Unit 8Section 5 Exercise 18 Medical Error

Clinical correlate #9 Medical error

Sandra Gilbert is an accomplished poet, author and scholar. In Wrongful Death, she tells the story of her husband’s death post-operatively, after undergoing surgery for prostate cancer. This ‘medical tragedy,’ as she herself calls it, redirected her career and scholarly interests. See Dr. Gilbert's website for biographical and bibliographical information: www.sandramgilbert.com. As she later wrote in a paper on medical error, “I understood [in writing Wrongful Death] that I was writing (recording) as well as seeking to right (to recitify) wrong, and now, as I retell the tale, I realize that I am still writing and seeking to right a terrible wrong.” (Sandra Gilbert “Writing/Righting Wrong”)

From Wrongful Death - A Medical Tragedy, by Sandra M. Gilbert

MONDAY, FEBRUARY 11, 1991, 8:15 p.m.

A little more than twenty-four hours later, my husband is dead in the recovery room, after what my daughters and I had been told was a successful surgery.
We don’t know this, at least not right away. The surgeon, Dr. Ralph W. deVere White, has spoken to us several times during the day, always assuring us that everything is all right and urging us to leave the hospital, where we’ve been waiting since Elliot was taken to the OR – the operating room – at six in the morning. Telling us to go out for lunch, for a nap, for dinner, while the recovery-room nurses are “waiting for a bed in the Intensive Care Unit.”
In fact, it isn’t until nine p.m., February 11, that the elevator doors in the hospital lobby slide open and Dr. deVere White, the surgeon, strides grimly out in a dark gray suit, flanked by his white-coated resident and a harried-looking, unfamiliar woman carrying stacks of papers.
My daughters and I have come back from the meal we were told to go out for only to discover that “the doctor is coming down to see you,” so I am standing at a long counter near the elevator, biting my nails, when the door gapes wide and the three emerge.
The surgeon, an Irishman, becomes oddly hearty.
“We’ve had a problem, luv, a big problem,” he begins briskly, as he steers me out of the lobby and down a hospital hall I didn’t know existed.
I manage to say “What-what-?”
“Dad’s had a heart attack,” he replies, shaking his head with what seems to be strange ruefulness.
“But what, but what are you-?” I begin.
In the background, from the pastel depths of the empty late-night hospital lobby, I hear the screams of my daughters, who are talking separately to the white-coated resident.
The harried-looking woman and the Irish surgeon are struggling to open the door of a secret room that turns out to be hidden in the hallway just off the lobby.
I begin to cross myself compulsively. “Are you trying to tell me, Doctor,” I whisper, “that my husband is dead?”
In the lobby, one of my daughters has flung her shoulder bag across the floor. Keys clash on the ceramic tiles. Her wallet flies open. IDs and credit cards spring out. She and her sister and her sister’s roommate are screaming and screaming.
I am still crossing myself as the doctor and the harried-looking woman and I finally enter the secret chamber, a small reception area with straight chairs ranged stiffly along the walls. As the unfamiliar woman comes toward me to take my hand, I see that she is wearing a badge which says “Carolyn, Office of Decedent Services,” and she is carrying a large folder labeled “Bereavement Packet.
My daughters and their friend are brought down the hall by Dr. Poonamallee, the resident, who hovers beside them in an uneasy silence. Looking around the room, I notice that there are no tables or magazines in here at all, not one of the Times, Newsweeks, or Sunsets that we associate with “waiting rooms”. This is the room, I realize, where you don’t wait any more. This is the room where they tell people that people are unexpectedly dead.
And this is the room where you may begin to understand what “medical malpractice” – or call it “negligence” if you like – might really mean.
Although we don’t yet suspect it, we are going to learn within the next month that my husband didn’t die from a “heart attack”. On the contrary, he evidently died as a result of medical neglect; indeed, he may have died because someone in the recovery room failed to get the results of a simple blood test. Failed, in other words, to notice that amidst the efficient bustle of a modern recovery room, in a major American medical center – indeed, a teaching hospital – while my daughters and I were dutifully picking at the restaurant dinner the doctor had told us we should go out and eat, my husband was truly in mortal danger.
Had something gone wrong in surgery? If so, why hadn’t we been told? How could the doctor have repeatedly urged us to leave the hospital when my husband wasn’t (to say the least) doing well? And why had he told us that Elliot had a heart attack when, as he must have understood, we’d soon find out he hadn’t?
Most horrifyingly, why and how had a supposedly sophisticated team of nurses, residents, surgeons, and anesthesiologists let things get to such a pass that when at 7:20 p.m. they finally invoked “the code” (to bring a rescue team for an emergency), it was too late to resuscitate someone who had twenty-four hours earlier been vigorously healthy?
These are questions that will haunt us for years to come. What Dr. Reitan had so jovially called “defensive medicine” has turned into offensive medicine. And it has changed my life, along with the lives of my children, forever.

MONDAY, FEBRUARY 11, 1991, 6:15 P.M.

