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washingtonpost.com>Health

ACaseThatShookMedicine
ByBarronH.Lerner
SpecialtoTheWashingtonPost
Tuesday,November28,2006

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Manypeoplehavevowedtoavengetheuntimelydeath
ofarelative.LawyerandjournalistSidneyZionactually
didsotothebenefitofpatientsanddoctorsintraining
nationwide.

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Afterhis18yearolddaughterLibbydiedwithin24
hoursofanemergencyhospitaladmissionin1984,Zion
learnedthatherchiefdoctorshadbeenmedicalresidents
coveringdozensofpatientsandreceivingrelativelylittle
supervision.Hisangersetinmotionaseriesofreforms,
mostnotablyaseriesofworkhourlimitationsinstituted
bytheAccreditationCouncilonGraduateMedical
Education(ACGME),thathaverevolutionizedmodern
medicaleducation.

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JustabouteveryoneinvolvedintheLibbyZioncase
herfather,herdoctorsandthepeoplewhotestifiedat
thetrialthateventuallyresultedhasadifferent
accountofwhathappened.Buttherearesomeundisputedfacts.

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LibbywasacollegefreshmanwithanongoinghistoryofdepressionwhocametoNewYork
HospitalinManhattanontheeveningofOct.4,1984,withafever,agitationandstrange
jerkingmotionsofherbody.Shealsoseemeddisorientedattimes.
Unabletodiagnoseherconditiondefinitively,
theemergencyroomphysiciansadmittedher
forhydrationandobservation.Asthe
physicianofrecord,RaymondSherman,a
seniorclinicianwhohadtreatedseveral
membersoftheZionfamily,approvedthe
decisionbyphone.
Onthehospitalwardwhereshewassent,
Libbywasevaluatedbytworesidents:Luise
Weinstein,aninterneightmonthsoutof
medicalschool,andGreggStone,whohad
oneadditionalyearoftraining.They,too,
werenotquitecertainofLibby'sdiagnosis.
Stonetermedita"viralsyndromewithhystericalsymptoms,"suggestingthatLibbywas
overreactingtoarelativelymildillness.Thedoctorsprescribedashotofmeperidine,a
painkillerandsedative,tocontrolhershaking.Shermanapprovedtheplanbyphone.
Theeventsofthenextseveralhourswillalwaysremaincontroversial.Atabout3inthe
morning,Weinsteinwentofftocareforsomeofthe40otherpatientsshewascovering.
Stonewenttosleepinanadjacentbuilding,wherehewouldbeavailable,ifnecessary,by
beeper.
Afterthedoctorsleft,Libbybecamemoreagitated.ThenursescontactedWeinsteinatleast
twice.Weinsteinorderedphysicalrestraintstoholdthepatientdownandpreventherfrom
hurtingherself.Shealsoprescribedaninjectionofhaloperidol,anothermedicationaimedat
calmingherdown.Busywithotherpatients,WeinsteindidnotreevaluateLibby.
Libbyfinallyfellasleep,accordingtothenurses,butwhenanurse'saidetookher
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temperatureat6:30a.m.,itwas107,dangerouslyhigh.Weinsteinwascalledandemergency
measuresweretriedtolowerthetemperature.ButLibbyZionsufferedacardiacarrestand
died.Weinsteincalledherparents,tellingthemdoctorshaddoneeverythingtheycould.
Tothedoctorsatthehospital,thecasewasaninexplicable"badoutcome"inwhicha
healthyyoungwomanhaddiedofamysteriousinfection.
ButthemoreSidneyZionlearnedofthecircumstancesofLibby'sdeath,themorehe
rejectedthisassertion.Hebecameconvincedhisdaughter'sdeathwasduetoinadequate
staffingattheteachinghospital.Andhegrewdeterminedtoensurethatothersnotfallvictim
tothesamegapsintheteachinghospitalsystemthatheblamedforhisdaughter'sdeath.
ASystemUnderScrutiny

