Losing Laura
November 7, 2018 6:35 PM   Subscribe

This part of our story, I have shared before. I wrote a letter thanking the doctors and nurses who tried to save Laura’s life that The New York Times decided to publish. “Every single one of you,” I wrote to the medical staff, “treated Laura with such professionalism, and kindness, and dignity as she lay unconscious.” The letter was featured on NBC Nightly News, shared across Facebook, and republished on websites across the world. Less than three weeks after Laura’s death, millions were touched by her life. But that was not the whole story. Far from it.
This is the story of how my wife’s life was wasted by the actions of people whose job it is to save lives. It is the story of how our entire emergency-response system can completely fail us [...] And it is the story of how there will be no justice through our legal system for what happened to Laura.
posted by flibbertigibbet (57 comments total) 31 users marked this as a favorite
 
Well that's a terrifying and upsetting story. I'm going to summarize it because reading it almost gave me a panic attack. Basically when Laura called 911 it went to a middle-man who couldn't do anything to help, who just transfers calls, and that person hung up without telling the ACTUAL dispatcher where Laura said she was, instead they relied on the inaccurate cell phone location.
posted by bleep at 6:43 PM on November 7 [7 favorites]


What a fucked up thing. That poor woman.
posted by mwhybark at 6:44 PM on November 7


I have a friend who works in healthcare IT and his wife died unexpectedly less than a decade ago as the result of a repeated bad diagnosis regarding a heart problem she had. He was at work, and their four year old was at home with her, and watched her die, and stayed with her body until his father came home. I fervently hope he has the sense of self-care not to read this article immediately, because for him, no good can come of it. Knowing him, he'll wait until he feels ready and read it (because multiple colleages and friends will have forwarded it to him) with the intent that he is performing a professional, and possibly a funerary, duty. It will fuck his shit up for weeks. I am grateful that Mr. DeMarco wrote this piece, it is important both to him and his family, and as a civic duty. I hope that my friend is ready for it when he reads it.
posted by mwhybark at 6:53 PM on November 7 [7 favorites]


.

Jesus, this poor woman. This poor family. This is a hard and excellent tribute.

As someone who was once covered in blood and yet unable to attract the attention of any concerned person on a major medical campus, I have learned that people are so, so unequipped to help in unexpected ways. And when that is combined with a lack of give-a-fuck (exacerbated no doubt by hard jobs but a lack nonetheless), then vulnerable persons fall through the cracks.
posted by Countess Elena at 7:05 PM on November 7 [13 favorites]


Ouch. That's a very powerfully written piece. Each step keeps layering another "and then someone else fucked up, in a way that would've been recoverable, if it weren't for someone beyond *that* fucking up", and so on, in a way which just hits you in the gut each time
posted by CrystalDave at 7:06 PM on November 7 [8 favorites]


This is the kind of story I find very hard to take, because I have this profound distrust of systems that manifests itself in a fear that some day I will be in desperate need of help and through sheer freaking incompetence the system that is supposed to take care of me will abandon me.

At bottom, that nurse just didn't want to do her job that evening. Nursing's a tough job. But if you can't get juiced up when you hear that someone's stopped breathing in your immediate vicinity without anyone to help them, you should hang it up.
posted by praemunire at 7:41 PM on November 7 [22 favorites]


This is filling me with bees.
posted by The Underpants Monster at 7:47 PM on November 7 [13 favorites]


.

I've never had an emergency services type job dealing with life or death situations, so it's bewildering to me the difference in intensity in how different parties responded. The firefighters are frantically performing CPR and running around banging on doors and shouting at people, while Nurse X is like "I guess I could glance outside for a sec ¯\_(ツ)_/¯". Do some people get that desensitized to the intensity of their work?
posted by allegedly at 8:04 PM on November 7 [3 favorites]


People do get desensitized. Nurses do too. I was in the hospital for an overnight stay after a long surgery, and the nurse in charge of me was so full of contempt and sarcasm that I couldn’t believe it. I was extremely vulnerable, in pain, and had to be unhooked from three places every time I needed to pee, which was often. The way she huffed and rolled her eyes - if I hadn’t been coming down from anesthesia and had a clearer head, I probably would have found someone, anyone, to report her to. But I didn’t. So I was at her mercy for many long hours. I considered wetting the bed just to avoid seeing her, but decided against it.

My heart aches for this young woman and her loved ones. So many opportunities to avoid this horrible outcome, so much truly eye-opening mismanagement at almost every level.
posted by 41swans at 8:24 PM on November 7 [16 favorites]


I kept reading expecting him to reveal Nurse X's name at the end. I have mixed feelings about the fact he decided not to, to not eff up her life beyond what he imagines is the guilt with which she must live. There are so many things that went wrong that night, but the story as he tells it, Nurse X was all out of fucks to give and "mailed in" her efforts to find Laura. The guilt with which she lives may or may not be punishment enough. People rationalize their actions all the time in order to survive trauma. I hope they forced her to watch the video, the video where she half ass looks outside and then claims it was too dark.

