Excerpt: “Hospital, Heal Thyself: One Brilliant Mathematician’s Proven Plan for Saving Hospitals, Many Lives, and Billions of Dollars” - Winner of the CWA Book of the Year Award for Indie Non-Fiction

By Mark Taylor

Chapter 2

This excerpt from Chapter 2 of “Hospital, Heal Thyself,” explores the very real consequences of hospital failure to manage patient flow. The chapter is about Lewis Blackman and other patients whose lives were ended or uprooted by hospital overcrowding, which can cause long delays in treatment in hospitals and emergency rooms, ambulance diversions to other hospitals and higher incidence of medical errors and even death. The book is about the life and work of Eugene Litvak, Ph.D., a Harvard professor and applied mathematician in his native Soviet Union who discovered one of the primary causes of hospital overcrowding, as well as a solution that reduces it, saving individual hospitals millions of dollars and many lives, while improving quality f care.

The Human Toll

ewis Blackman, a healthy 15- year- old high school student with a bright academic future, arrived on a Thursday November morning in 2000 for a planned surgical procedure at one of America’s best children’s hospitals, the Medical University of South Carolina (MUSC) Children’s Hospital in Charleston.

Lewis was a star student and budding actor born with a concave chest, a congenital deformity known in medical terminology as pectus excavatum, a condition in which the sternum and ribs develop abnormally. This “sunken chest,” which appears in 1 to 300 to 400 children, often causes embarrassment in locker rooms and on beaches for boys born with it. The condition was long thought to be only a cosmetic defect. However, some researchers have claimed that concave chest patients may later experience chest pain and shortness of breath and that can sometimes lead to cardiac and respiratory problems, according to Johns Hopkins University research.

Former Johns Hopkins Children’s Center pediatric surgeon Fizan Abdullah, MD, now with Lurie Children’s Hospital in Chicago, said that sunken chests are sometimes found among children with Marfan syndrome, a genetic disorder with potentially life- threatening complications like arterial aneurysms or aortic ruptures.

“Concave chests can make boys feel self- conscious,” said Lewis’s mother, Helen Haskell. “This was a cosmetic procedure for Lewis. We thought of it as something like getting braces to straighten his teeth.”

Correcting the problem involved a minimally invasive procedure to implant a metal bar to reshape his chest. He’d have a small scar, but a cool one he could later show off. His parents, Helen, an archaeologist, and LaBarre “Bar” Blackman, a high school social studies teacher, waited until after Halloween to schedule the procedure, honoring Lewis’s request.

“He didn’t want to miss Halloween,” Helen Haskell said.

So instead of booking the operation on a Monday, the family moved it to a Thursday. That decision may have played a role in the eventual outcome, because most US hospitals routinely become clogged up later in the week as overcrowding occurs when jammed emergency rooms (ERs) compete with the rush of scheduled surgeries in hospital operating rooms (ORs).

The Columbia, South Carolina, family arrived early on November 2 to MUSC. The surgery took more than twice as long as the predicted 45 minutes and Lewis awakened in pain in the recovery room, Haskell said.

But instead of being transferred to a better equipped hospital surgery ward staffed by nurses trained to monitor and treat Lewis’s condition, he was taken to a room within a cancer wing. That transfer was key, Haskell said, because the oncology nurses appeared to be unfamiliar with Lewis’s surgery or its pain management and potential complications.

“The hospital never told us that he was not on a surgery floor. We gradually figured it out.”

Litvak has proven in multiple research papers that transfers to inappropriate hospital wards or departments are frequently caused by overcrowding and poorly managed patient flow.

This and other hospital decisions, along with many other failures contributed to a horrific outcome. Because his surgery was performed on a Thursday, his family knew he would be hospitalized over the weekend. At most American academic medical centers, medical residents – physicians in training – handle much of the hands- on medical care on weekends. Multiple resident physicians visited Lewis over the next four days, but when the weekend came, no fully trained, credentialed, and board certified doctors examined him between Saturday and Monday morning. Even on Monday, Haskell said, the doctors were busy in the operating room and did not come until Lewis was coded, an announcement of a patient whose heart has stopped. And those resident physicians missed the signs of his rapid decline, a condition marked by a hardening belly and deteriorating vital signs. He was also suffering from severe peritonitis caused by a perforated duodenal ulcer, a postoperative complication Haskell said was due to poorly managed pain management and overdosages of pain medications.

“Any nurse, especially an oncology nurse, should recognize deterioration. What these nurses did not know was what to expect from a surgical patient. This kind of pectus surgery requires near ICU- level care because it has such difficult pain management. Places that do a lot of minimally invasive pectus surgery sometimes have dedicated nurses for this procedure. Some put their pectus patients directly into the ICU. These nurses did not know any of that. I think they saw Lewis as a healthy child having elective surgery, not a sick patient like most of the other children in the cancer ward.”

His parents watched helplessly in disbelief as their son lay dying. On Monday he expired after losing 11 pounds and nearly three liters of blood. Hospital physicians were perplexed at the death of an otherwise healthy teenager.“The whole thing fell through the cracks,” Helen Haskell recalled. “What we saw in the hospital there was chaos. There was no rhyme or reason to their care.”

Lewis Blackman’s death became a national cause célèbre driving patient safety improvement in hospitals. With the proceeds from a wrongful death and medical negligence lawsuit, the Blackmans launched a foundation in his name and created the patient safety organization, Mothers Against Medical Errors.

Today, Haskell is an advisor to the World Health Organization (WHO) Patients for Patient Safety group and works with patient advocacy and safety organizations around the globe.

The Blackmans were instrumental in the passage of the Lewis Blackman Patient Safety Act in South Carolina’s legislature and in securing practice changes within MUSC, the hospital where he died.

“I think Lewis’s death has been a catalyst,” she said.

Haskell met Litvak at a patient safety conference in 2014. They were seated at the same table “when he started talking about my son,” she remembered. “He had no idea that I was Lewis’s mother. If you have lost children, you want others to remember them, because so often children who die young are forgotten. I was honored that he was so interested in Lewis’s story. We’ve struggled to create a legacy for my son.”

Litvak remembers that meeting a little differently.

“When we were introduced she mentioned that she was a patient safety expert. I’d met so many so- called patient safety experts who are unwilling to address the underlying problem in patient safety – recurring excessive patient demand – that I was a little impatient. However, I was trying to be polite. She said she was working to reduce medical errors. I said that should support her nicely until she retires and suggested her time would be spent more wisely studying the Lewis Blackman case. Then she said, ‘I am his mother.’ I didn’t know that. I was almost crawling under the table in humiliation.

I apologized multiple times for bringing this up. But she couldn’t have been kinder.”

Before meeting Haskell and inspired by the tragedy of her son’s death, Litvak published an opinion piece in the Wall Street Journal on December 2, 2013, titled “Don’t Get Your Operation on a Thursday.”

Since their meeting, Haskell has been supportive of Litvak’s work and now understands the hazards of ignoring patient flow.

“America’s ER bottleneck is an international disgrace and due to many of the conditions Dr. Litvak described,” Haskell said. “What keeps us going is so many people in healthcare like Dr. Litvak are dedicated and committed to change. The zeitgeist has changed. Now the system has to change from the inside. Hospital executives around the country should be galvanized to learn about his ideas and methods of changing hospital care.”