Anna Brown And Appropriate Emergency Medical Care

[My comments to the following copy of an original web article from White Coat's Call Room blog are highlighted below. For a revised version with sarcasm toned down, see DeadlyDismissal.]

"I’m surprised that this case hasn’t gotten more press. [Me too]

A patient named Anna Brown was unhappy with the care she received at several [several, really?] hospital emergency departments. [Unhappy because she was still in significant pain, perhaps?] When she was discharged from the last emergency department, she refused to leave. Police were called and the patient was carried to a police car. She said that she couldn’t walk. Police took her to jail, carried her into the cell and left her laying on the floor. About an hour later, she was still laying there … dead.

From the public’s point of view, the case appears outrageous. But as I read through the description of what happened and thought about what could have been done different, from a physician’s point of view, I’m not sure what else could have been done. [I don't know... maybe save her life?]

Christine Byers wrote an excellent article describing events that took place, and then wrote a follow up article in which the hospital defended its care. I’m hoping that the St. Louis Post-Dispatch commends her for her work. She did a great job with the stories. [I agree.]

Background
A summary taken from Ms. Byers’ article shows that Anna Brown was admitted to the hospital for spraining her ankle while walking near a ditch. EKGs, blood tests, and lab work were performed. Ms. Brown was in the hospital from Sept 13 to Sept 15 and then discharged. She walked on crutches after her discharge.

Early in the morning of September 20, 2011 Ms. Brown returned to the hospital complaining of knee and ankle pain. X-rays were taken and were negative. She was discharged with a prescription for pain medicine, but refused to leave. [Perhaps because she couldn't walk and had nowhere to go?]

At 5AM she wheeled herself next door to the children’s hospital. Doctors there found tenderness in her legs, but did not want to treat her since she was an adult seeking care at a children’s hospital. Ms. Brown demanded to be sent to a “better hospital.” She was then transferred to a third hospital. [So, then, due to an error in judgment on her part, she ended up at the wrong place. Therefore, she was really only treated at 2 hospitals, not 3, as you've taken pains to insinuate so that you can stick her with the label of “frequent flyer”]

She arrived at the third [as in numero tres] hospital at 11:45 AM. At the third hospital, [Which hospital again? Oh yeah, the 3^rd one. Some might have just eventually used a pronoun.] her left ankle was swollen. During this visit, ultrasounds were performed on both of her legs and showed no blood clots. A nurse witnessed the patient standing.[On her good leg? Oh, no, that's not what we're presuming here, is it?] Ms. Brown was discharged at about 7PM.

At roughly 3AM the following morning, Ms. Brown came to the third hospital again by ambulance, this time complaining of abdominal pain. Some reports also state that she was continuing to complain of leg pain. [Only some reports, plural? How many reports more than 2 do you need?] She was in the emergency department for another 4 hours and was then discharged at approximately 7AM. The article did not mention if or what type of testing the patient may have had on that visit. She refused to sign discharge papers.

By 10 AM, Ms. Brown was complaining to a security guard that she “did not receive adequate medical attention” and therefore did not wish to leave. Police came to the scene [perhaps because they were called?] and Ms. Brown was told to leave or she would be arrested for trespassing. Ms. Brown yelled that “You can’t arrest me … I can’t even stand up!”

At 12:30 PM, Ms. Brown had been re-examined by a physician and the physician completed a “fit for confinement” report. Police stated that Ms. Brown yelled “My legs don’t work!” while she was being wheeled from the room. [You left out the part where she tumbled over on the floor while they were trying to pull her out of her wheelchair—it's on the video]

Police then took Ms. Brown to jail. She refused [is it “refusal” when you aren't able to do something?] to get out of the vehicle, stating “I can’t put pressure on my legs.” Officers then carried her into a jail cell and left her laying on the floor. [moaning: is that at all significant to you?]

At around 2 PM, Ms. Brown was found dead. Cause of death was pulmonary emboli – blood clots from her legs that dislodged and went to her lungs.

An investigation by the Centers for Medicare and Medicaid services did not find any violations involving Ms. Brown’s treatment. [And she wasn't complaining about it anymore, either.]

Discussion
There are other issues with Ms. Brown, but I think that they tend to detract from the issues regarding her medical care. Ms. Brown was homeless. She had lost custody of her children. She had nine other siblings with whom she did not live during her homelessness. After being admitted to the hospital for spraining her ankle, she resisted discharge at that time as well. Ms. Brown also had potential psychiatric problems and refused some psychiatric testing a court had ordered relating to her child custody problems. [Maybe she refused because she thought that psychiatric testing may have led to some diagnosis that would have lessened her credibility at a future date when having such credibility might become a matter of life and death?]
There were also questions about the appropriateness of police leaving Ms. Brown laying on the floor instead of putting her on the bed when she arrived at jail. [The indelible image there is of her being abandoned on a concrete floor, moaning, while the door is latched behind her. Go re-watch the video with the sound turned up if that had no effect on you.]

