Patient’s unexpected death changes the way one obstetrician thinks all doctors should be educated

October 28, 2016

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Shocked, bewildered and angry, Dr. Amy Nakajima pored over her medical notes, trying to coax from them some sense of the bloody chaos she'd just experienced. 

Earlier in the day, a healthy and expectant young mother had come in for a routine delivery at the Saskatchewan hospital where Nakajima worked. It was 2001 and Nakajima was just 14 months into her practice as an obstetrician-gynecologist. 

Nakajima had been called in to assist just as the woman was pushing because the baby's heart rate seemed to be dipping. A vacuum procedure went well, a healthy baby was delivered, but the woman was bleeding a bit afterwards. Nakajima repaired a tear in the vagina but the bleeding didn't stop. 

"We worked on that, and still she continued to bleed," Nakajima says, recalling a day that altered the course of her career. 

"I called my second on-call in to give me a hand and then the anesthesiologist said that he was struggling too. So he called a second anesthetist to come in and help. Then, it became clear that we were having trouble even accessing IV lines. So the general surgeon came in to do a cut down. 

"It had started with what appeared to be a fairly routine case, then it started drifting into 'this doesn't feel right; this isn't working; she's not responding in the way I'm expecting her to respond. We're all struggling now. It's not just me. The entire team, every set of providers, we're all struggling. It felt ... we all felt, I think, at a loss." 

It descended into a scene of controlled confusion, with everyone doing what they've been trained to do, everyone doing the right thing to make things better, and yet getting no results. They managed to stabilize the patient enough to transfer her to the ICU, where, she shortly coded and died. At that moment, for the entire medical team, there was an immense sense of unreality, Nakajima says. 

"It was a horrible event. It was traumatic for everyone. Of course, primarily for the family. But it left such a mark on the entire team. I think just hearing that story, you can imagine how I might feel, but the guilt and the shame that come with that event, I think is really unknowable until you have encountered it yourself." 

When she called the hospital's chief of staff and told him what had happened, his response was disbelief. They hadn't lost a mom in decades. Nakajima informed him she was scheduled to be on call for the entire weekend but she'd need a replacement to cover for the remainder of her call and would stay on call until her replacement arrived the next morning. She was absolutely drained and felt so shattered she didn't feel safe to work. 

Nakajima took two weeks off work. She had told herself that if the autopsy didn't turn up embolus or some other rare cause, she would quit her young career. She knew that the medical team should have otherwise been able to save that patient. 

In the end it was determined the woman had suffered an amniotic fluid embolism, a rare and usually fatal obstetric emergency that occurs when amniotic fluid enters a mother's blood stream and triggers a catastrophic, allergic-like reaction. 

"I attended her funeral. It was amazing. I don't think I'll forget that, ever. It was completely full. I felt so sorry for this family," Nakajima recalls. "I came back to work two weeks later and I'd come back to a hospital where I'd lost a patient, and not one word of blame. Incredible support everywhere I turned. So, in hindsight, now knowing what other second victims encounter and endure, I feel so very fortunate for having had that support and that amount of compassion shown to me." 

The experience marked her in many ways, Nakajima says. The helplessness and frustration she encountered that day, feeling so entirely unprepared to go out to that young father and tell him that his wife was dead and his children orphaned. She doesn't know the person she would have become had this not happened to her, Nakajima says. This event early in a fledgling career in many ways informed her choice of practice, the way she interacts with her patients and colleagues, and the way in which she teaches. 

Nakajima provides care at Wabano Centre for Aboriginal Health, within the Family Health Team at Bruyere, and at St. Vincent's Hospital, with a specific interest in working with patients who traditionally would be considered marginalized. In her teachings with third year medical students at the University of Ottawa, she stresses patient safety, candid communication and the importance of acknowledging harm. She promotes the use of simulation to explore and teach safety issues, including disclosure skills. As the interim Director of Research and Development of SIM-one, the non-profit healthcare simulation network, she will be developing programs on ways to use simulation to advance patient safety. 

"It is such a challenging discussion to have with a family, to say, 'I'm really sorry, we couldn't save your mother," she says. "Some people have made a parallel to breaking bad news curriculum in undergraduate medical education, but I think it's fundamentally different. In breaking bad news, I could say, 'I'm really sorry, remember the tests that we did last time? It shows that you have cervical cancer.' It's terrible news for a patient. I will feel terrible giving that news to her because I know what's coming. But that's fundamentally different from me saying, 'I'm really sorry, you have breast cancer; we removed the wrong breast." 

Says Nakajima, "It is a very different conversation because you now have to take ownership of your participation in the harm that came to this patient through healthcare. I think this needs to be part of undergraduate education and postgraduate education. And we need to consider how to most effectively and impactfully deliver this curriculum, so our students are thinking of how to optimize safety, and are better prepared when bad things happen."