During the roundtable’s first session, we had the opportunity to view the award-winning film, Faces of Medical Error…From Tears to Transparency: The Story of Lewis Blackman. The film, produced by two of our faculty members Drs. David Mayer and Timothy McDonald, is part of a series of educational films focusing on managing medical errors and participating in honest, open communication with patients and their families.
The story of 15-year-old Lewis Blackman is tragic and completely preventable. In short, Lewis underwent elective, corrective surgery for pectus excavatum (http://en.wikipedia.org/wiki/Pectus_excavatum
), and his post-operative course was littered with numerous signs and symptoms of deteriorating medical status. Over a five day course he experienced increasing levels of pain, a steadily, consistently increasing HR that topped out in the 160s, systolic blood pressures into the 140s, physical exam signs consistent perhaps subtle but then blatant acute abdominal pain, and severe hypovolemia.… Continue reading