SURGICAL ERRORS: A MAJOR CAUSE OF DEATH

It’s been over 24 years since the Institute of Medicine’s “To Err is Human” report was published, drawing broad attention to medical mistakes that kill up to 98,000 Americans (alone) annually. The exact number of deaths is controversial, mostly because there isn’t a standardised way to collect and report this kind of data. Death certificates don’t reliably code medical errors leading to death, further obscuring the problem. A 2016 study found about 250,000 deaths annually are due to medical error, making it the third leading cause of death in the United States, where it’s more problematic than other developed countries. For instance, and looking at a specific reported case study, Louise Aron was injured during surgery—her small intestine was nicked during a liver stent procedure—and she died shortly afterward. Though she had stage 4 colon cancer, the surgery wasn’t considered high-risk. The mistake prompted the surgical team to suture her and transfer her to immediate hospice care.

Her daughter, Dr. Rosia Parrish, stated that she’s still overwhelmed with regret and sorrow and has yet to review the medical records to understand how the situation was handled. She added that “The sudden shift to hospice was heartbreaking, as the surgery was initially expected to be life-saving or at least life-extending, but it did not achieve either of these outcomes.” Well, of course, surgery accounts for about a quarter of medical errors, but others might involve care received before or after an operation. For instance, medication, communication, and infection are common sources of mistakes outside a surgeon’s purview. BUT, regardless of who’s to blame, the lack of accountability—or even acknowledgment—breaks a learning feedback loop that protects patient safety in the future and reduces major catastrophes.

BUT PATIENTS EXPECT ERRORS, NOT LIES

Perhaps the irony of medical errors is that honesty turns out to be the best policy for hospitals, doctors, and sometimes even patients. A great deal of research shows that patients who are told about mistakes are more likely to follow medical advice, and continue with care while being less likely to seek malpractice lawsuits, according to “Patient Safety and Quality: An Evidence-Based Handbook for Nurses.” This book further states that “Patients have the right to know; patients and the public strongly desire disclosure. Failure to disclose mistakes and unanticipated outcomes limits opportunities for evaluation of systems and processes, and for sharing knowledge gained by publishing safety alerts across organisations, conducting educational sessions, modifying practice, and offering opportunities for improved performance.”

Well, Louise Aron’s daughter, Dr. Parrish, found herself once again facing the horrors of surgical complications a year after her mother’s death when she had an emergency caesarean birth. In this case, the staff didn’t thoroughly review her medical history. Dr. Parrish experienced cardiomegaly (enlarged heart), postpartum hypertension, and nocturnal hypoxia—a condition characterised by low nighttime oxygen levels. She used an oxygen tank for more than a month, had a series of pulmonology and cardiology appointments for several years, and continues to have no nerve sensation above and below her c-section scar.

In stark contrast to her mother’s death after which there were no apologies, Dr. Parrish’s hospital provided postoperative care with additional visits and even provided her with internal medical records that were not part of her file. Apologies facilitated healing. Dr Parrish also stated that she worked with them for approximately six months, and that their support was invaluable.”she also added that “In her case, there were apologies from her main surgeon, who acknowledged the shortcomings of the surgery and the birth.”This brings us to another development on the matter of surgical errors – the apologies.

DO INSTITUTIONS DO MORE BEYOND THE APOLOGY?

Many states have “apology laws,” which are designed to allow for honest communication between physicians and injured patients. However, the American Medical Association Journal of Ethics said they don’t go far enough. For instance, few states have laws protecting expressions both of sympathy and of fault from being entered into medical malpractice lawsuit evidence. This puts an unofficial gag on doctors! On the other hand, only 10 states even require physicians to disclose an error to the patient. Some doctors hide behind the fact that the definition of “medical error” is vague. More specifically, adverse events are a type of injury that often happens in surgical treatment that isn’t really caused by the underlying medical issue of the patient. Adverse events are preventable, but not all are the result of an error, according to medical error and prevention training for clinicians. Preventable adverse events occur when there is a “failure to follow accepted practices.” There are also 29 “serious reportable events,” dubbed “never events” for the fact that they should never happen to patients. The list was created in 2006 by the National Quality Forum. And so, it appears that there isn’t a lot that institutions (private of public) are doing to remedy surgical errors beyond the apology.