As I looked through the newspaper article, I kept asking myself: What I would have done differently while she was in the emergency department. I couldn’t think of much.[So you couldn't think of much and what you could think of is not worth disclosing? Or is it because any disclosure may be seen by some as criticism of St. Mary's and criticism is nothing but an indirect accusation, isn't it? And we all know what happened to Anna Brown after making such indirect accusations, don't we?]

Ms. Brown had been evaluated by multiple physicians for her complaints. She received x-rays, blood tests, EKGs, and even a cardiology evaluation. An ultrasound performed less than a day before she died excluded the very disease process that ended up killing her – even though she had the same complaints for more than a week. [Not the exact complaints—her pain had clearly escalated if she could no longer walk when she was hauled off to jail. Oh wait, I forgot, she was likely “feigning illness” as many prison inmates do. And why was she a prison inmate? Because the hospital had her arrested, that's why. Can you not see that Kafkaesque logic in that?]

Did Ms. Brown receive appropriate medical care?
Many people who commented on Ms. Byers’ article stated that animals get better treatment than Ms. Brown received. I disagree. She received multiple evaluations from multiple physicians for her complaints. No emergency was found. Hospitals can’t admit people just because they might develop a disease in the future. [Do you think perhaps these commenters were impressed by the way she was physically dragged out of the hospital against her will, like animal control would come in and physically remove a wounded animal? Moreover, an abused animal would likely be removed from a place of confinement to a place of care--not the opposite as occured here.]

Probably the most troubling part of this case for many people was that Ms. Brown died from a problem related to her repeated complaints of leg pain. To those people who suggest that additional evaluation was needed, I ask what should have been done? Another ultrasound? How often should patients who have leg pain and swelling receive ultrasounds? Daily? Weekly? Hourly? How many ultrasounds should every patient with these symptoms receive in order to exclude a blood clot in the legs? It is easy to look back and say “they should have done this differently.” But to be fair, we have to look forward and ask ourselves what medical care is appropriate for all patients with similar complaints. [I don't know: How many patients have you got who have leg pain and swelling who claim they're not able to walk?]

Retrospective bias is a powerful contaminant in Ms. Brown’s case. The autopsy showed that she died from a blood clot which was presumably in one of her legs and which presumably dislodged and went to her lungs at the time of her death. Therefore, many people who know the end result think that there is no way the blood clot should have gone undiagnosed. However, Ms. Brown didn’t come in complaining of a “blood clot.” She complained of leg pain and swelling after having suffered a leg injury the week prior and received multiple evaluations and tests to address those complaints. There is no medical evidence that all patients with leg pain and swelling should receive multiple ultrasounds on their legs to rule out DVTs. Without some type of scientific evidence as substantiation, allegations that the medical providers “didn’t do enough” for Ms. Brown really don’t hold much water. [Are you worried more about 'allegations' or improving care?]

Was Ms. Brown treated inappropriately?
This is a difficult question. Of course she could have been treated more humanely, [not according to the St. Mary's hospital—they will claim they treated her with the utmost care and compassion, as they do all patients, end of discussion] but we also have to consider the events leading up to her treatment that day. She had multiple tests performed at multiple hospitals [two hospitals] to evaluate her complaints. Those tests did not reveal a cause for her problems. When asked to leave, she became uncooperative with the police.[How do you cooperate when you can't get up to walk?] Unfortunately, many patients feign illness when faced with the possibility of being incarcerated. [She was already complaining of 'illness' before they called the police] This may have caused some bias in the minds of the police officers, thinking that Ms. Brown was feigning illness as well. [Do ya think? She was being booted out of a hospital for Christ's sake!] Even so, police acted appropriately by requesting that Ms. Brown receive medical clearance before being taken to jail. [The discharge was effectively the clearance--they didn't wheel her back in to be re-examined, but rather kept her and the police parked for 3 hours while they were discussing who-knows-what in the administrative offices. And I'm not buying that it is appropriate to have anyone who is seeking help arrested for tresspassing in a hospital. Such people need help, not punishment. If you're more into punishment, maybe you're in the wrong profession.] 


