A German movie made me cry.  It was the first time I had ever cried because of what I saw in the language I am teaching myself.

The movie:  Engel der Gerechtigkeit Ärztepfusch, or Justice Angel for Doctor Screw Ups, I found exceedingly moving.  The ending was beautiful. I knew music could be powerful; I had no idea the effect it could have on me. I was in tears, and I didn’t care.  I cry, and when I let go, I feel perhaps more human than at any other time.

I’ve seen the ending at least 40 times.  For the next week, it is on zdf.de (24 November).

The movie opened with a woman standing in the middle of railroad tracks, wondering whether to commit suicide.  Later, we learn why, as she comes out of the shower, learning that she had breast cancer, and the wrong breast was removed.  She had therefore a double mastecomy, brief clips being shown of ugly scars where her breasts once were. The woman had to pay for the surgery, had no recourse to justice, until she finally met the lawyer.

The hospital stonewalled, saying the doctor was Spanish, didn’t speak German, and no longer lived in Germany.  The fact that nobody else spoke up, in the OR or anywhere else may be surprising to some, but the culture of silence of medical errors in Germany may parallel that here in the US, where I saw errors hidden, denied, and blamed, in some instances, upon me, as medical director of a hospital.

Back to the movie:  at the end, the lawyer for the woman said she would go to the press before the end of the day.  The hospital administrator said that he would allow the breast reconstruction, but no blame was to be levied.  The lawyer started to think, then smiled, and the music began.  The lawyer walked to the dry cleaners, where the woman and her husband worked.  In the crowd of people waiting for clothes, the woman spotted the lawyer, who had a smile on her face.  The husband, working, looked up, surprised.  The woman said, “Enschuldigen Sie mich, bitte” (excuse me, please) and came to the lawyer.

“The operation will be next week. The papers were signed.”  The woman was stunned, the music continued, as the woman broke down and hugged the lawyer.  The smile on her husband’s face was wonderful.  It was an incredibly powerful scene.

I saw three cases of wrong side surgery during my time as Medical Director of the hospital–the wrong knee, the wrong side of the colon, and the wrong side of the brain.  The last, I had to explain to the woman’s friend, since the woman had no family.  The internist taking the case wasn’t told and was so angry, he signed off the case, without finding another physician.  This unethical practice was not uncommon where I worked, where it meant that I had to find somebody–sometimes myself–to take over.  My colleagues never sanctioned the physician.  Indeed, at a Medical Executive Committee meeting in 1998, one blamed me for taking care of a patient who had no doctor.  I left the meeting, went outside where nobody could see me and cried.  That is the medical culture I was part of.

I was told by the head of the OR that 99.9% of the cases had no problem.  No, I retorted, it was 99,99% of cases, and per cents didn’t matter, counts did.  There are certain things where the counts should be 0, not a high percentage of successes.  The hospital administrator used the same words, and the lawyer pointed out 160,000 cases of errors and 20,000 deaths in Germany every year.  Wow.  They count.

Medicine here never really changed.  We have at least 20 wrong side cases annually nationwide.  True to medicine, everybody began his or her own process for ensuring safety, which of course meant in some places the proper limb or breast was marked for surgery, or the improper one was marked.  This leads to confusion as well.

When I objected to just a letter being sent to the neurosurgeon, I was told I was no longer welcome to attend department of surgery quality assurance meetings.  At first, I was incensed, because I knew about systems, and my knowledge should have been desired, not forbidden.  I also had discovered our carotid endarterectomy complication was far too high to warrant surgery.  I literally was screamed at, when my data were presented. My patients got statistics, probability, and my recommendation; other patients were not told of these risks.

After I left medicine, my mother refused a CT scan after a fall, and we were not told of the refusal  When she later died of dementia, we discovered during her final illness that originally she had refused the scan.  I was furious and published an article about it in Medical Economics.  My father, before he died, had weeping edema, swelling so bad that it went through the skin of his legs.  The nurses called it a weak heart, when in fact low protein in his blood caused the problem–simple osmosis.  Had he been diuresed, he would have become hypovolemic and died.  He did die, but from pneumonia.  I had to tell the Nursing Home Director that I was not the enemy, but I was trying to be my father’s advocate. My oldest brother had a brain tumor missed, causing him blindness in one eye.  He was a professional photographer. I had a medical error occur in me.

Engel Gerichtigkeit was only a movie, but it was powerful and beautiful; the medicine well portrayed. 

In 2001, I developed a reporting system for medical errors. Sadly, I was naive enough to believe I could implement it.  Looking back, I didn’t have a chance against the entrenched system of hospital and medical associations.  I wrote legislation for two years for the Arizona House, with 10 co-sponsors but went nowhere.  Doctors shunned me.  One response was, “We aren’t like aviation.”

“Yes, “ I replied. “Aviation deals with their problems honestly.  You sweep them under the rug.”


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