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From Libby Zion to Jesica Santillan: Many Truths
- The University of North Carolina Press
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from libby zion to jesica santillan many truths barron h. lerner At first glance, the Jesica Santillan case is a textbook example of how experts believe that medical errors occur. There was a human error, when no one at Duke University Medical Center checked that the donor heart and lungs matched Jesica’s blood type. But, in fact, this error actually masked a larger systems flaw, which was an inadequate strategy for preventing organ mismatches. What needs correcting, according to this paradigm, is the system . ‘‘The most important problem identified through this whole sad story [of Jesica Santillan],’’ stated Thomas Murray, president of the Hastings Center, ‘‘is the failure to build a system that would prevent such a disastrous thing from occurring in the first place.’’∞ Yet while this is a reasonable conclusion regarding the events in the Santillan case, it is not necessarily the ‘‘truth.’’≤ This essay, by revisiting the case of Libby Zion, who unexpectedly died at New York Hospital in 1984, demonstrates how di≈cult it is to draw simple lessons from individual cases of medical error. Four reasons are given for this phenomenon: 1) di√erent participants and commentators construct di√erent narratives of events beginning immediately after the mistake occurs; 2) explanations of catastrophic medical errors, like any past events, are historically contingent and therefore reflect the era in which they were constructed; 3) as witnessed by the legacy of malpractice litigation, issues of blame and responsibility—not systems flaws —tend to be the enduring legacy of medical error cases; and 4) the randomness of disease complicates e√orts to prove that errors occurred and that they produced bad outcomes. Although the Santillan case was, in some ways, more straightforward than that of Libby Zion, these factors also interfered with e√orts to draw definitive conclusions about what had occurred at Duke. Thefirstthreeofthesefactorsdrawprimarilyonmyknowledgeasahistorian of medicine. To explicate them, I reviewed standard historical sources, ranging from scholarship on the history of malpractice and medical errors to contemporaneous newspaper clippings and correspondence about the Zion case. The from libby zion to jesica santillan 83 fourth factor stems more from my knowledge as a physician experienced in caring for patients and reading medical charts. Although these approaches di√er epistemologically, I believe that they are complementary. Before studying the ways in which the Libby Zion case has been told and retold, here are the skeletal ‘‘facts’’ of what happened.≥ Zion was an eighteenyear -old student at Bennington College when she became ill in early March 1984 shortly after a tooth extraction. Her symptoms included a low-grade fever and an earache, for which a private doctor had prescribed erythromycin. At home, Zion got worse instead of better and began acting strangely, with periods of agitation and jerking motions of her body. This led her parents, Elsa and Sidney Zion, to bring her to the emergency room of New York Hospital on the night of March 4, 1984. Sidney Zion was a well-known investigative journalist originally trained as a lawyer. The emergency room physician could not determine a clear source for Zion’s temperature, which was 103 degrees, but found an elevated white blood cell count of 18,000, possibly indicative of bacterial infection. He also learned that Zion was taking an antidepressant known as Nardil. Aside from marijuana, she denied any use of cocaine or other illicit drugs. The emergency room physician notified Dr. Raymond Sherman, who Sidney Zion had called before the family left for the hospital. Sherman was an attending physician who had treated both Libby Zion and other family members in the past. The decision was made to admit Zion to the hospital given her fever and strange body movements. On the floor, a nurse noted that Zion was lucid at times but had periods of delirium. Two resident physicians, Luise Weinstein, an intern, and Gregg Stone, a junior resident, evaluated her. Neither knew exactly what was going on, but they were not extremely alarmed. Stone’s admission note raised several possible diagnoses, but highest on his list was ‘‘a viral syndrome with hysterical symptoms.’’ Stone touched base with Sherman. The main plan was to hydrate Zion and to give her Tylenol for her fever, while awaiting the results of other tests. Sidney and Elsa Zion went home around 3 a.m., having been reassured that their daughter was all right. Although what happened subsequently remains contested, some facts seem clear. Zion was given a shot of Demerol, an...