Then the whole cap on suing a public hospital. It seems as if they (th hospital) did learn from the incident and took action to change, but I am not so sure that the individuals did. With the cap in place, it seems as if the best course of action would be for Mr. DeMarco to file the suit and rather than the hospital spend a lot of money defending themselves and a plaintiff lawyer spending time and money preparing the case, that an independent mediator/judge/arbitrator simply weigh the facts and decide what to award the plaintiff between $0 zero and $100,000. The hospital saves the legal fees or rather pays the plaintiff instead of the lawyers, the plaintiff gets a small amount of justice(?) satisfaction(?) something (but definitely some cash) and the hospital is repremanded. Not sure why the US Dept of Health and Human Services gets the fine of $90,000, but I guess they cannot just give it to the relatives of the deceased.

Also, maybe he can get the enhanced 911 system in place faster and everywhere.

This whole story is so sad, so unnecessary that it happened and just plain sucks.
posted by AugustWest at 8:30 PM on November 7 [2 favorites]


I'm guessing that he felt that whatever Nurse X deserved as a consequence, the Internet vigilantes would take it far beyond that. He's probably right, and so I really respect that decision, which must have been very difficult for him.

Nurses get desensitized; to some extent, they have to. You can't have someone coming over all woozy or freezing up when they see someone's insides spilling out, as you or I almost certainly would. But there are levels, and this woman was clearly well beyond any acceptable one.
posted by praemunire at 8:40 PM on November 7 [18 favorites]


Hospital staff work incredibly hard under difficult conditions: it's common for hospitals to have staff to patient ratios at below recommended levels leading to insane levels of overtime that would not be acceptable in any other industry. Add to that the stress where every decision could potentially be fatal, and dozens of decision points where staff have to prioritize certain patients over others (literally how the ED works) and the danger of working in an environment where unstable family members assaulting staff is commonplace. Who here hasn't made a single mistake or error in their career, particularly under constant time pressure? Your "job" is what management rates your performance on and I would guess that if this hospital is typical, the main metric they're judged on is how fast they can turn over the beds to kick existing patients out and bring new ones in.

The fact that hospitals are immune to being sued for millions of damages is a good thing. Does anyone think patient care at a hospital would get better after the hospital just lost millions and has no choice but to cut working hours and shifts and reduce staffing levels further because they are running low on cash? If care is substandard we need to be adding staffing hours and giving the hospital more money, not taking it away via lawsuits.

The idea that we achieve justice or less error rates by heavily punishing offenders for their missteps is a fallacy long dispelled by decades of safety advances. A plane is not safe because of a courageous or brilliant pilot who goes beyond the call of duty every night. Ruining the life of a nurse or destroying one hospital doesn't make the industry any safer. Good safety practices and strict implementation of policies means that of the 90,000 airplane flights per day in the US, you are assuredly going to safely get to your destination in one piece even if you draw the worst of the worst 0.1 percentile pilots that exists in the country (90 per day!), and that's the way medicine and emergency services should work as well.
posted by xdvesper at 8:46 PM on November 7 [43 favorites]


Were you all able to read the entire article without subscribing? I tried to read in two different browsers, but it blocked me from reading to the end. Any suggestions?
posted by jj's.mama at 8:46 PM on November 7 [13 favorites]


I had to resort to Reader View in Safari which managed to pull the text out before the subscription plea locked it down.
posted by Kyol at 8:48 PM on November 7 [5 favorites]


The idea that we achieve justice or less error rates by heavily punishing offenders for their missteps is a fallacy long dispelled by decades of safety advances. A plane is not safe because of a courageous or brilliant pilot who goes beyond the call of duty every night.

OK, but here's the thing; if you gut regulation (or never implement it properly in the first place) and you don't punish individuals, either, then there are basically no incentives not to hurt people.

Everyone yelling about tort reform in this country is oddly quiet when it comes to the alternative: effective regulation. Probably even most tort lawyers would agree that a well-run system of regulation, inspection, and fixed compensation out of a common fund for harms would be preferable to the present, lottery-like system for personal injury and death. But the tort reformers don't want that. They want no accountability for institutions at all.
posted by praemunire at 8:54 PM on November 7 [40 favorites]


Ruining the life of a nurse or destroying one hospital doesn't make the industry any safer.

Expelling a nurse whose negligence has led to the death of a patient from the profession isn't ruining their life; it's saving them from killing again.
posted by jamjam at 9:25 PM on November 7 [47 favorites]


This was heartbreaking to read but so powerful. DeMarco is commendable in his acknowledgment that naming Nurse X and others involved would only bring more pain. I think, in the end, it has to be the systems and structures that change and that there are (good) reasons that individuals like Nurse X are protected.

