The Libby Zion Case

Background

Libby Zion, a Bennington College freshman, was living at home in New York during her Winter Recess. During this break, she had been working as an intern at Manhattan Borough President Andrew Stein’s office. One Sunday — March 4, 1984 — after returning home from a party in a friend’s apartment, Libby experienced spiking fevers and agitation. Her brother proceeded to call Libby’s parents come home and figure out a plan. Libby had experienced fevers like this in the past but assured her parents that if it spiked again, she would seek further medical attention.
When Libby’s parents arrived home and saw her, they immediately called Libby’s pediatrician. Once unable to reach her, Libby’s father – Sidney Zion – reached out to his own doctor who instructed Libby’s parents to take her to the Emergency Room at New York Hospital where he promised that ER staff would help Libby.
Upon arriving to the ER – at approximately 11:30 p.m. – Libby and her parents were met with interrogative doctors and nurses asking about medical history. In January of 1984, Libby had begun psychiatric treatment for stress and was taking an anti-depressant called Nardil. She was also taking over the counter cold medicine and erythromycin for a tooth extraction that she had had. Additionally, the medical staff asked Libby – both in her parent’s presence and alone – if she had used any illegal drugs; Libby replied no on several occasions. Libby’s initial prognosis was an unspecified viral infection and “hysterical symptoms.”
Once admitting her to the hospital, Libby was given Demerol to stop her fever-induced shaking. The Doctor who had prescribed this medication – Dr. Gregg Stone – left the hospital to get a few hours of sleep and instructed Libby to get some rest. He placed Dr. Weinstein as in charge of her care. As the night progressed, Libby’s condition got worse; she began thrashing and still had a fever. Dr. Weinstein directed Libby to take Haldol, a sedative to try to calm her and relieve some of the agitation. Additionally, to stop her from hurting herself, the doctors and nurses restrained Libby and tied her feet and hands to the bed. At 6 A.M., the nurses revisited Libby and saw that her fever had spiked to 107 degrees. They tried to cool her but Libby suddenly entered cardiac arrest. She died at approximately 7:30 a.m. on March 5, 1984.

How the Jury Reacted
On March 6, 1984, the medical examiner for Libby’s case reported that her cause of death was bilateral bronchopneumonia. Cocaine was found from Libby’s nostrils after death and before her death, she tested positively for cocaine by radioimmunoassay. The medical examiner considered the cocaine in her system but did not associate that with her death.
Sidney Zion, Libby’s father and a Yale-trained lawyer, urged the Manhattan District Attorney to launch a criminal investigation into the negligence that resulted in his daughter’s death. Though the grand jury did not place the New York Hospital or its physicians at fault for what happened, much scrutiny was placed on the system of residency training and staffing in teaching hospitals. The District Attorney made a statement about the fact that junior interns were in charge of life-and-death decisions without supervision from higher ranking medical staff.
The Jury, the District Attorney, and the Medical Examiner unanimously agreed that reforms must be made to the residency training system. The Jury particularly emphasized five major points about corrective procedures that may prevent a tragedy such as this from occurring henceforth.
The first two points the jury made exist in tandem. Upon arriving to the hospital, Libby Zion was evaluated by a junior resident. Though the resident did confer with the attending physician on the phone, no one of higher medical understanding examined Libby. In conjunction with that, she was admitted to the hospital under the care of an intern. The jury recommended that emergency rooms must have doctors with three years of post-graduate training before they are able to work and evaluate care for patients and that physicians – and not interns or junior residents — should be the ones to admit patients into the hospital.
When Libby was admitted to the hospital, she was admitted at 2:00 in the morning when the people who were caring for her had been at work for more than an eighteen-hour shift. The Jury mandated that there must be a limit on the working hours for interns and junior residents in teaching hospitals. The lack of a limit on hours that junior residents and interns can work was at the crux of the debate; is it negligence by the hospital staff themselves or is it a problem with the regulations on the hospital? This provision was written to try to minimize time that hospital staff had to stay awake so that they could more efficiently do their jobs.
To try to stop Libby’s tremors, she was restrained at the hands and feet. However, an intern ordered this physical restraint from an examination an hour prior to the order. The intern did not re-examine Libby again and the order to restrain her was given by telephone. The jury prescribed that a law should be enacted that determines when a patient should be physically restrained and how the care and attention should be given to that patient during the time that they are restrained.
Lastly, the jury recommended that the hospital have a system to determine the ways that specific drugs do not work well together. Libby’s anti-depressant medication Nardill produced severe side effects when paired with the other drugs that they gave her causing further adverse reactions to treatment. Had there been a way for hospitals to check for contraindicated combinations of drugs, the doctors would not have prescribed Libby a medication that would not work with the anti-depressant that she was taking. The jury suggested that hospitals develop a computerized system to check for the linkage and possible harmful impacts associated with mixing different drugs.

