restorARTively

Memorial Day 2002 was the first year that the holiday brought on new meaning; though at the time and in the years since I wondered what was making me feel so melancholy. Nine Memorial Days later, I finally get it. The flag. Read more at http://www.jamessproject.blogspot.com/ where I am transferring my blogging to to allow it to be more personal. More real. More about how preventable medical errors and patient-physician communication affect patients and clinicians on a day to day basis.

Deep within the 117 page 2009 annual report of the Pennsylvania Patient Safety Authority is a sliver of light into what neonatal hospitalized patients face. A study from 2006 at St Christopher's Hospital in Philadelphia on ventilator-associated pneumonias (VAP) is shared. VAPs are a preventable medical error. At St. Christopher's in 2006 after noticing an increased rate of VAPs that were significantly above the national average, the hospital proactively initiated a literature review and collaborated with other pediatric hospitals. Per the report, this "multidisciplinary team implemented a series of revisions to an existing pediatric ventilator bundle to better serve the neonate population." The changes that were implemented addressed standards for oral hygiene of neonates depending on their gestational age at birth, "securing endotracheal tubes using standard procedures, discarding all tubing and circuits from standby ventilators, altering the frequency of vent...

It is hard to maintain a restorative mindset when preventable death and pain keeps rearing its ugly head in pediatrics. This morning I learned of the death of a 40 day old baby who had been diagnosed with a treatable CHD (congenital heart defect ) - but the parents had never been told of the diagnosis. So the patent ductus arteriosus killed the child. I shed a tear and screamed in my heart. The parent should have been told. Of course, there is no guarantee as to the outcome - but what would have been guaranteed is that the family would have been a part of the treatment team. If tragedy still struck, there would have been a community of support built already the parent and the medical team. This brings me back to why I am here to begin with. Why James died. Why I ended up enduring the additional trauma of civil litigation. Why the book is titled, "Split the Baby ". Such a phrase can evoke disturbing imagery. Trust me. What James looked like after the medical interventions was...