If the doors needed to be locked (perhaps for security reasons), why wasn't there a panic button or doorbell to alert people inside? The fact that it took only a matter of minutes for the security guard to go out and speak to DeMarco when he re-visted the bench where she died goes to show that the hospital most likely changed protocols to keep a guard out front and to check in with people outside. New signage and lighting must have helped visibility, too.

But also as was mentioned in a brief paragraph, "she should never have walked alone to the hospital." This is so heartbreaking that he acknowledges this. I was in awe of the fact that she walked to the ER. It made sense at first, though, when DeMarco mentioned that it was only a few blocks away and that getting an Uber would take more time. I don't know what asthma is like but the physical activity of walking and then the panic that must have ensued for her when she found the first doors locked which compounds the attack were devastating.

In the end so many things went wrong and nothing went right for her and it's utterly devastating.
posted by jj's.mama at 10:03 PM on November 7 [1 favorite]


I'm out of views of The Globe for the month, but apparently the article has forced Somerville Hospital to issue an apology today.
posted by TwoStride at 10:06 PM on November 7 [4 favorites]


if you gut regulation (or never implement it properly in the first place) and you don't punish individuals, either, then there are basically no incentives not to hurt people.

I don't really need an incentive to not hurt people. I just need a world where it's not necessary and I have enough sleep and food.
posted by amtho at 10:33 PM on November 7 [2 favorites]


^^^yeah Nurse X was in a system where she was conditioned to not give a fuck. Maybe understaffing, maybe poor treatment by management, lots of things contribute to burnout. But it’s the institution’s responsibility to make sure their employees come to work motivated and empowered to do their best work, to be able to step outside their narrow job descriptions and focus on the larger target — patient safety. Honestly, this situation is common now. Financial constraints are putting so much pressure on those working in health care and providers are micro managed by stuffed shirt bean counters who know nothing about the complexity and unpredictable chaos of doing what needs to be done to save patients and have engineered “system” that keep providers doing as much as they can with every second of their day to maximize numbers. Going out and searching the parking lot is just not an item that fits into the binders full of protocols to which we have to adhere strictly adhere now. Every time something like this happens it needs to be aired out fully and completely to everyone, including the patient’s family, so that the institution and the larger community learns and makes sure it doesn’t happen again. I believe, and the published evidence bears this out, that the so-called bad apple is rarely the real root cause of the problem and that line of thinking doesn’t yield useful information to make changes to prevent future mistakes. And the malpractice system is arbitrarily effective at fairly compensating the family and creates a culture of secrecy around events like this. We need a system that openly exposes the flaws, gives opportunities to learn and give patients fair compensation for negligence. Right now, we do everything possible to cover up and protect but never let the providers involved work out what needs to change to make things run better the next time.
posted by Slarty Bartfast at 11:42 PM on November 7 [24 favorites]


I can understand the reasoning behind the awards caps as it applies to public hospitals, but I can't understand why it's never been linked to some sort of COLA schema.  When the maximum amounts set down back in the 70s won't even cover your legal fees today, something isn't right; it basically makes hospitals untouchable through the only legal means left to us.  Raising the cap yearly by the reported inflation in medical costs might actually make it into a useful tool.
posted by los pantalones del muerte at 12:55 AM on November 8 [6 favorites]


This is the kind of story I find very hard to take, because I have this profound distrust of systems that manifests itself in a fear that some day I will be in desperate need of help and through sheer freaking incompetence the system that is supposed to take care of me will abandon me.

I recommend you not spend too much time visiting managed-care facilities or nursing homes, then. The endemic under-staffing, over-working, minimal-training, and low-pay is frightening. And it only gets more frightening the older you get and the possibility of being in one of those places becomes ever more real.
posted by Thorzdad at 2:23 AM on November 8 [7 favorites]


Medical mistakes is the third ranked cause of death in U.S. (apx. 250k/yr)
posted by shnarg at 2:49 AM on November 8 [6 favorites]


Two days ago, Massachusetts voters rejected a ballot initiative sponsored by nurses, in favor of mandating a minimum nurse-to-patient ratio. The hospital industry and doctors' organizations spent millions on a massive ad campaign claiming the measure would somehow reduce the number of nurses caring for patients, along with "government interference" dog whistles and warnings of increased costs.

I have not been so disappointed in my neighbors in quite a while.
posted by Kirth Gerson at 2:50 AM on November 8 [31 favorites]


If you haven't read Pete's original article (as in the letter he refers to in the quote above) from after Laura died, please make sure you do, it's one hell of a companion to this piece.
posted by wellred at 5:12 AM on November 8 [1 favorite]


It's hard enough to find the right emergency entrance sometimes when you're the one driving, but the ill person next to you is insisting, because they're sick and panicking and can't read the signs clearly, that you're going to the wrong entrance. So you drive around an under-construction hospital in the dark, panic rising, before deciding to rely on your own read of the signs, and if they want to be mad at you, they can be mad at you. And so, 10 minutes later, you arrive at the correct door and drop them off. So this scenario is entirely too familiar.

