A nurse entered Room 12 of Providence Everett Medical Center’s emergency department to take one final blood draw.
It had been about six hours since Ken Simon collapsed in his home and medics rushed him to the hospital.
The nurse said he was going to prepare the Snohomish man’s discharge papers.
He glanced at Simon’s wife, Jennifer, and, she recalls, said as a friendly way of wrapping things up, “Figure out where you want to go to dinner.”
Simon held her husband’s hands, assuring him that they would be home soon. She’d tuck him into bed and feed him dinner.
Suddenly, her husband cried out “Oh no!” He clutched his chest, then his body convulsed into seizures.
“Don’t you leave me! Don’t you leave me!” his wife pleaded, before running down the hospital hall screaming, “We need help now! Please help us!”
After a while, a team of doctors and nurses rushed in.
Nurses tried to start an IV and draw blood. A doctor put a tube down Ken Simon’s throat to help him breathe. Others worked the crash cart, trying to save him.
Ken Simon, 55, died about a half hour later, at 7:15 p.m. on July 12, 2003. The athletic man, so fit that he ran marathons and half-marathons, died of a tear in his aorta, the heart’s major artery.
Emergency room doctors had believed Simon was only having a panic attack, which shows similar symptoms: chest pain and pressure.
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Simon also had disorientation, a fluctuating heart rate, tunnel vision and periodic loss of consciousness, his wife said.
In the months after the funeral, she considered her next step: Calling the hospital for a meeting, or calling an attorney and suing.
The case had all the makings of a bitter lawsuit. A man in his 50s, making a six-figure salary, dies after an incorrect diagnosis.
And an angry, grieving widow says hospital staff did not respond to her repeated attempts to alert them to her husband’s worsening condition.
In fact, Jennifer Simon admits one lawyer told her she had a strong case for negligence.
“I had a tough decision to make,” she said.
“I wanted this to mean more than lawyers and money. I wanted something to change.”
‘They listened’
After her husband’s death, Simon said she was depressed and couldn’t sleep more than two hours a night, even with medications.
She still grieves for her husband of 32 years.
“Physically, mentally and emotionally, it costs me beyond words,” she said. “Every morning waking up without him is almost unbearable.”
Last year she called Providence. They agreed to sit down with her.
One of the ground rules she laid down for the doctors and administrators who were there: No one was to leave the room, not even to respond to an electronic page.
They met twice to discuss her husband’s case.
Hospital representatives, she said, acknowledged that mistakes were made.
Paula Bradlee, who oversees quality and safety issues for the Everett hospital, has talked extensively with Simon about her husband’s case.
“I won’t make any excuses,” Bradlee said of the outcome.
“It was a misdiagnosis.
“The biggest thing that hurts us… is not (having) the right type of communication to make sure we understand what’s going on with the patient,” she said. “Our focus today is on patient safety. We never want to do less than provide excellent patient care.”
Dr. Jeff Wajda, who was then medical director of Everett’s emergency room, was another one of those who met with Simon.
Although an aortic dissection is a condition some people may have heard of – it’s the same condition that killed actor John Ritter – it can be difficult to diagnose, he said.
Its symptoms, which include chest pain, can be similar to a heart attack or a blood clot in the lung.
Statistically, if it is diagnosed and treated quickly, chances of survival are better than 50-50, Wajda said.
“It’s like being struck by lightning, it happens so infrequently it’s easy to miss,” he said. “You can practice 20 years and not see a case” like Simon’s.
The hospital staff’s straightforwardness was something she needed, Simon said.
“I think the hospital stuck their neck out to meet and talk with me,” she said. “I stuck my neck out to meet with them. The fact they listened to me was huge. It satisfied a lot.”
‘We took a chance’
Slowly, painfully, a bridge of trust was built.
During their second meeting, the hospital asked Simon to join a new group of former patients, their families and members of the community to talk about problems at the hospital and give advice.
Next, the hospital asked permission to retell her husband’s story at a meeting of emergency room staff from other Providence hospitals on the West Coast.
The biggest, and most unexpected, step came earlier this year.
Providence Health &Services, the Seattle-based parent organization to Providence Everett Medical Center, decided to produce a DVD on patient safety issues.
It would be distributed to its 29 hospitals in California, Oregon, Washington, Alaska and Idaho.
But Providence wanted one powerful story to drive the message home. Simon admits she was surprised when she picked up the phone and was asked if she would tell her story.
“It was hard, very hard, for everyone involved,” Bradlee said. “We took a chance asking Mrs. Simon to be in it. She chose to say yes. It just supports our belief of how important patient safety is.”
The video includes frank interviews with Providence employees acknowledging the chain of events leading to Ken Simon’s death.
Ken Simon had been misdiagnosed with a panic attack. Communication was not good among staff members.
Simon believed her husband’s condition was getting worse, but was ignored when she told hospital staff.
Patients and their families need to be listened to if they think something is wrong, the video continues. And if a different diagnosis had been made, Ken Simon’s life “possibly could have been saved.”
