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Death of a gunshot wound victim: Lessons learned from patient safety 

Sharon Griswold

Many years ago before obtaining my MPH, I was working in the USA as a physician in an inner city ER surrounded by the usual chaos.  Until learning valuable lessons from the patient safety course, I didn’t have the lenses to see the changes that needed to happen.  The ability to see system issues which resulted in harm during this scenario in a different way has helped me become a better physician, team member and provide better patient care.  The Safety Event Investigation Tool provided by the Johns Hopkins Quality and Safety Research Group is utilized in this essay to help describe the system issues that contributed to less than optimal care.

On a day just like any other day, a 21 year old, male “Mr. X” was shot in the chest and brought to an inner city Level I Emergency and Trauma Center by paramedics.  Emergency Department, (ED) and Trauma personnel were notified three minutes prior to the patients’ arrival and were ready and waiting for his arrival.  He was directly taken to the operating room (OR) in the ED.  Although the patient had been talking to the ambulance crew immediately prior to arrival, as he rolled through the doors, he passed out and lost all signs of life. Immediately, a rare procedure to surgically split open the chest (a thoracotomy) was performed and a single gun shot wound (GSW) through the heart was identified and defined as easily accessible and potentially reparable.  Fortunately, the bullet did not seem to have damaged other vital structures.  During the early resuscitation the patient received twelve units of un-crossmatched, un-warmed Type O blood in addition to un-warmed crystalloid.

The single GSW was repaired appropriately; first with an inflated foley catheter that worked much like using an inflated balloon to plug a hole and then sutured for definitive repair.

The attending Emergency Physician returned to the resuscitation and noted that the patient was in a fatal heart rhythm. As the ED operating room was disorganized and infrequently utilized, the location of the code cart was not readily apparent.  The code cart was equipped with a defibrillator but the appropriate paddles needed when applying directly to heart muscles could not be found.  In the interim, alternate attempts were made to save Mr. X.  He was given appropriate medications: epinephrine and amiodarone but remained in the fatal heart rhythm that would require an electrical jump start of the heart that the missing paddles could provide.  After a delay of five minutes, an initial defibrillation attempt of 200 Joules was delivered with internal paddles and the ventricular walls were singed leaving the stench of burnt flesh.  Recurrent attempts at resuscitation failed and Mr. X was pronounced dead.

Points where failures occurred:

  • The patient received a large amount of un-warmed fluids and blood early during the resuscitation.  His resultant hypothermia likely contributed to his deterioration (1) and may have played a role in heart rhythm change to the near-fatal rhythm known as Ventricular fibrillation, (VFib).  A rapid blood warmer was in the room but never used.  The nurse who was most familiar with its use had been pulled out of the room.
  • Lack of communication between team members and ownership of task responsibilities.  The resuscitation was chaotic and disorganized. The patient had been in VFib for three minutes (according to the review of the cardiac monitor log) before the dysrhythmia was recognized. 
  • As providers infrequently utilized the OR space in the ED, there were overlapping errors in team work, tasks, the local environment and training and education factors.  Furthermore, the organization and layout of the ER OR was unfamiliar to providers as it was unlike any other ED or Operating Room patient care space.
  • A task factor deficiency was identified as providers were unable to easily access the code cart and the internal defibrillation paddles could not be found. This factor independently resulted in an additional five minute delay to defibrillation attempt.
  • Once internal paddles were located, the patient was defibrillated at 200 Joules (the recommended dose with transthoracic paddles) rather than 20- 30 Joules (recommended adult dose with intracardiac paddles). The senior nurse who knew that the order for 200 Joules was excessive did not speak up as she felt intimidated by the physician and confused by the chaos in the room.

Patient Factors: The patient had an emergent condition and rapidly deteriorated upon arrival.  Although the patient had “appeared” well in route to the hospital, he quickly took a turn for the worse and would never come back.  Consequently, the providers knew nothing of the patient’s Past Medical History and he was unable to participate in his care.  He presented with a life-or-death emergency requiring the knowledge, skill and cooperation of multiple providers.

