June 13, 2019
Donna Penner was having routine surgery but something went horribly wrong and through the failure of her anesthesiologist - Donna was awake during her abdominal surgery, but also paralyzed so she couldn’t tell the surgical team. Donna could feel every excruciating scalpel cut, and the surgeon moving her internal organs around.
In torturous pain, and suffocating through lack of oxygen, Donna resigns herself to death and mentally says good bye to her family. But the surgeon notices Donna’s heart rate is very rapid and she can hear him ask the anesthesioligist why Donna is in distress.
Donna feels a sense of relief that the surgeon has noticed and that she is about to be saved from death. But then she hears the nurse reply that the anesthesiologist has left the operating room.
The surgery continues, the excruciating pain continues, the suffocating continues - as death nears, Donna has an out of body experience and is immersed in warmth and safety and she welcomes its sweet embrace.
But death does not come in that moment, and Donna finds herself in her body again - with the pain and suffering.
But the medical errors do not end there - as the surgery ends Donna can’t believe she has survived, but her breathing tube is removed prematurely and Donna’s paralyzed body cannot breathe on its own and she starts to suffocate again - the nurse yells at Donna to breathe, but she can’t….
I wish I could say Donna’s trauma from the medical system ended after the botched surgery, but as you are about to hear, Donna’s experience with a system designed to protect physicians and undermine patient victims adds another layer of trauma onto her life.
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SHOW NOTES - TIME STAMPED
Donna grew up on a farm in Manitoba, Canada, middle child of 3, cows, dogs, cats, hogs - very happy childhood - raised to be responsible, honest, hard working, good values and qualities - parents did a good job
Donna's health care error started several years ago when she had abdominal pain and went to the local clinic - kept for 24 hours they didn't know what was going on - but transferred Donna to another hospital - had laproscopic surgery scheduled
Donna has had surgeries before, anasthetic before no problem - but feeling anxious this time and asked for sedative and was refused - the first thing that went wrong - taken to operating room (OR) and prepped for surgery - anesthesiologist said to Donna take a deep breath and Donna 'was out'.
The next thing she remembers is waking up and hearing sounds in the OR and thinking 'good it's over' and know I can feel relaxed and don't need to feel nervous any more' - and then the surgeon spoke and what he said haunts Donna to this day: "Scalpel please." - then Donna felt the first incision - excruciating pain, beyond description
Donna tries to alert surgeon and staff that she is awake and tried to scream - but couldn't open her mouth - couldn't sit up - realized she's paralyzed by the paralytic medication used for abdominal surgery - so the anasthesia did not take effect, but the paralytic did - Donna could not scream or move but could hear her heart rate on the monitor as it sky rocketed to 147 according to the surgeon (later) - Donna starts to panic - trapped in body and couldn't do anything.
As Donna heart rate quickens, she needs to breath faster to supply more oxygen but she couldn't take a breath because she was intubated (tube in her throat to ventilator that breathes for her) - but the ventilator set at 7 breathes per minute, but what Donna needed was much more - so she felt like she was suffocating
"She's in distress, she's in distress" surgeon says, asks anasthesiologist what's wrong - a nurse replies that the anasthesiologist is not in the OR anymore and doesn't know where he is - Donna panic increases - surgeon tells the nurse to find the anasthesiologist immediately - Donna's hears the nurse leave the OR - after what felt like an eternity, anesthesiologist returns - Donna feels relieved that he will realize she's not unconscious and will save her from the pain
That did not happen - anesthesiologist gave her another medication via IV, but did not make Donna go back to sleep - for the next 90 minutes Donna felt the surgery happen - insertion of instruments into her abdomen, exploring, she could her the surgeon comment as he looked at her appendix, kidneys, colon - the whole time Donna is experiencing excruciating pain while he pushes her organs around
Donna hears the surgeon exclaim that there is a lot of blood, and this is not good - Donna continues to panic and wonders why they are not noticing she's in trouble - Donna didn't think she was going to live through it - the pain was so bad she thought she was going to die - this is every surgery patients nightmare
Donna thought about her kids, her husband and worried that if she died they would never know what her last few hours of life were like, the pain and torture - Donna resigns herself to death and says her mental good byes to her family - and ask God to take her away from the agony and pain of surgery.