Should Ms. Brown have been left on the floor of the jail? Not really a medical issue, [It becomes a medical issue when there is no concern for her well-being at a time when her moans were the real moans of a dying woman—if those moans are indistinguishable to you from those of an actor, and a persistent actor at that, then I'll chip in to send you to actors schools to research if there's any person alive who could possibly discern otherwise and then teach that to medical students.] but what if the police put Ms. Brown on the bed and she fell off the bed and injured herself? If there is a bad outcome, police are going to be blamed for inappropriate behavior as well. Again, retrospective bias creeps in. [And the retrospective bias you're using seems rather about vicariously avoiding blame, identifying as you do with your colleagues.]

What should have been done differently?
Before answering in the comments, I want you to consider whether you would still feel that way if Ms. Brown had instead been complaining for several days at a restaurant because the food was poisoned, at a department store because a display was dangerous, or at a place of business because the services weren’t performed properly, and those complaints were properly investigated by the involved business. [Weak analogy. A business would know it's own food, display, and service, respectively, better than a customer would. Conversely, a patient knows their own pain better than any other person does.] If it were your business oryour home and the circumstances were the same, would there be any change in the expectations of how Ms. Brown should be treated? [I've worked at businesses and been at numerous homes over the course of 50 years. Never once have I had to have anyone forcibly removed nor have I heard of anyone being forcibly removed for behavior remotely close to that which you're describing] Remember, you need to look at the case prospectively, not retrospectively.

One reader sent me an e-mail that summarized this case better than I could ever do. “This case was the perfect storm of homeless woman perceived to be crazy who had a serious medical condition that didn’t show up on diagnostics, who was arrested by indifferent police officers, and which included a series of personal circumstances that would have driven anybody nuts.” [So, in other words, she was crazy after all and therefore lacked any credibility. Whew, that gets everyone off the hook.]

Additional stories (and comments) on the case can be found at the Daily Kos and atMSNBC."

Love tubes, don't fear them

"We Love Our Tubes! Disability activists are returning to Pinellas Park FL to tell the simple truths about tubes: feeding tubes, breathing tubes, peeing tubes and other tubes we need and love, to express our ridicule for the pathetic response of the nondisabled majority to these simple pieces of latex rubber. Terri Schiavo's feeding tube is the reason she is being killed." http://www.notdeadyet.org/

"...the life-and-death issues surrounding Terri Schindler-Schiavo are first and foremost disability rights issues -- issues which affect tens of thousands of people with disabilities who, like Ms. Schindler-Schiavo, cannot currently articulate their views and so must rely on others as substitute decision-makers. That’s why 26 national disability rights organizations have adopted a position in support of Terri Schiavo’s right to continue to receive food and water. The evidence that Ms. Schiavo would refuse tube feeding is so unclear and conflicted that it does not satisfy legal standards. The lower court in Florida can pretend otherwise, and the Florida appellate courts can refuse to question the lower court judge, but it serves society poorly to give guardians such an unfettered right to kill."
http://www.prweb.com/releases/2005/3/prweb220201.htm

A higher-order logic

As Crazy Diamond suggests, I am asking myself "what was the twisted logic...", and one of the answers that I'm developing is that the logic seems all too simple. It's cold, mathematical reasoning, but it's old school. Judges are like computer programmers following simple algorithms. Simple algorithms about how to live life, or, rather, how others should live life or be forced to die. You don't want a computer programmer telling you how to live; I can say this with some authority because I've been one for many years. It seems to me, if one is going to have this kind of limited computer programmer mentality, one should at least consider expanding one's mindset a wee tad and look at fuzzy rules, part of the branch of mathematics known as fuzzy logic. This is what gives us such a smooth ride in modern elevators. I don't have that sense here. I feel like I've been jerked up and down at every floor whenever I turn on the news.

What would the fuzzy rule(s) be here? Please see my previous posts, but I would say something like: if the husband considers his wife to be a dead and her body an incommunicative vegetative form not worth bothering with, but the parents consider her to be alive and want to take care of her as they did when she was an infant, then shift care away from the husband and onto the parents. I'm sure others could come up with some good ones as well. Such overarching principles as always erring on the side of life can be applied. These techniques do not require a lot of processing power. You could do the calculations with the processor found in an old video Pong machine unearthed from a landfill and have power to spare.