‘A debt of thanks’
“My hat is off to the hospital,” said Charles Bosk, a professor of medical ethics at the University of Pennsylvania.
Bosk received an award last year from the Robert Wood Johnson Foundation for his work investigating patient safety and medical errors.
Part of the problem is that emergency rooms across the nation often are short-staffed, he said.
“Those are difficult conditions. Often, people have more than they can manage to actually slow down and listen” to patients.
Providence’s video, he said, shows that the hospital recognizes the problem.
“They’re trying to teach people to do the right thing,” he said.
The video, completed in April, already has been shown at several meetings at the Everett hospital, including one with its emergency room staff.
“We all owe Mrs. Simon a great debt of thanks,” said Julie Zarn, clinical director of emergency services. “It’s her husband. He died in my department. I know my staff feel that when they see the video.”
The video ends with a cinematic pause. The screen shows a photograph of Ken Simon, and his birth and death dates.
Many were in tears, Zarn said.
“We’re clinicians. We see people come in. Most get better. Some die. You do develop an ability to deal with that,” she said. “Sometimes you need to be reminded of the impact of what you do.”
Simon said she tried to brace herself emotionally, to not expect too much, before watching the video for the first time.
“My reaction when I first saw it was ‘My god, they get it,’ ” Simon said.
“I felt like the weight of the world was lifted from my shoulders.”
“If we can change the way the hospital listens when the family and patients come in … more people will survive.”
Harvey Field to FAA
Three years have passed since her husband’s death.
Yet every Saturday, as the hands of the clock edge toward noon, Jennifer Simon finds herself replaying the same scene in her mind: Her husband, who was finishing some paperwork on his computer, strolls across the living room into the kitchen.
“We talked about going to a movie,” she said.
As he reached the kitchen, she heard him call her name before slumping to the floor.
“I’ve tried so hard to distract myself,” she said.
Sometimes, she climbs aboard the tractor and mows the pasture on her five-acre farm overlooking the Snohomish River valley. Or she tends the farm’s Thoroughbred, Kuma, and an older pony, Magic.
“The pain is ongoing and real,” she said. “The loss still hurts.”
A workbench in a living room corner is filled with needles, thread, awls, knives and special hammers, all needed for fixing horse tack. An English riding saddle straddles a wooden railing.
“I stitch saddles and bridles and do other repairs,” she explained. “Anything that horses break, I can usually fix. People say: ‘Where did you fix it?’ That’s the whole point. It should be invisible.”
Nearby, are framed photographs of her husband. In one, he is in a crisply pressed pilot’s uniform, his smile calm and steady.
He attended high school in Monroe, she in Snohomish. Ken learned to fly just after his high school graduation in 1966. She would sit at the airport and read, waiting for him to finish his lessons.
After their marriage in 1970, he started giving flying lessons, first at Harvey Field in Snohomish and then as chief pilot at Willard Flying Service in Everett.
He flew as a pilot at Horizon Air, then worked at the aviation safety program at Boeing, and as a flight examiner for the Federal Aviation Administration.
The year before he died, he was honored as the region’s safety inspector of the year.
One of his last projects was reducing the militarylike command structure in the cockpit, making it easier for crew members to speak up if they felt something was wrong.
He was a man with such wide-ranging interests that the family joke was he could be happy reading a dictionary.
One morning before she could even reach for her coffee, her husband launched into a discussion of black holes.
“He was a consummate teacher,” Mrs. Simon said. “A good negotiator. He could defuse the tension in a room.”
‘One more lesson’
Simon received a modest settlement from the hospital. They never went to court.
Although she declined to disclose the exact amount, Simon said it is far less than the six-figure settlements often awarded in court battles.
Her fight wasn’t about money, she said.
It was about making sure Ken Simon’s story serves as a sort of beacon, pointing the way to improving patient safety, she said.
Among the changes the hospital has made is the way employees communicate about patients.
Now, the hospital encourages staff to speak up if they feel a symptom or safety issue is being missed, said Bradlee, the Everett hospital’s safety administrator.
Nationally, communication problems have been linked to up to 70 percent of medical errors.
“We need to have a system where people can speak freely, where people are not afraid to speak up,” even if it involves contradicting a person of higher rank or experience such as a doctor, an administrator or head nurse, Bradlee said.
This new way of discussing cases was introduced in March in the hospital’s emergency room and critical care unit, where the highest-risk patients are treated.
“In the past, nurses and other (staff) might see mistakes happening and were afraid to share them,” Bradlee said. “That’s the kind of thing we need to stop.”
These changes in the way staff communicate on patient care issues are similar to the steps Ken Simon promoted for better, safer communication in airline cockpits.
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While there’s nothing to offset the loss of her husband, Simon’s work with the hospital “does make something positive out of a tragic situation.”
“Here was a patient who spent his whole career involved in aviation safety,” Jennifer Simon said. “He came into a hospital system and it failed him.
“I needed the hospital to listen to me and hear my husband’s story,” she said. “He had one more lesson to teach.”
Reporter Sharon Salyer: 425-339-3486 or salyer@ heraldnet.com.
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