His very first episode of angina went untreated for ten full days before he finally received nitroglycerin. Years later, after being diagnosed with pancreatic cancer, he chose Gamma Knife radiosurgery for pain control. During the Gamma Knife treatment sessions, his coronary heart disease suddenly flared up and quickly progressed to heart failure. He died within a month.
Death
Everything traces back to the root cause: the first angina attack was left untreated for ten days. The necrotic tissue produced when Gamma Knife radiation targeted the pancreatic tumor may have entered the bloodstream and reached the coronary arteries, triggering occlusion in vessels that were already critically narrowed. This triggered an acute coronary event that quickly progressed to heart failure.
If the patient had contacted our service at the time of his first angina attack, the root cause of all the subsequent problems could have been prevented. If he had reached out to us in parallel with his regular medical care, the pancreatic cancer might have been caught early — before it spread to the lungs. Pain management would never have led to Gamma Knife. The coronary event would not have been triggered, and heart failure and death would have remained a distant possibility. In the end, he simply had no way to look down from above and see the whole picture. From the ground, the medical world appeared to be a towering presence, almost the entire world. Only from above could one see that it was merely one small patch in a much larger landscape. Audit means exactly that — the view from above.