There was something bothering me about this column by the Globe and Mail’s Christie Blatchford, published a couple of weeks ago. It contains the the semi-standard Tale of Woe in Canada’s health care system. To précis the story, it concerns the travails of Hilda Conley, 84, previously well, hale and hearty, apart from a “benign” brain tumour and two cysts; she was admitted to the untender mercies of Stevenson Memorial Hospital in Alliston, Ontario for a “minor” urinary tract infection; she was held beyond her discharge day over a weekend for a swallowing assessment; she subsequent suffered, due to either nursing stupidity or malfeseance or maybe both, what sounds to be a haemorrhagic stroke related to a choking incident; subsequently in a coma, she developed bedsores; her daughter repeatedly asked for a “special mattress”, more frequent dressing changes, and also a “feeding tube”, because Mrs. Conley was beginning to recover to the point of “speaking”. In the meantime, the hospital and/or staff “basically left [her] to starve” for five weeks. In the end she was discharged home with a decubitus ulcer the “size of a fist” with, evidently no home care arranged. It sounds like a typical case of a senior abused by the system, and then cast out to cope on her own.
I don’t doubt that all of this occurred in some fashion. But I don’t think it’s simply a case of a fit elderly woman, with all of her faculties, with minimal health issues, who was chewed up and spit out by the health care system. The specifics of the story don’t jive with what I understand of how the heath care system or hospitals work. But first a few preliminaries. I don’t work at Stevenson Memorial and I know nothing apart from what Blatchford reports. This suggests the principal problem in Blatchford’s reporting : the reader is getting only one side of the story. Blatchford does, in fact, speak with an administrator at Stevenson Memeorial, and adds some snark about the hospital’s “minimal response”: one gets the impression of a tepid or fearful interview, but haughtily dispensed. What Blatchford doesn’t tell you, and what the administrator surely told her, is that the hospital cannot disclose details of Mrs. Conley’s case to the media. Patient confidentiality is not just an excuse; it’s a legislative requirement. In that light, we have the (perhaps justified) grievances of the patient’s daughter, and nothing else.
But it is in the details provided, I think, which present a considerably more complex picture than Blatchford suggests. Some instances:
1. “Benign” brain tumours are not trivial, as Blatchford implies; they are only benign in the sense they are not malignant. They can and will continue to grow, compressing and shifting healthy brain tissue, ultimately causing neurological issues.
2. Patients, even elderly patients, are generally not admitted for “minor” urinary tract infections. This suggests to me, at least, there were some other problems in Mrs. Conley’s health or social/living arrangements Blatchford doesn’t remark on, or perhaps the “minor” bladder infection wasn’t quite so minor.
3. Being held for two days over the weekend for “a swallowing test”, frankly isn’t credible, unless again, there were some other co-morbidities Blatchford doesn’t disclose. Beds in any Ontario hospital are too much at premium to hold patients for this one diagnostic. But in any case, this particular test wouldn’t be ordered unless there was a strong suspicion this poor woman was having difficulty swallowing, and perhaps needed further intervention. Difficulty swallowing is a pretty significant health issue. It impairs nutrition and can lead to aspiration, that is inhalation of chewed food and/or stomach contents into the lungs.
4. Which is apparently what happened, in turn causing Mrs. Conley to choke and made a “blood vessel break in her head.” This is, of course, immensely unfortunate. Blatchford is pretty clear in her column that staff (nurse?) incompetency led to this sequence of events. Perhaps. But equally it is easy to imagine a scenario, where the patient was discharged home (as Blatchford implies she should have been), choked on her dinner, and had a stroke. Or maybe the bleed was completely unrelated but coincidental to the choking incident, but perhaps as a consequence of the “benign” brain tumour. Who knows?
5. Quite a lot is made of the “special mattress” not being provided, the implication being the hospital and/or staff was being wilful in its refusal to provide one. Unfortunately, it is the rare hospital indeed that provides any sort of special mattress for patients at risk for bedsores. Two very practical reasons for this: difficulty in cleaning, leading to issues in infection control, and cost. (Personally, I usually advise families of patients with breakdown in skin integrity to purchase a relatively inexpensive egg crate pad, which can be taken home and reused.)
On the rest of Mrs. Conley’s stay in the hospital I can’t surmise. I don’t know if Mrs. Conley, for example, was truly “left to starve” receiving only intravenous fluids, or got some version of Total Parenteral Nutrition, or even got some sustenance orally. Blatchford doesn’t tell us. It strikes me as unbelievable that any nurse would deliberately starve a patient, or not strongly advocate for her patient, but that’s just me. However it’s significant Blatchford chooses to drag out some old steroetypes of nurses to evoke a poignant response to Mrs. Conley’s suffering: we’re either all Nurse Ratched or plain dummies. “Stupid, lazy RNs” is a frequent meme in the Comments.
Undoubtedly, there were some issues with Mrs. Conley’s care. Blatchford mentions issues that imply poor oral hygiene, and missed feedings. From a nursing perspective, these need to be addressed. The suffering of Mrs. Conley was enormous. But I don’t think it was entirely at the hands of the hospital or its nursing staff. Clearly, Mrs. Conley apparently had some pretty significant health issues even prior to her admission. Being treated for a urinary tract infection in the hospital setting implies her condition was not “minor”. Mrs. Conley’s co-morbidities complicated her course of treatment in hospital. Blatchford would have us believe Stevenson Memorial almost killed Mrs. Conley.
The truth, I fear, is more nuanced.
[Part II tomorrow]