And every time you drive up to that door and drop them off, you go park, afraid all the while that this might be the one time they fall down before making it in, and if they did, would staff see them and help them before you get back from the parking lot and have to try to lift their bulk, to call for help and wave through a set of automatic double doors? And to have it happen like this while they were apart... For me, a long-term caregiver to a partner and a now-deceased parent with chronic illnesses, this a lot of nightmares, all rolled up into one.

I've even had loved ones forgotten inside the hospital, e.g., admitted and brought up to an empty room on a new floor without handoff being completed, with no call button. I always wait until the process is complete and a nurse has come by now, because that's happened without anyone coming by for at least a half hour before anyone noticed we were there. And this was all at the best hospital in town.

And what if it were me? I'm always the one who's been there for my partner, the one who's driving, through rain and ice and snow and vomit and yelling and panic. And I'm the one who yelled for help and got strangers to call 911 the one time I was alone and seriously injured. Sigh.
posted by limeonaire at 6:51 AM on November 8 [9 favorites]


To be fair, both sides on the nursing intitiative spent millions (though No did outspend Yes by about 2-1, it looks like). That whole initiative was a mess in terms of the framing. But still the shortage of staffing that we now somehow accept as "normal business" is horrifying.

But what really guts me about this article is how vividly he repeats that everything was just so close and came up short; for example, Nurse X didn't have to search the whole parking lot. She had to step maybe two steps outside of her own station door, or walk from her station door to the other station door.
posted by TwoStride at 6:52 AM on November 8 [4 favorites]


I couldn't read the whole article. Is the hospital's inevitable bullshit explanation for why the Emergency entrance was locked in it? Because that is fucked up. I once (long ago) arrived at the Cambridge City Hospital Emergency Room bleeding, and had to wander around for a while before I found a person, but at least the door opened.
posted by Kirth Gerson at 7:25 AM on November 8 [5 favorites]


So last spring, a sophomore at my then-senior daughter's high school died by suffocation in the parking lot of the school, trapped under the folding back seat of his van. He used the voice system on his cell phone to call 911 at least twice (maybe three times, I can't remember). One of the 911 operators told the police that she thought maybe it was a prank. The police made it to the parking lot but never actually got out of their car. His death was the result of a series of "if, then" circumstances, and it should not have happened that way. He did what he was supposed to do: he called 911 and it failed him.

His parents have started a foundation in his name to get Enhanced 911 *everywhere* in the US. It is maddening, infuriating, rage-inducing that Uber can find you in a heartbeat but 911 regularly gets locations wrong.

I do wonder how well Laura's asthma was maintained. She shouldn't have been surviving by using rescue inhalers on a regular basis, which is sounds like she was doing based on what Peter wrote.

Regardless, it's a tragedy and I wish the family peace.
posted by cooker girl at 8:02 AM on November 8 [5 favorites]


Is the hospital's inevitable bullshit explanation for why the Emergency entrance was locked in it?

There were two entrances - the emergency room door was unlocked, but it did not have a lighted sign and was off to one side. The door that Laura tried to use was for ambulances only and the security guard that was supposed to be stationed there was on patrol of the ward. After getting fined by a state regulatory agency, the hospital made the ambulance entrance the main entrance and installed lighted signage.

I thankfully have a very limited experience with emergency rooms, and in my one trip to an emergency room via ambulance (for an asthma attack), the EMTS took us to the wrong floor because of insufficient or incorrect signage On the weekends you have to come to the 3rd floor, ignoring the sign in the elevator that says 'ambulances 2nd floor.' Thankfully my family member was stabilized in the ambulance so the delay was not a huge deal, but at the time it really did not occur to me that probably dozens of ambulance crews likely made the same mistake every weekend.
posted by muddgirl at 8:11 AM on November 8 [4 favorites]


I was rushed to hospital after a heart attack and the ambulance dropped me at the wrong doors which happened to be open.
It saved my life because the wrong doors happened to be to the heart ward rather than the emergency entrance. The heart specialist just happened to be in the middle of his rounds and he was the only person in the hospital that knew me personally and my medical history ( which did not include heart problems so knew it was something new).
posted by Burn_IT at 8:32 AM on November 8 [7 favorites]


It should be taken for granted that people will make mistakes. We can't expect doctors, nurses, police officers, pilots, and the like to never make mistakes or, for that matter, make fewer mistakes than the rest of us. That's not how you solve these sorts of problems.

