Mourning Neil Armstrong: Healthcare’s Test Pilot

 In CHR Blog

We had just finished celebrating the 50-year anniversary of man’s landing on the moon.  When abruptly, troubling news appeared that famed astronaut Neil Armstrong may have died from hospital errors associated with his cardiac care in 2012. It was a punch to the gut.

Like many Americans, I had been reliving the fulfilled dream of that special day in July 1969, when first, Commander Armstrong, then joined by Edwin “Buzz” Aldrin, stepped on the moon. I watched the TV coverage as a 13-year old then, and joined the new millions now who watched anniversary shows from every conceivable angle. On public television it was Space and More Space, weeks on end. Apollo astronauts, the early Gemini program, the exploration, JFK’s declaration of putting a man on the moon. Even stories of women never heard of before, who sewed each man’s survival suit by hand, or who cut new ground as NASA engineers. The end result was total success.  Pride, joy and admiration for our heroes – Armstrong, Aldrin and Collins. In the original film footage, Walter Cronkite, the newscaster dubbed the most trusted man in America back then, was nearly speechless. He had tears in his eyes at the accomplishment, and quite possibly, from the relief of fear that something might have gone wrong. This was pioneer work.

Wonderment at the Moon Landing, 50 Years Later

It was easy to marvel at the technology of the 1960s, primitive by today’s standards, but entirely effective. Imagine that we could even see anything of the moonwalk at all back in 1969, let alone the flying of the American flag on the moon’s surface. I wondered today how amazingly clear the audio came through in 1969, with Armstrong’s pronouncement of “one small step for man, one giant leap for mankind”. After all, the moon is nearly 250,000 miles away. Through today’s lens, I looked at what seemed to be a flimsy lunar module and wondered how that contraption was able to both land and, importantly, take off again to go back into orbit and dock with the Columbia. The wonderment of today seemed as big as it was 50 years ago.  Across the country and across the globe, people cheered.

 

Shocking Announcement About Neil Armstrong’s Death

For these past weeks, Neil Armstrong was very much alive in my mind. I hadn’t recalled when he died – it was August of 2012, in Ohio. If I’d have thought about it, age 82 is not bad. That is, if he had died of natural causes.

But all of a sudden – seemingly out of the blue – a shocking story broke. According to the Cincinnati Enquirer and the New York Times, an Ohio hospital paid the Armstrong family $6 million in 2014 to settle a wrongful death claim. The family believed Neil’s death in 2012 was associated with missteps from cardiac bypass heart surgery and the in-hospital follow up care. Experts the family consulted believed something had gone seriously wrong. While the hospital disputed the claim – and we may never know the full facts – it is sickening to think Neil may have been robbed of the last seven years. He didn’t get back on the golf course. He and his family didn’t get more opportunities to enjoy time together. He didn’t get the next round of interviews for the 50th anniversary. It’s quite easy to imagine how fun it would have been to hear from him this past week. He would have been a few days shy of his 89th birthday.

 

Old Faded Newspaper

My husband pulled out the 1969 St. Paul Pioneer Press newspaper he had saved from the day after the landing. Old, yellowed, fragile, ragged in places, but entirely readable. Its headline:

U.S. Puts 1st Men ON MOON

There was Neil Armstrong’s picture up in the right corner. Serious, resolute, young. Over the years, the photo had been torn, so I gently tried to slide it back into place.

Staring at his photo, I tried to reconcile the possibility of a medical error – or series of errors – ending this life too soon. This heroic figure could have gone to any hospital he wanted. He may or may not have checked the national ratings. One possibility was just up the road, Cleveland Clinic, which today is on the top of US News Best Heart Surgery hospitals. In 2012, there may have been other leaders. Neil chose a nearby community hospital and cardiac surgeon, because he likely had faith, they could provide the care he needed.

 

What Should Patients Know About Hospital Quality?

Just how much research should patients be responsible to do?  For example, should Neil have located mortality rate research that says those age 80 and up have lower survival rates?  Should he have then asked how many patients 80 years and older had received a cardiac bypass at that hospital, with that specific cardiac surgeon?  Would the hospital and doctor have been forthcoming with answers?  At least seven states, including New York and California, provide detailed reports about heart surgery survival to consumers, naming hospitals and surgeons that are significantly better or worse than average. Unfortunately, Ohio is not one of those states who openly share performance results. Who, then, in the other states, bears the responsibility to inform patients about past performance?

