The Lewis Blackman Story, as presented by Helen Haskell

QUESTION

III. View the Helen Haskell videos on the QSEN website https://qsen.org/publications/videos/the-lewis-blackman-story/ Helen Haskell is the mother of Lewis Blackman, a 15-year-old boy who died in a hospital following routine surgery. The videos featured were part of a lecture and interviews with Ms. Haskell recorded at the UNC-Chapel Hill School of Nursing in summer 2009. Videos Part 1 and 2 present Lewis’s story and a client/family perspective of lessons learned from a tragic outcome. Videos 3-5 include selected segments of an interview with Linda Cronenwett and the dialogue between Ms. Haskell and the audience following her lecture. Watch ALL 5 parts of the video. Answer the following questions about the video. . What is Ketorolac (indications, side effects, normal dosages for 15-year-old, risks and benefits)? . What was the significance of lack of urine output (to underlying problem, amount of Ketorolac, and need for fluids)? . What are possible reasons why health care providers dismissed implications of undetectable blood pressure? Why would they think it was an equipment failure? . Do you agree that it was significant that Lewis’s crises developed on the weekend? Explain why or why not. . Lewis died from septic shock. Describe the incidence, signs/symptoms, and appropriate interventions for this problem. . What are your ideas about patient empowerment and nurse empowerment in terms of the overall safety of our health care systems? What is your opinion on what happened to the patient and the actions of the nurses/doctor’s involved?

ANSWER

The Lewis Blackman Story, as presented by Helen Haskell, is a poignant and eye-opening account of the tragic death of her 15-year-old son, Lewis Blackman, following routine surgery. The video raises critical issues surrounding patient safety, communication, medication administration, and the role of healthcare providers in preventing adverse events. Here are the answers to the questions posed about the video:

1. Ketorolac (indications, side effects, normal dosages for 15-year-old, risks, and benefits): Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain management. It’s typically indicated for short-term treatment of moderate to severe pain. Side effects may include gastrointestinal bleeding, renal impairment, and an increased risk of bleeding. In the case of Lewis, the dosage and administration of Ketorolac were not appropriate for his age, contributing to his deterioration.

2. Significance of lack of urine output (to underlying problem, amount of Ketorolac, and need for fluids): The lack of urine output was a critical sign indicating renal failure, which was likely exacerbated by the administration of Ketorolac. The absence of urine output is a concerning indicator of acute kidney injury, and Lewis should have received appropriate fluid resuscitation and close monitoring.

3. Reasons healthcare providers dismissed implications of undetectable blood pressure: The video suggests that healthcare providers may have dismissed the undetectable blood pressure due to various reasons, including equipment failure. This dismissal could be attributed to several factors, such as over-reliance on technology, fatigue, lack of critical thinking, or failure to recognize the severity of the situation. The assumption of equipment failure was a grave oversight.

4. Significance of crises developing on the weekend: The crises occurring on the weekend is significant because it may have contributed to delayed responses and limited access to experienced staff and resources. Hospitals often have reduced staffing levels and limited specialist availability during weekends, potentially impacting the timely recognition and management of deteriorating patients.

5. Sepsis (incidence, signs/symptoms, and appropriate interventions): Sepsis is a life-threatening condition resulting from the body’s extreme response to an infection. Signs and symptoms include fever, increased heart rate, rapid breathing, altered mental status, and signs of organ dysfunction. Timely intervention involves administering antibiotics, providing fluids to maintain blood pressure, and supporting organ function. Early recognition and treatment are crucial for sepsis management.

6. Patient and Nurse Empowerment:Patient empowerment involves actively involving patients in their healthcare decisions, ensuring they have the information and resources to make informed choices. Nurse empowerment includes providing nurses with the autonomy, authority, and support to advocate for patient safety. In Lewis’s case, better communication, adherence to safety protocols, and empowerment of both patients and nurses could have prevented the adverse outcome. The actions of the healthcare providers involved in Lewis’s care were deeply concerning, and the tragedy underscores the importance of improved communication, safety protocols, and vigilance in healthcare settings.

In conclusion, the Lewis Blackman Story serves as a stark reminder of the critical need for patient safety, effective communication, and adherence to best practices in healthcare. Lewis’s death was preventable, and it highlights the importance of constant vigilance and commitment to patient well-being within the healthcare system.