The Operating Room Factory

[magpie]

High Volume, Big Dollars, Rising Tension

https://projects.seattletimes.com/2017/quantity-of-care/hospital/

In its ambitious rise to become one of the largest hospital systems in the country, Providence Health & Services struck a deal in 2011 to claim a Seattle-area rival, Swedish Health.

Providence added five hospital campuses in the process, including Swedish-Cherry Hill, an institution with a storied history and a budding reputation as a global center for neuroscience research, treatment and clinical trials.

Just a few years later, Providence and Swedish had overhauled the way Cherry Hill’s neuroscience program approaches the business of medicine, enriching the nonprofit institution and its star surgeons.

A steady churn of high-risk patients undergoing invasive brain and spine procedures allowed Cherry Hill to generate half a billion dollars in net operating revenue in 2015 — a 39 percent increase from just three years prior. It also had the highest Medicare reimbursements per inpatient visit of any U.S. hospital with at least 150 beds.

By those metrics, Providence’s acquisition of Cherry Hill has been a rousing success story.

But the aggressive pursuit of more patients, more surgeries and more dollars has undermined Providence’s values — rooted in the nonprofit’s founding as a humble home where nuns served the poor — and placed patient care in jeopardy, a Seattle Times investigation has found.

The Times spent a year examining more than 10,000 pages of records in four states, analyzing federal and state databases containing millions of records, and interviewing more than 100 people, including more than 30 current and former Cherry Hill medical staffers.

Among the findings:

The doctors in the neuroscience unit are incentivized to pursue a high-volume approach with contracts that compensate them for large patient numbers and complicated surgical techniques. Of the six top-producing brain and spine surgeons in Washington state in 2015, five were part of Cherry Hill’s neuroscience team, averaging $67 million in billed charges.

The hospital touts its star surgeons to draw patients from hundreds of miles away, but six current and former staffers said those doctors will sometimes do little in the operating room once the patient is under anesthesia. Instead, the surgeons will leave less-experienced doctors receiving specialized training to handle parts of a surgery. That allows the primary surgeons to be in another operating room — a practice known as “concurrent surgery” — to maintain high volumes. It is not prohibited but can test the limits of Medicare rules.

Hospital leaders recruited one doctor from another institution as he dealt with an internal investigation and allegations that he had high rates of complications and may have performed unnecessary surgeries. At Cherry Hill, more allegations of patient care problems emerged about the doctor, but administrators promoted him to a top leadership position.

Cherry Hill patients have undergone surgeries that are more invasive than available alternatives. That’s particularly the case in the treatment of aneurysm patients, where data show a pronounced spike in a technique that requires opening a patient’s skull and working on the brain instead of utilizing a less-invasive procedure that does not require a craniotomy.

The increased volume of patients has left medical staffers from the operating room to the intensive-care unit with massive caseloads, dividing the attention of ICU nurses who would otherwise provide one-on-one patient care. A loophole in a Washington state law designed to enhance patient safety has forced some nurses at Cherry Hill to be on duty for 20 hours in a day.

There are indications that the high-volume model is taking a toll on patient care. In benchmarks tracked by the federal government, Cherry Hill was flagged for having high rates of blood clots, collapsed lungs and serious surgical complications. State data show a rise in other problem indicators over the last several years, including aneurysm patients with high numbers of strokes.

A Lost Voice

https://projects.seattletimes.com/2017/quantity-of-care/talia/

Talia and her father had met Dr. Delashaw just a few weeks prior. He had suggested a cervical spinal fusion, a procedure in which he would use metal rods and screws to better stabilize the vertebrae in Talia’s neck. No surgery is without risk, but Talia’s youth and overall vigor made her a great candidate for the spinal fusion.

And Delashaw seemed like the perfect candidate to do the job, with a superb public reputation and résumé.

Swedish called Delashaw a “world-renowned” surgeon sought by patients from across the country. And fusions were a routine part of his care — records show he did at least 140 of them in 2014.

Delashaw, who had been recruited to the Cherry Hill neuroscience unit in 2013, had a reputation as a workhorse whose ability to churn through surgeries could single-handedly alter an institution’s financial picture.

Patient and financial data show he was delivering on that promise. In February 2014, the month Talia went in for surgery at Cherry Hill, Delashaw was listed as the attending physician on 51 inpatient cases. He managed his workload by booking multiple operations at the same time and by allowing his surgical fellows — essentially doctors getting specialized training — to handle portions of the surgeries.

Delashaw’s methods bothered some of his colleagues, according to records. And in the months after Delashaw arrived at Cherry Hill, his new co-workers filed a range of internal complaints questioning his practices and commitment to patient care.

The available medical records don’t show how much time Delashaw spent in the operating room while Talia was under anesthesia. Delashaw and a spokeswoman for Swedish declined to comment for this story, citing patient privacy.

Delashaw’s surgical fellow filed the initial surgery note after Talia’s procedure, and then records indicate Delashaw filed a more detailed one a few days later. The note does not include when Delashaw arrived in the operating room, and it’s unclear who handled certain parts of the surgery.

Delashaw wrote that he was “present” during critical portions of the surgery.

