Stop.
What?
I said, stop.
Why?
Because you’re in the wrong lung.
No, I’m not.
You’re in the wrong lung. Just look at the fluoro.
Oh, my God. Have you taken biopsies?
Yes. Just stop.
Twenty minutes before Dr. John Riley stepped back into the bronchoscopy suite of University Hospital and uttered the word “stop,” the day seemed promising. As an attending physician at one of the largest lung transplant centers in the country, Riley enjoyed being on the Bronchoscopy Service. His day was filled with bronchoscopies—procedures that involve technical prowess and precision. Performing procedures gave him immediate satisfaction and results, and he was good at them.
John Riley’s decision to work with a dying population of patients, as most lung transplants are, seems incongruous when one first meets this affable, almost lighthearted man. Inclined to humor, liked by his colleagues and patients, Riley fosters a sense that he is easygoing. He nicknamed one patient “Santa” because of the patient’s uncanny resemblance to the mythological character, and actually addresses the patient as “Santa”—much to the chagrin of his colleagues and the unending amusement of his patient. But he approaches his work and his patients in a measured, meticulous fashion. His colleagues describe him as an excellent doctor and have seen him rounding at the hospital until ten o’clock at night, attending to his patients. John Riley uses the absurd as a shield because he treats emotionally demanding patients like lung transplants: patients who routinely require ten to twelve medications each, are frequently hospitalized in intensive care units because they are immune-suppressed, and undergo at least six bronchoscopies just in the first year after transplantation.
A lung transplant is a treatment of last resort. After a patient undergoes lung transplantation for a chronic lung disease like emphysema or cystic fibrosis, bronchoscopies become part of a vigilant plan to detect infection or rejection of the donor/transplanted lung. Infection and, eventually, rejection frequently cause death in lung transplant patients. According to the most recent data collected by the United Network for Organ Sharing (UNOS), survival after lung transplantation is only 47 percent nationally at five years.
In order to monitor for the two most common causes of death in transplant patients—infection and rejection—doctors need to look directly at the transplanted lung and take a biopsy, a piece of the lung. A bronchoscopy accomplishes that goal. Unfortunately, it is invasive—it necessitates physically entering and manipulating the body. It falls under the category of same-day surgery, with risks of bleeding, infection, puncture of the lung (pneumothorax), and even death.
University Hospital’s lung transplant team prides itself on a survival rate well above the national average, despite the fact that it performs lung transplants on higher-risk patients than most other centers in the country. The team cites the cumulative experience its members and the hospital staff gain from the sheer volume of lung transplants they perform each year, working in one of the largest centers in the country. In other words, the more transplants they do, the more experience they gain, and the better they get. Their claim is supported by several studies published in two of the most prominent journals in medicine, the New England Journal of Medicine and the Journal of the American Medical Association, which agree that high-volume centers have better outcomes. University Hospital’s morbidity rate—the number of patients who suffer side effects after a bronchoscopy—is also lower than the national average.
When Thelma Jones appeared on a stretcher before the large steel double doors leading to the bronchoscopy suite, she was greeted as usual by Paul, the lead nurse. I imagine their conversation went like this:
“It’s you again, Thelma? Is it that time already?”
Thelma tried to laugh. “Actually, Paul, I don’t feel too good this time.”
“I’m sorry to hear that, Thelma. Are you having trouble breathing and coughing more than normal?”
“Yes.”
“I guess that means it’s not a surveillance bronch. We’re looking for something. Well, you’ve been here so much you know the routine, right?”
“Yes.” “I still need you to sign the consent for the bronch that the docs are gonna do.”
“I know.”
“Is your son gonna wait for you?”
“Yes.”
“Now remind me, Thelma, which lung did we transplant in you?”
“The left one.”
Chatting about Thelma’s house in the remote Upper Peninsula of Michigan, her son driving her the many hours into the city, and the lack of parking around the hospital, Paul wheeled Thelma into the white-tiled procedure room. As he hooked up the heart monitor to her chest and the pulse oximeter to her right index finger, Frank, the bronch technician, prepared for the bronchoscopy. Already suited up in his blue lead-filled apron to protect against the radiation used during the procedure, Frank was also masked, gowned, and gloved. Carefully he laid out the instruments on a metal tray: tiny metal forceps, syringes filled with sterile saline and 1 percent lidocaine, plastic tubes and containers for specimens to be collected, and the black bronchoscope with its bulky camera lens and portals at one end followed by a long, narrow cylindrical tail containing flexible fiberoptic bundles. Images from that camera would be transmitted to a seventeen-inch television monitor bolted to the ceiling above the patient. All those involved with the procedure could see where in the lung the bronchoscope was located.
