Collateral Damage

I once heard Don Berwick say, shortly after taking over as Director for CMS, that he originally thought quality and safety where the biggest challenges facing healthcare today. But after spending time in the district, he quickly came to realize he was wrong. It was fraud that was the biggest challenge.

Collateral DamageHis message came to mind after recently reading a book given to me by Rosemary Gibson, entitled “Collateral Damage”, written by Dan Walter. I can honestly say that after reading the book, I felt embarrassed to be working in healthcare.

In the book, Mr. Walter shares the story of his wife, Pam, who underwent a cardiac catheter ablation procedure for an abnormal heart rhythm known as atrial fibrillation. He describes what went wrong during Pam’s procedure, and then details the pain, suffering, lack of transparency and denial of accountability that followed for both he and his wife. The procedure was performed at what is considered to be one of the best hospitals in the country, which makes the reader wonder what is going on at the “not so great” hospitals across the country, as well as who is defining what makes a hospital “great”. His aim in writing the book was to, “accurately portray what happened to my wife…without detracting from the skill, kindness and compassion of the majority of the people who work there…and to prove to Pam that she does matter, and to tell her that despite what the leadership of that hospital says, her life is important – and her story is important – and it deserves to be honestly told”.

The book is Mr. Walter’s account of the facts related to his wife’s care, so it is only his side of the story. However, it is remarkably well written, and gives a deeply researched account of the cardiac catheter ablation “business”. He includes information:

  • Taken from numerous publicly available FDA transcripts and testimonies on how unsafe these catheters were thought to be.
  • Promotional materials from companies making these catheters who were trying to get them through the FDA approval process hyping the wonderful results being seen in patients who were the first to be “experimented” on.
  • Transcripts from advisory panels and cardiology meetings where leading experts acknowledged the lack of evidence that these catheters even worked.
  • Conclusions from peer-reviewed journals showing complication rates much higher than what was being shared with patients.
  • Medical records highlighting a lack of real informed consent related to the risks and benefits of these procedures.

Mr. Walter also shares numerous other patient stories and holds nothing back. Not only does he name names, but he includes pictures of physicians and others who he and Pam encountered along their journey.

In one section of the book, the author shares thoughts on the difference between a “witness” and an “accomplice”, a witness being one who sees wrong and reports it.  He raises the question that if we as caregivers witness something wrong and don’t report it, aren’t we really accomplices to the wrong when we turn our back and walk away?  His statement caused me to reflect back on my career. As an anesthesiologist, I remember days when I was assigned to provide anesthesia for a catheter ablation case. Although I spoke with the patient about anesthesia related risks and benefits – I never thought of questioning the merits of the procedure I was to be a witness to. It was challenging enough keeping up with all the new findings in my specialty let alone comprehend everything being published in the numerous specialties anesthesiologists support. But after reading Pam’s story, I felt that I too may have been an “accomplice” to possible wrong doing.

I applaud Mr. Walter for sharing Pam’s story. I also struggle to understand why this book has not received similar attention, or the same hype experienced by authors of recent books published on medical error. Collateral Damage goes much deeper in highlighting problems facing healthcare today…a reason why I believe this book should be required reading for all resident physicians and health science students entering the field.

As quality and safety leaders and educators, our daily efforts are built around things like standard work processes, shared best practices, care bundles, checklists and universal protocols–“things” we do in the best interest of our patients. The bigger picture, as Don Berwick alluded to, requires that we overcome the personal, political, legal and financial agendas inherent within many high-level stakeholders. Otherwise, I sometimes feel we are just moving chairs around the deck of the Titanic.

For those interested, Dan’s book is available free on Amazon Kindle as of June 12th http://amzn.to/15TQmkU