Jeff Goldenberg, Talia’s father, typically kept his background private when he visited a hospital. He was a doctor who practiced family medicine and, as a professional courtesy, he didn’t want other doctors to feel like he was there to second-guess their decisions.

But in the hours after Talia’s surgery, Jeff felt the medical staff was too dismissive about his daughter’s difficulty breathing. He found himself referencing his credentials to make it clear that he was more than just a nervous father.

It alarmed him that nobody was considering what would happen if Talia’s airway suddenly closed. He’d seen it before: In the late 1980s, when he was a young medical resident working an obstetrics rotation in Montreal, one of his co-workers was caring for a pregnant woman about Talia’s age. The woman had a cough that didn’t alarm the staff when she was first admitted. But while she was in labor, the woman went into respiratory arrest and died.

To intubate someone who stops breathing, doctors typically need to pull the patient’s head back. Jeff feared that Talia’s surgically fused neck would make that nearly impossible, and her locked jaw would make inserting an intubation tube down her throat just as difficult.

Jeff pointed out to medical staffers that if Talia stopped breathing, the only way to get her air would be with a cricothyrotomy. In the procedure, doctors use tools in a “crike kit” to cut a hole in the throat to establish an emergency airway.

At 6:15 p.m., a nurse paged Delashaw to discuss medication for Talia, but he apparently didn’t respond. The nurse then sought help from Delashaw’s physician assistant, according to records. She later paged the assistant again, asking for a doctor to come check on Talia as soon as possible. Eight minutes later, as Talia’s breathing grew more labored, the nurse paged Delashaw’s neurosurgical fellow. Then she called a Rapid Response team to come examine her instead.

Delashaw’s fellow eventually came to hear Jeff’s concerns. Jeff said Talia’s locked jaw and immobile neck meant doctors needed a plan in place to establish an emergency airway in case her throat closed off.

Doctors agreed to move Talia to the intensive care unit.

“Talia has never experienced anything this extreme,” her mother, Naomi, wrote of the breathing difficulties in a message to family and friends at 11:19 p.m.

In the early-morning hours, while Talia’s parents rested, Dr. Delashaw and the neurosurgical team made a brief visit to see Talia in the ICU. Delashaw was scheduled to fly to California later that day to give a lecture about brain and spinal tumors at a conference of neurosurgeons.

Talia later would tell her parents that she explained to Delashaw about her trouble breathing and that her jaw wouldn’t open. She said Delashaw responded that there was nothing he did that would have put her jaw out of place and that he suggested she see a specialist after leaving the hospital.

In a note signed by Delashaw, the surgical team reported that Talia had “subjective mild difficulty breathing,” something they suspected was related to the tracheal tube used during surgery. They seemed to take issue with her being in the ICU, writing that while Talia sounded hoarse, she didn’t appear to be in distress. They said she was ready to get out of bed and transfer out of intensive care.

“Patient better,” Delashaw wrote in a note filed at 10 a.m.

Talia was thirsty but struggled to swallow drops of water administered with a swab. Every time she rolled on her back or tried to sit up, she panicked because the new position made it difficult to breathe. A speech therapist tried to have her suck on ice chips, and Talia said she felt as if she might choke.

Despite the message by Delashaw that Talia was ready to move out of the ICU, her father remained concerned. He kept reiterating to doctors and a nurse that a crike may be needed in case things went awry.

Jeff read Talia a message from a family friend who was dealing with a new baby having medical problems. Talia chuckled at the friend’s lament about the medical care being provided. She grabbed her phone and sent the friend a note: “a little mutual amen to your frustration with docs and hospitals.”

“Still having a very, very hard time breathing and feel like the docs aren’t quite takin it seriously,” Talia wrote in a text at 11:56 a.m.

Jeff and Naomi had taken over much of the communicating so Talia could focus on her breathing. She was still in the ICU.

At 1:26 p.m., by her parents’ account, Talia twitched, barked out a harsh cough and called for a suction tube to help clear her throat.

Then she looked up at her mom and dad. A sudden terror crossed her face as she strained to bellow out a message through her hoarse throat: “I can’t breathe! Help me! I can’t breathe!”

Talia’s blue eyes bulged in a panicked struggle to get another gasp of air. Naomi ran to the door and cried out for help. A nurse practitioner in the room attempted to suction Talia’s throat clear.

“Don’t worry,” Jeff said to his daughter. “We’re going to help you.”

Talia thrashed in her bed. Another medical staffer hurried into the room and tried to put an oxygen mask over her nose and mouth. They adjusted Talia onto her back, but she thrashed around even more. It was clear that oxygen wasn’t getting through Talia’s closed throat.

Jeff yelled that it was time for the crike.

Naomi stood at the foot of the bed, holding Talia’s foot, keeping a connection like an umbilical cord. Talia writhed as if being smothered by a pillow. But there was no pillow to hide her torment and the desperate plea for help etched on her face.

Talia’s body went still.

Instead of grabbing a crike kit, ICU staffers first tried to force an airway device into Talia’s mouth. When one didn’t work, they tried swapping out various sizes, but they couldn’t get past her clenched teeth. They shoved, twisted and leveraged the devices to try and pull Talia’s jaw open. It didn’t work.