We’re late returning to the hospital. We were all so exhausted that we slept too long after making our phone calls. Elliot is probably already in the ICU. He’s probably enraged at us, at me, for being late. I’m always late, and he hates it. I can imagine him saying groggily, “You’re always late for everything, sem. You’ll be late for your own funeral – or mine.” (“Sem,” a girlhood nickname made up of my then-initials, was what he called me at intimate moments.)
As the car pulls into the parking lot, I sneak a glance at my watch. It’s after six already. “Oh my God,” I say guiltily to the girls, “we’re so damn late! He’s going to just kill us!”
“We were tired, Mom,” Susanna begins, “he’ll understand that we –“
Before she can finish talking, almost before Kathy has finished parking, Liz is leaping out of the car. “There’s Dr. deVere White,” she cries. “Over there. I want to ask him about the blood.”
On the way over here, we’d remembered that we hadn’t asked him if he’d had to use any of the blood Elliot had donated. That was an important question, we told each other.
We’re all crowding around deVere White, who is standing on the steps talking to some other doctors. He’s back in his starched white coat and appears refreshed, rejuvenated – a lot better than he’d looked this afternoon.
“The blood? Did you have to use any of the blood?”
“Five units.”
“Five units!” I gasp. “But he only donated two-“
“We always have backup units.”
“My God, but isn’t that bad?”
“It’s neither bad nor good.” His inflection is neutral.
“But why, why did you have to use so much blood?”
Suddenly he’s almost shouting. “It was stock, stock!” he seems to me to be saying in an angry Irish tenor.
“Stock?” I turn helplessly to my daughters. I have a strange vision of bouillon, broth, soup stock. “Stock? What does he mean?”
“Stuck, Mom, he’s saying it was stuck,” Kathy explains patiently.
“Stuck? What was stuck? Why would it be stuck?”
DeVere White still sounds angry. “The hormones. I told ye, the hormones. I warned ye.”
We’re all silent, frowning. We must look very frightened because he becomes quieter, kinder. “I just saw him,” he volunteers. “He was fine but he didn’t want to chat. He was woozy from the anesthetic, the way he was after the biopsy. He said somethin’ like ‘I feel lousy.’”
Oh. We are placated, we exchange reassuring glances. It’s easy for us to imagine Elliot being cross and uncomfortable. “I feel lousy.” He’d hate pain, be angry at it. That’s just the sort of thing he would say. Reproachfully. “I feel lousy. Look what you did to me, you creeps!”
I light a cigarette. You can’t smoke in the hospital so I’ll have a puff before going up to the ICU. The grayish twilight is pleasantly cool, with lights winking on all around the parking lot and in the windows of the hospital above me.
“So we can see him now in the ICU?” somebody asks.
“No, not yet, luv.” DeVere White’s tone is regretful. “They’re still waiting for a bed in Intensive Care. They’re very busy tonight. Probably won’t have one till around eight. Why don’t ye go out and have a good dinner? No sense hangin’ around here some more.”
“Well…” I hesitate. But we do have to eat sometime. Perhaps it would be efficient to eat now. There’s a Chinese restaurant a few blocks away that a friend who lives in Sacramento recommended. Maybe we should try it out. We’re going to be needing a supply of good restaurants next week, so we might as well start our investigations right away.
One of the girls has thought of another question, though. “Do you think he’s going to need radiation, Dr. deVere White?”
He looks at us enigmatically. “Now, now, let’s not get away from ourselves,” he says. “It’s only the day of the surgery, y’know. We have to take things one day at a time right now. One day at a time.”
“One day at a time?” Just this afternoon, he’d told us we’d come back in three weeks to have the catheter removed.
One day at a time? What can he mean? And why don’t we ask him what he means?

THURSDAY, FEBRUARY 14, 1991, 12:30 A.M.

