The Human Face of Medical Error

Lewis Wardlaw Blackman: When Doctor’s Fail

 

by John L. Godwin

 

Fifteen-year-old Lewis W. Blackman had good reason to be nervous as he made his way into the Medical University of South Carolina in the fall of 2000. He entered the Children’s Hospital at Charleston, a division of MUSC, on his own two feet, of his own choosing and in good health. He went in the company of his parents, Helen and LaBarre Blackman of Columbia South Carolina, who encouraged him and supported him in his hope for a better life through a special surgical technique recently refined and improved upon by the MUSC.

Born with a condition called pectus excavatum, Lewis might have anticipated some discomfort from the rippled breastbone in his chest for the remainder of his years. About one in 300 to 500 people have this mild deformity, and up until recently, it could only be relieved by means of a dangerous and painful surgery to open the rib-cage, individually resetting each rib to uplift and transform the chest. Although the condition is not much more than a cosmetic impairment in children, complications can become more serious as children turn into adults.

But in November of 2000 as Lewis Blackman walked into the hospital, he had every reason to expect that modern medical science would have the solution—and by all rights it should have worked out that way. It should have—but it didn’t.

In an article that appeared on June 16, 2002 by John Monk, staff writer for The State, a Columbia, S.C. newspaper, the agonizing reality of how Lewis Blackman was betrayed by modern medicine, his short life made into another statistic, was first told in all its horror. Monk’s moving and evocative account of young Blackman’s last hours won the South Carolina Press Association’s Public Service Award, the highest award for journalism in the state. But today the Blackman story in the Palmetto State for the most part has been quietly shelved; lasting reforms through legislative enactments in the area of patient care that might have prevented Lewis’s death have been placed on hold.

Yet Monk summed up the story with a simple eloquence from the perspective of Dr. Greg Korbon, a veteran anesthesiologist and former assistant professor at both Duke University and the University of Virginia medical schools. Korbon studied Blackman’s medical record with an expertise that is the product of many years of clinical and academic professional experience.

When it came to the ability of doctors at MUSC to recognize Lewis’s condition and respond to the side effects of his medication, “Even a Boy Scout could have done better,” said Korbon.

 

An Exceptional Young Man

 

“Lewis was just one of those boys who would have made a real difference in the world. He had this particular combination of intelligence and enthusiasm and essential goodness. People loved him.”  Mary Jeffcoat, Drama Teacher.

 

By all accounts, Lewis Blackman was an exceptional young man whose future should have been bright. He loved both reading and writing, was an experienced actor, both on the stage and in television, and received lasting praise from his teachers. His parents, Helen and LaBarre Blackman, both attended Duke University, where they had recently visited with Lewis in anticipation of his college career.

Lewis was a boy who rose easily to the top. As a seventh grader, he had achieved the top score in the Columbia area on his competitive standardized test. And on his college board preliminary test, taken just days before entering MUSC, Blackman scored the highest of any ninth grader at Hammond Academy, a private school in Columbia.

A second grade teacher recalled that Lewis had written a story about a butterfly, winning first place in the school district visual and literary contest.  “Lewis was truly the most gifted student I’ve ever had,” said Ms. Nancy Jarema, a veteran with twenty-seven years of teaching experience who taught Lewis both in the second and fifth grades.

Lewis appeared in more than a dozen Columbia theater productions. At age seven, he was selected out of a field of hundreds of competing candidates to appear in a soft drink TV commercial along with NASCAR racing legend, Dale Earnhardt. He also appeared in the nationally syndicated ETV program, “Mama Phonics.”

Of his performance in the South Carolina Shakespeare Company’s rendition of A Winter’s Tale, one critic observed, “Lewis Blackman as the young prince was wonderfully unstage-kid-like,” adding, “this young performer should go far.”

Up to the end, even when faced with overwhelming pain through his last hours, Lewis was able to joke darkly with the hospital staff as they trundled through with an EKG unit, blood pressure cuffs, an X-Ray machine, needles, needles, and more and more medications—always mindful of their equipment, yet somehow never able to observe that the child that lay before them was slowly dying.

Would anyone have thought that a young man, so full of wit and intelligence would come to a sudden, unexpected end within a medical system known throughout the world for its technical sophistication?

 

How did it happen?

For years, Helen and LaBarre had considered the possibility of corrective surgery to help Lewis. The open-chest procedure had seemed too risky, but when an article appeared in a South Carolina paper that described in glowing terms a new procedure as a vast improvement over the older one, the couple decided to investigate by consulting with physicians at MUSC. Receiving assurances that the new procedure was simple, safe and “minimally invasive” Helen, LaBarre, and Lewis decided to go through with the surgery.

The MUSC, South Carolina’s oldest and most reputable medical school, inspired confidence in the middle-aged couple.

“We thought this was something nice we could do for him, that would make his life easier later on. We had no idea of the risk we were exposing him to,” said Helen later on.

On the whole, the surgery that was performed on November 2 turned out well enough. But instead of the one-hour procedure they had prepared for, the surgery lasted two and one-half hours. Lead surgeon Dr. Edward Tagge told the couple that he’d been forced to reposition the metal bar designed to uplift Lewis’s rib-cage, a total of four times. 

The Medical University of South Carolina is the Palmetto State’s primary teaching hospital, and has been recognized as one of the top such facilities in the USA. The Children’s Hospital occupies the seventh floor of a twelve-story building complex that houses the University. MUSC’s medical science training program receives students from throughout the U.S.

