Our firm’s client Lyn Gross, then 57 years old, underwent a complex treatment by an interventional radiologist to repair a swollen artery, an aneurysm, at the base of her brain so that it wouldn’t burst open and kill her. But the cure ended up worse than the disease: she suffered massive brain damage that left her completely disabled and in need of round-the-clock nursing care.
What went wrong?
The radiologist was originally supposed to limit his work to taking some detailed pictures of the swollen artery so they could be studied by a neurosurgeon and a radiologist and together decide if she would be better off with the surgeon’s technique (drilling a hole in the skull and putting a clamp on the swollen part of the artery) or the radiologist’s technique (using tiny scaffolding – stents – plus wires inside the vessel to try to seal off the abnormal section while keeping the blood flow open).
The radiologist instead talked the family into letting him go ahead with his type of treatment without any consultation with a neurosurgeon. Another wrinkle: the stent that he was going to try to use to hold open her artery was a new device that had only been on the market for six months, so the track record was too short to have good evidence on who did well and who did poorly with the stent.
During the surgery, the radiologist ran into trouble because the stent didn’t work. He had to block off the entire artery that he had hoped to keep open.
He assumed the loss of blood flow through this artery wouldn’t harm her brain, but he didn’t wake up the patient to make sure her brain was tolerating the alteration of blood flow he had caused.
In the hours after he had finished his work and had moved onto another patient, Lyn Gross lay in an intensive care unit having strokes on both sides of her body, which the ICU staff didn’t recognize because they did not realize that the artery the radiologist had blocked off was vital for feeding both sides of the brain.
Had they known, she could have had treatment to boost the blood flow to the brain and reduce at least some of the damage from the blocked artery. The radiologist was busy with other patients while Mrs. Gross’s brain damage gradually became irreversible.
Lyn Gross’s family didn’t discover until it was too late that by the time of her procedure, a team approach for aneurysm treatment had developed at most major hospitals across the country, but not at the one where she was treated. Leaders in aneurysm treatment recognized that instead of having neurosurgeons and radiologists compete for business, patient by patient, the best way to sort through the specialist rivalries and give patients the most objective advice was to have patients meet with both kinds of specialists, and also to free up team members from having their income tied to how many cases they did. Plus it was recognized that since radiologists were not trained to provide post-surgery care, patients needed a team of neurosurgeons, neurologists and specially trained nurses to get the right kind of care in the critical hours after they had a brain artery intervention.
No effective team was in place for Lyn Gross’s aneurysm surgery, because the system had not been thought through by the hospital staff where the radiologist did her procedure. Patients were randomly assigned to one of five intensive care units presided over by a single ICU “attending” who had to race among the five units to oversee care given by residents in training. Neither the attending nor the residents were specialists in neurology or neurosurgery. The radiologist, when he finished with Mrs. Gross or his other patients, would jot a short note describing what he had done and then turn the patient over to an anesthesiologist to deliver the still-unconscious patient to the ICU.
It was a system made for miscommunications and what in the jargon of medical error analysis is known as “handoff errors.”
The Patrick Malone firm obtained a settlement from the hospital and the radiologist that ensures Mrs. Gross will have skilled lifelong care for her brain damage.
This story is adapted from Patrick Malone’s book, The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.
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