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A Reflective Case of Patient Safety: The System and the Individual

The night flow team had picked up a woman in her late 60s with a history of diverticulosis presenting to the ED with bleeding from the rectum.  She was scheduled for colonoscopy the next day and orders were placed for NPO (nothing by mouth) after midnight and GoLytely (bowel cleanser) to be finished within three hours before midnight. As a third year medical student, I picked up this patient the morning of her colonoscopy.  She was in mild distress after a difficult night.  She had not been given a bed-side commode and was told to just get up to use the restroom despite her risk for falls; the patient had debilitating arthritis, needed a walker to ambulate, and was morbidly obese  Given the difficulty in physical maneuvering, she decided not to complete all of her GoLytely. In addition, she spent the night NPO without IV fluid replacement and was feeling light-headed by morning.  The patient expressed her difficulties to me that morning during my pre-rounds, stating in tears how poorly she was treated and how judged she felt because of her morbid obesity.  She had no intention of returning to our medical center after her current visit.  The Internal Medicine (IM) team – including the attending physician, residents, and medical students including myself – addressed the patient’s concerns during rounds by apologizing for the failures of her care and advising her to get a hold of the floor supervisor in order to reach her attending physician in times of need.

This was not the end of her ordeal in the hospital setting. She was then transported to a neighboring hospital where she had her colonoscopy.  I accompanied her to the procedure and witnessed the concern of the nurses regarding the patient not having finished her GoLytely.  Additionally, the physicians were concerned in light of the IM resident’s forewarning of her difficulties in past colonoscopy procedures, and special accommodations were made to retrieve a smaller pediatric scope.  As expected, the procedure was done with great difficulty.  After the procedure, there was suspicion that the patient may have suffered a perforated bowel, which was confirmed on X-ray, and surgery took her to the OR for exploratory laparotomy.  The patient spent several days intubated in the surgical ICU with an NG (nasogastrictube draining her stomach contents and a colostomy bag diverting stools from her area of perforated bowel.

I had the good fortune as a student to follow the patient from the beginning of a difficult hospital stay until her discharge.  She and I spent time discussing her difficulties, and the experience was enhanced by the invaluable skills I picked up during my psychiatry rotation.  After initial stages of rapport building and small talk, I began to identify her underlying core issue:  she perceived that her poor treatment in the hospital was secondary to being a handicapped person due to morbid obesity.  We discussed the diet and exercise plan that she had already begun trying prior to admission; her aspirations of losing weight so she could be a better mother for her son; and her desire to get back on her feet so she could work and buy him a laptop for school.  With long-term goals established, we also readdressed any difficulties in her current stay and how to get a hold of supervisors as recommended by the IM team.  However, I felt that I could personally do more than defer on some of her acute issues.  During my pre-rounds every day, I made sure she had her suction tube to keep drool from building up around her intubation tube. I changed the ice packs on her abdomen as she felt the room was too warm. I took a look at her colostomy bag which she complained of leaking and infrequent staff attention to clean it. In addition, before leaving her for the day, I would remark upon her newest achievement:  at first it was being able to tolerate ice chips, then sitting up in a chair for 10 minutes, then walking to the bathroom and back, etc.  On the last few days of her stay, she made sure I gave her the contact information of her attending physician for future outpatient follow-up at our medical center.

Although her stay at the hospital was overall a dismal one, she told me that it just made the helpful people all the more wonderful to her.  She felt her life had meaning.  Addressing the healthcare system’s flaws is one career avenue that motivates me to refine my clinical skills and knowledge as well as engage in humanistic medical practice. This patient encounter offered me great growth towards my goals that I never expected from my clinical rotation.

Kimberly Ku (2 Posts)

Editor Emeritus: Former Medical Student Editor (2012-2013) and Former Resident Editor (2013-2015)

Wayne State University School of Medicine

My name is Kimberly Ku, and I am a member of the Wayne State University School of Medicine Class of 2013. I graduated from the University of Michigan Ann Arbor with a double major in biology and anthropology. Since the start of medical school, I have been a fervent advocate of patient safety and quality improvement, founding the WSU Chapter of the Institute for Healthcare Improvement (IHI) as well as the WSU SOM student organization, Wayne IHI. Through the IHI, I have written multiple quality improvement projects, including a grant award-winning project at the Barbara Ann Karmanos Cancer Institute in Detroit. I work closely with WSU's Vice Chair of Medical Education as well as many other faculty to promote greater patient safety and quality improvement mindfulness in the clinical curriculum of both the WSU SOM and the residency programs at the Detroit Medical Center.

Outside of patient safety and quality improvement, I contribute widely to authorship and co-authorship of clinical research projects at the DMC. As a member of the Gold Humanism Honor Society, I am a strong believer of volunteerism and dedicating spare time to the creative arts. I am applying for an Internal Medicine residency program with specific interest in Oncology/Palliative Care. I also plan to pursue an MPH or MBA after residency in order to incorporate public policy/business management into my work as a future academic physician.