Perhaps Neil assumed healthcare had the same quality levels he had come to rely on in space. Perhaps he thought there was no way a cardiac bypass could be more complicated than flying men to the moon. Perhaps he felt more like a test pilot the day he agreed to have the surgery, accepting the known risks. Maybe nobody reminded him that hospitals are dangerous places, even though they perform life-saving procedures – many that seem miraculous – every day.

Consumer Health Ratings Examines Ohio Hospital Ratings

Consumer Health Ratings examined the standing of the Ohio hospital where Neil Armstrong had his surgery. The ratings from 2012 are long since gone. Only today’s ratings are readily available online, and the hospital’s cardiac bypass ratings are fine. The hospital in question even received a Best Hospital award from a national ratings company for Cardiac Care in 2017[1].  Curiously, they did not repeat that award however in 2018 or 2019.  Still, today, the hospital’s CABG performance (Coronary Artery Bypass Graft) is “as expected”; it was neither worse nor better than average. The ratings company examined five additional types of cardiac care for Medicare patients. It found performance rates for patient survival at the Ohio hospital to be acceptable, or better than average in all areas except one.  Unfortunately, in heart valve surgery, significantly more patients died within 30 days, than the number one would expect.

I turned my attention back to the family and carefully paged through the old faded newspaper.

 

“Dad Is On The Moon”

The old Pioneer Press was filled with numerous stories on the space program. In section two, a pair of photos caught my eye. Here was 10-year old Andy Aldrin, Buzz Aldrin’s son. He was pensive, quiet, maybe even emotional, sitting alone in his backyard. His right hand shielded his eyes and cradled his forehead as he bent forward, looking down.  I was reminded of the risk of the mission and the need families might have for privacy.

The second photo of “Dad Is On The Moon” was of “Ricky” (Eric) Armstrong, Neil’s 12-year old son. He stood barefoot, waving the American flag in front of his brick home. He expressed happiness. Maybe he was full of pride; maybe there was acknowledgement that America did this, that HIS DAD did this.  Ricky appeared as the joyous son of an accomplished astronaut.

Once I heard the news of the $6 million settlement, my own jubilation of the anniversary days turned pensive and quiet. I was completely disheartened, saddened, dismayed. I even felt embarrassed at the healthcare field where I’ve spent my career.

 

Families and Medical Errors

I mention the photos, because while our astronauts are heroes, hospital patients are primarily family members. When something goes wrong from surgery, or its follow-up care, the patient and his or her family will feel the pain acutely. And perhaps forever. The hospital disputes there was any malpractice. They reportedly settled to avoid publicity, which as we now know, also failed in the end. Yet, the new publicity suggests care was not without its problems.

The case was settled privately. Consequently, we may never know how to reduce hospital mistakes. Additionally, there is no clearinghouse in the US to gather and learn from preventable medical errors.  We have no NTSB[2] like the airlines have, to investigate tragic accidents. Each hospital does its own investigations, with or without outside experts. The Ohio hospital may have learned something from Neil Armstrong’s care, and made improvements since 2012. But whatever they learned does not automatically get disseminated to the rest of the field. Hence, hospitals are very limited in their quest to speed up the rate of healthcare improvement in the United States.

Neil Armstrong was a famed astronaut, a fully qualified naval aviator, a Korean War veteran, a test pilot, a university professor. He was husband, father, grandfather, friend. His untimely death should propel healthcare institutions to launch stronger quality improvement efforts. Neil Armstrong tested our healthcare system, and it apparently did not deliver.

 

Healthcare Safety Compared to Aviation

Sometimes tragic mistakes serve to refocus everyone on safety, ultimately making the system stronger. In 1967, the entire Apollo 1 crew – astronauts Grissom, White and Chaffee – died in a horrifying flash fire on the launch pad. Substantial improvements were made to construct a safer spacecraft and to address issues in the culture. Such strides contributed to the successful moon landing.

