Aug. 15, 2004 was a Sunday. It was not a typical hot summer day, so I decided to go to the deck of my home on Union Street to take a nap on the hammock.
My wife was at the hospital visiting her father, and my father was in the same hospital recovering from a broken hip. He had fallen during an earlier hospitalization on the day of his discharge while putting on his clothes. My father was an impatient man, a trait I have inherited, and the nurse had told him to wait a few minutes and she would return to help him put on his clothes.
Unfortunately, they discharged him without X-raying him, and he went home with a broken hip. After a long night of extreme pain, we took him back to the hospital to have his hip repaired.
My father was not doing well in his rehabilitation. That is a huge understatement. The plan was for him to be transferred to a nursing home the next day. He would have gone fighting, kicking and screaming; I suspect my father would have been one of the worst nursing home patients ever.
Two of my brothers were visiting my father that Sunday. My wife heard the code blue on the hospital intercom, and she suspected for some reason that it was my father who was the subject of the code blue. She was correct. My dad was talking to my brothers one moment, and the next he was gone.
I was in deep slumber on my hammock when my brother-in-law came to our house to wake me up to let me know that my father had died. I lived a block away from my mother and she had returned home that weekend from a trip, and so I drew the short straw to tell her that dad had died.
I entered the back door of her home and called for her and she came walking down the back stairs of the house and as she descended, I gave her the bad news. I don’t remember what I said, but I do remember that she sat down on one of the steps and began crying. I am sure I did my best to console her, but I cry as I write about it 15 years later, so I am sure I was crying too.
My mother and father began dating my mother’s junior year in high school at William Chrisman in 1941, and they had been married for 57 years.
Of course, we went to the hospital, where we learned that my father had a pressure ulcer on his buttocks that had become infected and he was suffering from sepsis at the time of his death. Not one of us had any idea that he had the pressure wound or that it was infected. My father was a noncompliant diabetic, but he was otherwise in pretty good health. His death came as a big surprise to all of us.
At that point, I had not handled a pressure ulcer case. Unfortunately for my clients, I have handled many such cases since then. It was in 2001 that the phrase “never event” was first introduced by the National Quality Forum and recognized by the Centers for Medicare and Medicaid Services. Stage 3 and 4 pressure ulcers are such “never events,” which means that they should never happen. I never looked at my father’s medical records, but I am confident it was at least a Stage 3 ulcer at the time of his death because he had infection throughout his body that originated at the wound on his buttocks.
We never considered exploring a medical negligence case against the hospital. His fall in the hospital, also considered as a “never event,” was his own fault and thus he would never have been there to have a pressure ulcer if his impatience had not caused him to fall. If you can ever consider a death of a loved one to be a blessing, my father’s passing might have been because he would have spent his last days in pain and misery in a place he did not want to be, attempting rehabilitation that he did not want to do. He lived 80 years and while we all miss him, he is a better place without pain.
I recently thought about that Sunday afternoon in August after one of my clients died at the young age of 56. My client did not die of a pressure ulcer, but he had acquired one of the worst pressure ulcers on his buttocks that anyone has ever seen.
They only discovered his stage 4 pressure ulcer after he was transferred following a two-week hospitalization, to Rusk Hospital in Columbia to undergo rehabilitation. He was a paraplegic from a tragic accident when he fell from the roof of his house. The doctor who examined him at Rusk asked all the nurses in the hospital to come to the examination room to look at the pressure ulcer because it was the worst one any of the would ever see. Ironically, my client did not know he had it because he had no feeling below the waist.
It was in that case that I met Dr. Joyce Black, a nursing professor at the University of Nebraska in Omaha, who is one of the leading experts in the world on pressure ulcers. In every case, Black testifies that you can put anything you want to on a pressure ulcer except the patient. With her help, I have learned a lot about preventing and treating those wounds. It is ironic that my father and one of my favorite clients had avoidable pressure ulcers. It would be nice if these “never events” never happened.
Bob Buckley is an attorney in Independence, www.wagblaw.com. Email him at firstname.lastname@example.org