You solve these problems institutionally. You create procedures, reduncies, fail-safes and the rest, and you train and re-train and habituate everyone involved to follow procedure and the whole carefully thought-out system ameliorates the mistakes made by fallible individual persons.

Ten years ago, my father was found dead on the floor of his hospital room, covered in vomited blood, three days after pancreas surgery. This is the whole extent of what we know. My father, sister, and myself -- all sufferers of a congenital condition -- have spent our lives dealing with medical professionals and Dad always said that he didn't believe in suing doctors. He understood, and my sister and I understand, that doctors make mistakes. My sister didn't like the idea of an autopsy and, after discussion, we agreed we weren't likely to pursue any legal action even if there had been negligence or malpractice. I think we both understood that if some individual was actually to blame, knowing this might be worse than not knowing. So, in the end, we didn't push for any answers.

I have mixed feelings about this, but aside from the simple fact that this seems like an awful way to die and there's no way to avoid wondering what exactly happened, my main concern about not pushing for answers is this whole issue of systemic failure. Did the hospital as an institution, its facilities and its procedures and its people, fail my father? Maybe. Maybe there was no fault to be found, but then again maybe there was. And, if so, then the flaws in the system need to be fixed.

I don't think it should be about Nurse X or any individual person. Even when there's an individual who behaves egregiously, it's still the case that the system should be designed to account for that ... because individual people will, on occasion, behave terribly. It seems clear to me that it's not so much that Nurse X failed Laura as it is that a few related institutions failed Laura. Any one of the individual mistakes described wouldn't, alone, have been fatal. Taken together, they were. And that's because, if we want to place blame on someone, it's the people responsible for the system who failed Laura.
posted by Ivan Fyodorovich at 8:33 AM on November 8 [11 favorites]


I don't really need an incentive to not hurt people. I just need a world where it's not necessary and I have enough sleep and food.

Better save those kinds of comments til you're tested. Humankind is failing it everywhere every day when it has the chance.
posted by praemunire at 8:40 AM on November 8 [4 favorites]


I dunno. I looked at this a bit differently. I seems that Laura is the one who made the mistake of not calling for help until seconds before she went unconscious. This wasn't her first asthma attack but for some reason she thought she could tough it out until it was too late. This reminds me of mountain climbers who make fateful decisions to keep pushing on until it is too late.

There were a lot of minor things that all together led to her death. That is how climbing deaths and airplane crashes occur. You can't point to any one thing but a series of minor things compounded to result in tragedy.

But I don't see anything that anyone did as actually wrong. Yes there could be better 911 services. Yes there could be better geolocation services. But no one did anything wrong.

Laura unfortunately went to the wrong entrance, the ambulance entrance instead of the main emergency entrance. It was 4:30 in the morning. Only one of those entries was manned. Yes there could be better signs but how often does someone arrive alone in a condition unable to walk 100 feet to the open door?

And the dispatcher did not tell Nurse X that someone was dying outside the door. They just said someone was having an asthma attack. Most people walk in under their own power with an asthma attack. She looked outside the door and didn't see anyone. You would expect to see someone standing at the door to get in. You would expect to see a car that she arrived in. She had no reason to go searching though the parking lot and if she had abandoned her position at the front desk and some other emergency on the floor occurred, people would be faulting her for that.

And the bit about the security camera is irrelevant. Cameras can see things in low light conditions that are invisible to the human eye.

People see what they are conditioned to see. The dispatch call conditioned her to see someone standing at the locked door waiting to get in, probably with a car nearby. She didn't see that.

This is all a very tragic outcome, but Laura set it all in motion by failing to call for help until too late.
posted by JackFlash at 8:47 AM on November 8 [8 favorites]


Yeah, mistakes are inevitable; I like to be able to judge a person, institution, or system based on how they acknowledge and fix their mistakes when they happen.
posted by The Underpants Monster at 8:49 AM on November 8 [3 favorites]


I strongly disagree, JackFlash. Both Nurse X and the security guard seemed to have an unfortunate case of "not my job." This is a really easy disease to catch in sick systems. The charge nurse was informed that a patient called from hospital property having an asthma attack, but the police did not know where she was. That is a life-threatening emergency. The nurse apparently did nothing to inform anyone else at the hospital that someone was having a medical emergency. That's unacceptable. The fact that Laura was right outside the doors isn't really the problem - that just lends insult to injury. She could have been sitting in her car and the delay in finding her would be more understandable, but the fact that no search was conducted by hospital staff at all is the source of the problem.
posted by muddgirl at 9:08 AM on November 8 [15 favorites]


She had no reason to go searching though the parking lot

Laura wasn't in the parking lot, though? She was on a bench right out front of the emergency room, right between both doors.

I live a block from one of the mina emergency rooms in my city. I have walked there both times I went, because getting in my car, and driving all the way around the hospital, and finding parking would've been much more ridiculous than just walking right into the emergency room. Luckily, my ailments were just chest pains (turned out to be an all-day panic attack) and a dog bite (needed 4 stitches.)

