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Lesson of the Titanic

From: The Hospitalist, November 2007

The healthcare system, like the doomed liner, faces peril

by Jeff Glasheen, MD, FHM

Jeff Glasheen, MD

Author’s note: More than 1,500 passengers died in the Titanic, a disaster that resonates nearly a hundred years later. The equivalent of about 50 Titanics capsize annually in U.S. hospitals, nearly one every week (based on the Institute of Medicine’s estimate of 44,000-98,000 deaths per year from hospital adverse events). As hospitalists, it is our obligation to ensure the hull is solid, the crow’s nest properly manned, and the ship is turning in the right direction.

I’m the Rev. John Harper, and it’s April 10, 1912.

As I grasp my boarding pass I can’t contain my awe and excitement. Imagine me aboard the world’s most luxurious cruise liner heading to America. Granted, I’m booked in second class. But as everyone knows, second class on the Titanic outstrips first class on most liners these days. It should—for $66 this is an expensive way to travel. Still, it’s less than the cheapest first-class ticket of $125 and much less than a $4,500 booking in the millionaire’s suite. I could buy several houses for $4,500.

Walking along the gangway I recall hearing that this ship—the largest ever built—weighs nearly 47,000 tons and cost $7.5 million. Outside my cabin door I encounter a fellow passenger who exults over the ship’s amenities. The liner has a heated indoor swimming pool, four electric elevators, two libraries, a Turkish bath, a squash court and gymnasium, and ample room to move about. The White Star Line has thoughtfully limited the amount of lifeboats to 20 to preserve precious deck space for passengers.

The healthcare system—like the doomed Titanic—is a costly endeavor that can imperil lives if not steered correctly.

I’m Jeff Glasheen, and it’s Sept. 15, 2007.

As my wife prepares to deliver our first child in the coming weeks, we visit the labor and delivery deck of the hospital.

It will be our first major interaction with the healthcare system as patients. It’s the largest healthcare system ever and costs nearly $2 trillion a year to operate. We have chosen a new hospital that features an amazing array of amenities, including a birthing center with private suites, in-room baths with oversize soaking tubs, an in-room sleeping area for family and friends, and a DVD player and flat-screen television. There are even Internet connections.

Room service is available 24 hours a day, and the staff is top-notch. I’m told some choose to stay in the VIP suites for an extra $1,000 a night. This restricted-access area offers 600-square-foot rooms with original art on the walls, luxury mattresses and 350-thread count linens, complimentary robes and slippers, and an office area supplied with newspapers, a printer, fax, voicemail, and teleconferencing capabilities. There is a family room as well as a private refrigerator, an assortment of beverages and a dedicated chef. Unfortunately the cost is too steep, so we’ll spend this voyage in second class. However, as everyone knows, second class on this vessel outstrips first class in most hospitals these days.

Midnight, April 14, 1912

Something has gone wrong; the ship just hiccupped a bit. From my cabin I clearly hear a grinding that could happen only when two large objects come into contact. It’s strange, but I assure my bunkmates there is nothing to worry about. The Titanic is unsinkable, built with every feasible safety feature. The ship’s hull is made of inch-thick steel and held together with nearly 3 million steel rivets. In the unlikely event the hull is breached, the ship contains 15 watertight bulkheads to contain the leakage. Further, 3,560 life vests, 48 life buoys, and the aforementioned 20 lifeboats (four more than required by British law) allay my concerns.

On the off chance something should go wrong, the ship is outfitted with the recently developed Marconi wireless telegraph capable of communicating with any ship or shore within 500 miles.

5 p.m., Sept. 17, 2007

As I write this column I consider that something could go wrong during our hospital stay. The Institute of Medicine reports that medications harm 1.5 million people annually (400,000 incidents occur in the hospital) and that nearly 100,000 die annually in adverse hospital events.

I assure myself there is nothing to worry about. The hospital of today is unsinkable, built with every feasible safety measure. Today’s hospitals require two patient identifiers, time-outs before procedures, read-backs, standardized abbreviations, rules for reporting of critical results, standardized approaches to hand-offs, awareness of look-alike/sound-alike medications, hand-hygiene guidelines, medication reconciliation, core measures, quality and patient safety committees—and, on the off chance that something should go wrong, requirements for communicating sentinel event reviews with regulatory agencies.

1:30 a.m., April 14, 1912

The scuttlebutt is that the Titanic has hit an iceberg, tearing open the hull, flooding the bulkheads, and overcoming the ship’s pumps. Apparently the crow’s nest spotted the iceberg only 30 seconds before the impact. The crew tried to change course immediately. But the unprecedented size and speed of the ship (there is a rumor that the captain may have been trying to set a new trans-Atlantic crossing record) made it impossible to avoid our destiny.

We are clearly sinking. As I anxiously pace the deck waiting for a spot on a lifeboat, I chat with a crew member who assures me help is coming. The ship’s band plays on deck, the music soothing in the night air.

1 p.m., Aug. 26, 2007

I’m about halfway through the Titanic exhibit at the local museum of nature and science. The display is designed to give you the experience of being a passenger aboard the RMS Titanic.

Prior to entering, visitors receive a boarding pass with information about one of the actual passengers. I am the Rev. John Harper, traveling to America with my young daughter to begin a series of revival meetings in Chicago. At the end of the tour I’ll view the passenger manifest to discover my outcome.

Reluctantly, I board the ship, anxiously awaiting my fate. I gaze upon thousands of trinkets and treasures rescued from the Titanic since its remains were discovered 2.5 miles below the ocean’s surface 900 miles off the coast of New York in 1985.

I marvel at dioramas of first- and third-class cabins with recovered china settings, uncorked and still-full bottles of champagne, toiletries, jewelry, and clothing.

One of the most fascinating pieces is a chunk of ice the size and shape of a small whale. The display represents the iceberg that doomed the Titanic and simulates the temperature of the water that fateful night. At approximately 28 degrees Fahrenheit, the average person would survive less than 15 minutes in the water. I was able to hold my hand on the ice only a few moments, quickly understanding the horrific way most passengers would die.

As I complete the tour and nervously approach the passenger manifest I am struck by how many lessons from the Titanic can be applied to modern medicine.

We operate in a system surrounded by perilous obstacles in a huge vessel that is slow to change course even in the face of extreme danger and poor outcomes.

We steam along at unparalleled speed embracing new, relatively untested technologies, procedures, and medications. Modern healthcare, like the Titanic, values building technologically advanced, well-adorned vessels rather than investing in the basic infrastructure to make it safer. We eschew quality for appearance.   

We spend money on heated indoor pools, squash courts, and Turkish baths rather than computerized provider order entry, bar code administration, and hand-off improvements. Despite all of this, our passengers trust the vessel is safe. They trust that we will protect them—that we have enough lifeboats.

The Rev. John Harper perished on April 14, 1912; unlike him, as I cross the threshold of the healthcare Titanic I am not filled with awe and excitement. I feel fear and dread. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver and Health Sciences Center, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.


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