My sister went to the hospital seeking help. Instead, she died. [PODCAST]

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“I am heartbroken at the loss of my sister. No, breast cancer didn’t physically kill her, and for that, I am grateful. Its presence in her medical history, however, quite possibly did as it was apparently used as the justification for all that went wrong. Perhaps the young hospitalist will remember her. Perhaps he will consider the harm that was done and how assumptions delayed what might have been life-saving treatment. If so, others may benefit. As a physician, I hope for that. As a grieving sister, that hope brings me no solace, but perhaps, someday, Hippocrates can stop crying.”

Sydney Lou Bonnick is an internal medicine physician.

She shares her story and discusses her KevinMD article, “Hippocrates is crying.”

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Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/podcast. Today on the show we have Sydney Bonnick. She is an internal medicine physician. Her KevinMD article is titled “Hippocrates is crying.” Sydney, welcome to the show.

Sydney Lou Bonnick: Thank you so much for having me. I really appreciate the opportunity.

Kevin Pho: We’ll get into your article in a little bit. First off, just briefly share your story and journey to where you are today.

Sydney Lou Bonnick: I am an internist, as you’ve already mentioned, and I actually knew when I was 12 years old that I wanted to be a physician. Now, I realize deciding to be a physician at a relatively young age is not particularly unique, but I also knew that I wanted to attend the University of Texas Southwestern Medical School in Dallas and, at the end of my residency training, become a board-certified internist. In fact, when I was 12, I actually wrote to Southwestern to ask for their catalog, which they sent me, and I can’t tell you the number of hours I spent turning the pages, looking at the photographs, reading the course titles, and imagining myself there. Fortunately, I was able to attend Southwestern, and at the end of my residency training, I did become a board-certified internist.

I practiced general internal medicine for quite a few years, and then an orthopedic surgeon with whom I frequently worked began to refer to me women that he saw with postmenopausal osteoporosis and a variety of different kinds of fractures. Additionally, he had arranged for the hospital where we both worked to purchase one of the very first clinically available bone densitometers and asked if I would be interested in learning how to utilize it. One thing led to another, and we found ourselves doing clinical research in the prevention and treatment of postmenopausal osteoporosis. That led to the publication of quite a few articles reporting research study results, which then led to invitations to sit on a variety of consultant boards and to lecture. And finally, I like to think because of the expertise that we developed in bone densitometry, I was asked to be one of the six founding members of what was then called the Society for Clinical Densitometry and is now known as the International Society for Clinical Densitometry. But at heart, I have always remained a general internist.

Kevin Pho: So we have a lot of medical students who listen to this podcast. I’m a general internist as well, but from your perspective, tell these medical students reasons why they may want to consider general internal medicine as a career.

Sydney Lou Bonnick: I always wanted to be able to help my patients no matter what was wrong with them. Of course, where that starts is in finding out what’s wrong with them: what their complaints are, what disease has caused their complaints. And so as an internist, I am very much a diagnostician. I may not be the one who cures their disease, but I wanted to be the one to find out what their disease was, and I think that need still profoundly exists in medicine today.

We have a lot of subspecialists. In fact, when I became an internist, internal medicine was a specialty, and the cardiologists and the endocrinologists, those were subspecialties of internal medicine. I tend to think that people now consider the internist a primary care physician, and all of those other things are the specialists. Indeed, I think the good internist is a specialist in the diagnosis of adult disease, and that is something we sorely need today.

Kevin Pho: All right, let’s transition into your KevinMD article titled “Hippocrates is crying.” Now, for those of you who get a chance to read that article and story, just share it with my audience today.

Sydney Lou Bonnick: Well, the article is essentially about my sister’s last week in the hospital, the last week of her life. After she died, in addition to grieving, I have found myself becoming increasingly angry with each passing day, to the point that the anger was almost incapacitating. I just kept thinking, “I have to do something,” but I didn’t know what. Then one morning, about 3 a.m., I realized I could write about what had happened during that hospitalization. I had written before and had things published. I knew how to do that, and I thought perhaps if I could write about it and tell my colleagues what had happened, I could help prevent it from ever happening again.

So I began to write the very next day, and there were several versions at first. Each time I reread them, the anger was just palpable, and I thought, “This is going to be too painful for anyone to ever read, let alone anyone to ever publish.” So I stopped for a while and then started to write again. As I did so, I realized that it wasn’t my anger that was important. What was important was why I was angry. At the same time, as horrible as it is to lose someone you love, what I wanted my colleagues to know was not that my sister had died, but why she died. And so I began to write again with those things in mind.