The camera of the bronchoscope would be blinded by mucous and blood at the moment the metal forceps took biopsies, however, and so fluoroscopy or X-ray capability was also necessary so that the doctors could see where they were in the lung. A radiopaque image, tracing the bronchoscope from the vocal cords, past the trachea, down the bronchi and bronchioles into lung parenchyma, would show where the metal forceps grabbed a piece of lung. These X-ray images would be projected onto circular screens below the rectangular bronchoscope screen. The color images on the bronchoscope screen would move; the images on the fluoro screen would be freezeframes in black and white. Frank would turn on the fluoroscopy engine last, because the din of that machine would compete with any other sound in the room, including the rhythmic beeps from the monitors sounding out Thelma Jones’s heart.
While preparations were going on, Bill White, a physician in training, stepped into the room to speak with Thelma Jones. A tall, broad-shouldered man, Bill inspired confidence in the people he worked with. All those involved in this case describe a competent physician, someone with adequate knowledge, a trainee with several years of experience. He was not a greenhorn, nor was he disparaged by the bronchoscopy staff as a “box-of-rocks.”
By all accounts, Bill White introduced himself and reviewed with Thelma Jones the details of the bronchoscopy: she would be sedated, numbing medicine would be applied to her vocal cords, the bronchoscope inserted, and washings and biopsies taken. Bill also discussed with Thelma Jones the possible side effects of a bronchoscopy—excessive bleeding or a punctured lung being the most common. But he assured her that at University Hospital, the incidence of either happening was less than 1 percent, significantly lower than the 2–3 percent reported nationally. What he didn’t tell her was what would happen if the wrong lung was biopsied.
***
“The patient is on the table” are the words the bronch staff uses to tell an attending physician, like John Riley, that his presence is required for a bronch. Riley does not remember those words being spoken that day, however. He remembers briefly speaking with Thelma Jones in the bronch suite. He recalls meeting with the nurse manager of the bronch suite in her office, then walking down the hall with her to the procedure room. He thinks he partially propped the door open as they finished their conversation about patient safety. Then he stepped into the procedure room and into what he later described as the worst nightmare of his professional life.
Riley’s eyes flicked to the fluoro screen and froze. He saw the image of the bronchoscope in the black and white shadows of Thelma’s right lung.
“What is going on here?” he asked with disbelief in his voice. Bill turned his face, shielded behind an orange mask and plastic eye guard.
“We’re doing the bronch.”
But Bill knew that as a trainee he was not supposed to go past the vocal cords without an attending physician in the bronch room.
“Where do you think you are?”
“In the left lung.”
“Stop.” John Riley tried to control the panic in his voice.
“What?”
“I said, stop.”
“Why?”
“Because you’re in the wrong lung.”
“No, I’m not.”
Before John Riley could respond, Frank, the bronch tech, chimed in. “What are you talking about, John? Bill’s in the right lung.”
“That’s my point. He’s in the right lung, not the left. We transplanted Thelma’s left lung,” John Riley answered.
“I’m in the left lung.” Bill defended his position. Paul, who had his back toward the procedure while he was charting Thelma Jones’s vital signs, turned and looked at the fluoro screen.
“The hell you are,” he said flatly.
“I did not go into the wrong lung. I’m telling you, I’m in the left lung,” Bill persisted.
“You’re in the wrong lung. I’m sure of it. Just look at the fluoro.”
As John Riley uttered those words, Bill glanced upward. His gaze locked on the fluoro screen. There was no denying it; the silhouette of Thelma Jones’s heart, the shadows of her ribs, clearly showed he had gone into her right lung, her nontransplanted lung.
The wrong lung.
“Oh, my God.”
“Have you taken biopsies?” John Riley asked tensely.
“Yes.” A single word that spoke volumes.
Bill had overstepped his bounds by proceeding past the vocal cords without an attending surgeon in the bronchoscopy room. But taking biopsies without an attending surgeon flagrantly disregarded the policy of physician-trainee behavior.
“Just stop. Just stop and pull out the scope.”
The ensuing silence seemed to press on John Riley’s shoulders. He slumped as he crossed his arms and fixated on the image of Thelma Jones’s right lung on the fluoro screen. The image would remain frozen there until a new picture was snapped. He scanned for evidence of a pneumothorax, or air trapped between the lung and the chest wall. A pneumothorax during a bronchoscopy is a dangerous consequence of puncturing the lung and air leaking from the lung into the pleural space. The pleural space is hemmed in by the bony sternum, ribcage, and spine. As air fills the pleural space, it pushes against the lung until it causes the lung to collapse.
