it was ‘too late’ for treatment with t-PA (or whatever). So Stan was admitted to the ICU.

While in the ICU, Stan fell and crushed the bones around one of his eyes. The eyeball was out of the socket, and 15 stitches were required to close the cut. After performing the necessary repairs, the physician checked the sight in Stan’s eye by holding up three fingers and asking Stan to count them. At that point, Stan was in no condition to count anything.

When Stan’s wife left the hospital the night of his fall, the rails of the bed were up and an alarm was in place. Stan’s condition would have prevented his lowering the rail by himself, and the alarm should have alerted the nurse had he done so. Yet the nurse in the ICU said that the rail was down when Stan fell (of course it was, but who lowered it?). Stan was her only patient. And so the risk management and legal issues began. Ultimately, Stan and his wife had to accept what they considered a very inadequate settlement from the hospital.

The final outcome as of January 2007 was as I described at the beginning of our conversation. Stan’s wife became his constant caregiver. Stan recognized me but not the names or anything about many of our close college friends. He could say ‘hello’ and ‘good-by,’ but his long sentences were quite incomprehensible. We planned to see Stan and his wife whenever we visited the far-away city where they lived, but reminiscing about our college days would have been pretty difficult.”

“Curmudge, that is so sad. And it appears to have been preventable. So what occurred in Stan’s life between your last visit and now?”

“It was not good. Stan experienced a botched removal of a kidney stone that resulted in a nosocomial infection that kept him hospitalized for a month. Then on December 18, 2008 Stan died of an apparent heart attack.”

“The latter years of Stan’s life appear to have been a tragedy of errors. I guess that explains why you became a patient safety zealot.”

“Julie, everyone should be a patient safety zealot, but it’s inevitable when tragedy strikes close to home.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.