“B’s Story”
I had a patient. For sake of anonymity lets call him “B”. B had diabetes and hypertension and over the years developed kidney disease and eventually kidney failure. He needed to go on dialysis, but before you can go for dialysis you have to have access placed. The most common procedure used to create access is the creation of an AV fistula. This is usually done on an arm and involves a surgery where a doctor connects a vein to an artery in the forearm. The AV fistula creates a place with enough blood flow that a needle can be introduced and get enough volume back to handle the high volume needed for dialysis, and that is durable enough that the constant use of it wont cause it to collapse and occlude.
Because of this, I had to get B ready to see his surgeon. B had pretty good veins and arteries on one side and not so good on the other. So I did the ultrasound mapping study requested by his surgeon and sent B to see the surgeon to get access. I also told Bob that under no circumstance was he to have any sort of IV, PICC line, blood draw or sticks in that arm. B agreed but unfortunately in the weeks leading up to him seeing the surgeon and having the procedure, he got ill and required a trip to the hospital. Unfortunately, I did not know B was in the hospital until after he had been released. In the ER, a well intending nurse drew blood from B’s protected arm, and then later another nurse started an IV in the same arm which was followed later by another nurse starting a PICC line in the arm B was supposed to have his operation on for dialysis access.
When B finally got out of the hospital, the PICC line, IV and needle sticks had ruined the access on his arm. To make matter worse he did not have good access on the other side. Despite this, a surgery was attempted on the other arm, but this failed to produce a competent fistula. Meanwhile B’s kidney function had continued to deteriorate. He needed access now. Without a source in either of his arms to start an AV fistula, B’s surgeon discussed with B the need to put in another type of access up in B’s neck. This access is much less preferred as it can cause infection and has to be changed out regularly. B agreed to this and had the line placed.
Three weeks after placement, however, B was found unresponsive on the floor at his home and rushed to the hospital. He was admitted to the ICU where he was found to have a massive infection, likely due to contamination of the line that had been placed in his neck. He was in septic shock and very ill. Despite aggressive antibiotics, heroic interventions and almost two weeks in the ICU, however, B never regained consciousness, and he eventually died.
The real tragedy is that B died from what could have been prevented during his initial hospitalization, had his medical staff realized his condition and were there a reliable system in place to alert them regarding his condition and interventions that were contraindicated. Not only did B lose his life, but his wife lost a husband, his daughters lost their father and they all lost a chance for a longer life together. I am haunted by the pain and anguish I saw on their faces and felt completely at a loss as how to address their grief. I also lost B. He was my patient and he was my friend. To B and B’s family, though it is completely inadequate to address the magnitude of this situation, I’m so very sorry we let B and you down. We must and will do better.
Submitted by a medical provider somewhere in US.
