About lunchtime, I was driving across what some say is the world’s longest floating bridge, one running across Lake Washington between suburban Bellevue and Seattle. About halfway across, I noticed a large pillar of black smoke to my northwest. Since the fire creating that smoke had to be over five miles away, I knew it must be huge.
Exiting the bridge near the University of Washington, I headed north for home. It was then that I began to worry. The smoke seemed to be coming from where I lived. Could that be on fire? When I got home, all was fine, but I could see the smoke rising high into the sky to the north and within walking distance. It proved to be a fire in a block-long row of small retail businesses. The area around was filled with fire vehicles, firefighters, and hoses.
Have you ever wondered how fire departments manage these large fires? Later, when I worked as a volunteer for an emergency response team based at Seattle’s hospitals, I discovered the answer. It’s called the Incident Command System (ICS).
Think of a major fire. First to arrive is a fire truck with husky guys from the nearest fire station. Seeing the situation is bad, they call for assistance and concentrate on making sure everyone gets out of the burning building. As other vehicles and firefighters arrive, the situation grows complicated. In minutes, a fire scene with six firefighters can grow into one with hundreds. How do fire departments prevent the situation from descending into chaos?
That’s where Incident Command comes into play. When someone’s workload becomes unmanageable, a division of labor takes place. Responsibilities are formally divided, with each party knowing what their new role is. Because everyone has been trained in the same system, fire fighters from other cities can join. At that large fire I saw fire trucks from Bellevue.
In short, under ICS, everyone has assigned responsibilities, no one has too many responsibilities, and no necessary responsibility gets neglected. The goal is to prevent a situation that was joked about when I studied engineering: “When you’re up to your neck in alligators, it’s hard to remember that your original goal was to drain the swamp.” Incident Command would assign someone to alligator control, so the others could focus on draining.
Incident Command grew out of necessity and experience. While I was involved in an emergency drill involving the area’s hospitals, I talked with a physician who’d come from Japan to study how we respond to disasters such as earthquakes. In Japan, he told me, they usually react by forming a group and discussing the situation until a consensus was reached. Unfortunately, he said, that takes too long. For an emergency, there must be one person responsible for specific decisions. A good decision made quickly can be better than a perfect decision made too late.
For instance, if fire fighters are running out of filled air tanks for their respirators, there must be someone responsible for that. He could say, “I have a truck with tanks and air compressors coming. It’s ten minutes out and will park at the south end of this street.” That’s Incident Command. Every task has a taskmaster.
Today, hospitals, particularly their emergency rooms, often study Incident Command to prepare for major disasters. Many have brightly colored vests designating who does what, and there are call lists to bring in additional staff when required. That’s good.
But hospitals can fail to see a crisis that develops slowly. The result can be like the tale from India about several blind men examining an elephant and coming away with radically different descriptions. One sees one aspect and acts on that. A second person sees another aspect, and acts differently. A third sees nothing and does nothing. No one sees and understands the whole.
That’s exactly what was happening with air embolisms. We’ll look at the parties involved, what each saw, and how each responded.
First were our nurses, who were in the front lines of this new technology. Our central lines were so new, most nurses were passing in a few months from having no experience with them to having handled several with no specific training. They were muddling along as best they could. Because those lines worked like peripheral IVs, many thought that was all they were. Typically, they only realized the seriousness of an air embolism when one struck them. That was true in all four of the cases where I was involved. Nurses often learned but too late. Experience can be a poor teacher.
Just above them in the hospital’s hierarchy were the head nurses. There my experience was limited to two full-time and one temporary substitute, so I can only describe how the two full-time ones that I worked under responded. I touch on them here and devote the next chapter to the role they played in what happened.
Unfortunately, their response to a problem was one I saw them repeat time and again. They did not investigate or reflect on the circumstances. They searched for someone to blame, so no responsibility would fall on them. That was how they operated. Since the primary cause for an air embolism was their failure to ensure that nurses received the proper training, that must have never entered into their reports. As a result, the real cause was never pointed out at their level.
Moving higher still, the hospital’s administrators did do something constructive. They looked at the incident reports filtering up and concluded, quite rightly, that new IV pumps were needed. They moved to replace our existing pumps after a year-long testing period. But they failed to do the one thing that would make an immediate difference—comprehensive training for nurses. I’ll explain why later.
Finally, there were the nurse training staff. Training did exist. Classes in CPR were taught, and seminars on infectious diseases were held, along with an occasional nursing grand rounds. On my own time, I attended most training sessions that impacted what I did, whether for doctors or nurses. Doing that for free was one of the fringe benefits of my job. But as far as I know, there was never any formal instruction on the new risks created by central lines—none.
I’m not sure why that was true. Perhaps those who were responding to the incidents weren’t in touch with those who set the content of training. Perhaps those responsible for training thought a central line was just another type of IV. Despite being one of their part-time instructors, I don’t know. It wasn’t even discussed.
And yes, I could see the whole. Having discovered those four embolisms, I knew the problem all too well. In this book, I’ve offered excuses why, despite seeing the big picture, I did nothing. I certainly should have done better. But keep in mind the extenuating factors.
First, as nursing staff we almost never heard about problems on other units. A air-tight lid seems to have been placed on all such communication. Even gossip seemed to have been ruthlessly discouraged.
That was certainly true of an incident I describe in My Nights. A young woman had heart surgery followed by a terrible blunder in ICU. Bicarbonate from her IV infiltrated into her arm, leaving the tissues badly damaged and her arm a sickly slate gray. A few days later, when she became my patient, I tried to discover what had happened. I drew a blank. After her surgery, her medical record suggested all was going well up to a certain point. After that point, it was clear all was not well, but nothing explained what had gone wrong. That’s the air-tight lid.
A similar lid was placed over air embolisms. As much as I might suspect other embolisms were happening, I had no way of knowing. If the hospital had been more open about other incidents, perhaps I would have spoken out about the need for training..
Second, during my 26 months at the hospital, no one in the administration ever asked me or anyone I was working with for suggestions. I don’t recall a single general appeal for nursing staff to make suggestions. That leaves the impression that they are unwanted. The letter of resignation I submitted was the only such action I knew about.
Third, on some but not all units, the head nurses presented an intimidating wall between the nurses and the nursing administration. They not only did not want criticism to flow upward—criticism that might implicitly condemn them—their hostility blocked nursing staff from discovering if the nursing administration was open and receptive to suggestions.
Even the exceptions fit that pattern. The hospital was in a terrible Catch-22. On a unit where the head nurse led well—and I know of one —the nurses had no issues to raise and thus no need to communicate past their head nurse. In contrast, on the units where there were problems, the head nurses seemed to do their best to intimidate any effort to raise issues directly with the nursing administration.
That’s where a senior nurse mentor operating outside that structure would have been helpful. A nurse talking with her wouldn’t be taking the risk of enraging her head nurse only to discover an administration unwilling to hear her complaints. The senior nurse mentor would be tasked with solving problems independently. She might agreed or disagree with what a nurse was saying, but no nurse would ever be punished for talking with her. She could, if she chose, raise those issues with the administration, while refusing to reveal the source of her information.
In the next chapter, we look at some of the problems created by those highly critical head nurses.