The Libby Zion case

[drscott]

One of my commenters reminded me of this famous case of malpractice, so I dug up some material to remember it.

Malpractice in using Demerol on a patient taking phenelzine. Interesting, and points up how these errors are systemic, and not directly related to the uninsured being poorly treated:

The Libby Zion Case

You may never have heard of the Libby Zion case, but it has probably influenced your career as a house officer more than any other litigation. Libby Zion was an 18-year-old woman admitted to Cornell Medical Center's famed New York Hospital the evening of March 4, 1984. She was brought there by her parents, manifestly ill, with high fever (41C), signs of dehydration and "uncontrollable shaking." She had a clear chest x-ray and a WBC of 18,200/cu. mm. Libby was admitted to a four-patient room, with a tentative diagnosis of "viral syndrome." The admitting orders specified "routine vital signs." The Zions left their daughter's bedside in the early hours of March 5, 1984, assured by the house officers that she would be OK.

A few hours later, at 7:45 a.m. March 5, the parents received a call that Libby Zion was dead. From the beginning, medical negligence was assumed by the family. Sued were three hospital residents, the attending physician, and New York Hospital. Investigation revealed that, prior to admission, she had been taking Nardil (phenelzine), an antidepressant prescribed by her psychiatrist, and that one of the house officers gave 25 mg. Demerol to control her shaking spells. The drugs are not supposed to be used together.

The intern in charge was off on another ward between 3:30 a.m. and 6:30 a.m., when Libby Zion went into cardiac arrest, and during that period she never checked on her patient. Also, the nurses reported calling this house officer two or three times because of the patient's agitation, and the intern had ordered "a posey jacket."

At the trial there was conflicting evidence about cocaine being present in Libby Zion's blood (one test showed it was, one test showed it wasn't). The medical examiner officially ruled her death as due to "bilateral bronchopneumonia" and that she died of a very high fever and "sudden collapse" soon after receiving injections of Demerol and Haldol "while in restraints for toxic agitation." Libby had not been started on any antibiotics while in the hospital.

This would be just another tragic case of medical negligence were it not for the crusade undertaken by Libby's father, Sidney Zion, a well connected reporter for The New York Times, as well as a lawyer and former prosecutor. He turned the loss of his daughter into a crusade for reforming the training conditions of interns and residents. He hired a private investigator, plus physician-experts to examine her medical records. They confirmed his worst suspicion, that Libby's care had been "slipshod, and that errors, not disease, had killed her." In addition to filing a civil malpractice suit against the doctors and hospital, Zion convinced the Manhattan District Attorney to convene a grand jury for possible criminal indictments.

The grand jury report, issued December 1986, did not find cause for a criminal indictment of the physicians, but it did indict the way medical residents were trained at New York Hospital and elsewhere in New York. The report claimed that the "medically deficient care and treatment in this case" which included lack of supervision and overworked residents was "systemic" and posed a grave potential danger to patients. It specifically cited:

* lack of exam in ER by an attending physician
* admission to medical service under supervision of only an intern and junior medical resident
* fact that at the time of admission (2 a.m.) the two house officers had each been up for 18 hours
* use of physical restraints without an interim exam by a physician
* administration of Demerol without knowledge of prior treatment with phenelzine


The result of the grand jury report was a series of reforms that reverberate to this day. Initiated in New York State directly because of the Libby Zion case, they have been adopted by most training programs across the nation: a maximum 80-hour work week (down from 100); a mandatory day off during a 7-day period; closer attending supervision of residents, particularly in the ER; night float coverage to relieve busy house officers; and fewer numbers of patients under the care of single resident.

And the result of the malpractice suit? Because of legal delays the civil trial did not take place until late 1994. New York Hospital was exonerated, despite the earlier findings of the grand jury. Negligence was assigned to the intern for not responding to the nurse's calls on March 5, 1984, and to the attending physician for allowing his patient to receive Demerol when it was a contraindicated medication. (The attending was also sued for not coming in to see his patient, but this charge was not upheld by the jury.)

The jury also believed that Libby Zion had ingested cocaine, and so assigned "blame" for her death 50-50, to the doctors and to the patient. Since the total awarded was $750,000, the family stood to receive just one-half, or $375,000. In one of those legal twists common to litigation, the judge threw out the 50% blame assigned to Libby Zion, but also lowered the total amount awarded to $375,000, so that the net amount to the family remained the same. He also granted Sidney Zion 30 days to opt for a new trial on the specific issue of cocaine use raised at trial. Sidney Zion did not re-file.

In the end, therefore, negligence was assigned to the doctors, and not the hospital. Sidney Zion won an almost pyrrhic victory, monetarily receiving far less than asked for, and failing to get from the jury the stinging rebuke of the house staff training system. (Zion later stated that the $375,000 was less than had been spent on legal fees.)

Nonetheless, the Zion case was in large measure responsible for several reforms of the resident training system. Realistically, though, these reforms do not target what killed Libby Zion. In fact, her intern at the time was not overworked (she was not caring for other critically ill patients that night), was not incapacitated by lack of sleep, and was under the same type of supervision as is typical of today's training programs. The intern was in the hospital, on another floor, and could have responded, could have transferred Libby to intensive care, could have asked for help from any number of physicians. In truth, Libby Zion's intern at the time was simply too inexperienced to properly care for the patient, to recognize when someone needs more than a posey and Demerol.

In her defense, the supervision of junior house officers at the time was inadequate, and also typical of big teaching hospitals. However, this defense only spreads the blame and does not exonerate any involved doctor. As stated in a New England Journal of Medicine review published in 1988 (long before the malpractice trial), "the grand jury confused professional incom-petence with long working hours."

Libby Zion would most probably have lived had she been in an intensive care unit, monitored closely for pulse, blood pressure, blood gases and other critical parameters, by a physician who could make changes in therapy as necessary. That type of care was available in every teaching hospital in the land in 1984. The tragedy occurred because Libby Zion was simply in the wrong part of a teaching hospital, under the care of inexperienced house officers.

This type of mistake continues right along. Sick patients sometimes flounder because they are on the wrong service, or under the care of an inexperienced intern or resident. Often, just transferring a sick patient from Service A to Service B, or from the regular ward to the ICU, or from Dr. X's to Dr. Y's care, makes all the difference in the world. The Libby Zion tragedy, minus the powerful and crusading relative, continues to happen more often than we care to admit.

Comments

[kitchenbeard.livejournal.com]

I'm currently working for a medical malpractice insurance provider and in our CME offerings, I see case studies like this all the time. Frequently vary basic and (at least to me) common sense could prevent tragedies like this. But agan, I'm not a doctor, and just a marekting guy.