First,therewasaquestionastowhetherthemeperidine,knowntocausefatalinteractions
withphenelzineLibbyZion'santidepressanthadproducedthehighfever.Second,
SidneyZionquestionedtheuseofrestraintsandshotsforanincreasinglyagitatedpatient.
"Theygaveheradrugthatwasdestinedtokillher,"Zionlaterstated,"thenignoredher
excepttotieherdownlikeadog."Tothedistressofhisdaughter'sdoctors,Zionbeganto
refertoherdeathasa"murder."
Zion'sangerwasexacerbatedbywhathelearnedaboutthehospital'sstaffingonthenight
Libbydied."Youdon'tneedkindergarten,"hewroteinaNewYorkTimesopedpiece,"to
knowthataresidentworkinga36hourshiftisinnoconditiontomakeanykindof
judgmentcallforgetaboutlifeanddeath."Inaddition,Weinstein,theinternassignedto
Libby,wascoveringalargenumberofpatientsStone,theotherresident,wasnever
awakenedandthesupervisingphysician,Sherman,wasn'tcalledwhenLibbydeteriorated.
AsacolumnistfortheNewYorkDailyNewsandafriendandconfidanteofmany
journalistsandpowerbrokersinthecity,Zionventedhisoutrageaboutthestateofmedical
educationwidelyandloudly.
Overtime,theimageofthebedraggled,unsupervisedinternwreakingdamageinhospitals
wouldbefeaturedinthepagesofTheWashingtonPost,theNewYorkTimesand
Newsweek.Oneovertiredintern,interviewedonTV's"60Minutes,"obliginglyforgotone
ofMikeWallace'squestions.
InMay1986ManhattanDistrictAttorneyRobertMorgenthauagreedtoletagrandjury
considermurdercharges.Althoughitdeclinedtoindict,thejuryissuedareportstrongly
criticizing"thesupervisionofinternsandjuniorresidentsatahospitalinNewYork
County."
Inresponse,NewYorkStateHealthCommissionerDavidAxelrodestablishedablueribbon
panelofexpertsheadedbyBertrandM.Bell,anoutspokenprimarycarephysicianatthe
AlbertEinsteinCollegeofMedicineintheBronx,toevaluatethetrainingandsupervisionof
doctorsinthestate.Bellhadlongcriticizedthelackofsupervisionofphysiciansintraining.
In1989,NewYorkstateadoptedtheBellCommission'srecommendationsthatresidents
couldnotworkmorethan80hoursaweekormorethan24consecutivehoursandthat
seniorphysiciansneededtobephysicallypresentinthehospitalatalltimes.Hospitals
institutedsocallednightfloats,doctorswhoworkedovernighttospelltheircolleagues,
allowingthemtoadheretothenewrules.
Still,somephysiciansresistedreformefforts.Onesimplycouldnotbecomeaqualified
doctor,theyargued,withoutexperiencingfirsthandwhathappenedduringtheoften
unpredictablefirst36hoursofapatient'sillness.Criticsattackedthenightfloatsystem,
arguingthattheconstanttradingoffofpatientsamongphysicianswouldimpedecare.Many
institutionsessentiallydisregardedthenewregulations.
Until2003.Inthatyear,theACGMEmadereducedworkhoursmandatoryforthe
accreditationofresidencytrainingprogramsacrossthecountry.ThenewACGMEstandards
lookremarkablysimilartothoseoftheBellCommission.
Nowitiscommonplacetoseechiefresidentsatmedicalcenterschartingthenumbersof
hoursworkedbytheirstaffs.Residentswhowishtostaylongeratworkareattimessent
hometosleep,adevelopmentthatwouldhavebeeninconceivableinthepast.
Asmightbeexpected,thenewrequirementsareaworkinprogress.Astudypublishedinthe
Sept.6,2006,issueoftheJournaloftheAmericanMedicalAssociationfoundthat80
percentofinternsnationwidestillsometimesworkexcessivehours.
Datameasuringwhetherworkhourlimitshaveimprovedpatientcarearejustcomingin.
OnestudypublishedintheNewEnglandJournalofMedicinein2004didfindthat
eliminatingextendedworkshiftsimprovedtheattentionspanofinterns.
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HistoricalLegacy

Historiansthesedaystendtodistrusttheideathattheactionsofspecificpeopletrulycause
largescalechange.Rather,manyargue,changemorecommonlyresultsfromacomplex
interplayofculturalandpoliticalfactors.
InthecaseofLibbyZion,however,itispossibletotraceastraightlinefromherdeathto
SidneyZion'scampaigntotheBellCommissiontotheACGMEregulations.Tobesure,it
tookthesocialchangesofthe1960sand1970stomakegraduatemedicaleducation
susceptibletoreformfromtheoutside.ButSidneyZionspedthingsupconsiderably,
ensuringthatLibbyhadnotdiedinvain.
Inthewinterof1994,Zionv.NewYorkHospitalfinallywenttotrial.CourtTVavidly
coveredtheproceedings,whichwerefullofvitriolonbothsides.Inpresentingitscase,the
hospitalintroducedaclaim,unsupportedbytoxicologytestingandvigorouslydisputedby
theplaintiffs,thatLibbyZionhaddiedasaresultofcocaineingestionthatshehad
concealedfromherdoctors.Thejuryhedged,attributingresponsibilitytoboththedoctors
andthepatient.SidneyZionstillcallsthe$375,000juryawardtohimatravestyofjustice.
ThereisoneotherlegacyofZion'scrusade.Bychampioningthecauseofpatientsand
familieswhobelievedtheyhadbeenharmedbythemedicalprofession,Zionhelpedsetthe
stageforthemedicalerrorsmovementthatbeganinthe1990s.Toaggrievedpatientsand
theirfamilies,Zionbecameasortoffolkhero.
"Thereisaconspiracyofsilenceamongdoctors,"declaredawomanfromQueensinaletter
toZion."Theylietodeadpatients'families."Likewise,amanwhohadundergone
unsuccessfulsurgeryurgedZion,"Donotgiveupyourfight."
Throughouthiscrusade,SidneyZion'sangerwasparamount.Indeed,itisquitepossiblethat
withoutthisrage,hemightnothaveaccomplishedwhathedid.Zionwas"aggressive,
narcissistic,selfindulgent,pushy,persistentandparanoid,"psychiatristWillardGaylin
memorablywroteintheNation,"butthatispreciselythestuffsuccessfulreformersaremade
of."
BarronH.LerneristheAngelicaBerrieGoldFoundationAssociateProfessorofMedicine
andPublicHealthatColumbiaUniversity'sMailmanSchoolofPublicHealth.Thisessay
drawsonhisnewlypublishedbook,"WhenIllnessGoesPublic:CelebrityPatientsandHow
WeLookatMedicine"(JohnsHopkins,2006).
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