October 29, 2014
When it comes to treating people in her care with honesty and compassion, Carole Jukosky has chosen to up her game. Her dad, a retired RCMP officer, would not have expected anything less.
Carole’s father Herbert Strasser died unexpectedly on Sept. 19, 2011, after a tortuous six-week hospital odyssey, ping-ponging between a number of health care facilities in Ontario, and growing sicker at every stop.
“I think a lot of people blame the system – that people are overworked and understaffed “says Carole, a registered nurse and senior administrator of two long-term care facilities in Ontario.
“And I think that’s part of the problem. We are understaffed. We do work hard. We do cut corners and we’re making it a very dangerous situation. But I also think that there are people that just aren’t conscientious – and that scares me more than anything. “
Strasser, a very active, seemingly healthy 72-year-old collapsed at his home in Belleville, Ont. on the morning of Aug 3, 2011. One minute he was standing at the door drinking his coffee, watching the birds in his backyard, and the next minute he was on the floor. Instantaneously, he became a paraplegic. He was rushed to the local hospital and then onto the bigger center of Kingston General Hospital.
Surgeons questioned a spinal stroke versus a disc decompression, requiring urgent surgical intervention. Yet the surgery was scheduled for the following day. When she asked, Carole was told that despite the urgency, surgery would be performed in the morning due to “budget issues.”
Immediately following surgery, while Strasser was still in recovery, a nurse with a clipboard entered the waiting room calling out surnames and proceeded to give Carole and other family members a full personal report within earshot of a room full of strangers.
In the same waiting room, again in front of strangers, one of the surgeons later came in, plopped down on a coffee table in front of the Strasser family, and struck another wrong chord.
The diagnoses of stroke, disc compression and cauda equina were used interchangeably, as though the distinction really didn’t matter. Strasser’s family was told that surgery had been necessary to determine the root cause.
Strasser spent 10 days recovering from surgery that seemed uneventful before being transferred to a rehabilitation center. He was there five days before he was sent back to Kingston hospital for symptoms of a urinary tract infection and a new problem of dangerously elevated blood sugar levels. He stayed overnight in the ER, without being seen by the initial neurological team, and was then transferred back to the rehab despite the fact that his blood sugars remained critically high and a physician’s order that he not be sent back until he was stable.
Once back at the rehab, where his condition was poorly managed, Strasser continued to deteriorate and after several days was sent back to Kingston where it was determined he was septic from an abscess that had developed at the surgical site on his back. He received antibiotics, an incision and drainage and was reassured that a very close eye would be kept on this infection. Over the next several days he lost his appetite, developed a severe thrush in his mouth and suffered episodes of chills and shakiness every evening. He began to sleep a lot more. During this time his wife, who lived 45 minutes away in Belleville, had emergency surgery of her own and could not visit. It was discussed with the doctors at Kingston that Strasser desperately wanted to be transferred back home. The doctors agreed he was stable and “nothing that was being done at Kingston couldn’t be done at Belleville.”
Strasser waited anxiously for an empty bed for days. Finally he was transferred late one evening without pertinent transfer records. They were to “follow.” A physician-to-physician report did not occur and within 24 hours he became quite ill with various issues. Prior to transfer a very important antibiotic for the spinal abscess was accidently discontinued. This information was reported to Carole by the internist the day her father passed. The woman was very honest and forthcoming in regards to this error; however, this was just one of several miscues and communication lapses that Carole discovered after an exhaustive study of her father’s medical records following his death.
“My dad’s case is very complex, in the end he had a multitude of issues, he had been cared for at three facilities, which was very confusing to the medical system, very confusing to him and very confusing to our family,” Carole notes.
Continuity and follow through were huge issues. Within six hours of being transferred from one facility to another, as a “stable” patient awaiting transfer to the rehab unit, Strasser tested positive for C. difficile. He was severely dehydrated, the thrush in his mouth persisted to the point where eating and drinking had become painful for days, he had a systolic blood pressure of 60 , he was receiving boluses of fluids, and he had began vomiting .
The patient presented on paper from Kingston was not the patient lying in the Belleville hospital bed. After several days of referrals and trying to play catch up it was far too late. In all fairness, Carole says, the Belleville physicians had accepted a patient that they did not know was as ill as he was. When he was subsequently transferred to ICU Carole was told it was simply for monitoring of medication and that she shouldn’t worry. But his charts indicate he was “urgently being transferred to ICU for aggressive therapy.”
In the wake of her father’s death there are a lot of things Carole says she should have done differently. One thing was to have been perhaps a little less trusting, and more aggressive with questions. Her father had always been a very strong man with black and white convictions and a deep respect for professionalism. With the police he had a “brotherhood “and he extended that philosophy into his medical care. There were many times Carole felt the urge to press doctors and nurses on certain issue but Strasser would always say “don’t start any trouble.”
“I think my dad’s generation is a generation that has a lot of faith in physicians still. They have a lot of faith in that God-like syndrome and he did not want to rock the boat.”
At one point even Strasser’s trust wavered the day he looked at Carole and said “they are going to kill me in here. The right hand does not know what the left hand is doing.”
In a telephone conversation the day her father died, one of his doctors explained to Carole that they were battling several health issues but that they would deal with each problem and he’d be okay. He died approximately eight hours later. Post mortem it was determined that the spinal abscess had not resolved, it had in fact crept up from the base of his spine to his neck and the infection was literally disintegrating his neck. The C. difficile was so severe his colon was macerated and the thrush in his mouth had extended all the way down his throat.
Carole was not at her father’s side when he died but she’s been there every step of the way since, digging deep through every medical file and lab result trying to make sense of it all. She has met with all the facilities to review her father’s case, supported by the coroner’s investigation into what he termed “a perfect storm” of miscues and false assumptions.
Carole’s prodding and inquiries have led to several health care improvements in the involved facilities.
At Kingston General Hospital, post operative reports are now delivered respectfully in a private setting. New protocols have been initiated to identify patients at high risk for C. difficile; patient reports are given at the patient’s bedside; transfers are limited on weekends and off hours; and physicians give doctor-to-doctor reports.
The Belleville hospitals have made positive changes to medication reconciliation as well as communication between physicians. The rehab facility has also made positive changes involving communication and nursing staff issues.
The experience has also had a profound effect on the way Carole conducts business at the two long-term care facilities she manages.
“I’m much, much more empathetic. I’m much, much more compassionate. I expect more of my nurses. I watch for attitude issues,” says Carole, who continues her advocacy work through Patients for Patient Safety Canada
“I encourage families to come to me as quickly as possible with issues. I assure them there won’t be any repercussions because that won’t be allowed.”
If she had a single message to pass on to health care providers out there, what would it be?
“What I would say to health care providers across the country is that it’s an honor to care for people, we went into health care for a reason. Not to forget what that reason is and to always think with your hearts.”