Surgery ends and Donna feels relief that she survived the surgery, but she's still in an immense amout of pain - Donna notices she can mover her tongue a little bit as paralytic wears off - starts to wiggle breathing tube in her mouth to get their attention - anesthesiologist noticed and he removed the tube from her throat - but Donna is still paralyzed and cannot breathe and starts to suffocate and realizes she's about to die - the nurse starts telling Donna to breathe, but Donna cannot breathe
Something amazing happens - Donna has an out of body experience - she could hear OR sounds, voices - in a place somewhere between heaven and earth - Donna could feel a presence and felt it was God with her - her fear left, the pain was gone, it was warm and she felt safe and protected - Donna smiles when she thinks of this - at this point she knew she would be okay whether she lived or she died
Donna prayed and asked God to take her - she heard a voice that said she would be okay - that was reassuring - Donna gets very emotional when she thinks of that - Donna hears the anesthesiologist say 'bag her, bag her' and put a mask on her face to force air into her lungs - immediate relief with oxygen - lungs were on fire - anesthesiologist gave her another injection, a paralytic reversal and within a few minutes Donna started to regain movement
Donna moves her head side to side to get their attention - nurse asks anesthesiologist why Donna is doing this, anesthesiologist says he doesn't know
"I was awake, I felt him cut me" were the first words Donna was able to speak - 2 nurses and anesthesiologist in room, but they had shocked look - Donna repeated herself and told them what she heard during the surgery - but 2 nurses and anesthesiologist did not say a word - Donna realized they were not going to even acknowledge what she had said, a wall of silence went up
Donna asks for husband Brian but he was not allowed until Donna was in recovery room and tells him immediately what happened - Brian tells nurse they want to speak to anesthesiologist immediately - nurse says anesthesiologist has already left the hospital - Brian says 'I don't care, you go find him, bring him here' - a while later the anesthesiologist walks into Donna's room
anesthesiologist has papers in his hand with portable table and shuffled papers - did not make eye contact with Donna or Brian - Donna tells him her experience - anesthesiologist shrugged his shoulders and said 3 words "It happens sometimes" and left the room - Donna and Brian shocked
Scott says 'invalidated trauma deepens trauma' - Donna says it is secondary harm - just as traumatizing as original trauma itself - felt like she didn't matter, no big deal for anesthesiologist - Brian asked for surgeon - Donna told surgeon her experience, he held her hand as she spoke with tears in his eyes and said he was sorry this happened and we will get you help to get through this and do an investigation - but the nurse did not acknowledge or offer words of comfort or kindness
Donna went home that day and that night the nightmares started - the surgeon called the next day to check how Donna was doing - she spoke to him several times over the next few weeks - Regiona Health Authority (RHA) was notified and Donna was in therapy 2 weeks later and diagnosed with complex post traumatic stress
3 weeks later Donna asked for an interview by RHA for an investigation and asked her to meet with them at the hospital where the trauma occurred - they did care how the location of the meeting would impact Donna - one of the worst things they could've done - Donna says they have changed this practice since
Donna does RHA interview and doesn't hear from them at all - Donna went back to work to use as a distraction and to feel 'normal' - 3 months later Donna is scheduled for a hysterectomy surgery - she struggles with PTSD and the need for more surgery - still no word from RHA, Donna contacts VP of medical services to talk - Donna had to reach out, when RHA should have been following up
Donna is given a contact at RHA for any of her questions - but Donna is just given the run around - Donna realizes that is futile and goes directly to VP with her questions - as time went on, Donna was able to get some information - many things wrong - Donna very mistrustful as her next surgery approaches at different hospital - but she needed the surgery - they gave her a spinal anesthesia instead - But Donna does wake up half way through surgery and turns to the anesthesiologist and says 'just checking to make sure you're here' - that surgery went well
Donna told by RHA she would get a report of her medical error - Brian did a lot of research about anesthesilogy and standard of care and found that anesthesiologists are never to leave the OR - "crictical incident" report to be sent to Manitoba health and Donna keeps asking for it and given the run around - finally after many, many months of trying to get a report she finds out that it was not recorded as a 'critical incident' because the patient had reported the error, therefore labeled a 'complaint' - only when staff report an error is a 'critical incident' report filed
No critical incident report filed because the patient made them aware of the error - the system is set up to help providers, not to protect the patient - Donna asked for internal report - and again given the run around - Donna meets with Theresa Oswald Provincial Minister of Health - Oswald says she will get the report for Donna - about 3 weeks later Donna get a copy