Task Factors: The patient received multiple units of un-warmed blood and crystalloid which likely resulted in extreme hypothermia and subsequent VFib.  Although there was a rapid infusion pump in the room with the capability to warm the blood prior to infusion, it was not used during the resuscitation.  In the chaos of the resuscitation, no one had the specific assignment to use the machine or even thought to turn it on.  Some proposed solutions for emergent trauma resuscitations would be: First to implement a debriefing session that the resuscitation team reviews prior to the patient’s arrival.  As Dr. Sexton discussed in the Playing in the Sandbox lecture, brief structured encounters have shown to improve communication and safety in the OR and the aviation industry. There is often a window of opportunity for this conversation to occur as providers wait for a trauma patient to arrive.  During a debriefing session, individuals could have identified themselves and identified roles and tasks then verbally practiced a worst case scenario.  Secondly, although it would seem preposterous to most in today’s culture, a checklist (2-4) may have sparked someone to remember to use the warming equipment.  Alternatively, it may be beneficial that rapid warming occur in the blood bank prior to delivery to critical patients when blood is released in large quantities.

Many individuals were fascinated by the technical repair of the bullet wound to the heart. There was a sense of awe in the OR despite the reality that many providers were yelling. No individual provider was focused on the cardiac monitor to witness the change to the fatal heart rhythm (VFib).  In fact, there was no definitive code leader who was not preoccupied with a specific task.  Alarms had repeatedly gone off and were silenced as providers thought they were due to the inability to obtain a blood pressure and other vital signs.  In this case, a significant delay to defibrillation may have been shortened by a standardization of code carts within the hospital. In fact many code carts in most institutions are now standardized when the practice wasn’t nearly as common when Mr. X. was shot.  It is intuitive that providers more familiar with the organization of the cart may have been able to locate equipment more expeditiously.  Finally, when the required paddles could not be found, the least experienced person who didn’t know where to find the required equipment was ordered out of the room to locate it.  He did not admit that he didn’t know what he was looking for; he tried to comply with his orders.  He did not feel that it was his place to challenge a request made by his “superior”.

Care Giver Factors: The patient arrived at 2am on a Saturday night.  The trauma attending had been in the hospital with little sleep for 48 hours.  Few of the caregivers in the room had ever participated in the care of a patient requiring emergency thoracotomy.  The discord and din made it nearly impossible to understand and clarify verbal orders.  The ED saw an extraordinary number of trauma patients arrive simultaneously with Mr. X.  All but the most senior ED nurse was pulled out of the ED OR to care for other trauma patients.  The experienced OR staff remained but were unfamiliar with the arrangement of the room.

Team Factors: All senior team members were focused on specific tasks during the resuscitation. No one individual was “coordinating the care” of the patient. The room was crowded, very loud and chaotic with multiple individuals yelling orders, instructions and insults.  In reference to Dr. Sexton’s work mentioned previously, a very brief preparatory communication prior to the patient’s arrival may provided more “structure” to the patient encounter and may have helped caregivers function under more “controlled” circumstances. Proposed Solutions to team factors have been identified in previous work as teamwork training and a the decreased emphasis on hierarchical culture to increase willingness of trainees to speak up.(1;5) Additionally, if a team leader would simply recite his or her medical decision making algorithm during the resuscitation, this would effectively implement the Situation Background Assessment and Recommendation (SBAR) (6) process shown to be effective in other arenas.  Finally as delineated JCAHO initiative, it is imperative to “Repeat Back” (5) verbal orders to ensure understanding.  However, this does not readily occur in resuscitation or critical cases where it may be most important.

The ED nurse who set the defibrillator for 200 Joules thought that it was a very high energy but felt inhibited to speak up as many of the caregivers in the room were yelling at one another.  As Dr. Sexton demonstrated in his cross sectional surveys of teams in medicine and in aviation; (BMJ) Junior team members in medicine often believe they should not question decisions made by senior team members.  To the contrary, it is acceptable and encouraged for Junior team members to speak up in the culture of aviation.(7)

Training and Education Factors:  In this case, the senior trauma resident, the emergency medicine resident, nurse anesthetist, and anesthesiology resident participating in the care of the patient had never participated in an emergency thoracotomy.  The operating room technician was working his first week of shifts after orientation and had never been to the ED/OR before.  The senior ED nurse was the only individual in the room who knew how to operate the rapid infuser/ warmer and no one asked her how to use it. A junior operating room technician was sent out of room to search for the intracardiac paddles but he didn’t know exactly what he was looking for. Some significant research has been done to suggest that there is a great need for the use of multidisciplinary simulation for these “rare” emergency situations.(5;8-18)  Such training may improve the communication between healthcare providers; decrease the level of chaos; improve a culture of teamwork; and decrease the likelihood of error repetition.