Now, recounting the conversations and events of that week was not difficult, because those things were burned into my brain. The initial conversations I had, particularly with one of the physicians, were angry, and I couldn’t remove the anger from my words, because I wanted to repeat that conversation exactly as it happened, and I was angry.

When I arrived at the hospital, I didn’t know anything had gone wrong. The night before, my sister had gone into the hospital because of epigastric and abdominal pain. She had a history of stage 4 breast cancer, but that was not the issue. She was having abdominal pain, and they had attempted to place an NG tube in her hospital room and could not do so, and so they had decided to place that NG tube under anesthesia. That I knew, but I did not know things had gone so horribly wrong during that procedure.

So when I arrived at the hospital the next day, I had a room number for her, and as I rode up in the elevator and looked at the signs in the elevator, I realized that the elevator was taking me to an ICU and that her room number was within that ICU. At that point, the elevator couldn’t move fast enough, and I was numb. I remember going through those double doors into the ICU, ignoring the visiting hours sign, going back to her room, and seeing her lying in that ICU bed with an endotracheal tube, on a ventilator, a cardiac monitor showing her heartbeat and her blood pressure, numerous IVs running, and she of course was not conscious.

There was a young doctor standing at the foot of her bed. I told him my name and that I was her sister and that I was an internist, and by then I was already becoming angry, angry at what had happened to her, although I had no idea what that was at the time. And so I said to him, “How do you go for an NG tube and end up in ICU on a ventilator?” And then my anger spilled over, and I said, “Other than medical incompetence?”

He never looked at me. He never told me his name. He simply stared straight ahead at my sister in the bed, and finally he said, “She has stage 4 breast cancer.” And I said, “You don’t know that,” assuming that he was offering that as an explanation. I said, “You don’t know that.” A brief period of time went by, and he simply repeated, “She has stage 4 breast cancer.” And I said, “You don’t know that. Yes, she has stage 4 breast cancer, but she has stage 4 because she had metastases in distant lymph nodes, not in any viscera, never in any viscera.”

As I looked at her, I saw her abdomen was swollen, and I asked him, “Are you pumping air into her abdomen? Have you even bothered to check the tube placements?” And again, without looking at me, he said, “Her abdomen looked like that when she came up to ICU last night.” I was horrified at his response, because it told me that she had looked like that for over 12 hours and no one had ever done anything. I was livid, and I said to him, “She walked into this hospital asking for help. Look at her now.”

He stared at her for the longest time, and then finally he turned on his heel, and as he walked out the door, he said, “I guess we could get an abdominal CT.” I heard him give the nurse the order, although he didn’t order it stat. The abdominal CT was done several hours later. After it was done, she was taken for emergency surgery, because the CT showed that there was free air in the abdomen. For a brief period of time, I thought, “All right, they can fix this. This is something they will fix.”

But then I spoke to a surgeon after the surgery was over. The surgeon knew I was a physician, so she knew she didn’t have to explain the terminology or soften the results, but she told me what they found was a huge rent in the posterior fundus of the stomach, and that had allowed over 3 liters of fluid, undigested food, bile acid, and stomach acid to spill into her abdominal cavity. Clearly, that is likely why she went into respiratory distress at the conclusion of the insertion of the NG tube under anesthesia.

They repaired the tear in the stomach as best they could. They cleaned out all the debris from her abdomen. They had to leave the abdominal incision open because of concerns about infection, but the surgeon told me her electrolytes were in disarray, her pH was down to 7, and she said, “Frankly, I don’t think she’ll survive the night.” She did survive the night, and the next day as well. They corrected her electrolyte disturbances. Her pH climbed back up to 7.3, and 48 hours later, they took her back to surgery to look again, to make sure they had cleaned out all the debris, and to close the incision, which they did. But she was never able to come off the ventilator. She required pressor agents to support her blood pressure, and while she initially responded to painful stimuli, after about four days she no longer did, and several days later, she died.

After all of that, I truly tried to go back and look at those events not as her sister but as a physician, to try to make sense of it all. Now, I would be the first to admit that it’s impossible for me to totally separate those two things. I am her sister, and I am a physician. But for the life of me, I cannot understand how, when a patient goes into respiratory distress in the immediate aftermath of an invasive procedure under anesthesia, any physician could so readily attribute that to a pre-existing condition, a condition they had when they walked into that hospital, when they could give a lucid and complete medical history and were conversant and oriented. They had that pre-existing condition then. How could it possibly be the cause of respiratory distress now? I could not understand that.

