Health spending is now the largest part (28%) of the United States federal budget, yet medical mistakes are now the third leading cause of death.
How did things get this bad?
I have some ideas. The first that springs to mind is that the process of paying for health care services has been completely taken out of the hands of the patient.
If we were running a business and we received an invoice, before paying it, we would ask ourselves whether the goods and/or services invoiced were actually received, and whether they were acceptable. Patients should get to do likewise.
Without such a basic closed-loop mechanism of financial control, I see our health care system becoming overrun with incompetence and fraud.
Meet the hospital that starved my father nearly to death:
El Camino Hospital®, “The Hospital of Silicon Valley”
If that name seems familiar, it should.
Hardly more than a week after El Camino Hospital starved my father, on June 11, 2018 emergency room physician Dr. Beth Keegstra ridiculed a patient in distress, 20-year-old Samuel Bardwell, saying (among other things), “Are you dead sir?”.
The patient’s father recorded video that is now posted online, and news of the doctor’s gross misconduct quickly spread across the world.
Lindsey Bever of the Washington Post wrote that Bardwell’s father told ABC News that he “questions her fitness as a doctor”, adding “In my mind, I don’t think she should be practicing medicine at all, because if it’s not a race thing and she treats everybody that way, then that’s a problem.” Bever also notes that “Public corrective action was taken against Keegstra” after she was reported to the Minnesota Board of Medical Practice in 2016.
El Camino Hospital’s Chief Executive Officer Dan Woods responded with the following statement dated June 14, 2018:
“This week, a patient who visited the emergency department at our Los Gatos campus had an interaction with a physician whose demeanor was unprofessional and not the standard we require of all who provide care through El Camino Hospital. We have expressed our sincere apologies and are working directly with the patient on this matter. Please know that we take this matter very seriously and the contracted physician involved has been removed from the work schedule, pending further investigation.”
“Our number one priority is and always will be to serve our community with exceptional care and the utmost dignity and respect for all. This matter is being immediately addressed at the highest level of our organization; however, patient privacy laws prevent us from providing specific information regarding the treatment or services provided to any patient under our care.”
“Please be assured that this recent interaction is not reflective of the care and services our over 3,000 dedicated caregivers provide every single day.”
Is this truly “not reflective the of care” that El Camino Hospital provides?
Let’s look at what happened to me last year.
I’m a middle-aged man with my own health issues.
In September 2017, I was brought by ambulance to El Camino Hospital with tachycardia and atrial fibrillation (AFib). In the emergency room, I was given medicine to slow my heart rate. Then apparently there was a shift change, and the person coming in saw the order for the medicine and was going to give me another dose.
Had my significant other not been there to ask what was being done and why, I think that unintended double dose likely would have stopped my heart, and could have killed me.
Nice try, El Camino Hospital.
Let’s look at my father’s case.
My 82-year-old father was pretty active and strong until, while gardening in April 2018, he fell about 10 feet from a ladder onto his back and hitting the back of his head.
He was unconscious due to a traumatic brain injury and swelling in his brain, for which was he was brought by ambulance to Santa Clara Valley Medical Center, where surgeons drilled a drain hole in his skull, and he was kept sedated for eight days. Luckily, he was able to communicate soon after the sedation was lifted. But, he was quickly forced into getting a thracheotomy and an abdominal feeding tube. (According to the Leapfrog Group, Santa Clara Valley Medical Center ranks poorly.)
He was moved to a long-term acute care hospital followed by a sub-acute facility, where he was able receive physical rehabilitation before the abdominal feeding tube became dislodged causing an infection and fever.
My father was brought by ambulance to El Camino Hospital where the tube was removed and his abdomen cleaned and treated with antibiotics. Despite our many requests for intravenous nutrition and the recommendation of the nutritionist, Dr. Troy Thoai Lam MD did not give the order and allowed my father to starve for nine days in the hospital, losing about 20 pounds and exhibiting symptoms that appear to be common to those approaching death by starvation.
What I find particularly striking is that:
- Despite our many requests, no one on the staff of El Camino Hospital intervened to assure that my father received nutrition until after I escalated the matter to the hospital’s administration.
