On the first day of Christmas the reindeer brought to me
Advent Calendars to make my kids crazy.
Aly is happy to be home. She still has a little bit of a cough and gets tired easily. She’s excited to make a wooden tree for Christmas.
Hannah has slime, but she doesn’t know it yet. She has to wait for Daddy to wake up before she can open day one. For the last 45 minutes, I’ve been told, “This is torture.”
What holiday traditions do you celebrate with your family? Share in the comments.
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.
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.
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.
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.
Aly has been healing on a 2 steps forward, 1 steps back pattern today. They were able to lower her oxygen from 6LPM to 3LPM, until she was eating dinner and her SATs dropped into the 70s.
She has been receiving her oxygen through the nasal cannula all day, but needs a full mask when she sleeps because she’s a mouth breather.
I had planned to present the incident that yesterday’s Law and Order case was based on, but I didn’t quite finish it. Hopefully tomorrow is better.
I love my new job, but I swear it is sending me down rabbit holes. I spend 8 hours a day reading through the charts of terminally ill patients and making sure they qualify for the hospice care they are receiving. All humans should qualify for medical care that makes our quality of life better and more comfortable, but that’s a whole other rant for a different day.
Today I am writing after going down a rabbit hole about the pharmaceutical industry, the FDA and alternatives to prescription medicines. The amounts of drugs prescribed each day feels exorbitant to me, and I wonder if they are all necessary. That’s what lead me to read Death by Prescription by Ray D. Strand MD
Experienced family doctor Ray Strand writes his patients prescriptions every week, but he also believes that prescribing drugs should be a last resort in most medical cases-not a first choice. In Death by Prescription he provides simple guidelines to help readers protect themselves and their families from suffering adverse reactions to prescription medication.
My Review
I have always found it odd how many commercials there are for prescription drugs. The majority of people watching TV aren’t doctors and therefore aren’t qualified to know if a new medication is effective for treating themselves. The fact that the government allows these commercials but not ones for cigarettes is just bizarre, after all we know the FDA regulates both.
I knew the FDA wasn’t “protecting” Americans, but before reading this book, I didn’t realize that more than 50% of their funding comes from pharmaceutical companies. They are literally paid to approve medications at a fast pace. Then once they hit the market, side effects are reported on an voluntary basis to data entry clerks. Most of the time, the worst thing that happens is a medication gets a new warning label. Very rarely is one removed from circulation.
Instead of focusing on keeping the population safe and healthy, pharmaceutical side effects become a blame game. Pharmaceutical companies claim no responsibility, because they did the testing required for approval. The FDA has no responsibility, because they provide warnings for doctors. Doctors aren’t to blame, because they can only talk about side effects they know and the pharmacist should council the patient. The pharmacist gave the patient the warning inserts, it’s their fault.
Well heck! If I the patient am responsible for my medical care then why do we pay the doctors, pharmacists, FDA and pharmaceutical companies? Oh wait! Maybe It’s not about keeping people safe and healthy. It’s about making sure everyone makes money off your ailment.
I know we are all going to need some form of pharmaceuticals in our lifetime. Heck my daughter is getting a ton as we speak while laying in her hospital bed. I’m just saying sometimes we should start with something like hot tea for a sore throat before we buy numbing spray, or cranberry juice for UTI symptoms before we run to the doctor. Let’s stop creating super bugs and start embracing the nutrients in Mother Nature.
The plan for this weekend was to empty the house and get settled in the camper. Rob got it set up at the campground on Friday. We have a dumpster in the driveway for old furniture and whatnot. My eldest is spending the day helping load the moving truck as well.
Unfortunately I am not helping at all. Aly was admitted to the hospital last night with Covid pneumonia. I took her in thinking bronchitis and because she was struggling to catch her breath. In the last 12 hours she’s had a Chest X-ray, multiple breathing treatments, a CT scan and is currently on continuous oxygen.
She’s doing a little better, but we are still expecting to be here for 5 days. I know I’m where I need to be, but I’m still torn because I hate dumping everything on other people.
Please pray that my baby girl bounces back quickly.