So, why are surgical errors called “never events?” Because they are never supposed to happen – but they do. Mayo Clinic surgeon Dr. Juliane Bingener discusses a study in which Mayo researchers identified 69 never events among 1.5 million physically invasive procedures performed over five years and chronicled in minute detail why each occurred.

THE TERROR OF ERRORS: THE CASE OF LINDA KEHART

Let’s also look at the case of Linda Kehart, where errors seemed probable but the situation was full of ambiguity, which can be the case with surgery. Risks are heightened when patients are under anaesthesia. In such situations, the only witnesses to errors are the health care team. Fear of negative consequences—retribution, job security, malpractice lawsuits, and reputation damage—might mean providers only report those errors associated with harm or those that can’t be “covered up.”Earlier this year, Ms. Kehart woke up in an intensive care unit unable to get answers for why she was there after a standard stent procedure. She was told she needed a longer hospital stay. She thought she overheard someone mention that she had coded—medical language for a cardiac arrest. There was also talk amid staff of contrast dye allergy listed on her chart that she repeatedly told them was an error. Despite large teams of clinicians going in and out of her room, nobody seemed interested in anything she asked.

Frustrated by the lack of transparency, she demanded to be discharged. The hospital refused to let her leave in a wheelchair and made her sign paperwork, which later disappeared, on which she wrote that nobody would answer her questions about what transpired during her surgery. She used her connections and story to challenge the local system. She had never met her surgeon prior to the procedure, and later discovered she had an arterial hematoma, an injury to a blood vessel in her neck. One hospital administrator did ask her to write about how the ordeal made her feel so he could use the example with residents that he teaches.

Most patients don’t believe filing reports will make a difference. Four in 10 of those who didn’t report medical errors in the Institute for Healthcare Improvement (IHI) poll said they didn’t know how to. Confusion is understandable. There is no universal system that patients can use for reporting errors. Most states have few guidelines, and the burden of creating a system for reporting errors falls on each individual hospital or health system.

Errors can be reported to the state public health department and the state medical licensing board to make a complaint about a physician, as well as to the Joint Safety Commission, a nonprofit organisation that accredits hospitals and is responsible for patient safety. There are some voluntary reporting systems, too, such as the Institute for Safe Medication Practices, which takes complaints related to medication errors from patients and health care providers.

THE WAR ON HEALTH: WHEN DOCTORS INTENTIONALLY HARM PATIENTS

Now, here on ‘The War Room’ we have discussed many issues that emanate from the medical and pharmaceutical industries – including the harmful medication from big pharma, to doctors being bought by pharmaceutical companies to prescribe drugs or procedures that are harmful to patients. But one issue from the medical industry that is difficult for many to come to grips with is when doctors intentionally harm patients, outside of error or even sinister motivations from the industry. There are a number of reasons society has a difficult time acknowledging that this happens: in part, it is based on the idea that being a medical practitioner is incredibly time intensive, and so the general perception is that people who are in this industry are in it due to passion to care for those who require medical assistance. In addition, doctors (as people who are supposed to make others well) have generally been given a presumption of good intent for the longest time.

But, history and even developments in the status quo provide a sharp rebuttal to these assumptions. Consider the documentary titled ‘Sickened to Death’. In this documentary, the President of Loveworld Inc highlights the critical truth that there is nothing natural about sickness, and that the emergence of sickness can be traced back to Genesis Chapter 3, and since the fall of men, there was a corruption of creation – including the entrance of sickness and disease. Furthermore, the documentary also highlights that the second and last Adam, being Jesus Christ, brought us divine health, and therefore the end of sickness. However, we are still seeing so much today that brings into question the medical industry; and the realisation that it was never there to make people well! In fact, most doctors are doing things that are against the hippocratic oath (or at least the original one, and not the modified version that was inspired by the pharmaceutical lobby).