Now this hospital is under a huge amount of construction. They are building 4 or 5 new buildings on the campus and I can barely even walk up the street there from my house, which is a direct hot, because it's all fenced off construction. The roads into the emergency room area are equally under construction and fenced off, and I actually do worry a lot about whether people are able to even find the emergency room and get in there and get the care they need.
posted by Squeak Attack at 9:13 AM on November 8 [1 favorite]


I don't see anything that anyone did as actually wrong.

The sensible next thought is "so I must be missing something, given that the hospital has already been found to have done something wrong by the agency in charge".
posted by the agents of KAOS at 10:15 AM on November 8 [19 favorites]


People need to take asthma more seriously. It is not normal to need to use your inhaler. Inhalers should be for rare flare-ups, not every day. Please see a doctor to adjust your treatment if you are using the inhaler regularly.

The first major asthma attack I had, happened during Mardi Gras. I didn't know I had asthma. I thought it was a chest cold. I let everyone leave to go to the parades, and I stayed at home to recuperate. At the time we lived in "the box", an area of town that is often blocked off by parades. There was a hospital in the box, but it was not the one covered by my insurance. My hospital was well outside the box, too far to walk. The other was a few blocks from my house. There was no way I could drive anywhere, all of the roads were closed for parades. I hemmed and hawed about it, wasting time. It wasn't getting better and I was having trouble breathing, so I walked alone to the emergency room. I made it and was seen by a doctor, but this story scares me.
posted by domo at 10:18 AM on November 8 [7 favorites]


I dunno. I looked at this a bit differently. I seems that Laura is the one who made the mistake of not calling for help until seconds before she went unconscious. This wasn't her first asthma attack but for some reason she thought she could tough it out until it was too late. This reminds me of mountain climbers who make fateful decisions to keep pushing on until it is too late.

I once walked to the hospital during an asthma attack. The hospital was a block and a half away. It was very late, I'm single and live alone, and the friend that I would call lived at least 15 minutes or so away. Calling an ambulance or taxi seemed extreme for one block. It was a very scary walk but I made it there safely.

My asthma is better controlled now so I don't keep inhalers everywhere but I used to - car, jacket/coat pockets, various purses, work, my friend's house who has a cat.

I went to Hermann Memorial ER in Texas twice, the first was a great experience and the second was awful. After speaking with the nurse and being able to only whisper answers, she said my blood oxygen levels weren't that low and had me wait almost two hours to be seen. I've always been seen right away with asthma. I had to go back and ask for help "right now". I ended up hospitalized for five days. If I'd been treated immediately, I could probably have left after a few hours. I was uninsured.

I went to Kaiser ER in a ZipCar (car-sharing service) and parked by accident in the ambulance parking area because the sign said emergency parking, turns out the part of the sign saying emergency "vehicle" was obscured. I'm in the ER, hooked up to a breathing treatment and oxygen and at least three people asked me to move my car. Finally, the ER doctor borrowed my keys and moved it for me.

I called ZipCar and told them I was being checked into the hospital and couldn't return the car but I could have my friend do so. They asked me if he was a member of ZipCar.
posted by shoesietart at 10:18 AM on November 8 [7 favorites]


Both Nurse X and the security guard seemed to have an unfortunate case of "not my job."

It does sound like the security guard wasn't informed of what was going on. He said that, had he been informed, he would have followed the normal procedure of patrolling the campus looking. Now that's a statement made in hindsight, but I don't see anyone saying that he knew?
posted by praemunire at 10:55 AM on November 8


Taken together, they were. And that's because, if we want to place blame on someone, it's the people responsible for the system who failed Laura.

I was planning to post something very much along those lines. This is an excellent example of the Swiss cheese model of failure, something that I see taking place everywhere now that I know what it looks like. When I came across this article the other day I could see the various holes lining up; some avoidable, others not. Four in the morning was probably the worst possible time to have the asthma attack, and in addition probably contributed to her decision not to ask someone to go to the hospital with her. From there staffing issues, lighting and signage issues, and technological failures all combined to result in this tragedy. I felt the article was too focused on Nurse X. Yes, she could have done a better job of looking, but quite frankly I am not sure what I would have done in similar circumstances. If someone told me there was a patient who had called in from our parking lot claiming to be dying how much time should I spend looking for them? How far should I go? To be honest, I would probably call public safety and ask them to look as they are used to patrolling the parking lot and have flashlights to look in cars or shadows. Also, we don't know what else Nurse X had to do at that time. There may have been several other things waiting for her to get to and this was an unusual situation, to say the least. I have been involved with several critical incident reviews over the years, and I am often dismayed at how little attention is paid to competing duties that a health care provider has when they make a mistake. And in any event, if even one other link in this chain of events was not present Nurse X might not have needed to go looking for her in the first place.

