Christmas was always my Dad’s favorite holiday. But, Christmas 2012, he just wasn’t himself. I could tell he didn’t feel well, but he just kept telling me he would be fine. By his 64th birthday on December 30th, my mom took him to the doctor for a spot on his foot. My Dad was a diabetic who refused to acknowledge that or monitor it in any way. The spot on his foot was a small diabetic ulcer which the doctor told them to keep cleaning out and changing the dressings if they got wet.
This went on for a month or so until my Dad had more spots on his feet and legs. They went back to the doctor toward the beginning of February 2013. He ordered him to start going to the wound clinic to help the healing process. Between visits to the wound clinic twice per week, my mom was to do the very painful dressing changes on her own. Neither of my parents had any medical background and simply followed the limited instructions given to them.
My mom took him to the wound clinic twice per week, but he wasn’t getting better. In fact, we felt he was getting worse. The beginning of March 2013, my mom called the doctor. She asked him if they could come in for another visit to the office so he could re-evaluate the treatment to make sure it was working. He told her that wasn’t necessary and simply prescribed antibiotics for my Dad to start taking.
My Dad’s second favorite holiday was St. Patrick’s Day. I knew he had really deteriorated when he did not want to go out to celebrate with even one green beer. In fact, he was not getting better, his legs were looking worse. So, on Monday, March 18th, my mom asked if there was a doctor at the wound clinic they could see. They told her there was not and she would just have to take him to the Emergency Room. She did. He was admitted to the diabetic floor of a very large hospital in Kansas. My parents called me to come to the hospital as another set of ears. By the time I got there, only about an hour later, they were moving him to the ICU. He was being diagnosed with Congestive Heart Failure (CHF).
We felt some relief. We felt like things would finally get better. He had the wound team coming around daily. He had a cardiologist and now a nephrologist assigned to him because some of his lab work indicated something might be wrong with his kidneys. He then had an infectious disease to assist wound care. We felt by Easter, March 31, 2013, we were turning the page and making some good strides.
I visited my Dad on Monday, April 1st, and immediately knew something was wrong. He was confused, combative and had gotten very angry. I asked the nurse about what had happened in the night as I could tell something was extremely wrong. She told me nothing out of the ordinary. I had my Mom come back in to see if she could calm him down. I went home that day only to be called back because my Dad had a ‘minor heart attack. I raced back to the hospital and was met by the cardiologist and my Mom. He told us there was nothing more they could do at this hospital, but that he needed a procedure and needed to be transferred. We agreed to have him flown to a larger hospital approximately three hours away. We raced up there by car at 2 a.m. We arrived to find an even more confused and combative man.
My Dad was sedated and assigned a one-on-one sitter, so he didn’t pull out any tubes or lines. His kidneys had shut down and he needed dialysis, which the doctor ordered immediately. They wanted to place a pace maker, but weren’t sure he would survive the surgery. The intensive care cardiologist told us that his heart was the least of his concerns right now. My Dad held on, in the comatose state, for eleven days. He was inundated with antibiotics, provided continuous dialysis and flooded with fluids. It was too late. He never woke up. He had no brain activity. My family had to take him off life support.
His body was overtaken by sepsis on April 11, 2013.
So many people interacted with him and his care. Each provider took care of the body system they were to address, but none of them really communicated or brainstormed the case together. His wounds were open lines of the infection that cost him his life. It was not until it was too late that anyone realized what was happening. By the time he got to the last facility, we were fighting a losing battle of one organ shutting down after another.
If one person – nurse, paramedic or doctor – would have said, “I suspect sepsis”, my Dad might be here today. Just one person to identify the symptoms with the high probability of the infection, he might still be alive today. I can logically see how this progressed, but my heart still struggles with how could so many miss this.
Walt Aikman was a husband, dad, brother, grandpa, uncle and friend. He had a great laugh, a warm smile, was a terrific dancer and had so much more to offer this world. He was my cheerleader and so proud of all I accomplished. Just one person might have been able to ensure he was still here to fill all of those valuable roles. Be Heard. Spread the Word.
This story was told by Susan Runyan, Great Plains Quality Improvement Consultant in Kansas.