For instance, you would have heard of Dr Death. More specifically, Christopher Daniel Duntsch is a former American neurosurgeon who has been nicknamed Dr. D. and Dr. Death for 33 incidents of gross neuro-surgical malpractice while working at hospitals in the Dallas–Fort Worth metroplex, which maimed 31 patients and caused 2 deaths. But, here what makes this a concerning systemic issue, and not an isolated case: Dr Death was accused of injuring 33 out of 38 patients in less than two years – BUT, this was a track record so unlikely that hospital administrators and district attorneys simply felt that it was too unbelievable to be true, AND THEN ALLOWED Dr Duntsch to continue to practice before his license was finally revoked by the Texas Medical Board, and to avoid prosecution for years. Then, in 2017, Dr Duntsch was eventually convicted of maiming ONLY ONE of his patients and sentenced to life imprisonment. This is to say that not only did Dr Duntsch (AKA Dr Death maim and kill patients, but the medical industry simply thought the issue was unlikely, and allowed him to practice. Then when he was eventually convicted, it was for maiming only one of his patients – this is a systemic lack of accountability for doctors in the medical industry.

THE PHARMACEUTICAL INDUSTRY ALSO CREATED DOCTORS WHO KILL

But, and as alluded to earlier, the pharmaceutical industry is also culpable in the creation of this problem of doctors who kill. For instance, chemotherapy is literal poison that destroys cells indiscriminately, with its consequences mostly being experimental – so much so that 97% of the time, chemotherapy actually does not work to kill cancerous cells – while destroying other cells in the body, and thus causing more harm to the patient! But, despite this, chemotherapy is almost always what is prescribed to patients with cancer. So, why would doctors do this – why would they prescribe an intervention that does not work 97% of the time?

Well, a doctor blew the whistle, and exposed that it is for one reason , and the reason is financial greed. In particular, he explains that if you go to a medical doctor, an MD, with a sinus infection, and that doctor prescribes an antibiotic, he gets no financial kickback. However, if he prescribes 5,000 products of that antibiotic in one month, the drug company that makes it might offer him an indirect remuneration, like sending him to a conference at a holiday destination. BUT, it is not this indirect with chemotherapeutic drugs. Chemotherapeutic drugs are the ONLY classification of drugs that the prescribing doctor gets a direct cut of. And so, if your doctor prescribes chemotherapy for you, he is able to get a monetary cut from the prescription. Here’s Dr Peter Glidden detailing this corruption.

This means Doctors literally have a financial incentive to prescribe chemotherapy to patients that do not have cancer. But, someone might say, that would be too drastic; at best doctors would perhaps just coerce patients who already have cancer to take chemotherapy. But, there is empirical evidence of the fact that this financial incentive for big pharma has motivated doctors to prescribe chemo to patients who did not have cancer, thus proving that the pharmaceutical industry is also culpable in creating doctors who kill.

THEN THERE IS THE PROBLEM WITH FALSE DO NOT RESUSCITATE ORDERS

Then there is also the issue with false DNR orders, and how hospital protocols allow medical practitioners to literally get away with murder. For instance, Dr. Mary Talley Bowden exposed a chilling case in a Wisconsin jury trial where the Schara family sought justice for their daughter, Grace Schara, a 19-year-old with Down syndrome, allegedly euthanized under a false DNR order at Ascension St. Elizabeth Hospital.

Admitted for COVID-19 in October 2021, Grace was given a lethal combination of morphine, lorazepam, and Precedex without family consent, leading to her death, which the family claims was not due to COVID but hospital protocols.

Dr. Bowden, having reviewed similar patient records, confirms such practices

written By Lindokuhle Mabaso