- Even after he had been starved and started receiving nutrition, my father was being undernourished because the nutrition had been calculated for a smaller height.
- Even after he had been starved and started receiving nutrition, my father’s source of nutrition was removed twice.
For more details, see my father’s timeline of events.
Meet Dr. Troy Thoai Lam, MD
It is clear to me that Dr. Troy Thoai Lam, MD was the physician given responsibility for my father’s care, and that he was wrong to chart that my father had a broken hip, both upon admission and upon discharge to Dr. James J. Chen, MD. What remains unclear is his motivation for doing so.
It is clear to me that Dr. Lam hurt my father. It is my opinion that this was a criminal act of endangerment and elder abuse, which may be prosecuted by the Santa Clara County District Attorney’s Physical Abuse, Endangerment and Neglect of Children and Elders (PACE) Unit of the Family Violence Division.
That Dr. Lam could have intended to kill my father is certainly within the realm of possibility; German nurse Niels Högel confessed to killing 30 patients and in November 2017, “German prosecutors said that the number of victims was at least 106”. What is clear, however, is that El Camino Hospital does not have the requisite processes in place to stop such illegal intentional acts of malice.
Whether Dr. Lam acted out of negligence, intent, or even malice has yet to be determined. In any case, Dr. Lam seriously hurt my father and should not be given the opportunity to hurt another patient in this way, so I have asked the Medical Board of California to revoke Dr. Lam’s license.
Meet CEO Dan Woods
After I found my father looking like he was going to die and finding that my trip to the hospital’s administrative office got me in touch with someone whose job appeared to be only to placate my complaints, I guessed at the CEO’s email address and sent him a message that evening. To his credit, he responded early the very next day with this:
John,
I am very sorry to hear about this experience and will ask the Chief Medical Officer and Chief Nursing Officer to look into the care we have provided to your father and ask for the appropriate information to be shared.
We make our best efforts to provide world class care to our patients and appreciate the opportunity to improve and address any concerns a patient or family member has during their stay at El Camino.
Sincerely,
Dan
Dan Woods has been CEO of El Camino Hospital for only about nine months before the “Are you dead sir” incident, joining El Camino Hospital in September 2017 and stating in November that patient care would be his top priority. According to El Camino Hospital’s recent safety grades, patient safety under the leadership of Mr. Woods has dropped from A and B grades to a C.
Nice work, Mr. Woods.
Meet CNO Cheryl Reinking
Chief Nursing Officer Cheryl Reinking came to meet me on June 6.
The next time she came to visit, she mentioned that “Everyone makes mistakes.” This certainly seems true of everyone who works at El Camino Hospital.
I have degrees in business administration and management (and am also a licensed pilot), so I immediately found myself explaining to her something that I find obvious: that because people make mistakes, as a manager, it is her responsibility to implement systems to catch and correct mistakes so that they don’t have catastrophic results.
Meet Interim CMO Mark Adams
Interim Chief Medical Officer Mark Adams came to meet me on June 6.
The last time I spoke with Mark Adams, he mentioned that he was new to the job and had never met Dr. Lam, who is a contractor. A brief web search suggests that Mark Adams has been on the job at least a few months; I would expect that the first thing a new manager would do is to meet his or her staff.
I believe he promised me that he would investigate and get me an explanation of what went wrong and why my father was starved.
I’m still waiting.
Conclusions
El Camino Hospital may in fact have many good care givers.
However, few seem to read medical charts and—exactly as Atul Gawande suggests in his 2012 TED Talk “How Do We Heal Medicine?”—by making patient safety everyone’s responsibility, no one takes responsibility.
The hospital’s staff fails to work together as a system, and that is a total failure of the hospital’s current management.
Silicon Valley’s public hospitals have no financial incentive to improve or even maintain their levels of care because they can bill and get paid by health insurers, including Medicare.
If these things can happen at a hospital accredited by the Joint Commission, then clearly its accreditation means nothing.
Contact me to share your feedback or your story.
As Louis Brandeis wrote in 1914 (before becoming an Associate Justice of the United States Supreme Court in 1916), “Publicity is justly commended as a remedy for social and industrial diseases. Sunlight is said to be the best of disinfectants; electric light the most efficient policeman.”