To illustrate the result of a pneumothorax, John Riley describes a scene from the movie Dances with Wolves: an arrow is shot into a herd of bison thundering across the American Plains. The arrow pierces the right chest wall of a large male bison, shattering bone, tearing muscle, causing air to rush into the pleural cavity. The bison labors to keep running. But he can’t breathe; air has collected in a space where it doesn’t belong, squeezing both his lungs until they shrivel like deflated balloons. Oxygen no longer flows to his heart, his kidneys, his brain. Soon he crashes to the ground, a dead brown heap.
But bison have only one pleural space, while humans have two distinct pleural spaces, one surrounding each lung. In Thelma Jones’s case, a pneumothorax causing collapse or “dropping” her right lung would not be imminently life-threatening if she could still breathe with her left lung. But the reason she was in the bronch suite in the first place was because they needed to biopsy her left lung, her transplanted lung, the lung that Riley suspected Thelma Jones was rejecting.
Performing a biopsy on a lung always runs the risk of a pneumothorax. Obtaining a biopsy of Thelma Jones’s right lung had been useless. Worse, it may have placed her life in peril. The woman was sick. If she was rejecting her transplanted lung, only a biopsy of her left lung could give them the answer. John Riley was caught between the proverbial rock and a hard place. If he did not biopsy her left lung now and she was rejecting, then he was delaying diagnosis and lifesaving treatment. If he biopsied her left lung now and she “dropped” both her lungs, she could die. An opportunity wasted or a risk of death.
As the attending physician, John Riley had to make the decision. Ultimately he was responsible. He decided to get a higher resolution X-ray than the fluoro could provide. Because air rises, a pneumothorax of the right upper lobe of the lung should show up more clearly if they sat the patient upright and took an X-ray. If there was no evidence of a pneumo on the right side, they could bronch her left lung as intended, although they still ran the risk of giving her a pneumo on the left side.
While they waited for a radiologist to give them an official reading, Riley pulled Bill aside.
“What happened back there?”
Implicit in the question was John Riley’s anger.
“I’m sorry.”
“Bill, you went into the wrong lung.”
“I’m sorry.”
“How did that happen?”
“I don’t know. Look, John, I’m really sorry.”
“We’ll get through this. We just have to deal with what happened.”
Those were the only words John Riley said in response to Bill’s attempt to seek reassurance. Bill probably wanted Riley to say that it was OK; he wanted someone to forgive him for making a mistake. But it was not OK. A patient had suffered consequences, and everyone in that room had played a part.
When the reading of the X-ray came back as “no pneumo,” the relief was palpable on Riley’s face. But it was cold comfort. He knew that they had transplanted Thelma Jones because of emphysema, and emphysematous lungs are more likely to develop a pneumothorax after biopsy because of their friable nature. So the fact that Thelma Jones’s right lung, her emphysematous lung, was biopsied and showed no evidence of a pneumothorax remained unsettling.
They combed every inch of the right lung with the fluoroscope. Still no evidence of a pneumothorax.
They bronched Thelma Jones’s left lung, taking washings and biopsies quickly and efficiently. They scanned her left lung for evidence of a pneumo and found none. Then they scanned her right lung again. This time, a pneumothorax was plainly visible in the right upper lobe. As Riley had feared, mistakenly biopsying her emphysematous lung had resulted in a pneumo.
“I’m sorry” were the only words spoken. Bill’s remorse permeated the silence. All they could do was wait and see if a pneumothorax would also develop in Thelma Jones’s left lung. If she had pneumothoraxes of both her lungs, she could become that bison in Dances with Wolves.
The treatment for a pneumothorax entails inserting a chest tube between the ribs and sucking out the pocket of air in the pleural space, allowing the lungs to re-expand and the patient to breathe. Thelma Jones was fortunately still under anesthesia when a clear, plastic catheter was emergently pierced into her right chest wall between the third and fourth ribs. But because she was still under anesthesia, she could not be informed about the consequences of her bronchoscopies. Riley had to inform her next of kin, her son.
“We need to speak about what happened during your mother’s procedure today.” Riley started the conversation as soon as they sat down in the bronchoscopy suite conference room.
“Is something wrong, Dr. Riley?”
“I need to inform you that a complication occurred during your mother’s procedure.”
“What happened?”
“While there are times that we biopsy the native lung as well as the transplanted lung in order to get better answers, that was not the case with your mother today. We only intended to biopsy her left lung, her transplanted lung. Inadvertently, we biopsied your mother’s right lung.”
Riley paused. “As a result of that biopsy, your mother developed a pneumothorax. We punctured her lung; it should not have happened.”
