Lewis Blackman: Lessons learned from a ninth-grader

I came home from work one November day several years ago to find my identical twin daughters in tears. One of their ninth-grade classmates — Lewis Blackman — had just died unexpectedly after undergoing routine surgery at the Medical University of South Carolina in Charleston. Little did I realize then, that while his name was unfamiliar to me at the time, the medical community in South Carolina, where I used to live and work, would forever remember Lewis Blackman from that day onward. As I sat and consoled my daughters that afternoon, I also had no idea of how far-reaching the events surrounding his death would become.1

Just over two months earlier, Lewis had transferred, with a generous merit scholarship, to the private school my daughters had attended since kindergarten. An exuberant and outgoing boy, he fit easily into the small, close-knit student body and had made many friends in the short time he had been there.

Lewis was something of a star, even at the age of 15. He was a veteran actor who had worked from an early age in television and community theater, including the South Carolina Shakespeare Company. An academic high achiever, he garnered state honors in math, English, and science. He played the saxophone, read widely in history and anthropology, and wrote for the youth section of the local newspaper. He was an avid soccer player, planning to go out for the varsity team in the spring. Among his friends, Lewis was known for a trenchant but understated sense of humor, and to a smaller circle, for his sensitivity to the vulnerabilities of others. The week before he died, a new boy had entered the school. Lewis had reached out to pull him into the circle of friends he himself had so recently joined. A week later Lewis disappeared and did not return, but the new student never forgot the kindness of his first friend at school.

The route by which Lewis had ended up in the hospital that fateful November day was not a straightforward one. He had been born with a condition known as pectus excavatum, in which the front of the chest curves inward, causing potentially embarrassing disfigurement. Lewis’s pectus condition had little effect on his life and in fact had scarcely been visible for most of his childhood. But when he hit puberty the indentation had begun to deepen and by the age of 14 was definitely noticeable.

Lewis’s parents had seen an article in their local paper featuring a safe, new, minimally invasive surgical procedure to repair pectus excavatum. They asked their pediatrician to recommend a pediatric surgeon and, after some deliberation, decided to go ahead with the surgery. Hopes of a summer surgery were dashed, however, by months of delays in the insurance approval process. Eventually, the pediatric surgery department proposed the date of Monday, October 30. Lewis’s mother asked to postpone the operation so that Lewis and his sister could celebrate Halloween with their friends. The pediatric surgery department agreed, and Lewis’s surgery was moved to Thursday, November 2.

Thus it came about that Lewis entered the hospital and underwent minimally invasive pectus surgery early on a Thursday morning in the first week of the month, just as the surgery interns began their new rotations. The residents who cared for him were general surgery residents with little prior background in pediatrics, while many of the nurses were recent nursing school graduates who, their supervisors said, often had a preference for the pediatric units.

After the operation, Lewis’s surgeon told his parents that the surgery had gone well. In the recovery room, Lewis seemed in good spirits. Then it was realized that he was not urinating. Postanesthesia staff replaced his Foley catheter, to no avail. After several hours, Lewis was discharged from postanesthesia care, still with no urine output. Due to a high census and a lack of beds on the surgical unit, he was admitted to the pediatric oncology unit. Pectus surgery patients were not routinely placed on this unit, and the oncology staff were unfamiliar with their specialized pain regimens.

Lewis finally began to produce urine late the next day, after a nurse and pharmacist teamed up to get his intravenous fluids increased. But he continued to have unremitting nausea and his pain remained poorly con- trolled, in spite of high doses of opioid narcotics and regular injections of the intravenous nonsteroidal anti-inflammatory drug (NSAID) ketorolac. On Friday, the surgeon went home for the weekend, leaving Lewis in the care of an on-call attending physician. His day-to-day care was provided by weekend staff consisting of a general surgery intern and nurses from the nursing pool or floating from other departments.

Early on Sunday morning, Lewis’s condition took a sudden turn for the worse with an abrupt onset of severe epigastric pain. Frantically, he said this was a new pain, quite distinct from his surgical pain, and characterized it as “5 out of 5” on the pediatric pain scale. His nurses, initially alarmed, concluded that he must have an opioid-induced ileus and recommended that he walk the halls to alleviate the pain.

As Sunday wore on, Lewis’s pain did not dissipate. He grew progressively weaker and his vital signs began to deteriorate. The on-call attending had not rounded since early Saturday and the only member of Lewis’s medical team present in the hospital was the intern, who appeared tired and overextended and had few insights to offer into the situation. By late afternoon, Lewis’s mother asked the nurse to call an attending physician. When a young man arrived two hours later, she assumed he was the attending she had requested. He was, however, another resident, and he reflexively confirmed the diagno- sis of opioid-induced ileus. The traveling nurse who was on duty did not call the doctor again when Lewis’s temperature continued to drop and his heart rate rose into the 140s during the night.

When the hospital sprang to life on Monday morning, the return to full staffing did not ameliorate the situation for Lewis because his doctors were fully occupied in the surgical suite and did not come onto the patient floors. Then the vital signs technician, rounding at 8:00 A.M., could not detect a blood pressure. In the assumption that the problem lay with the equipment, the intern and nurses spent the morning searching the hospital for different blood pressure machines and cuffs. All told, they took his blood pressure 12 times with seven different cuffs and machines without getting a reading.

At noon on Monday, while having blood tests that had been delayed from Sunday night, Lewis went into cardiac arrest and could not be revived. An autopsy the next day revealed a large perforated duodenal ulcer, a known side effect of the intravenous NSAID Lewis had been taking. In addition, the autopsy showed 2.8 liters of blood and gastric secretions in his peritoneal cavity.

