A Patient dies in Los Angeles - Systems Views

The LA Times reconstructed the scene today from the videotape and interviews.

Parked in the emergency room lobby in a wheelchair after police left, she fell to the floor. She lay on the linoleum, writhing in pain, for 45 minutes, as staffers worked at their desks and numerous patients looked on.

Aside from one patient who briefly checked on her condition, no one helped her. A janitor cleaned the floor around her as if she were a piece of furniture. A closed-circuit camera captured everyone's apparent indifference....

Alerted to the "disturbance" in the lobby, police stepped in — by running Rodriguez's record. They found an outstanding warrant and prepared to take her to jail. She died before she could be put into a squad car.

How Rodriguez came to die at a public hospital, without help from the many people around her, is now the subject of much public hand-wringing.

Questions are being asked of "How could this happen?"

Rodriguez's son, Edmundo, 25, said he still couldn't understand why his mother died. "It's more than negligence. I can't even think of the word."

And blame is being focused on the last person in what always proves to be a very long chain of contributing events:

David Janssen, the county's chief administrative officer,... said that the preliminary investigation suggests that the fault primarily rests with the nurse who resigned. "I think it's a tragic, tragic incident, but it's not a systemic one."

But, while legal issues of blame proceed, from the bleachers we can start an analysis of the "system factors" that all came together in this tragic result. And, as with many previous studies in errors, odds are very high that there are many more distant factors that were are work here. It is important to delve into the always-surpising world of "How could this happen?"

You can read the Times article, and start with as much information as I have, but I'll try to put it into a "systems thinking framework."

First, though, let's abandon the idea that the nurse is "to blame." Yes, she may have made an error in judgement - but that's a type of problem humans have that is fully predictable, and the collection of other people around her should have caught that and reversed that error before harm occurred. So, remove the nurse entirely from your mental picture of the scene, and just look at what else was going on, as we change the "zoom" setting on the lens and back out to larger and larger contexts.

First, an entire room of other people, patients and staff, was apparently paralyzed. We need to ask how that sort of thing happens. This brings to mind the Kitty Genovese stabbing and slow death in New York City, where hundreds of people watched from their apartments and did nothing, not even call 911. It brings to mind Stanley Milgram's famous experiments, where subjects, told by a person in a white coat to deliver electric shocks to another person, continued to do so far past the point where the other person screamed and finally went silent. It brings to mind not only "It's not my job" but also "... and the last time I intervened I was punished and told if I did it again, I'd be fired."

It seems that everyone in the room, staff and patients, had been conditioned to observe an unfolding tragedy, and sit passively by and do nothing. Hmm. Sounds like the sort of operant conditioning and behavior modification that 20 years of watching television might create.

Actually, it also sounds like a lot of people were in a burned out, depressed, helpless, hopeless state and maybe had given up trying to change the world around them, and this was just one of a hundred things around them daily that was going wrong.

It appears that the patient was Latina, overweight, and had no health insurance or regular family doctor. We might investigate bias, bias, and an entire nation that seems to stand by indifferently while 50 million residents of the US with no "coverage" try to get adequate primary medical care by swamping emergency departments. This problem is very well publicized, but the American public is too busy with other problems right now to focus on that.

On a mid-range scale, it seems that California or Los Angeles is standing by, not helping, while another hospital that attempts to help the poor sinks into debt and finally drowns.
The LA Times article points out:

The incident has brought renewed attention to King-Harbor, a long-troubled hospital formerly known as King/Drew....Over the last 3 1/2 years, King-Harbor has reeled from crisis to crisis.

Based on serious patient-care lapses, it has lost its national accreditation and federal funding. Hundreds of staff members have been disciplined and services cut.

Janssen said he was concerned that the incident would divert attention from preparing the hospital for a crucial review in six weeks that is to determine whether it can regain federal funding.

If the hospital fails, it could be forced to close.

Then what? Then what will the people in this neighborhood do for primary and emergency medical care? Drive 45 minutes to Beverly Hills? The same problem of inner city hospitals closing is visible across the US. They want to move out to the rich suburbs and focus on care for rich people with great health "coverage." Or, they have no choice, because of the perverse "unintended side effects" of demanding that they must provide emergency services to anyone who shows up, whether they can pay or not - and a national health care system that means 50 million people can't pay. The public hospitals and all the caring staff in them are being burned out, gutted, and deleted.

One of the roles of the field of "Public Health" is to hold up such uncomfortable mirrors, stop focusing entirely on how to repair gunshot wounds in the Emergency Room, or how to get faster ambulance dispatch, and start asking why so many people are getting shot in the first place.

Yes, in this case a nurse resigned. But, in many ways, it appears that she was a victim too, and likely a person who went into nursing because she really wanted to help, and tried to help, and just finally ran out of the ability to cope with the job that society had created for her. Day after day, night after night, social tragedies that could at best be patched and sent back out into the world to be damaged again and return again. I doubt that she started as a mean or uncaring person. How many hours had she been on duty? How was she coping with the fact that even this job looked like it would evaporate soon? What else was going on that she needed to attend to?

No, I don't think that removing this single person will "fix" this problem and stop such things from ever happening again in this hospital or in Los Angeles or in the USA.

How can people just look the other way? It's baffling.

But, now that we've all seen this larger issue squirming in pain on the floor, and feel helpless to do anything about it, it must be time to shake our heads in disbelief at "those people", and go see what else is on TV.

I'm not trying to be mean - only to illustrate that this problem of being overwhelmed with other people's problems is not some local thing that only happens in this hospital ER in LA. That doesn't make it less of a problem - it makes it more of a problem.

When a whole nation says "there's nothing we can do..." it's right, but it's wrong.


Article: Tale of last 90 minutes of Woman's Life,
By Charles Ornstein
Los Angeles Times
May 20, 2007

The Future of Emergency Care in the US Health System
Institute of Medicine, June 2006

Crisis Seen in Nation's ER Care
The Washington Post (registration required)
June 15, 2006

Emergency medical care in the United States is on the verge of collapse, with the nation's declining number of emergency rooms dangerously overcrowded and often unable to provide the expertise needed to treat seriously ill people in a safe and efficient manner

Emergency Medical System in Crisis, USA
Medical News Today

Emergency Care - A system in crisis
Journal Watch

Kellerman AL. Crisis in the emergency department. N Engl J Med 2006 Sep 28; 355:1300-3.

Photo credit: In the Emergency Room by ebilflindas