“Are you saying you made a mistake?”
“Sometimes when we are in the lungs, the bronchoscope becomes obscured by mucous or blood and we get turned around. In your mother’s case, we went into the right lung instead of the left lung and took a biopsy where we should not have. It was not our intention. It should not have happened.”
Thelma Jones’s son must have heard the distress in John Riley’s voice, must have read the anguish on his face.
“I understand that mistakes happen. I understand that sometimes, even in the best of circumstances, things go wrong. My mother and I appreciate the care you have always given her. She wouldn’t be here without you taking care of her. I know you did your best.”
Thelma Jones’s son sounded almost consoling.
John Riley has never been named as a defendant in a medical malpractice suit. And he wants to keep it that way. He knows that half of all physicians, regardless of ability or error, are sued during the course of their careers. As calculated as it may sound, Riley was very careful not to say the word “sorry.” Hospital risk-management lawyers have advised him that in the current medical-legal environment, that word is tantamount to an admission of fault and therefore an invitation to be sued. Some patients and their families hear “sorry” and immediately assign blame and take punitive action. Of medical malpractice claims, 40 percent are without merit, according to a study published in the May 2006 New England Journal of Medicine.
But John Riley wanted to say that he was sorry. It weighs on his conscience that Thelma Jones’s son, and Thelma herself, when she was informed, were both so understanding about his part in a serious medical error. Riley does not deny that a mistake occurred; he readily admits he was ultimately responsible. Nor does he blame his trainee; he says he failed his patient in adequately assuring her safety and he failed his trainee in adequate supervision. He lives with his failure—his failure of human error.
The Institute of Medicine (IOM) in its 1999 report To Err Is Human: Building A Safer Health System claims that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors. This makes medical errors the eighth leading cause of death in the United States—ahead of car accidents, breast cancer, and AIDS. Two weeks after the IOM released its report, the Clinton administration issued an executive order instructing government agencies to implement techniques for reducing medical errors, and Congress launched a series of hearings on patient safety. Yet medical errors continue to plague the nation. Four years after the IOM report was issued, one expert in medical error declared that he could not “find evidence that health care in the United States is becoming safer.”
The Institute of Medicine defines medical error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” Most medical errors are preventable. According to one landmark study on medical error, over 75 percent of adverse events were either preventable or potentially preventable. What the IOM calls an “epidemic” of medical errors costs the nation an estimated $17 billion to $29 billion each year, with no end in sight. Beyond the cost in human lives and dollars, however, is the unquantifiable cost in the “loss of trust” by patients and the “loss of morale and frustration” by doctors.
What surprised many people, but should not have, is one of the IOM report’s main conclusions: “The majority of medical errors do not result from individual recklessness or the actions of a particular group—this is not a ‘bad apple’ problem. Most commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.” In other words, medical error is not about one bad doctor or even a group of them; it is about the controllable conditions or situations under which even a good doctor makes a mistake. The IOM report clearly states that “mistakes can best be prevented by designing the health system at all levels to make it safer—to make it harder for people to do something wrong and easier for them to do it right.” This means changing the “error prone” environment in which doctors practice medicine. It means correcting what Lucian Leape, a leading expert in medical error, calls “defects in the design” of systems that lead good doctors to make mistakes that are often “no different from the simple mistakes people make everyday.” In his article “Institute of Medicine Medical Error Figures Are Not Exaggerated,” published in the Journal of the American Medical Association, Leape agrees with the IOM that medical errors result from faulty systems, not faulty people. Furthermore, he contends that “errors are excusable; ignoring them is not.”
The IOM report also argues that “blaming an individual does little to make the system safer and prevent someone else from committing the same error.” Yet, according to a study published in 2002 by the New England Journal of Medicine, “Views of Practicing Physicians and the Public on Medical Errors,” the public remains unwilling to accept this. When asked what they considered one of the most important problems with health care and medicine, much of the public responded with the term “incompetent doctors.” Half of respondents viewed the suspension of licenses of doctors as an effective way to reduce medical errors. The public believes that doctors, not systems or processes, are primarily responsible for medical errors and should be sued, fined, and subject to suspension of their professional licenses. They cling to the notion that only bad doctors are responsible for bad mistakes. The American public doesn’t want to hear that good doctors make mistakes and perfection in medicine is impossible.
What does not weigh on John Riley’s conscience is silence. As tempting as it was to tell Thelma Jones and her son that a biopsy was planned of her right lung and that the pneumothorax was the unfortunate outcome of a necessary procedure, John Riley chose to tell the truth. I admire him for that. I know just how easy it is to be silent. Many years ago, I witnessed an ob-gyn make a terrible mistake during a routine hysterectomy. I stood in the operating room retracting the patient’s belly open while he carelessly hacked out her ovary. I stood next to her hospital bed as he lied to her about his mistake.