In Bethesda, right now, Dick is working on a time line of what happened to Elliot in the OR and the recovery room, in case such a document would be useful to a lawyer. When Leah comes to stay with me next week – she’s going to be the friend “on duty” after Susan has to go back to Indiana and start teaching again – she’ll bring Dick’s time line with her. So in a few minutes, Kathy and Susan are going to help me make a similar record of my own, a personal narrative of Elliot’s medical history between August 1990, when he was first diagnosed, and February 11, 1991, when he was pronounced dead in the recovery room at the UCDMC. My time line, too, is intended for a lawyer.
We don’t actually have a lawyer yet, but the phrase “you’d better consult an attorney” is becoming increasingly common in my living room. We don’t say too much about Dick’s suspicions – he has warned us to be circumspect – but we’ve said enough so that a number of the friends who drift in and out of the house have begun offering us the names of lawyers and law firms specializing in medical malpractice.
In Dick’s opinion, much of the case turns on 1) the issue of the hematocrits, and 2) the timing of the transfusions. He says that at around 3:00 P.M., when Elliot had been in the recovery room for forty minutes or so, his blood pressure dropped very radically. (“What happened?” Susanna had asked deVere White that night, in the white room. “I don’t know, luv, I don’t know. His pressure just dropped-” the doctor had said.) This probably happened, Dick speculates, because Elliot had been bleeding internally. It’s a well-known fact that internal bleeding causes a drastic drop in blood pressure. (“Why did his pressure drop? Why?” Susanna had asked. “I don’t know, luv, I don’t know,” the doctor had shrugged.)
Someone in the recovery room drew blood for a hematocrit, a test that measures the percentage of red blood cells in the body and can therefore help diagnose internal bleeding. The sample was sent to the hospital lab at 3:05, but Dick can find no record of a hematocrit having been returned. By 3:20, Elliot’s blood pressure had been raised through fluids (not blood) administered intravenously.
Then the pressure dropped again at 6:00. Another blood sample was evidently taken, and this time the hematocrit showed that my husband’s red blood count was dangerously low. A normal hematocrit should be in the thirties, Dick says. Elliot’s was seventeen. But “curiously,” Dick tells us, nothing much was done about this problem for a while.
For a dangerous while.
Orders to “type” and “cross-match” blood for transfusion apparently weren’t given until 6:50. And Dick doesn’t think much blood was given until 7:30, after the “code team” – the emergency team that’s supposed to try to resuscitate dying patients – had been called in.
Elliot was pronounced dead at 8:15. They had transfused the blood much too late. Dick thinks his heart failed because, as a result of hemorrhage or a “slow leak”, his red blood cell count dropped so dramatically that he wasn’t getting enough oxygen and the heart couldn’t work properly.
Dick seems to think, too, that one or two units of blood on hand in the recovery room were overlooked or misplaced, which was why there was a delay in transfusing after 6:00 P.M. He says, understatedly, that he’s puzzled about the missing results of the 3:05 P.M. hematocrit, and adds, dryly, that it’s odd we weren’t told anything about bleeding, about transfusions and hematocrits.
Of course, he notes, we have to understand that some of his points are still just hypotheses, just speculative, since the records are so messy and chaotic. Nevertheless, he’s afraid we’ll have to find a lawyer.
Afraid. He’s afraid. Afraid because he’d set out to reassure us.
And nothing that anyone tells us about lawyers and lawsuits is reassuring, either.
This morning Susan called her brother-in-law, who is a partner in a prestigious New York firm. Of course he could help us, he said. Of course he could come up with the name of an excellent malpractice attorney in San Francisco. But, “Does she realize what this might do to her?” he asked. “The strain? The horror of having to relive what happened over and over again? It’s very debilitating.”
Leah said the same sort of thing to me on the phone a few minutes ago. “Do you think you and the kids could take it, Sandy?” she wondered. “A malpractice suit can be pretty awful. You can’t get the death behind you. You have to keep thinking about it all the time.”
“That’s all I do anyway,” I said.
Both Susanna and my shrink made a different point. In a situation like this, they observed, as long as you’re suing you live with the illusion that a positive outcome to the lawsuit might resurrect the dead person. If we could get the doctors and nurses at the UCDMC to admit that they did something wrong, then maybe we could get them to go back and do the right thing. Like running the film of the Kennedy assassination again so that the fatal bullet doesn’t hit the president.
This problem doesn’t bother me, since in any case I live with the illusion – only I don’t think it’s an illusion – that Elliot is really still alive. When my shrink said something about my “dead husband” the other day, I stared at her indignantly. “Don’t you dare tell me that my husband is dead!” I exclaimed with hauteur.
In a funny way, the kids have the same feeling.
On the surface, they seem far more convinced than I am that their father is actually dead, but every once in a while, especially when we’re discussing the possibility of litigation, one or another of them slips and uses the wrong verb tense: “Dad wants us to sue. I know he does.”
Anyway, we’re all in complete agreement on that point. Dad wants us to sue. Dad will be – I mean would be – in a rage if we don’t sue.
Now Susan emerges from the kitchen. “He’s had no luck yet,” she sighs, standing in the doorway of the dining room. “But this time he thinks-“
“Here’s the calendar,” Kathy says, coming in from the study.
“Thinks what?”
“Thinks maybe there are several of them. Several skunks. One opossum,” Susan says.
“Oh my God, what’s he going to-?”
“Never mind.” She sits down across from me at the table, next to Kathy, and pushes a notebook toward me. “Let’s begin. What was the day of the diagnosis, who gave it, etcetera, etcetera.”
And I begin to write.
“July 31, 1990: Prostate cancer diagnosed by Dr. Humphreys, Elliot’s Berkeley urologist. August 23, 1990: First visit to UCDMC. First meeting with R.W. deVere White.”

Study Questions

1. Sandra Gilbert explains that her husband “evidently died as a result of medical neglect” rather than a heart attack.” In this work how does she illustrate the types of interactions that could lead to malpractice suits?

2. What function does the malpractice suit have in this narrative? Compare the purposes it might serve for this family with the role of the malpractice suit as suggested in the excerpt from Ruthann Robson’s narrative on the preceding web page.