QSEN: The Lewis Blackman Story (Part One)

Summary

The script recounts the tragic death of 15-year-old Lewis following elective surgery at a teaching hospital. Despite being a top student and athlete, Lewis' post-surgery pain management included the drug IV Insane Coutur, which the speaker blames for his complications. Due to inadequate IV fluid orders and a fragmented care system, Lewis suffered from a drug-induced ulcer and died. The speaker highlights the hospital's failure to recognize and respond to Lewis's deteriorating condition, emphasizing the need for better medical error prevention.

Takeaways

• 😢 Lewis, a 15-year-old top student and athlete, died following elective surgery.
• 🏥 The surgery was performed at a teaching hospital for a chest defect repair.
• 💊 Lewis was prescribed an IV drug, Insane Couture, which the speaker blames for his condition.
• 🌍 The drug is widely used in the U.S. but not approved in most of Europe and restricted elsewhere.
• 👨‍⚕️ A senior resident prescribed a full adult course of the drug without considering Lewis's age.
• 🚨 Lewis's post-surgery care was inadequate, with orders for IV fluids following guidelines for a much younger child.
• 🆘 It took two days to correct Lewis's treatment plan amidst a disjointed healthcare team.
• 🤒 Lewis's condition deteriorated rapidly, with over 30 hours of alarming clinical decline.
• 🩺 The healthcare team failed to recognize the severity of Lewis's condition, attributing symptoms to equipment malfunction.
• 🚫 The attending physician was never called despite repeated requests by the parents.
• 💔 The parents felt that the fragmented and unresponsive resident care system was the primary cause of Lewis's death.

Q & A

What was the name of the son who passed away following elective surgery?

The son's name was Lewis.

At what age did Lewis pass away?

Lewis passed away at the age of 15.

What type of surgery did Lewis undergo?

Lewis underwent minimally invasive surgery to repair a pectus excavatum defect of the chest.

What medication was Lewis prescribed after surgery that the speaker blames for his condition?

Lewis was prescribed a full adult course of the drug 'Couture Act' after surgery.

Why is the drug 'Couture Act' controversial according to the speaker?

The drug 'Couture Act' is controversial because it is widely used in American hospitals but never approved in most of Europe and severely restricted in most other countries. It is also implicated in a surprising number of cases the speaker hears of as an advocate for medical error victims.

What was the issue with the initial prescription of 'Couture Act' for Lewis?

The issue was that Lewis was prescribed a full adult course of the drug by a young senior resident who was following a written protocol but didn't realize that Lewis wasn't producing urine, indicating a potential overdose or inappropriate dosage for his age and condition.

How did the hospital staff respond to Lewis's declining health?

The hospital staff, including young nurses and residents, did not comprehend the severity of Lewis's condition. They were convinced that his abnormal vital signs were due to malfunctioning equipment and spent significant time trying to find a working blood pressure cuff rather than addressing his clinical decline.

What was the cause of Lewis's death as mentioned in the script?

Lewis died from an anesthetic-induced giant duodenal ulcer.

What was the role of the attending physician in Lewis's case?

The attending physician was never called despite repeated requests by the parents, and there was no plan for dealing with complications, which suggests a lack of oversight and responsiveness from the attending physician.

Why does the speaker find it hard to forgive one particular nurse?

The speaker finds it hard to forgive a self-important nurse who thwarted their attempts to reach the attending physician for reasons that remain unclear.

Who was the one person that helped increase Lewis's post-operative fluids?

A knowledgeable nurse managed to get the orders for Lewis's post-operative fluids increased after days of inaction by everybody else.

What was the overall issue with the hospital's care system as described by the speaker?

The overall issue was the fragmentation and unresponsiveness of the resident care system, combined with a nursing failure to recognize and respond to a deteriorating patient.