Health Train Express: There is No "Routine Procedure"

"Mrs Smith, this is a routine procedure, don't be nervous" How many times have I heard a nurse, or physician tell this to a patient in order to assuage their anxiety. Perhaps we as physicians are saying that to minimize our own anxiety when in fact we all know of the horrendous things that can go wrong during a 'routine procedure' ?

Martha Wright had her first colonoscopy at Missouri’s Cass Regional Medical Center. She died the next day of internal bleeding, an unusual outcome that has the hospital under extra scrutiny from regulators.

Her Attorney wants accountability

At 83, Martha Wright had never had a colonoscopy, even though government guidelines call for nearly everyone to be screened for colon cancer after age 50.

The Pleasant Hill resident was scared of the test, her daughter Dena Royal said, because she was petite — less than 5 feet tall.

“What she repeatedly said was, ‘I don’t want to have a colonoscopy; it will kill me,” said Royal, a former Kansas City paramedic and respiratory therapist. “We just kind of said, ‘Oh mom, it’s routine, it’s no big deal.’”

Wright had her first colonoscopy Aug. 2 at Cass Regional Medical Center, after a doctor recommended it because she was anemic.

She died the next day of internal bleeding.

Martha Wright celebrated her 80th birthday three years ago in Kansas City.

SUBMITTED PHOTO

It was a highly unusual outcome from a very common procedure that now has the Harrisonville hospital under extra scrutiny from government regulators.

State inspectors came out to investigate Wright’s death in late November after Royal filed a complaint. They found that Wright showed several signs of distress after the procedure, but Cass Regional staff didn’t properly respond. They also said 348 more colonoscopies had been performed there since Wright’s death, without addressing the deficiencies in care.

The inspectors passed their findings to the federal Centers for Medicare and Medicaid, which classified the situation as an “immediate jeopardy” that "placed all patients at the facility at risk.” It’s one of the agency’s most serious designations. If the situation is not promptly addressed, hospitals can lose their ability to bill Medicare.

THE TEST

In a colonoscopy, patients are under general anesthesia while a doctor inserts a small flexible tube with a tiny camera through the patient’s rectum and into the large intestine. It’s a key tool for detecting colorectal cancers, but according to the Centers for Disease Control, about one-third of Americans who should be getting the test aren’t.

Still, it’s one of the most common medical procedures in the United States and it’s usually safe. Serious complications occur in only about 1.6 percent of patients, though experts say that’s still too high, given that millions of colonoscopies are done each year.

Deaths are even more rare.

In one of the largest studies done on the topic, researchers examined 16,318 colonoscopies performed in Kaiser Permanente hospitals between 1994 and 2002. They found only one death they could attribute to the procedure — a rate of 0.006 percent. A 2008 study on Canadian colonoscopy patients came up with a similar number.

By contrast, the five-year death rate for people with localized colorectal cancer is about 10 percent, and it spikes to almost 30 percent once the cancer spreads to surrounding tissues or organs.

According to the inspection report and medical records provided by Royal, Wright’s colonoscopy was, at least at first, the type everyone wants to get.

There was no sign of colon cancer. There were no polyps to be removed. It was a “clean” test that was “completed without difficulty or complications,” according to medical records reviewed by the inspectors.

Wright was sedated for the procedure, and because she didn’t have anyone to drive her home and watch her for 24 hours, she had to stay at the hospital overnight per Cass Regional policies.

The test was in the morning. By 5 p.m. she was complaining of pain in her left upper abdomen, but said it was tolerable: a 3 on a scale of 1 to 10. By 10:15 p.m. the pain had increased to 7 out of 10 and had spread to her left shoulder. According to medical records, a nurse told her she probably had gas and gave her Tylenol.

The inspection report said this is when nursing staff should have contacted the surgeon to inform him or her of the change in Wright’s condition.

Instead, the doctor wasn’t notified until about 2:30 a.m., when Wright awoke complaining of nausea, clammy skin and shortness of breath, in addition to the abdominal pain. The doctor ordered some tests, including a CT scan, but Wright kept getting sicker.

She was taken to the intensive care unit at 4:50 a.m., but by then she was unresponsive, with no breathing and no pulse. Hospital staff tried CPR, but at 5:14 a.m. Wright was declared dead.

The radiologist who read the CT scan found a “large amount of hemorrhage ... within the abdomen and pelvis,” which the emergency room physician listed as her official cause of death .

“She basically bled to death,” said Aaron Woods, the Lee’s Summit attorney Royal hired.

Royal said she knew something must be wrong when the phone rang early in the morning. But it was still a “gut-wrenching” shock to hear that her mother was dead.

“I mean, my mom was 83 but I thought she still had a lot of life left,” Royal said. “This was just so unexpected.”

It wasn’t the incident itself that drew the most concern from government officials, though. Medical mistakes happen. Cass Regional rate of re-admitting patients after a colonoscopy is 15.5 per 1,000. That is actually slightly better than the national average (16.4 per 1,000 patients), according to federal data.

What was most concerning to regulators was the hospital’s response. They said Cass Regional officials should have recognized Wright’s death as a “sentinel event” that signaled potentially broader problems, immediately investigated to find out how it happened and then educated staff about how to keep it from happening again.

Instead it was more than a month before the internal investigation started, and “the facility also failed to educate nursing staff in a timely manner,” the federal report said. When staff were eventually trained more on assessing patients’ conditions, it “was informal and without documentation of who attended.”

Cass Regional correction plan includes many policy changes to keep that from happening in the future.

Upon reviewing the case it was apparent that staff failed to notify the surgeon of a change in her postoperative condition shortly after discharge in a timely manner.

Addendum

Several things readers should note:

1. There is no such thing as a routine procedure. Routine only means they do a lot of the procedure. If there is a problem the surgeon will make a note of it. If there is an abnormal postoperative course nurses must notify the responsible surgeon. The surgeon is responsible for making a decision, not the nurse

Familiarize yourself by watching the following videos.*******