“We had to take the right ovary, Gina.”
“Why? What happened?”
“Jesus Christ, Gina. It was a mess in there.”
“I’m sorry.” She apologized. As if it was her fault that he had butchered her ovary.
He offered no other explanations. Yet I did not speak up when this incident occurred. I was a medical student with my career in front of me; he was an attending surgeon. I participated in the complicity of silence.
John Riley’s honesty earned him a meeting with the hospital administration and the director of clinical operations for a root cause analysis—a meeting John Riley describes as one in which everyone else was dressed, but he had “no pants on.” And he repeatedly had to admit to the mistake for over an hour.
The hospital administrator stared at him over her half-moon glasses.
“Dr. Riley, were you present at the beginning of the procedure?”
“No, I was not.”
“Why?”
“I was distracted by my administrative duties. But I know that I should have been there.”
“Why did no one else in the room pick up the error?”
“It was not their job. It was mine.”
“But you don’t deny that the lead nurse or the bronchoscopy technician had the experience to detect the error.”
“I don’t deny that. The lead nurse was instrumental in confirming that the trainee had biopsied the wrong lung. But the fact remains that it was not anyone else’s job but mine to monitor the trainee.”
“Dr. Riley, why did the trainee make the error?”
“I don’t know. I can only surmise that he became disoriented and biopsied the wrong lung.”
“Was there anything you could have done to prevent the error?”
“Yes. I should have been there. I could have stopped him from biopsying the wrong lung.”
“Dr. Riley, did the patient have an adverse event due to the error?”
“Yes, the patient suffered significant morbidity.”
“What happened to the patient?”
“She had a pneumothorax. She required a chest tube as well as an admission to the intensive care unit.”
“Dr. Riley, are admissions to the intensive care unit routine after a bronchoscopy?”
“No. It was a result of our error.”
As a physician myself, I imagined John Riley’s experience in that root cause analysis like a deposition in a medical malpractice suit, though he maintains that the interrogation probably did not go as harshly as I envisioned it. Nonetheless, he acknowledges that it was painful and uncomfortable. He remembers many times wanting to get up and leave. But he does not wish he had kept silent. Because, as predicted by the Institute of Medicine, when mechanisms exist for the examination of a medical error, specific things can be learned and similar errors of process can be prevented.
Productive changes resulted from John Riley’s humiliation. At University Hospital, a radiopaque “YES” now marks the side of the chest where a bronchoscopy is to be done. Everyone in the bronchoscopy suite, from the attending to the bronch tech, checks for the “YES” before proceeding to a biopsy. Also, the bronch staff routinely conducts a “time-out”—for example, the physician performing the bronchoscopy might say, “It is Tuesday morning. The time is 10:15 and we are doing a bronch of Mr. Smith’s right lung. Does everyone agree?” A chorus of agreement must be heard from every member of the bronch team or the procedure is stopped. And no one allows a trainee to go past the vocal cords without an attending present. Now, before John Riley does any bronch, every single time he will say something like this: “Mr. Smith, we did a transplant of your right lung. Is that right? OK, then, today we are going to do a bronchoscopy of your right lung.”
But how many doctors are willing to subject themselves to a detailed examination of their error? The answer seems to be: not many. In the New England Journal of Medicine study “Views of Practicing Physicians and the Public on Medical Errors,” only one-fifth of physicians thought that voluntary reporting of serious medical errors to a state agency would be very effective in preventing them. Equally disturbing is what one expert called the “relative blindness” of physicians to the high frequency and relative severity of medical errors. Although nearly one-third of physicians reported witnessing an error and over half of those believed that a similar error was very likely to recur, most physicians still believe that individual doctors are to blame for preventable medical errors. Physicians remain resistant to the idea espoused by the Institute of Medicine that errors are primarily failures of institutional systems rather than failures of individuals. Doctors, like their patients, seem wedded to the notion that perfection is possible in medicine.
Thelma Jones did not develop a pneumothorax of her left lung. The pneumothorax of her right lung resolved with treatment, and she was transferred from the ICU to a regular floor within forty-eight hours and then discharged. Unfortunately, she rejected her transplanted left lung. She died six months after this incident. Whether this incident contributed to her death is questionable; chronic rejection eventually results in death, no matter the treatment.
I asked John Riley how often the wrong lung is biopsied during a bronchoscopy.
“I don’t know,” he answered.
“We don’t keep track of our mistakes.”