Unbelievable Incidents

In Napa, I am sitting and watching the life story of Lewis Blackman, a life-changing story not only for Ms. Helen Haskell or the healthcare professionals involved in Lewis’s care, but for many especially who are in the health care arena. Lewis communicated to the health care community by his elevated heart rate, uncontrolled pain and his appearance. His mother who was beside him throughout the hospitalization communicated her concerns. But, the health care team listened for what they wanted to hear. The first principle of patient care- believe your patient, was ignored. Lewis was a fighter. He fought for his life for days, but the health care system failed him. If the nurse recognized the inability to record a blood pressure as a warning sign, and the next person who recorded an acceptable blood pressure has not filled the hole as (s)he wanted to or the senior surgical professionals responded in a timely manner etc etc. Lewis would have been alive today.

As the story evolved,  I became uncomfortable. The disbelief, the sadness, the pain, the anger and so on. As health care provider, I reflect : how did it happen! Assumptions, perceptions and lack of communication took Lewis’s life.  When our assumption and perceptions interfere with the patient management, we don’t see the complete picture. It leads to ‘premature closure’. At my workplace, my attending physician frequently asks,  “What is the worse thing possible?”. Though this prompt made me to think about the “worst” possibility, I did it without realizing what it meant actually. I took it as my attending physician’s effort to help me think through it.Now my take home message from Napa will be the very same question as part of my each moment of clinical practice.

Stories are powerful. Lewis’s story and other similar stories can modify healthcare providers’ perspective on patient care delivery. The triple aim urges the importance of patient experience in health care delivery. The quadruple aim adds the providers’ experience to the triple aim. To ensure patient experience and provider experience, much work needs to be done. I can start with me!

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