For each minute of delay to defibrillation there is an increase in mortality of 10% per minute.  Consequently, as there were three minutes of unrecognized VFib and a five minute delay to defibrillation in this patient; his likelihood of mortality increased by 80% due to the VFib alone.  This case affected multiple individuals of the trauma and ED staff as it is rare that a patient who requires an emergency thoracotomy will survive due to the severity of their injuries.  However, Mr. X had an “easily” repairable wound and may have survived had he not he not been subjected to severe hypothermia and subsequent ventricular fibrillation.

The approach to safety in the medical culture has lagged behind the preexisting aviation model.  The medical community has been slow to implement simulated situations to practice and identify errors during resuscitation and crisis situations. In reality, these critical moments remain rarely or infrequently practiced.

Information Technology/CPOE (and technology) Factors: There were no distinctive alarms for the cardiac monitor to alarm ventricular fibrillation and caregivers “assumed” the alarm was due to the lack of blood pressure and pulse oximetry reading.  The alarms that did sound were silenced on multiple occasions.  No CPOE occurred at any time during this resuscitation.  The technology of the equipment may present an area for improvement. Some day we may have restaurant style touch menus that will make resuscitation medical records more reliable. In a futuristic, ideal world there may be a “best practice” electronic checklist that may guide providers in urgent resuscitations. 

Local Environment: The code cart in the operating room had not been properly stocked as the ED code carts were.  The ED team thought it was the OR teams responsibility and vice versa. Four other trauma patients in motor vehicle accidents arrived within two minutes of the patient’s arrival.  Consequently, resources were very limited.  Although this patient died and the events were stressful to the staff, there was no debriefing session or other opportunity for team members to learn from the case, discuss alternative solutions, or collaborate to improve teamwork.  As Dr. Reason described the alignment of the holes in the “Swiss Cheese”,(19) there was no attempt to minimize or realign the risk for the same errors to occur once more.

Institutional Environment:  There was no mechanism at the time to call in additional staff to support the ED other than the implementation of the institutional “disaster plan”.  The emergency department “diverted” further trauma patients but was already overwhelmed and caring for all of the patients involved in motor vehicle accidents.  The leadership of the institution frowned upon diversion of trauma patients as there are potential negative implications for trauma accreditation if diversion is implemented more than ten times a year.  There was a preexisting staffing shortage in the ED that night as there were two ICU patients in the ED (requiring one to one nursing care) who were being held there due to lack of bed availability in the ICU.  A procedure to urgently augment staffing of ED critical care nurses was subsequently implemented. 

In summary, the ED and OR are distinct “high reliability organizations” that frequently exhibit high levels of conflict which often are not constructively resolved.  The current system is too often accepted as the status quo and few changes have been made to alter the culture.  In many ways, the To Err is Human(20) report has opened a new chapter in the history of medicine. The hierarchy of medicine is in the spotlight as an example of how not to perform.  As Dr. Sexton delineated in they Playing in the Sandbox lecture of the Patient Safety course, pilots who may never see one another again resolve their conflict 80% of the time.  However, in the OR, conflict is resolved only 20% of the time, despite the fact that OR personnel frequently work together.  In fact, the aviation industry has improved safety with the implementation of simulated training situations where technical and complex situations are presented and pilots must work through their differences and focus on the task not the individual. (JHSPH Patient Safety Course: Playing in the Sandbox Lecture)  Furthermore, according to Dr. Sexton’s root cause analysis data, the number one and two causes of adverse events are the result of communication breakdown and lack of orientation and training. (JHSPH Patient Safety Course: Culture of Safety Lecture)

I was present for this resuscitation.  All of the facts of the case are accurate except for the detail that the senior nurse felt it was her responsibility to question the request to defibrillate the patient at 200 Joules with the intracardiac paddles. She did intervene and he was appropriately defibrillated at 20 Joules.

It is an ambitious but necessary goal to simplify emergent resuscitations.  The culture in healthcare in the past had posed a significant hurdle to patient safety as healthcare providers and hospital systems had seemed reluctant to change. Fortunately, over the last ten years I have witnessed an evolutionary change from beliefs that “medicine as an art” to the appreciation of medicine as a complex organization with the need for systems improvement to reduce the likelihood of error.  We need to continue to learn from other complex industries and further implement processes to improve care rather than accept the status quo.  Only then will we be able to reassure ourselves that “we did the best we could”.

Reference List

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Sharon Griswold, MD, MPH '10 is the Director of Simulation, Department of Emergency Medicine, Drexel University College of Medicine

 

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