Healthcare has learned much from aviation safety improvements. However, unlike aviation, healthcare has no similar accident investigation, nor incident reporting system for events and near misses. The Agency for Healthcare Research and Quality (AHRQ) provides many critical resources for patient safety, such as the Hospital Survey on Patient Safety Culture and the Patient Safety Network.  It has broad responsibility to improve the safety and quality of America’s health care system. Another federal resource is the Food and Drug Administration (FDA). The FDA operates MedWatch, a site to capture medication and device malfunctions.

Carl Macrae, PhD, from the University of Oxford, UK, contrasted health care’s approach with that of aviation:  “One of the most striking differences between health care and aviation is a bias in health care toward collecting and analyzing large quantities of incident data, compared to a bias in aviation toward prompt investigation and action.“

Healthcare does not have the nimble and specific kind of Center for Patient Safety that it needs. Such a healthcare center would regularly receive safety reports for input into a useful database. It would catalog problems, analyze data for trends and key issues, and disseminate well written reports to healthcare leaders. It would welcome incident and near miss reports.

Neither does the United States have an NTSB-type organization with investigators who can consistently and thoroughly examine accidents and prepare high quality reports. Rather, each hospital is left to its own devices, with learnings largely retained within the health system to which it belongs. Without a national healthcare safety board, the field learns only slowly.

Armstrong’s Death Calls Healthcare to Take a Giant Leap

Aviation has a terrific infrastructure that annually addresses fatalities in the hundreds. Healthcare has a safety infrastructure that still lets tens of thousands of patients die needlessly every year. The landmark book To Err is Human, published in 2000, put the number of preventable hospital deaths at 44,000 to 98,000 per year. Hospitals have made significant improvements since 2000.  Yet, Johns Hopkins revised that estimate upward to 250,000 needless deaths from medical care. More than 25 deaths per hour.

Though many lives are lost, the overall healthcare safety infrastructure remains undependable. To be sure, there may be some institutions that do an excellent job of pursuing perfection. But there is no reliable base of support to carry the learnings into space, to communicate to others in the healthcare field.

 

Neil Armstrong, Test Pilot for Healthcare

Neil Armstrong’s test pilot status unsettles me. He was not meant to be a test pilot for healthcare. We know that hospitals are not as safe as they could be – in Ohio – or in any other state. We know the reporting of near misses and incidents leaves much to be desired within a hospital, and across the industry. We know our root cause investigations are wobbly. We need to be more sophisticated in our approach to healthcare safety. It is time for a national healthcare incident reporting system[3] and an NTSB to investigate accidents in healthcare.

Neil Armstrong’s legacy could extend beyond space exploration. Healthcare could give him his full due, by using the truth about his death to serve as a call to action. We need to improve the system. We could set a goal for the end of the next decade. As John F. Kennedy said, “We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win.”

To improve American healthcare, the questions remain:

Are we willing to accept the challenge?

Are we unwilling to postpone?

If we could answer yes, we know that the talented people who work in, or care about, healthcare would undoubtedly win. No question it would be hard. This time it is healthcare’s “giant leap” that Neil Armstrong calls for.

Healthcare has been orbiting quality since 2000, conducting experiments and learning along the way. Now it’s time to make the commitment to land the ship. Let Neil Armstrong be our inspiration.

 

We welcome your comments about quality improvement and avoidable mistakes in healthcare. (We ask for your email, but do not show it to the public. It will be kept private.)

This post was updated July 31, 2019.

[1] The 2017 cardiac award was based on Medicare cases from 2013 to 2015.

[2] NTSB is the National Transportation Safety Board, with a FY 2018 budget of $110 million.

[3] The voluntary Aviation Safety Reporting Program (ASRS), established by the FAA, and operated by NASA, is “designed to stimulate the free and unrestricted flow of information concerning deficiencies and discrepancies in the aviation system. This is a positive program intended to ensure the safest possible system by identifying and correcting unsafe conditions before they lead to accidents. The primary objective of the program is to obtain information to evaluate and enhance the safety and efficiency of the present system.” During 2018, the ASRS received over 8000 voluntary reports per month, or nearly 400 reports per working day. The database is public and searchable.

Photo credit: David Besh
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Comments
  • Gretchen Dahlen
    Reply

    An interesting discussion – from 2017 – among nurses about skills and policies required in order to pull temporary pacing wires. This was a significant piece in the Armstrong case. Just nine entries cover a lot of ground on the question. https://allnurses.com/can-rns-remove-temporary-pacing…/

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