My point is that it is well within the capability of a human being to take all apects of a situation into consideration in accordance with deep principles, and not be so enamored of following such primitive IF-THEN-ELSE rules as our legal system seems to be so fond of doing. I guess it's a complicated and scary world out there, and it's nice to have simple rules and legal decisions to hold on to. But sometimes you need to apply the full range of your humanity to solving problems. Not as an Asperger's-riddled programmer/judges dealing with thousands of lines of executable code/laws. We know that such people are "made deeply anxious by any change in routine" . We also know that such people are prone to dig in their heels when challenged. They "will become more rigid and stubborn if confronted" . Missing here is a deep, human empathy--such impairment being what characterizes autism spectrum disorders such as Asperger's, which are sometimes referred to as "disorders of empathy." It's good to remember here that these disorders shade into normal and that people who have them can appear to be very high functioning. But I would not argue for removing their ability to "feed"--to economically sustain their own livelihoods-- even for the most severe cases.

Going to extremes

This excerpt from a fictional story in this month's Harper's magazine reminded me a little of the spectacle surrounding this case. It's a description of an extremely sick reality show:

"Well, nobody got hurt," says Chief Wayne.
"Except those kids who unknowingly ate their own mothers," says Brad.
"Well, they signed the releases," says Chief Wayne.
"Releases or not, Wayne, come on," says Brad.
"They killed people. They tricked people into eating their own mothers."
"I don't know that I'm all that interested in the moral ins and outs of it," says
Chief Wayne...
"It's interesting, that's the thing," says Doris. "The expectations, the reversals, the timeless human emotions."
"Who wouldn't want to watch that?" says Chief Wayne.

This isn't the first time Terri has been starved and dehydrated within inches of her life. What might Terri be feeling, or is she feeling at all? How can anyone say for certain without being in her head? Gail Pursell Elliott wrote in a recent installment of her newsletter, "Food For Thought", about a recent ER episode she saw where the everything that was happening was narrated from the perspective of a patient who was not able to communicate, but retained awareness of what was being done to her. This concept reminded me of a powerful film I saw back in college: "Johnny Got His Gun". In that story, the injuries that prevented any ability to communicate were inflicted by war. According to some of the reviews, the book is even more powerful. I wonder if, similarly to these fictional accounts, Terri is on some level aware of what is going on. Although I didn't vote for the dude, I think what President Bush said today is sound: that we should err on the side of life. There is very little time remaining to do that. The war in this instance is unfortunately one being fought between political opponents and a judicial system that has to protect its power at all costs--while Terri's physiologic systems react to the withholding of water and nutrients that are essential for human life.

Terri Schiavo

It's curious to me that this has become a partisan political issue. Though I'm normally a liberal Democrat, count me as a Republican on this one, if that's what it takes. Though I'm not a practicing Catholic, I'll pay homage to the Pope on this one.

The way I look at it is that as far as Terri's husband is concerned, she is already dead. If it were otherwise, we would be talking about premeditated murder. If this is the case, then her lifeless body is of no consequence to him; it is not her; she is gone; why not let her parents take their time in saying goodbye to her, in their own way, especially since to do otherwise is causing distress for them and for so many other people??

Terri has suffered an enormous injury to the very core of her being. When someone is injured thusly, in such a severe manner--I'm sorry I can't suggest references right now, other than some writings from holocaust survivors--the tendency is not to cry out for one's spouse. No, the utter catastrophic character of the injury violently transports a mature adult human being way back in time...past marriage, past youth, to the earliest consciousness of childhood, and threatens even that: "Mommy! Mommy! Help me!", puts to words the terror of a child who is more scared than she ever was during her original childhood and life to this point. The degree of injury is so profound, that it's even pre-verbal, a turning toward her mother, even though her damaged brain can no longer express that terror through facial expression. Terri doesn't need a husband right now; she needs her mom and dad, the people who brought her into this world and loved her as an infant, and to which state she has regressed. Whether that state can ever be progressed from again, is not something I can venture an answer to. I can only say, in view of the fact that her parents very much want to care for her, that to end her life now under force of court order falls short of the dignified death that the court intends, though the elaborate language and procedure of the legal system is engaged here almost as a form of end-of-life ritual. Rather, it is additional trauma to her and to those who believe a living part of her is still inside. It is a ritual culminating in a death chamber not all that dissimilar from the death chamber in capital punishment. After legal process gives way to medical procedure, death takes somewhat longer here than the few minutes from that of lethal injection.

I urge immediate action by the legislative branch on this issue, though the courts will no doubt resist. This is a very time-sensitive issue, dictated by the laws of physiology, laws that supersede those of any court. I am reminded of what Roy Masters used to say on his radio program: "Some people would rather be dead than wrong; what they don't realize is that they're going to be both dead and wrong!" I would add that apparently some would rather that Terri was dead than that they be wrong. I hope that dynamic will not determine the outcome here.