“I Could Have Caused Permanent Brain Damage”
By Peter Provonost, MD, PhD
I was a young doctor doing specialty training in critical care, and I was exhausted. Partway through a 36-hour shift at Johns Hopkins Hospital, I was hungry and hadn’t slept for 24 hours, but I was facing an overflowing intensive care unit and somehow needed to discharge five patients to make room for more. Mr. Smith,* who’d had esophageal surgery, was a borderline call. But because of the pressure I was under, I decided to remove his breathing tube and transfer him to another unit.
*Name changed to protect privacy
That turned out to be a very bad decision.
Before long, his breathing sped up as his oxygen levels dropped dangerously. I needed to reinsert his breathing tube. But what I didn’t know was that he had severe swelling in his throat—in fact, the anesthesiologists in the operating room had had difficulty placing the tube in the first place. When I looked into his mouth and tried to identify his vocal cords in order to insert the tube, all I saw was a swollen mass of dark pink tissue, like raw hamburger meat.
I took the instruments out and started to bag him, breathing for him, but he vomited, making that almost impossible. I finally got the tube in—but quickly realized it was in his esophagus, not his airway where it belonged. Understand that when you insert a breathing tube, you give the patient medication to stop his breathing. You have about four minutes before he suffers brain damage. It took me between three and five minutes to get the tube properly placed.
I waited anxiously for the medication to wear off, which usually takes about 15 minutes. But after an hour, Mr. Smith was still asleep. After six hours, I was panicked. I explained the situation to the patient’s wife—well, I sort of explained it. Fighting back tears of shame and guilt, I told her I’d had difficulty reinserting the tube, but I didn’t mention that it was the wrong decision to remove it in the first place. Doctors, especially Johns Hopkins doctors, didn’t make mistakes. If you did, you suffered your shame silently.
Luckily, Mr. Smith regained consciousness shortly thereafter and recovered with no ill effects. I still remember my overwhelming feeling of relief.
How to Fix the Problem
Many medical errors occur because hospitals lack standardized checklists for common procedures designed to minimize the chance of bad judgment. Airline pilots and NASCAR teams have them—why don’t doctors? I think it’s partly because it’s so important for us to believe in the myth that doctors are perfect.
Before I pulled that tube, I should have had to complete a checklist that included input from the patient’s senior physician and nurse. If anyone had disagreed, I wouldn’t have been able to act. A simple system like this not only protects patients but also promotes honesty, respect, and teamwork among hospital staff.
A few years ago, I helped develop such a checklist for doctors and nurses in more than a hundred ICUs in Michigan. It focused on a common intensive care procedure: inserting a catheter into a vein just outside the heart for delivery of intravenous fluids. It ticked off five steps everyone had to follow, and in 18 months, it lowered the rate of catheter infection by 66 percent and saved 1,500 lives.
Mr. Smith taught me a lesson I never forgot. It’s time we let him teach us all.
Peter Provonost, MD, PhD, is a professor at Johns Hopkins University School of Medicine and the coauthor of Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out.