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Two decades ago, an anesthesia catastrophe at a Wisconsin
hospital killed a pregnant woman named Joy.
The young mother-to-be was undergoing a scheduled C-section, but
a series of mistakes by the nurse anesthetist led to a tragic end,
leaving the baby brain damaged and the family devastated.
There was another victim that day. Dr. Gary Brandeland didn’t
make the mistake, but Joy was his patient. Her death sent him on
his own downward spiral of grief and gave him a first-hand view of
how doctors and hospital workers react to medical errors.
Dr. Brandeland, now an emergency room physician in Minnesota,
has chronicled the tragedy in a moving article in a 2006 issue of
the journal Medical Economics. What’s so fascinating about Dr.
Brandeland’s story is that it explores the emotional toll medical
mistakes have on doctors and nurses who witness them, and looks at
the economic factors that he says often are ultimately responsible
for medical errors.
After the recent publicity surrounding the medical mistake that
almost killed the twin babies of actor Dennis Quaid, I spoke with
Dr. Brandeland about how medical mistakes affect the people who
care for patients.
When medical mistakes happen, a lot of people blame the
health care worker involved. Is that entirely fair?
The greatest common risk to patients is the understaffing of
nurses. A nurse may make a critical mistake, and a patient might
die. She has to live with the error, but the real culprit, the root
cause often is that she or he was understaffed and overworked and a
mistake was made. The hospital doesn’t pay for it on a personal
level. They just get a new nurse.
I've seen excellent nurses who make mistakes when things get
overwhelming. They are minor, and fortunately I haven't seen a
death due to a medical mistake since this tragedy happened. But I
think we’re at a critical point right now where health plans and
insurance companies are trying to trim costs and are cutting back
on quality. Instead of the individual, I think the anger should be
at the hospital structure if in fact there is a history of
understaffing at that institution.
This wasn't your mistake and you weren't sued or blamed in
any way, yet you write about the enormous personal and professional
toll the tragedy took on you. Why did this affect you so
much?
Everyone in the operating room is going to feel somewhat
responsible. The patient came to me as someone who was going to
safely help her have a baby, and the end result was this disaster.
In the end, I was the one who talked to the family. I was closer to
them because I’d seen them for nine months.
Have you ever been the victim of a medical mistake?
I was a patient in 1998 at a world famous medical center. The
nurse came in to give me a pill. I had a heart condition and I
recognized right away that it was wrong and I would have died. She
came back and sort of laughed and said, “Oh, I guess the doctor
wrote the orders on the wrong chart.'’ I would have left there with
a toe tag if I had taken that pill.
How did the death of Joy change your view of
medicine?
I became overcompulsive and less tolerant of any sort of
mistakes at all. I felt more concern about people who were working
for me, such as the nursing staff, and the mistakes that could be
made. When there is a mistake, you go through almost the stages of
grief. You second guess yourself. I also developed a profound
sadness. I can’t describe it in words. I think about people who
have lost a loved one, I think of families who have lost troops in
Iraq and other tragedies where someone is killed in a car accident.
It's a sadness that doesn't go away.
I highly recommend that you take the time to read Dr.
Brandeland's complete essay, click
here.