MUSC boasts that every year thousands of patients receive their medications free of charge, saving millions for the University as a result of the generosity of the pharmaceuticals companies. All indications are that these companies enjoy a close working relationship with MUSC, comparable doubtless, to other such facilities around the U.S. Companies that provide free sample medications also sponsor special fellowships for individual students in the residency program, along with special funding for a wide range of research disciplines. MUSC residents enjoy golf at an area country club with special tournament action funded by companies such as Bristol Myers-Squibb, Glaxo Welcome, Pfizer, Astra-Zanaca and more. Special teaching chairs are endowed by drug companies for advanced instruction, with honorary awards totaling in the millions of dollars in gifts to doctors and nurses.

In Lewis’s case, one element in the new procedure was the medication used to manage the intense pain resulting from the surgery. In 1989, the Food and Drug Administration approved the use of Toradol (Ketoralac Tromethamine), belonging to a new class of pain management drugs designed to reduce the use of opiates. The FDA approved the drug in a sweeping action that included over 465 other medications. But almost ten years later, a 1998 report available at the Harvard School of Public Health showed that Toradol had been banned in a number of European counties, and that “the potential of this drug to cause GI lesions and bleeding is several times higher than that of other NSAIDs…Nor is it clear that within the labeled conditions Ketoralac is a safe drug.” Today, AccessMedNet, an Atlanta, GA. based consumers’ group asserts, “this medication has not been adequately tested for use in children under the age of sixteen.” A special bulletin issued by Roche Laboratories, which markets the drug Toradol, states clearly “Toradol can cause peptic ulcers, gastrointestinal bleeding and/ or perforation.”

Such warnings were certainly available to doctors at MUSC through the Physicians Desk Reference at the time of Lewis’s surgery. Use of Toradol in post-operative cases to control pain and inflammation  requires that the patient be closely monitored for these potentially lethal side effects.

Fifteen-year-old Lewis Blackman went into surgery at 7:30 on Thursday morning, and received his first dose of Toradol at 11:30 in the recovery room. For the next five days, he was given regular doses intravenously every six hours, along other medications. Wheeled out of recovery around noon that day, he was placed in the children’s cancer unit because of over-crowding in the children’s post-op facility. Dr. Edward Tagge, the chief of pediatric surgery, went off duty on Friday night. Dr. Andre Hebra, also of the surgical unit, remained on call for the weekend. He would check on Lewis the following Saturday morning, observing no adverse reactions at that time. Lewis would never live to see either of these attending physicians again.

A diary kept by Helen Blackman tells the story of what happened after that. The facts were also sustained by the medical records kept by the hospital.

At 6:30 Sunday morning, about a half-hour after an injection of Toradol, Lewis experienced a sharp, excruciating pain in his upper abdomen, the area of his stomach. By Sunday afternoon it was evident to the boy’s mother that he was in a state of crisis. Helen Blackman observed a range of symptoms in her son that included the cessation of urine flow, the persistent agonizing pain in his abdomen, a skyrocketing heart rate that exceeded 142 beats per minute  and a downward spiral in body temperature that touched on ninety-five degrees by midnight on Sunday.

In appearance, Lewis began to take on a deathly pallor, dripped wet with a cold sweat, with dark circles that appeared beneath his eyes. His abdomen, moreover, grew hard and lives in South Carolina. But in the Palmetto State as throughout the Carolina’s today, the prevailing approach to healthcare reform has stressed conservative solutions such as managed care, privatization, and “tort reform”—designed to cut costs and protect doctors from lawsuits. Helen and LaBarre understood that doctors at MUSC had failed Lewis, but the couple remained reluctant to place the blame on individual physicians. Why, after all, had the doctors failed? The sequence of events seemed to point to a deeper range of institutional factors. Did the big cash outlays from the pharmaceutical companies at MUSC have something to do with Lewis’s death? And wasn’t the FDA created to protect people like Lewis from dangerous substances such as Toradol?

Such questions as these remain to be answered. But today Helen Blackman is a woman animated by the cause that she believes in heartily. For Helen and the supporters of MAME, there remains a certain vision—the possibility that South Carolina could yet somehow break through and set a learned example for the rest of America. Each day she spends hours at the computer or in conversation by telephone with people like herself.

And other groups have responded to the appeal of MAME. The Center for Justice and Democracy, a web based consumer advocacy group fighting to inform the public about the dangers of so-called “tort reform” in cases of medical error has featured the story of Lewis Blackman on its website. In a recent book, Wall of Silence, The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans, (2003) the story of Lewis is also retold. Writing in the attempt to put a human face on the problem of medical error, the authors of the study echo the charges voiced by Helen and others like her, that have been sustained by major research. Medical error in the U.S. is part of a nationwide health crisis, with hospital death amounting to the third leading cause of mortality in the USA today.

For these people and others like them, it’s time we looked into the face of young Lewis Blackman. A beloved son and gifted youth, we can only guess what contributions he might have made to the state of South Carolina. His never should have been the face of medical error in the U.S.—but it is a face too tender, too poignant to be ignored. Doubtless, we would all of us like to think that Lewis’s life did not pass in vain. But for this, it all comes back to us, to who we are as Americans, and to what we will tolerate and the social and moral horizons we ultimately entertain. In one mother’s lament for a lost child, her energetic cry for responsibility and reform, we can yet perceive the spirit of the nation and its continuing quest to fulfill its promise for its people.

 

 

 

Interested readers should contact Mothers Against Medical Error by calling Helen Blackman at (803) 254-8804 or emailing mamemoms@aol.com.

 

 

 

 

From The People’s Civic Record

Vol. 4, No 10, October 2004