Please take a moment to read this excellent Blog post sent to my attention by Jake Poore. How many of us or our family members have had similar, but hopefully less dire healthcare encounters? How many others must needlessly die or be injured because of poor communication, fragmented records, and broken processes in hospitals and clinics?
“Just call me, Eddie”
I need to write about this, because this day still haunts me, years later. And it is amazing the clarity I still have of the entire day, of every word said, and how it made me feel.
My dad had a heart attack the same week President Clinton had been scheduled to have his heart surgery, but Clinton had to wait an extra few days until the blood thinner had left his body (important to note). My dad was on a fishing trip vacation with friends out of his home state at the time. His closest family and friends were hundreds of miles away. When he was rushed to the local emergency department and immediately admitted to the Intensive Care Unit, where the nurse gave him a blood thinner IV and said it would help with his heart palpitations. As it turns out, he had to have heart surgery, immediately, to save his life.
I flew from Florida to Michigan to be with him prior to his surgery. While he was waiting for surgery, he joked a lot with all the nurses who came into his room. Each nurse he met would call him, “Mr. Poore”, and he would immediately say, “please just call me, Eddie”. They would always reply, “Okay, Eddie. And I’ll make sure the next nurse knows that too.” Of course, the next nurse would come around and again address him as “Mr. Poore”, and Dad would reply, “Just call me, Eddie,”and this new Nurse would say, “Okay, Eddie. I’ll tell the night nurse”. They never got it right. After a while, my Dad became really frustrated and a bit concerned about his care team.
Each employee who entered my Dads room would also tell my Dad that he would need to take off his two gold necklaces prior to surgery and they would offer to take them off him right then and send them to security for safe keeping. My father was very attached to each necklace (one from his mom and the other from his deceased wife, a nurse) and did not want them taken off, ever! It was agreed (by one nurse) that the necklaces would be taped to his leg during the surgery so that he’d always have them on him. This too, of course, was never communicated to other medical staff, and every time someone new walked into his room, they would kindly suggest that he would have to “take off those gold necklaces”, finally my Dad just freaked out!
I would watch his monitor above his bed: His blood pressure would rise, his pulse would rise… there were clinical implications to their poor team communication.
The two most important things to him were his good name and his gold necklaces and they couldn’t get either of these right.
Finally, now in surgery, as I am saying my final ‘goodbyes’, a nurse anesthetist came up and said, “Hi, Mr. Poore (not "Eddie"), I’m the nurse anesthetist. Do you know what I’m going to do?” My father replied, “Put me to sleep, I guess”. And she continued, “Yep, that’s right. And I see you have some gold necklaces on….” While she was still speaking, My father turned to me with a huge look of fear on his face and said, “Oh lord, they can’t even get these necklaces right, Jake!” That was almost the last thing he said on this earth.
My father died on the operating table that day. After his surgery the doctor didn’t even come out to talk to me. He sent one of his assistants out instead. When I asked what happened, we were told, “your Dad couldn’t hold his sutures, he was bleeding to death.” I asked if the blood thinner he was given the day before had anything to do with that, and she said, “Blood thinner, what blood thinner?” I couldn’t help but saying, “You guys didn’t even communicate the name he wanted to be called or stop asking him about his gold necklaces, maybe you didn’t communicate the blood thinner, either.”
Thanks for sharing this, Jake. Your story breaks my heart; maybe because my grandfather, who had a genuine fear of doctors, was named Eddie. How many other “Eddies” will it take?
I’m not certain that electronic medical records would have prevented what happened to Eddie or will prevent every medical error, but having access to all of a patient’s information at the point of care would prevent most of them. That, along with vastly improved caregiver communication and collaboration tools and better solutions to manage decision support, clinical workflow processes and quality would go a long way in improving patient safety. Paper kills. So does apathy and ineptitude. The time has come for an information technology revolution in healthcare.
Bill Crounse, MD Senior Director, Worldwide Health Microsoft