Emergency: Breakdown In Communication

Emergency: Breakdown In Communication


L. Bradley Schwartz went to the emergency room expecting care.

He woke up a month later to the news he had lost vision in one eye and would lose all four limbs.

It was a beautiful Saturday afternoon in 2004, the day before Mother’s Day and Schwartz’s wife’s birthday. Schwartz, an attorney well-versed in healthcare (he grew up in a medical family and specialized in personal injury defense and insurance litigation) felt extremely fatigued and was experiencing a worsening headache throughout the day, to the point where his wife decided an ambulance was needed. It was not until midnight that the cause for his 105-degree fever, multi-organ failure, and septic shock was discovered. Schwartz did not receive antibiotics for 6-1/2 hours. By that time he had gone into septic shock, resulting in disseminated intravascular coagulation which severely compromised blood flow to his eye and extremities.

So, what went wrong? It started with how his history was taken and later communicated to ER staff. Paramedics on the scene at his home asked if he had anything to drink the night before. The Schwartz’s had hosted a wine tasting party, so he answered “yes.” His history as relayed by the transporting paramedics to the ER staff was that they had “an otherwise healthy 37-year-old man who had been drinking alcohol the night before who now had fatigue and a headache.” The ambulance crew had been called in the early evening, resulting in Schwartz arriving at his local hospital’s Emergency Room during a shift change. It was a holiday weekend and “spring fever” was in the air; the nurses and doctors who were working gave the impression that they really didn’t want to be there. It took a while for anyone to examine him.

Schwartz was triaged as a low-priority patient, and a tragic comedy of errors unfolded, including negligence on the part of his care team, who did not promptly nor thoroughly examine him nor take an independent thorough history.

Labs were drawn as per protocol shortly after his arrival in the ER but were not resulted nor reviewed in a timely manner. Had standard protocol been followed, Mr. Schwartz’s diagnosis (bacterial meningitis) would have been suspected. Cultures would have been drawn, a lumbar puncture would have been performed, and he would have been promptly started on broad-spectrum antibiotics. Instead, his blood test results went unseen for hours.

He became a victim of malpractice due to a series of avoidable breakdowns in communication and failure to follow standard established protocols.

After surviving the anger and eventual acceptance that follows a devastating injury, Schwartz began using his legal expertise and knowledge of hospital systems to benefit others and now focuses on medical negligence, amputee support, meningitis awareness, sepsis prevention, and elimination of medical error.

Medical error is the 3rd leading cause of death in the United States and patient advocates can help save lives. It became Brad Schwartz’s personal mission to make sure every patient’s voice is heard because in his case, it wasn’t.

It soon became his goal to prevent others from enduring the same systemic failures that almost took his life. Recognizing that many clinicians were leaving their practice to become Independent Patient Advocates, he founded Greater National Advocates, a nonprofit foundation determined to make these advocates known and available to everyone. From his perspective, an independent advocate by his side in the ER would have saved his limbs, so he started GNANOW.ORG, an online directory that connects patients and loved ones to immediate support.

For more information visit www.gnanow.org/about or get listed now at www.gnanow.org/advocates

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