I applaud the author for sharing this painful story. It sounds like improvements have already been made to the hospital, and better 911 service for cell phones is desperately needed as shown by this incident, which I remember getting a lot of attention at the time. Those are the sorts of things that will prevent this sort of thing from happening much more effectively than punishing any individuals.
posted by TedW at 11:31 AM on November 8 [8 favorites]


I am an EMT and I used to work for a private ambulance company. The company had contracts mainly with nursing homes and rehab facilities, and the bulk of our work involved taking folks who were too sick for a wheelchair van to their dialysis and doctors appointments. Sometimes, though, we'd get emergency calls from those nursing homes, and depending on the location of the nursing home and the patient's medical home, we'd go to hospitals all across the city. We ran into this problem (locked ambulance bay door to the hospital) once and it took 10 minutes for someone to let us in. Several people walked past in that time, but couldn't be bothered to let the EMTs WITH A STRETCHER into the EMERGENCY ROOM.

I don't work as an EMT anymore and that experience is one of the reasons.
posted by coppermoss at 11:39 AM on November 8 [11 favorites]


It does sound like the security guard wasn't informed of what was going on.
"One of those guards, identified as Patrol Officer #2 in the state's report, "said he overheard the nurse say something about he police and someone being outside," and decided to follow Nurse X out of the emergency room into the corridor. According to the report, he watched Nurse X open the ambulance-access door and take a step outside. But he never asked Nurse X what she was doing.
Both Nurse X and Patrol officer #2 were "just doing their job" - Nurse X looked in her domain for a patient. Patrol Officer #2 was waiting to be informed that there was an emergency, despite the fact they clearly suspected something out of the ordinary was happening.

To be honest, I would probably call public safety and ask them to look as they are used to patrolling the parking lot and have flashlights to look in cars or shadows.

This is apparently what Nurse X was supposed to do, and did not do, despite the presence of a patrol officer standing in the corridor. I agree that it's not fair to put all the blame on Nurse X, and I suspect that her bad attitude is contributing to a focus on her actions that night, but she did make one of the critical mistakes that led to Laura's death - she failed to notify either of the two guards assigned to her ward of what was in essence a missing patient undergoing a medical emergency.
posted by muddgirl at 11:41 AM on November 8 [1 favorite]


If someone told me there was a patient who had called in from our parking lot claiming to be dying how much time should I spend looking for them? How far should I go?

Keep in mind that that information about almost dying never made it to Nurse X. It first went to one 911 center, then relayed to a second 911 center and finally to Nurse X as a series of messages. All the nurse heard was that someone having an asthma attack was at the locked door. She had no idea that someone might be unconscious or near death.

She went to the locked door and expected to see someone there as she had been informed. If Laura had stayed at that door, she might be alive now. But she wasn't. I don't blame Laura for giving up and moving toward the other door. But I don't blame the nurse for acting on the only information she had, that a person was waiting at the locked door. Had they driven away? She then checked the other door just to be sure and no one there either. They must have left?

She had no particular reason to imagine that there was an unconscious person halfway between the two doors. Nobody had communicated to her the gravity of the situation. If someone is in an emergency, they call an ambulance. Walk-ins are generally not life or death emergencies so she had no reason to assume so.

Also keep in mind that the whole crisis took only about three minutes. It was only some time later, when 911 was unable to get Laura to answer her phone that the situation was escalated to a possible emergency at the hospital. Up until that time it was just a walk-in patient who was supposedly at the wrong door.

And meanwhile, the cell location had people searching a block away. And Laura wasn't at her last reported location at the locked door either. Where do you look next?

I know people who work search and rescue. It is always heartbreaking when you later find out you were only feet away from a victim and didn't see them. Should you have spent a few more minutes in that particular area before looking in another? You first look in the last reported location. It is only much later that you begin to expand the search area. Laura's two reported locations were the locked door and the cell ping a block away.

People are second guessing the decisions of people in real time that occurred over just a few minutes based on incomplete and inaccurate information. Sure, you know all the facts and circumstances after the fact, that she was only 50 feet away. The people involved did not have that benefit.

Laura had delayed calling for help until too late. At that point the only thing that was going to save her was if she was lucky to have every thing break her way. It didn't in her case.
posted by JackFlash at 12:27 PM on November 8 [5 favorites]


Two days ago, Massachusetts voters rejected a ballot initiative sponsored by nurses, in favor of mandating a minimum nurse-to-patient ratio. The hospital industry and doctors' organizations spent millions on a massive ad campaign claiming the measure would somehow reduce the number of nurses caring for patients, along with "government interference" dog whistles and warnings of increased costs.

I have not been so disappointed in my neighbors in quite a while.