To her credit, Lewis’s mother, after the loss of her son, fought to try to prevent something similar from happening to others. The Lewis Blackman Hospital Patient Safety Act now stands in South Carolina as a testament to her work in that regard. This statute requires that all clinical staff in South Carolina hospitals, including students and residents, wear badges that identify their names, departments, jobs, or titles. This was a response to the family’s confusion over the roles of hospital personnel, in particular Lewis’s mother’s misidentification of the resident who examined Lewis, which she believed had stopped the family from seeking further help.

The Lewis Blackman Act also states that any time a patient or family member requests to speak to the patient’s attending physician, the nurse must allow them to talk to the doctor directly, to prevent miscommunication of the family’s concerns as happened in Lewis’s case.

Finally, the law requires that all South Carolina hospitals have an emergency “mechanism” — an unspecified rapid response system — that families can call if they feel a patient is deteriorating without adequate clinical response. This was the first large-scale effort in the United States to create a patient-activated emergency response system in hospitals, a concept that gained widespread currency after The Joint Commission’s 2009 National Patient Safety Goal stating that emergency response systems should be available to staff, patients and families.

I want to make it clear that I think it was quite understandable and even commendable for Lewis’s mother and her legislative sponsors to work tirelessly to pass the Lewis Blackman Patient Safety Act. There were other factors involved in the death of Lewis Blackman, however. It is my contention that the authors of this statute should have further directed their attention toward the single most important underlying cause of this tragedy: variability in patient flow.

Variability in patient flow through modern hospitals is a very dangerous matter. Variability is manifest in the waves of patient admissions that flood into hospitals on certain days of the week. These peaks in patient demand overwhelm the ability of caregivers of all types to provide care safely to these frequently very ill people. The reason this flow is variable emanates from the way that work happens in most hospitals where providers, particularly surgeons, do their cases in the first part of the week, thereby overcrowding hospitals in the second part. (Note: Lewis’s case was on a Thursday morning.)

Hospitals also tend to function in much less than full-service mode over the weekend. Elective surgeries are not scheduled on Saturdays or Sundays. Case schedules are shorter on Fridays and Mondays. On-call personnel or residents make patient rounds on the weekends, and nursing and other clinical staff levels (such as ancillary services) drop significantly by the end of the week. (Note: Lewis’s surgeon left for the weekend, and Lewis was left in the care of a team of residents and an on-call surgeon.)

Most hospitals rely on surgical procedures to generate much-needed profits. Thus, when beds on the postsurgical units are fully occupied, rather than canceling surgeries, patients are diverted to other inpatient care units with open beds and perhaps less knowledgeable or inexperienced staff. (Note: Lewis was admitted to the cancer unit as opposed to the surgery unit.)

The dangers of peaks in flow are well-documented in the medical literature. Hospitalists, who care for patients only in the inpatient setting, when surveyed for a Johns Hopkins patient safety study, reported that they were routinely put into situations where having to care for large numbers of patients significantly increased their risks of making errors and doing harm.8

If variability in patient flow is the problem, and a significant cause of that variability comes from the admission of many elective surgical cases during the first part of the week, then why isn’t this being addressed?

There are many reasons. First, other solutions for the many problems that result from variability in patient flow are much easier to understand. For instance, a standard response to overcrowding in the emergency department (ED) is to expand capacity in the ED or to hire more staff. Other frequently deployed solutions include changing the ED triage system and improving or shortening other ED processes, such as bedside registration.10 None of these solutions has been shown to be superior to the removal of what is known as access block to inpatient beds. Smoothing the admission of elective surgery patients throughout the week, however, has been shown to improve throughput, even in areas remote from the operating room such as the ED, and other patient flow-related issues such as quality of care and patient safety, as well as hospital bottom lines.

Second, other solutions are much easier and less costly to implement. It is much simpler to hire patient experience consultants, who suggest that health care systems join the “experience economy,” than to try to convince the hospital’s surgeons, upon whom the hospital depends for precious revenues, to change their operative schedules. Likewise, many hospital administrators believe that when the physicians take the weekends off, other clinical staff (including nurses, rehab staff, laboratory workers, and respiratory therapists) should staff down as well. The rationale seems to be that when there are no doctors around to operate or admit new cases, hospitals do not need to run a truly full-service operation, despite studies that have shown this practice to be quite risky.

Although the effect of the Lewis Blackman Patient Safety Act has not been rigorously studied, the case of Lewis Blackman has been widely used in education both of nurses and medical professionals and has served as an inspiration in the implementation of rapid response systems. Nevertheless, if patient flow were rationalized, there might be fewer precipitating conditions for postoperative emergencies and less need for rapid response calls overall. I find it intolerable to think that the health care profession has failed to implement effective solutions despite the growing body of knowledge and understanding that smoothing patient flow can save lives and prevent harm. I am burdened with the knowledge that a few simple changes in Lewis’s care could have saved his life and the lives of others like him, who have fallen victim to the health care system’s reluctance to work on eliminating or reducing variability in patient flow.

If Lewis Blackman’s surgery had been performed on a Monday morning, rather than a Thursday morning, he might be alive today.18 He might, like both of his parents, have a degree or two from Duke. With his abilities in math and science, he might even be a young physician by now. This thought is especially haunting, for knowing what I know now about his short life and his inner character, I am sure he would be unable to tolerate a system that refused to do the right thing and institute the corrective changes needed to save patient lives.

We who genuinely consider ourselves caregivers should not rest until this resistance is overcome. Otherwise, we will fall far short of honoring the real legacy of Lewis Blackman.

NOTE: This story is taken from the prologue I wrote several years ago for a book on managing variability in patient flow for Joint Commission Resources. https://www.jcrinc.com/optimizing-patient-flow-advanced-strategies-for-managing-variability-to-enhance-access-quality-and-safety/