Alterations to Residency training
Though the long hours are thought to be a key part of physician training about the stamina that the profession requires, many claim that the quality of care is compromised for a resident who has been at the hospital for, sometimes, over 12 hours. Shift work is a proposed solution to trying to fix this. However, many doctors fear that their relationships with patients won’t be as effective with these time constraints. There is a disruption in the flow and continuity of care if new doctors are being brought in and out of a case. It interferes, sometimes, with setting an example for the proper amount of time spent caring for a patient.
Following the Libby Zion Case, officials in New York State aimed to propose regulations limiting the length of residents’ work shifts. The intention behind this was to limit the stress at the workplace and create a way for people to become refreshed for their shifts. However, according to a survey conducted by JW Smith, WF Denny and DB Witzke on the Emotional impairment in internal medicine house staff, emotional impairment is increasing for interns. The average patient today is sicker requiring more intervention from medical professionals. Therefore residents have greater responsibilities that they are required to do in a smaller period of time.
From 1997-1998, a study done at the University of Virginia—approved by the University of Virginia Human Investigation Committee – composed a study to quantify a medical intern’s need for sleep. In the study, an intern call schedule was created that followed one of three patterns: two interns would take long call (an overnight shift) every other day, three interns taking long call every third day or two interns taking long call every fourth night and day call only every fourth day. The program director assigned the number of interns to service and determined which schedule they would follow based on availability, intern career goals, and educational needs. To record data for the study, nineteen first-year residents would track their sleep using a daily sleep log, which included whether the resident was on call, post call or neither and how many hours they got to sleep. This included any times they had sleepless nights, fatigue while on call, inability to complete their work, and level of stress and satisfaction. Each question was measured on a 0 to 5 point scale.
With a 75% response rate to the questionnaire, the results of the survey dictated that being on call every other night led to significantly higher stress and fatigue levels and less productivity and satisfaction in the operating room. However, the level of error made while on call was distinctly minute between the groups. Most errors were made when high levels of fatigue were detected.

How This Relates to Politics of Health
When thinking about institutions is important to identify the factors that exist to create an institution. Institutions have structure and rules for the people in it that produce an output; they formulate the guidelines and expectations of behavior that exist in our society. Often times they restrict autonomy and are tied to government funding in an attempt to structure society.
Within this case, there are a lot of institutions that are working together to mandate the way care be administered to citizens. The hospital’s goal seems to be to ensure that the system itself runs smoothly – that patients move in and out quickly and seamlessly. When Libby Zion first arrived to the hospital, there was a notion that she did not understand her own illness, that because she was on anti-depressants there was an inherent inability for her to be cognizant about her own condition. There was human error – an often forgotten yet inevitable consequence of medical work that resulted in death.
Through an understanding of the Libby Zion Case, we can gain knowledge of the way institutions are interconnected in their operation. An institution that is usually associated with a multi-level G-d complex, such as the hospital, made an error in assuming that the members within it would do flawless work. Then, since the hospital was unable to save Libby Zion’s life, as they are expected to, the government had to interfere and created legislation that would protect the hospital. The idea of an institution is one that connotes perfection – a seamless machine that runs smoothly. However, in this instance, a life was destroyed at the mercy of an institution’s failing moments.
It is important to consider how institutions work with other institutions to create improvements in our society. The New York States government passed legislation to try to limit the hours that medical students are working. However, from the data in the above example, there may be a discrepancy in the action taken to understand the way these institutions work together. The legislation may not have been successful in contributing to less negligence in the hospital work place; it may be improvements in technology or different medical staff that has contributed to this.
It is necessary to understand the interactions of institutions, how we use institutions everyday and the necessity of skepticism of the ways our institutions are run.

Citations:
Asch, D. M., M.D. (1988, March 24). Sounding Board: The Libby Zion Case. Retrieved April 2, 2017.

Block, A. J., M.D. (1994, April 4). Revisiting the Libby Zion Case. Retrieved April 2, 2017.

Cohen, S. (2014, September 28). The Lasting Legacy of a Case that was “Lost”. Retrieved April 2, 2017

McCall, T., M.D. (2013). The Impact of Long Working Hours on Resident Physicians. Retrieved April 2, 2017.

Sawyer, R. G., M.D., Tribble, C. G., M.D., Newberg, D. S., M.D., Pruett, T. S., M.D., & Minasi, J. S., M.D. (1999). Intern call schedules and their relationship to sleep, operating room participation, stress, and satisfaction . Elsevier,126(2), 337-342. Retrieved April 2, 2017.

Sawyer, R. G., M.D. (1999, August). Table I [Results of weekly intern sleep/operative logs and monthly surveys]. Retrieved April 2, 2017, from http://www.sciencedirect.com/science/article/pii/S0039606099701741