Failure to Rescue: The Story of Lewis Blackman
An Interdisciplinary Viewing
As a surgery resident, I had a different reaction to the the film “The Faces of Medical Errors…From Tears to Transparency: The Story of Lewis Blackman” than some of my fellow scholars. This is absolutely the value of viewing and discussing it in such a forum, as every perspective highlights specific opportunities for improvement.
As our interdisciplinary discussion highlighted, Lewis’ death was the unfortunate result of a broken system. Lewis was a 15 year old undergoing a new repair for pectus excavatum. The first systems issue brought up by his mother, who remains a strong patient advocate, was the informed consent process surrounding a new “low risk” surgery. The pectus repair was technically successful, but issues started intraoperatively. He was making minimal urine during the case and after. He received multiple doses of toradol, up to post-operative day #5, with minimal oral… Continue reading
En Route to Colorado: A Belated Post
While technically already in Breckenridge, I’d like to share the thoughts and key moments that led me here:
I first heard about the Marseille experience from a classmate of mine from the BU School of Public Health several years ago. The stars never aligned as far as scheduling, but I feel that I have now reached the point in my training where I want to focus my energy on the patient-centered care I entered medicine to improve. I have been exposed to patient safety events since long before I entered medical school and became part of this tribe. A great uncle was the victim of an OR fire many years ago. A close family friend and mentor went with undiagnosed and ultimately rapidly progressive head and neck cancer until persistence and a patient advocate got him to the NIH. I was taken to a urologist/chiropractor/acupuncturist… Continue reading