Saturday, June 23, 2007

On Seeing and Being Seen: a meditation on the social psychology of medical intervention

I thought Bill Clinton's graduation advice to make sure you really see the person next to you was good.

I thought the failure of people to notice Joshua Bell playing at the Lafayette Metro Station was bad.

But there's worse.

What's worse is people NOTICING something notable, but ignoring it.

And worst of all is when failure to see, or act on, a noticeable crisis costs a life. It was one of this week's buzz stories in the O.R.: the death of Edith Rodriguez.

Edith Isabel Rodriguez went to the E.R. at Martin Luther King, Jr. Hospital in L.A. - also known as King-Harbor and formerly known as King/Drew - doubled over with abdominal pain. According to the Associated Press, "It was at least her third visit to Martin Luther King Jr.-Harbor Hospital in as many days. 'You have already been seen, and there is nothing we can do,' a nurse told her.”

This kind of situation can put any doctor or nurse in a tough spot. A patient presenting with a history like this is usually either afflicted with an ill-defined medical problem, sometimes chronically, often more than one, and typically difficult to relieve completely, OR...the patient is in SERIOUS TROUBLE.

Jonathan Larson, composer of the famous Pulitzer Prize and Tony Award-winning musical Rent, got sent home when more than one emergency department failed to diagnose the cause of his chest pain and nausea: aortic dissection, which killed him the day before Rent opened.

Sometimes it can be a tough call, but I think when someone goes from abdominal pain to vomiting blood, it's usually a clue that something really BAD might be going on, depending on the nature of the vomitus and the amount of blood present, and I have to wonder what the thought process was in that emergency department. I admit I don't know all the details, and hindsight after someone codes and dies is certainly 20/20, so I am in no way trying to point the finger here. I'm just wondering, like everyone else, what happened, and how could it have happened?

Edith Rodriguez's story has by now been publicized widely in the media. The articles I saw were on MSN and the L.A. Times, but I was struck most by the CNN video on It relates how Ms. Rodriguez lay on the floor vomiting blood, and somehow got help from NO ONE except a couple of individuals who tried to call 911 for an ambulance to take her to ANOTHER hospital. From the video and the articles I read, I've reconstructed part of the transcript of these calls here:

First call, 1:43 a.m.:
Caller: My wife is dying and the nurses don't want to help her.
Dispatcher: Okay, what do you mean she’s dying? What’s wrong with her?
Caller: She’s vomiting blood
Dispatcher: Okay, and why aren’t they helping her?
Caller: They’re watching her...uh...they're watching her there, and they’re just not doing anything. They’re just watching her.

Second call, from a different person, 1:51 a.m.:
Dispatcher: What’s your emergency?
Caller: It’s a lady on the ground here at the emergency room at Martin Luther King.
Dispatcher: Well, what do you want me to do for you, ma’am?
Caller: Send an ambulance out here to take her somewhere where she can get medical help.
Dispatcher: Okay, you’re at the hospital, ma’am, you have to contact them.
Caller: They have a problem, they won’t help her.
Dispatcher: Well, you know, they’re the medical professionals, okay? You’re already at the hospital. This line is for emergency purposes only. 911 is used for emergency purposes only.
Caller: This IS an emergency!
Dispatcher: It’s not an emergency. It is NOT an emergency, ma’am.
Caller: It is!
Dispatcher: It is not an emergency.
Caller: You have to see how they’re treating her.
Dispatcher: Okay, well, that’s not a criminal thing. You understand what I’m saying? We handle-
Caller: Excuse me, if this woman all out dies, what you mean there ain’t a criminal thing?

The call did not end well. The dispatcher insisted again that the situation was not an emergency and offered the caller a business number if she was displeased with what was going on. Just before 2 a.m. the caller said, "May God strike you too for acting the way you just acted." The dispatcher's reply: "No. Negative ma'am, you're the one." He has since received "written counseling" for the way he handled the call.

Edith Rodriguez was pronounced dead at 2:17 a.m.

