I am a system engineering graduate student, and I firmly believe that the vast majority of bad outcomes in health care are due to good people working in bad systems. However, today when watching the story of Michael Skolnik’s death after three years of complications from neurosurgery I felt like I had just seen one of the rare cases of a truly bad person in the health care system.
For those unfamiliar with the case here is the two-minute synopsis. A previously healthy 20 something year old male presented to the emergency room after having a syncopal episode. A head CT shows what may be a colloid cyst with no evidence of increased intracranial pressure. An MRI is done and may show the same colloid cyst. Michael and his parents go to see a neurosurgeon who immediately admits him to the neuro ICU. He gets the family to sign a… Continue reading
I wrote the following today on my scrap paper after learning of the story of the tragic death of the young boy, Lewis. The factor that most struck me regarding his death was the failure of the junior team members to recognize that something was wrong over the weekend. It led me to the following reflection:
The scariest part of my surgery rotation as a third year medical student was taking weekend call. It was me, an intern, and a junior resident – usually a PGY 2 covering the entire floor and everyone walking through the ER door. Not one of the three of us had enough clinical experience to have yet developed that sixth sense that helps you tell if someone is “sick” or “not-so-sick.” A good attending physician can look at a patient from across the room and know that something is wrong, but that skill comes with… Continue reading