Now, my sense was that the young physician I initially met came to realize what an egregious mistake they had made, and my hope as a physician is that perhaps some patient will benefit from that in the future. But as her sister, I still continue to grieve for her.

Kevin Pho: Thank you for sharing that story, and I’m so sorry for your loss.

Sydney Lou Bonnick: Thank you.

Kevin Pho: So sometimes interventional procedures in medicine don’t go as expected. If this were to happen again, what would have been the appropriate response from that clinician after realizing an unfortunate event occurred?

Sydney Lou Bonnick: You’re absolutely correct. Of course, even the most skilled physician performing a procedure can have something go wrong. That is a sad but absolutely true reality in clinical medicine. As I’ve looked back on this, my anger is not really that something went wrong during that procedure. My anger is because no one even bothered to think about that possibility. That is where I think those physicians failed my sister, because obviously, with a horrendous injury like that, a tear in the stomach that allows all of those things to flow into the abdominal cavity, every second is precious in correcting that if you’re going to save that patient’s life. But nothing happened for almost 18 hours, and it only happened because one very angry physician sister let that young man know that things were wrong. And perhaps I simply delayed the inevitable at that point in time, because if every second is precious if you’re going to save a patient, if you wait 18 hours, the chances of a successful outcome are virtually nil.

Kevin Pho: Now, after this event happened and you’ve had time to reflect, did you do anything afterwards? Did you ask for an apology? Were any apologies offered? What happened in the aftermath of this event?

Sydney Lou Bonnick: Actually, toward the end of the hospitalization, many of the nurses on that ICU floor, and the nurses were outstanding, knew what had happened, and they knew I was a physician. We’d had many conversations. And even the critical care specialist said to me at one point that this young physician told her that I had asked, “How do you go for an NG tube and end up in ICU on a ventilator?” She said that to me, and I said I thought that was a reasonable question, and she agreed.

They knew how upset I was, and actually, I think the nurses requested that someone from the hospital administration come up and speak with me, and a young woman did. She listened to what I had to say, what events had occurred. She took notes, and she assured me that there would be an investigation into everything that had happened. I asked, of course, if I would be told the results of that investigation, who they talked with, what they did, and she said because of privacy concerns, they would not identify anyone or what was done or what was said, but they would let me know the result of the investigation. What I was told, actually some months later, was that the hospital had decided no one did anything wrong, and the investigation was closed, and that was the end of that.

Kevin Pho: In your ideal world, what would you have liked the response of the hospital to be?

Sydney Lou Bonnick: So that is very difficult to say. There were clearly, to me, some egregious decisions made, or lack of decisions made. I honestly do not know. I know the young man I spoke with, I feel certain that he realized that he’d made a mistake, or at least an error in judgment. And I know, as a physician who’s been practicing more years than I like to admit, I think every physician can look back on their career and they’ll remember a patient, not because of some miraculous cure, but because they think there was something they could have done differently, something they could have done better, or something they did not do that they should have done. I think we all have that in our past, or most of us do, and it’s how we learn.

And so I think, as he goes forward, my hope is that he will actually remember my sister so that his patients in the future will benefit. There were other physicians involved, physicians who were more mature, who I think should have known better, but I can’t quite speak for them, what I would hope for them, because their motivations remain somewhat obscure to me. But for that young man, that is what I would hope: that he learned from this horrible thing and that his patients in the future will benefit.

Kevin Pho: And my final question, Sydney: What are some of your take-home messages that you want to leave with the KevinMD audience?

Sydney Lou Bonnick: Well, there are two, if I may. The first is that a woman with stage 4 breast cancer, or for that matter any patient with any kind of advanced cancer, can have other things wrong with them, things that are not cancer, things that are eminently treatable and even curable. And if we assume otherwise, certainly in the absence of proof, we do our patient a profound disservice.

And second, arrogance has no place in medicine. Confidence, yes, confidence in your knowledge, your expertise, your ability. That is something we would all hope to have, and it’s something that we need in order to function, but not arrogance. Because it was arrogance, I think, that allowed the physicians to not even consider that something could go wrong during a procedure in which they participated. And it was arrogance, I think, that allowed the young physician to stand at the foot of my sister’s bed and simply say, “She has stage 4 breast cancer,” as though he knew enough about breast cancer to know that was the cause, when that was a disease totally outside the realm of his specialty. Arrogance does not belong in our profession, because arrogance can kill.

Kevin Pho: Sydney, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Sydney Lou Bonnick: Thank you, Dr. Pho.

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