But the report is only 1.5 pages and has only 3 bullet points recommendations to improve safety - Donna cried because so disappointed - the report did not mention the effect on Donna, it did not admit a mistake was made, it was very vague - Donna asked again to meet with VP and with CEO of Hospital and confronts them with their own weak report and threw it on the desk and said 'you have to do better' - the report did not address what went wrong with Donna's surgery - they admit there were actually 3 more recommendations that they did not share with Donna
Donna demands to see the full recommendations - they were 'a joke', ludicrous, ridiculous, a shame they didn't learn anything from their medical error - then Donna learns that another report had been sent to Manitoba health - Donna has tried for years to get that report but the goverment has legislation that protects medical providers and does not allow public access to reports - 11 years later Donna still doesn't know what went wrong during her surgery
Donna knew early on she had to share her story to bring awareness - "need to tell my story, need people to know what happened to me" - contact with CPSI (Canadian Patient Safety Institute) with their Patients for Patient Safety Canada group - other patients or surviving family members, common factor is all have been harmed by medical system, and all have desire to change the system - through this group Donna started advocating and tell her story publicly - as time went on, HRA became less interested in Donna sharing her story publicly
Donna made a video with PPSC for HRA to use to make the process works to support the patient harmed by medical error - Donna wanted to share beyond her region - contacted Head of anesthesiologist at university and Donna invited to speak to medical students about her experience - travels to share with different medical conferences, nursing students - healing and empowering to do advocacy - making meaning out of horrible event
Husband Brian a solid support over the years - Donna worked for 2 years but was not dealing with the trauma - did not want to go on medical leave for PTSD, but had no choice - still has flashbacks, nightmares, memory problems - still struggles every single day
"I was surviving, I wasn't living" - Donna tells Brian she doesn't want to live any more - asks Brian to hide her medication - Donna wants to escape the pain - the darkest day she had - but has struggled with suicidal thoughts - but children and grand children are reasons to live and first grand child helped with wanting to live
Donna advises other medical error victims is to talk about it - therapist warns that some family and friends and co-workers will get tired of hearing about it, but to keep sharing with others - best advice she's ever received - but also has received negative feedback and judgment from family, friends, co-workers who do not understand PTSD or mental health and have accussed Donna of faking it
Donna persists in sharing and raising awareness of medical physical and mental harm - the more we share, the more people can learn - let people know how devastating medical error can be - some days feels like beating her head against a wall with frustration with the uphill battle of advocacy
There are days when she feels like giving up with advocacy - cried many tears - maybe time to move onto something else - feels like a loss, betrayed, abandoned - "I will not be silenced" - Donna will continue to share her story and not hide from the culture of silence - not an easy road - continues to receive therapy because of medical error - Donna continues to pay the price for someone else's error - dealing with unwanted change is the hardest change
There are people who listen and want to change the system so it is safer for patients - there are good people, not all are narcissists - Donna focuses on those who can make change happen, listen to patients, and learn from horrific mistakes - system allowed bad behaviours against standard of care, and allowed it to continue and that is why Donna was harmed
Surgeon said 'I hate it when he leaves the OR, it puts more pressure on me to monitor the patient' - so the hospital knew this was happening and against standards of care and allowed it to continue to happen until Donna got hurt - they shouldn't wait until there is harm to make changes
Donna has had to have multiple surgeries since and it is very difficult to trust the system that hurt you, and the people in those same positions, although at different hospital - takes courage - finds vast majority of doctors and nurses are good people, but a few bad apples can ruin it 1:17:20
Donna wonders what would've happened if she had of died on the operating table, would any one have known what she went through and things would've continued - using her survival as meaning making because there are bad behaviours - 1:18:15Who are the real experts in medicine?' - it is not the doctors or nurses - patients are the experts in their own care - doctors need to get off their pedestals - Donna tells medical students: don't confuse your 1 hour of training in PTSD with my 11 years of living with it
It is a hard story to hear - Donna tells it like it is because people need to hear - we need to educate people on patient safety - the momentum of patient safety advocates is great to see