Actually, the initiative was really poorly written. My mother is a nurse, and I voted no on it. It was quite unreasonable (giving nurses absolutely no option to use their own judgement in a situation, for example), and really would have been problematic financially. My mother said, "the people who wrote it were nurses, not policy makers, and were trying to shoot for the moon." Don't lose sleep on this one; hopefully they'll get it right the next time around. Because there will be a next time around, the system the way it is now is indeed problematic.
posted by Melismata at 12:37 PM on November 8 [2 favorites]


If someone is in an emergency, they call an ambulance. Walk-ins are generally not life or death emergencies so she had no reason to assume so.

This is demonstrably not true. Many people do not call an ambulance despite being in a life-or-death emergency, either because they can't afford an ambulance or because like Laura they don't recognize the gravity of the situation they are in. And many people come into the ER on their own, because they are single. Hospitals cannot assume that patients are going to arrive in an ambulance, which is why their duty of care does extend to the sidewalks and parking lot.
posted by muddgirl at 12:40 PM on November 8 [23 favorites]


And many people come into the ER on their own... or because their partner, roommates, or family is at work, or because someone needs to stay with the kids, etc. etc.
posted by muddgirl at 12:42 PM on November 8 [6 favorites]


It's the job of hospitals and the 911 system too look extremely critically at how they provide services and to work very hard to always be making it better. I would bet folding money that there have been many comments that the door was locked and the other door was not obvious, and that nobody ever picked that up and took it seriously. I have gotten crappy care at the big hospital-medical practice system I use, and have not been able to get a response from a Patient Advocate or Ombudsman. When I call, they seem befuddled at my request for such a person. Like any large institution, hospitals have a culture. Maybe Nurse X is an outlier, or maybe the hospital needs to take a long hard look at doing a better job. Complacency, complaining, lack of initiative are not uncommon.

I don't really get why 911 can't locate people better.

The article notes that Laura probably panicked at the locked door, escalating the asthma.
posted by theora55 at 12:56 PM on November 8 [3 favorites]


All the nurse heard was that someone having an asthma attack was at the locked door.

An asthma attack severe enough to bring you to the ER absolutely carries a meaningful risk of lethality. There were something in the neighborhood of 4,000 deaths in the US from asthma in the most recent year I could find stats on. This is utterly basic information and certainly something an ER nurse would know. Frankly I'm surprised there are adults who don't know it.
posted by praemunire at 2:19 PM on November 8 [2 favorites]


Laura's two reported locations were the locked door and the cell ping a block away.

BTW, if I read that diagram correctly (and I understand that sometimes 2D depictions can be misleading, plus I'm paywalled out of the article now), if the nurse had simply started walking from that one location to the next, she would have passed Laura within seconds.
posted by praemunire at 2:22 PM on November 8


The idea that we achieve justice or less error rates by heavily punishing offenders for their missteps is a fallacy long dispelled by decades of safety advances. A plane is not safe because of a courageous or brilliant pilot who goes beyond the call of duty every night.

So, it turns out that people can--and do--sue airlines and other industries all the time when there is an accident. Because organizations are frequently bottom-line oriented. And pilots can lose their certificates if they screw up enough. Also, airlines are regulated heavily and a fatal accident will get them swarmed with investigators.

Other than motivating organizations, the other reason to allow suits for money damages is to make people whole, to the extent you can do that with money.
posted by Gilgamesh's Chauffeur at 5:36 PM on November 8 [1 favorite]


jesus christ this all happened like 4 minutes away from me.
posted by youthenrage at 7:19 PM on November 8


A night nurse, partially responsible for entrances, that is, her purview contains hospital thresholds, should've had a flashlight and open instructions that those benches were extended and occasional parts of her responsibilities, with, of course, security backup with concomitant oversight responsibilities. That emergency section of the hospital was an institutional and architectural nightmare. Also, I'm surprised and disappointed that comments above put some or all of the blame on the doomed patient. Pretty much everybody who arrives at a hospital choking or bleeding or screaming in pain can be said to have made a mistake or two. As the kids say, "Duh!".
posted by Chitownfats at 11:48 PM on November 8 [9 favorites]


The author squicked me out to the point where I just stopped reading the article. He seemed to be trying SO hard to excuse the fact that he wasn't around when her attack happened. I don't know, it rang really false, and self serving. I quit reading.
posted by WalkerWestridge at 4:15 PM on November 9 [1 favorite]


I know hindsight is 20/20, but it seems to me that if I went to the locked door and didn't find the patient there, it might occur to me that hey, maybe failing to get in this one she could have tried to get to the next one.
posted by The Underpants Monster at 8:06 AM on November 10 [1 favorite]


WalkerWestridge- you mean Laura’s husband? I can imagine he feels tremendous guilt and pain but it isn’t for me to judge how he expresses it. That wasn’t my read on this story at all.
posted by 41swans at 1:49 PM on November 10 [5 favorites]


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