There’s something a little terrifying about researching the death of a younger woman due to a doctor’s mistake while living in the hospital with my daughter who has a very bad case of pneumonia. Aly is doing great and on the road to recovery. Her doctors have been wonderful. I just feel like I’m tempting fate with this research.

Libby’s Last Day

Libby Zion was a bright, 18 year old college student in 1984. She attended college in Vermont, but was home in New York that March. She had been experiencing flu like symptoms, a high fever and body aches, for a couple days when her parents took her to New York Hospital.

During triage at the ER, hospital staff was informed that Libby had been taking phenelzine regularly for depression. They made a note in her chart and began examining her symptoms. They decided to admit her for observation and planned to give her IV fluids in an effort to bring her fever down.

She was transferred to the 5th floor of the hospital. Her case was assigned to Luise Weinstein, a first year resident who was primarily working on the 3rd floor.

From the time of admission, Libby had been experiencing convulsions that caused her extremities to jerk uncontrollably. Dr Weinstein ordered Demerol in an effort to ease her pain and control the spasms.

Libby did not respond as expected. Instead she became more agitated. She ripped out her IV more than once. The nurses were afraid she would hurt herself. Her parents were encouraged to leave so as not to increase Libby’s distress. Then they contacted Dr Weinstein again. She ordered that Libby be put in restraints for her own safety, and be given Haldol to decrease her agitation.

After a while, this course of action seemed to work, because Libby eventually fell asleep. As she slept, her temperature began to skyrocket. At 630 am it was charted as being 107 degrees Fahrenheit. Dr Weinstein ordered interventions to decrease her temperature, but it was too late. Libby went into cardiac arrest and was unable to be resuscitated. On March 5, 1984 Libby Zion was pronounced dead.

What Went Wrong

Libby’s parents, Sidney and Elsa Zion, were shocked and devastated by the death of their daughter. They wanted to know what went wrong.

1. The first mistake was when Dr Weinstein ordered Demerol to treat Libby’s convulsions. The drug interaction between Demerol and the phenelzine she was taking for depression can cause serotonin syndrome. Symptoms of this include fever, high blood pressure, rapid heart rate and muscle spasms.
2. The second mistake was the usage of the restraints. Because Libby couldn’t move or uncover herself, she had zero chance at helping her body temperature to regulate.
3. No one was monitoring her fever. Part of the reason for her admission was a fever, yet the staff was not regularly checking her temperature. If they had been, they would have noticed her body temperature trending upward and could have ordered intervention before she had essentially cooked herself.

The Aftermath

Sidney Zion blamed inadequate staff and the hospital for Libby’s death. He felt that the doctors should have known about the deadly potential drug interaction between Demerol and phenelzine. He also felt doctors working 36 hour shifts were destined to make mistakes due to exhaustion.

He wrote his concerns in an op-Ed for the New York Times and he petitioned the District attorney’s office to file murder charges. In May 1986, a grand jury was convened, but failed to indict. 

Libby’s case didn’t end there though. The State Board for Professional Medical Conduct formed a committee that failed to find negligence on the part of the doctors involved in her case, since the drug reaction between phenelzine and Demerol wasn’t widely known. The Board of Regents overruled the committee and ordered the doctors to be censured for acts of gross negligence. That decision was successfully appealed in 1991.

Real change didn’t come from the previous committees. It wasn’t until 1987 that the state of New York’s Ad Hoc Advisory Committee on Emergency Services, headed by Dr Bertrand M. Bell, that the training requirements for new doctors changed. Their recommendations included:

• There should always be an attending physician present in the hospital at all times.
• Residents should be limited to working shifts no longer than 24 hours and now more than 80 hours total in a 7 day week.

New York State adopted these rules in 1989. The Accreditation Council for Graduate Medical Education went on to adopt them in 2003. Opinions are mixed about whether or not this is a good thing. Yes, new doctors are less exhausted and hopefully better able to make decisions. But they no longer go through the heel of a residency that older doctors believe made medicine a calling and not a 9-5 job.

I don’t have an opinion either way about whether this made medical care any better for the doctors or the patients. All I know is that I try to avoid hospitals in July when newly graduated residents begin “practicing” on us.

Stay well friends

Kristie