Zev Yaroslavsky, LA County Supervisor, was flabbergasted at the security video of the incident. He said it was even worse than the audio tapes. “Not one person out of a couple of dozen, including citizens and staff and doctors and nurses…[They] didn’t lift a finger to help her. They just ignored her. Even the janitors who were cleaning up the vomit from around the woman who was on the floor did a very elegant job of cleaning up the vomit but didn’t do a thing to help her. It was just indescribable.”

With her writhing on the floor in pain, vomiting blood, and her loved ones begging for help, how could someone NOT have assessed the need for some intervention? If nothing else, isn't that what emergency departments DO?

Now, I know about the Bystander Effect. I've heard of Darley and Latané's social psychology experiments demonstrating the failure of people to help others in a crisis if other people are also present. I've read about the terrifying case of Kitty Genovese, who was stabbed, raped, and killed over the course of half an hour even though 38 witnesses heard her desperate cries. I've even been a cautious bystander myself.

When I was walking back to my hotel from dinner with an anesthesiologist friend of mine (we were in D.C. about to take our oral boards, actually), we noticed a pair of human legs protruding from the bottom of the potted plant decorating the entrance of her hotel. We came upon a man passed out on the sidewalk, his head and neck cocked to a rather concerning angle. There was already someone palpating the carotid for a pulse (correctly, we observed), and we didn't want to contribute to a "too many cooks spoil the soup" situation, so we lingered in case our help was needed but stood quietly in the background. I did go into the lobby and try to get the hotel management to bring out any first aid or medical equipment they might have had, but they just stared at me blankly and said 911 had already been called. I insisted that someone go and retrieve the stuff anyway, and one of the employees went, but I didn't see him again. Anyway, the paramedics arrived and packed the guy up, and my friend and I saw that they needed no interference from us. But I should hope we would both have asserted ourselves immediately if the situation had really called for it.

What bothers me about the Edith Rodriguez case is that I could easily have been one of the bystanders in that hospital lobby and contributed to her death, although I can't say for sure what my reaction would have been without knowing all the details of the actual situation. We all want to think we would have been the different ones, the types who would have said "no" to the authority figure in the Milgram experiment and refused to apply the electric shocks to the subject, the types who would have called for help in Darley and Latané's experiment when the stranger started seizing. We all imagine we would have bent down in concern toward Edith Rodriguez and at least tried to figure out what was going on, if not offer actual assistance. I think I would have done this, I hope I would have...but I also think deep down we all know that it's easy for ANYONE to be swept into the middle of an inert crowd and stay there dumbly looking on.

Edith Rodriguez's brother, Eddie Sanchez, made this poignant comment on the glumbert video: “You go there to get help, and nothing happens, like…You get ignored like if you’re nobody.” How many times have I failed to SEE my patients, or unwittingly treated them as if they were "nobody?" I cringe to think that I may have done the very same, albeit without the fatal consequences. Or, even if I paid adequate attention to a patient, what if I made the wrong judgment about how to manage the patient's problem, out of a reluctance to admit, "Yes, we have a disaster, and it's right in front of our eyes?"

I pray every day for the ability and courage to make the right calls. A couple of weeks ago our friend who's a flight attendant was describing a flight during which a passenger was found doubled-over in his seat. She announced the need for a physician and said it took a long time for one to come forward. I understand that - the daunting sense of responsibility often competes with the desire to serve and relieve suffering. As it turns out, the physician who did examine the man also told our friend that the captain had to land the plane immediately because the man was in acute heart failure. I think that was a very brave doctor in there. That's a heck of a call to make, diverting a flight filled with passengers to save one life on the suspicion of a life-threatening condition NOT confirmed by the technological aids we get so used to relying on in hospitals. I spiritually bow my forehead to the ground in respect and admiration and pray I never have to make a call like that. Although, what's worse - being wrong about the heart failure, and causing an inconvenience, or being right but lacking the confidence to make the move, thus costing a life? I guess the answer's pretty unambiguous.

