'Sue, Can You Smile?'

Learning Objectives: At the end of this activity, you will be able to:

  • Explain the importance of keeping patients’ families informed about the care experience.
  • Analyze the concept of “the second victim” — the fact that providers also suffer because of an adverse event.
  • Discuss the role that potential litigation can play in a patient-provider relationship.

Description: In a new patient story, you’ll meet Sue, a nurse who und​ergoes several operations to remove a mass behind her ear, resulting in an adverse event. As you follow Sue’s story, you’ll be prompted to stop along the way to consider a number of questions about making mistakes, communication after adverse events, and the patient, family, and caregiver perspectives. When you get to the end of the story, you’ll hear from Sue and her surgeon, Dr. Rae, as they look back on the experience nearly seven years later.

In the fall of 2006, Sue Nevins, a 54-year-old nurse in Salem, Massachusetts, notices a lump behind her ear. It’s just large enough that she feels it whenever she inserts her earrings. Wanting to be proactive, she seeks the help of Dr. Keith Rae, a plastic surgeon, whom she’s known personally and professionally for many years. Together, they decide on a routine, outpatient surgery to remove the lump at the medical center where she’s employed as a nurse.

Sue goes in for the surgery in early December, a few weeks after noticing the lump. Dr. Rae is not able to remove all of the mass, but removes enough cells to get them tested. The results come back as potentially cancerous, so Sue decides to undergo another surgery a few weeks later — also at the medical center where she works — so that a larger incision can be made and all of the cells can be removed and tested.

Sue’s younger daughter drives her to the hospital the morning of the procedure. Her daughter plans to stay with her until the surgery begins, and is told by the care team that the procedure will take about an hour, and then she can drive Sue home. The operation is set to take place in the hospital’s smaller operating room (OR), but a time slot opens up in the main OR, so Sue is moved in there. Because the prep room is a part of the main OR, Sue and her daughter separate earlier than anticipated.

At the last minute, the anesthesiologist decides it would be best if Sue went under general anesthesia, instead of conscious sedation. Sue does not want general anesthesia, but grudgingly complies.

Before they start the procedure, Dr. Rae tells Sue he needs to talk to her about the risks of the surgery. She brushes him off, saying, “Oh, that’s okay. I trust you.” And the procedure begins.

Sue’s older daughter ― also a nurse ― calls her sister (who is alone in the waiting room) at 10 AM, asking why she hasn’t heard any news yet; the surgery should have been done at 9 AM. When she learns no one has talked to her sister in the waiting room, she decides to go to the hospital.

Another half hour goes by, then another. The daughters look at the clock on the waiting room wall and see that it’s almost noon ― three hours after the surgery was supposed to end. Still, they don’t hear anything.

Discussion Question: Put yourself in the daughters’ shoes. It’s 11:59 AM and the surgery should have finished three hours ago. Sue’s younger daughter was separated sooner from her mother than expected, and was alone in the waiting room for two hours. The older daughter has now made an unplanned trip to the hospital, concerned about her mother’s procedure since it was taking so much longer than expected. They have no updates. How would you feel sitting in the waiting room, unable to get answers?

Just after noon, Dr. Rae tells the daughters that the mass was difficult to remove, but that Sue has done well. Thirty minutes later, however, he returns with some additional news: He tells them he’s concerned Sue’s face isn’t working right.

When Sue wakes up in the recovery room, she has slight double vision, and is confused about the time. She is startled to find out the surgery has taken four hours plus an hour of recovery time, instead of the one hour like she had told her kids.

The nurses keep asking, “Sue, can you smile?” Sue thinks this must be a new test for patients coming out of general anesthesia. She feels different than expected; she feels like her whole face has been numbed.

When Sue is wheeled to a new room, her two daughters and grandson come out. They burst into tears when they see her and keep saying, “You’re going to be okay, Mom. Don’t worry.”

Nurses bring Sue water to drink in the recovery room, but she spills it, unable to properly use her mouth. She’s told not to look in any mirrors, and that she has severe facial swelling.

When Dr. Rae comes to talk to Sue in her room, it’s filled with her family, her coworkers from the hospital, and the nurses taking care of her. He tells Sue that he suspects she may have facial nerve damage. And although there is a chance that it’s mostly facial swelling, they need to monitor it for now.

Discussion Question: Pretend for a moment that you’re Dr. Rae. You just performed a surgery on a friend and colleague in your hospital, and it did not go as expected. It took much longer than it should have, and now your friend and colleague has facial swelling and potential nerve damage. You walk into her room to discuss the complications, and find it filled with her family and her coworkers. What do you say to everyone? How do you feel?

When Dr. Rae leaves, Sue’s daughter starts taking pictures of Sue’s face — she had already talked to a lawyer. Sue tells her to stop, saying, “There will be no lawyers. I just want to get better.”

Discussion Question: If you were the patient, would you involve a lawyer? Why or why not?

When Sue goes to the bathroom that night, she looks in the mirror. Her eye isn’t shutting, her mouth is open, and her face is drooping. She asks to be discharged the next day and goes home.

Under the care of her daughters, she tries to recover at home. When her grandson sees her, he runs away, so she stays in her room.

The next day, Sue goes to the ER for extreme head pain and stroke-like symptoms. The ER doctors find that no one had dealt with her eye that wasn’t shutting, and a dry cornea was causing her headache. Sue stays in the hospital for two more days while she receives physical therapy, speech therapy, and is taught how to use a straw and eat some soft foods again. During those two days, she repeatedly asks if Dr. Rae is working and if she can see him. Her coworkers caring for her assure Sue that they will check to see if Dr. Rae is in.

Discussion Question: What could the care team have done differently in the days after surgery?

A few days later, Dr. Rae tells Sue that her biopsy is negative. He tells Sue that he didn’t know she had been admitted. Despite Sue’s coworkers’ assurances, no one had informed Dr. Rae that Sue wanted to see him.

Six years have passed since the surgery. Sue has improved, but is not cured. She has permanent facial palsy on the right side of her face. Sue receives frequent neurological care at a large Boston medical center, but it is still not clear what exactly caused her facial palsy. The tentative diagnosis is a stretched nerve.

She has chosen not to file a malpractice suit against Dr. Rae, and they are still in touch.

No one, not a patient or a doctor, intends for an adverse event to occur, but sometimes they do. Let’s hear from Dr. Rae and Sue about the important lessons they learned from this life-changing experience.

Dr. Keith Rae

Sue Nevins, RN


 Discussion Questions:
  1. Do you feel differently about the story after hearing from the patient and Dr. Rae?
  2. How can we prevent the type of experience that Sue had from happening to others?​
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