Jeff pleaded for someone to do the crike to open an emergency airway. He paced at the bedside. Seconds ticked away on his wrist watch. Talia’s oxygen levels dipped on a monitor. Watching his daughter’s color turn gray, Jeff fathomed the irreparable damage being inflicted on her brain with every passing second she lacked oxygen.

The room bustled with staffers responding to the Code Blue. The hospital chaplain entered and noticed Jeff’s face turning ghost white. The chaplain helped Jeff to a chair. Jeff sat with his head in his hands and fought the need to vomit.

Naomi remained at the end of the bed, helpless, still stroking her daughter’s foot.

Swedish staffers continued their struggle to get Talia some oxygen. They alternated between trying to jam the airway device past Talia’s clenched teeth and trying to pump air down her throat with a bag and mask. Across the din of voices and instructions, someone asked whether the efforts had given Talia any air at all.

“No!” the respiratory practitioner responded. “Maybe randomly.”

About 15 minutes after Talia took her last breath, a new doctor came in the room and assessed the scene. He called for the crike kit.

None was in the room.

Talia’s heart gave way to cardiac arrest about 20 minutes after her desperate gasp for help. The medical staff performed CPR and then, after finally getting the kit, the cricothyrotomy. Talia regained her heartbeat and blood pressure, but she showed no signs of consciousness.

Naomi left her daughter’s foot and walked up the side of Talia’s bed, clinging to a hope that a familiar voice, a mother’s voice, would be enough to rouse her.

Naomi spoke her daughter’s name: Talia. It meant morning dew, a divine blessing, a tender nourishment of life.

Talia didn’t respond.

Dr. Delashaw was in California for his conference when he learned of Talia’s disastrous turn. He flew back that night and assured the family that he was “cautiously optimistic” about her prognosis.

“I remain hopeful for a good recovery,” he wrote in his notes.

But Talia spent the next nine days in a comatose state, the zebra and rhino by her side. Tests showed that her brain had been devastated beyond repair. Doctors left the decision on when to take Talia off life support to Jeff and Naomi.


COURTESY OF GOLDENBERG / KIRTNER FAMILY
Talia Goldenberg’s family gathers around her hospital bed.

Talia’s family members came to say goodbye. Her little sister read books at the bedside, confounded by a story about a bear who couldn’t sleep as Talia couldn’t wake up. The family made the call, and then waited at her bedside for the end.

She held on for 37 more hours. At 10:41 p.m. on Feb. 20, Talia Ranit Goldenberg died.

Swedish’s doctors performed an autopsy but reported that they were unable to pinpoint the cause of Talia’s sudden inability to breathe. Her parents still don’t know exactly what happened.

A week after her death, a letter addressed to Talia arrived at the family’s home in Eugene. It was a note from Swedish that asked Talia to complete a survey and describe her stay.

“By sharing your thoughts and feelings, you can help us improve the care we provide,” the letter said.

Jeff and Naomi instead filed a lawsuit against the hospital. Public court records in the case include detailed accounts of what happened, as well as accusations of negligence despite clear warnings — including Talia’s own complaints. In an interview, Talia’s parents spoke about her life and general aspects of her surgery. But the terms of the now-resolved legal case prevent them from discussing the hospital or staff involved in their daughter’s care.

Jeff and Naomi still struggle with the trauma of witnessing their daughter die in front of them. During the day, their minds snap back to vivid scenes in the hospital. At night, they have difficulty sleeping.

Jeff now grows distressed whenever he enters a medical setting. He has quit practicing medicine.

Swedish said this week in a statement, “We extend our deepest sympathy to any family who is grieving the loss of a loved one. Swedish caregivers strive to provide the highest quality, most compassionate care to patients and to their families. We care for patients who often have some of the most difficult care needs and our clinicians work to provide the best outcomes possible.”

It’s not publicly known whether Talia’s unexpected death led to changes at Swedish-Cherry Hill, or whether anyone faced internal discipline.

Dr. Delashaw has since been promoted. He’s now the chairman of neurosurgery.

 

[Tellenbach]

This story is very similar to the one in Black Box Thinking by Matthew Syed. In the book, the doctors killed a 30 something year old woman who had breathing problems while under anesthesia. Instead of doing the most obvious procedure and opening up the throat, the doctors tried other methods and lost track of time. Unfortunately, the mistakes made by this operating team and many other mistakes were covered up and attributed to "unexpected complications" and other vague terms.

This failure to learn from the mistakes of others is perhaps the biggest problem with the medical profession. Because of malpractice lawsuits, many doctors refuse to admit they made mistakes and other doctors aren't able to learn from them. By contrast, every mistake made by airplane pilots is recorded and shared instantly with every other pilot. This is why the medical profession kills over 400,000 patients each year while the pilotting profession is almost error free (less than a 0.2% error rate).

 

[Mole]

This is very hard to beat. All we have is someone impersonating a doctor for eleven years in our medical system and our hospitals. On being discovered he fled to his native India and remains at large.