I've alluded to the training we got in our medical simulator during residency. I am not allowed to comment specifically on our training scenarios or on people's actions within them, but I think I can make some general remarks on the experience. While the medical aspects of those scenarios were useful, I think a key element in teaching crisis management of any kind is a rehearsal and discussion of group behavioral dynamics. We did bring up and discuss issues like those raised by the Edith Rodriguez story. What makes us blind to another's needs? What makes us ignore data that's right in front of us, or help that's offered? How can we best structure a group's interactions so that efforts to provide help are focused and organized?

One take-home message I valued was that there should always be an "event manager" - one who's NOT involved in DOING tasks, but rather is WATCHING everything that's going on, processing it, and determining what steps are needed next. But of course, in the real world, this role separation is difficult, and often it's not possible to delegate. Or, people are reluctant to step forward to claim the role.

My heart goes out to Edith Rodriguez's loved ones. We in the medical profession failed them, egregiously. The only personal offering I can make at this point is a commitment not to rest smugly in the position of critic and judge, thinking, "Well, I would have seen her there, and I would have done something. I'm not blind." Sure I am. Or can be. And it makes me think twice about an old, familiar New Testament quote from a blunt, rather ticked-off Jesus:

Jesus said, "If you were blind, you would not be guilty of sin; but since you say, 'We see,' your sin remains." (John 9:41)

All I can honestly say is I would LIKE to think I would have treated the situation differently. But I cannot say that I would surely have been immune to group blindness or inertia. I think we need to learn to acknowledge our blind spots and make a promise to all patients, "We don't always see well, but we will always work to see better. Always."


Lee said...

I remember a babysitting job I had the summer when I was 14 or 15, minding two young children. We often went to the local swimming pool where lifeguards were of course on duty, but my two charges were small enough to stay only in the shallow paddling pool. I tried to watch them carefully, and fate must have been smiling on me, because they were fine. However, one afternoon quite a few mums were in attendance with their kids, and somehow a small toddler - if my memory serves me, he couldn't been more than two - somehow slipped and ended up facedown in the water. I watched for a moment or two, at first thinking he was playing, then suddenly aware that he was not, that in fact he was flailing ... actually drowning? I'm reluctant to admit that I didn't react at first - there were all these adults around - but then I did spring to my feet and haul him out.

I can still remember my first shameful thought: someone else will take care of it. As a result, I've always been painfully aware of how easy it is to become a victim of group inertia, and like you, sincerely hope that I'll always err on the side of caution.

DraMaru said...

I'm an anesthesiologist also. I chose to be one when I learnt that I woulb be a bridge between pain and people, and also to be a kind of firefighter for life in the O.R. I loved true emergencies there, the rush, the life&death situations. Anesthesia is beautiful. complicated, demanding it eats us alive, but this is the price. Think about it: how could anyone tolerate a surgery without the anesthesia bridge? Many did, in the past, and it was like hell. Thanks God is very different today. And yes, we are full time doctors like surgeons or cardiologists. And we care. Pain is a dreadful thing.

DraMaru said...

sorry, the comments were intended for a hug for the anesthesiologist, not for this.
But, as matter of fact, I could add some words: is not the system, is the people that forgot to care about others, no matter is in a hospital, in the street, in the market or at home. We are in the information era for technology and, at the same time, in the cave era for quality of life and relationships. I've a friend, an old doctor that was Victor Frankl's alumni, that talked about that in a conference: we know more, we have more, but we are less. Kind of sad truth. When I read about these terrible stories, I apologize as a doctor (not that it revives Edith) for not caring enough. God forgives us, each and all of the medical staff (and that includes nurses, doormen, paraclinic, and so on).

T. said...

Lee, thanks so much for sharing that story. I admire you for helping that child - which means you did better than the social psychology research shows most people do in those situations! EVERYONE has that initial thought - that someone else must be about to take care of it.

And Maria Eugenia - first, thank you for visiting! It's always nice to know of a fellow-anesthesiologist who loves and honors her work. Secondly, what a wise insight you brought up, that we have reverted to a "cave era" for relationships despite our "advances" in communication. It's a good reminder for all of us to make those moments of contact really count! Thanks!