Our Fractured Healthcare System: How One Patient Died Just Outside the ER

I read an article over winter break about a young woman’s death from an asthma attack. But the tragedy is that she died just a few feet away from the emergency room. Her name was Laura Levis, and she was 34.

A little after 4 a.m., Laura went to Somerville Hospital, a short walk from her apartment, because she felt an asthma attack coming on. She chose to walk the 375 feet to the hospital because her attacks came on gradually, and so she figured that she had enough time to get to the hospital, get treated, and go along her day. Normally, she would have gone to Mount Auburn Hospital with her husband to get treated for her attacks, but because of personal reasons she wen to CHA Somerville Hospital instead. Regardless, the change in hospital should not have played an impact.

Except that she didn’t make into the emergency room of CHA Somerville. She died a few feet away from the entrance.

What happened was that when Laura made it to CHA Somerville there was no bright “EMERGENCY” sign that we normally see at hospitals. It was darkness, and because Laura was unfamiliar with the hospital she chose to go to Entrance A because it was more lit. But when she arrived the doors were closed even though she saw a sign that said “EMERGENCY CHECK-IN” through the door. Panic set it, and for those with asthma, panic can worsen the attack.

While the hospital had a sign to direct patients to the actual emergency room, it’s unclear if Laura saw the sign. Surveillance video shows her walking in that direction, but she did not make it because when she was 29 feet away from the entrance she couldn’t walk anymore. The attack had become significantly worse that her only hope was to sit on the bench and call 911.

It gets worse. When Laura called 911 she was connected with a regional operator, and so Laura wasted no time explaining her dire situation. She explained that she was having an asthma attack, that she was outside the emergency room at Somerville Hospital, and that she felt that she was going to die. The operator connected with the local police, and so Laura had to explain the situation, again. But because Laura was in the middle of an asthma attack, she could hardly speak at the end of the call, so the regional operator jumped in the call.

“She’s outside of the Somerville Hospital,” said the regional operator, jumping in while still on the line. “She’s having an asthma attack. She can’t get into the hospital there.”

A satellite ping from Laura’s cellphone showed her location to be 68 Tower Street, but the police dispatchers needed a more precise location. They asked if she was at 230 Highland Avenue, the only address the dispatcher had for the emergency room because the hospital had not assigned its emergency room a specific address on Tower Street. But Highland Avenue is on the other side of the hospital, nowhere near Laura’s location. Had the regional operator stayed on the line with the police, then she could have told them that she was outside the emergency room.

Laura’s location is indicated by the red block. The ping off her cellphone is at location #1. But the dispatcher sent the ambulance to location #2. (Source: The Boston Globe)

At 4:25 am and 36 seconds, Laura uttered her last words.

I’m outside.”

At approximately 4:39 am, Laura was brought in the emergency room. About 13 minutes had passed without oxygen to her brain. Her chance of survival was slim to none.


SO WHAT HAPPENED?

When the police responders realized that Laura could no longer speak, they called Cataldo Ambulance to get to her location, which was still inaccurate and unclear at this time. The police then called the Somerville Fire Department and gave them a vague address saying that she was “probably on the Tower side”, neglecting to mention a very important piece of information that her cellphone pinged at 68 Tower Street, at the top of the hill. Because the information the Fire Department dispatcher received was vague, he had to rely on personal experience and went to the bottom of the hill. Again, more time wasted. The less likely that Laura was going to survive.

What is even more incredulous is that there is not direct line to the Somerville emergency room. So the police dispatcher had to call the night receptionist, who directed them to charge nurse. This whole process took 30 seconds. A nurse picked up the phone and went to go look for Laura. This nurse was sitting in Entrance A, the place Laura had first stopped at but found that its doors closed. According to the surveillance videos, the nurse takes one step out from the emergency doors and looks but doesn’t find Laura. The nurse would go back inside a mere 12 seconds later.

Laura’s location is the red block with the #3. The nurse is at Entrance A, 70 feet away from her. Entrance B is the emergency room Laura was trying to reach. It was only 30 feet away. (Source: The Boston Globe)

The nurse should not have even been the one to look for Laura. There was a security guard desk in Entrance A, but that desk was empty because the guards were on “patient watch”. Yet, one of the patrol officers overhead the nurse say something about the police and someone being locked out. The officer never asked the nurse for more info, and the nurse did not tell him anything.

Once she was done searching, the nurse told the dispatcher that she would call Laura’s cell phone. Except the nurse called from inside the emergency room, and so if she had called Laura’s phone number while standing outside she could have heard it ring or seen it light up. Laura was only 70 feet away from the nurse.

During an investigation, the nurse told the investigators that she could not see anything because it was “pitch black”, but the nurse never conveyed that information back to the police dispatcher. But if it was “pitch black”, then how was a surveillance camera able to clearly record Laura on the bench, 70 feet away from the nurse? There was enough light, and hospital officials would later agree.


IT GETS WORSE.

While Laura’s husband was by her bedside in the ICU, no one said a word to him that Laura was locked outside that door the night of her death. Hospital staff told him Laura had collapsed outside of the hospital and was unable to give the first responders an exact location, and he certainly didn’t think that any of them would lie to him. That she was less than 30 feet away from the entrance of the emergency room. She was that close to getting the care she needed.

After Laura’s death, her husband published a beautiful tribute and even thanked the doctors, nurses, respiratory therapists, and other staff members for their help. But for Somerville Detective Michael Laura’s death stuck by him. And so, Perrone conducted a full investigation into her death that he uncovered details that were not known by Laura’s family.

Once Laura’s husband read the police report, he went straight to Lubin & Meyer, one of the largest medical malpractice firms in Boston. Laura’s husband wanted to sue Cambridge Health Alliance, the organization that ran the Sommerville Hospital, a public entity. But because of a law enacted in the 1970s, it protects public hospitals from being sued for more than $100,000 and indemnified their employees.

Because malpractice firms operate off contingency fees, Lubin & Meyer would only receive, at maximum, $40,000 of the $100,000 verdict. $40,000 would certainly not be enough to bring her case to court.

Four weeks after Laura’s death, the Public Safety Officers held a meeting half of the emergency department’s staff to discuss “expectations of staff and public safety partners and providing a safe environment for both the staff and patients” according to a report by the Department of Public Health (DPH). Guess who has NOT at the meeting? The charge nurse who looked for Laura the night of her death.

The DPH’s report also found numerous patient-safety violations at Somerville and that the circumstances surrounding Laura’s death were not reported to DPH.


So Let’s talk.

If you are reading this and not morally outraged, then you and I need to sit down and discuss this story. Otherwise, I hope you are upset like me.

Let’s start at the beginning.

Laura was an active, energetic 34-year-old. You know what’s good for people with asthma? Being active, and Laura was certainly active. Yes, she was prone to attacks, but she had a routine that she established with her husband. She knew her attacks came on gradually, and so she knew she had time to walk to the Somerville emergency room. Yes, Laura most likely should have called her husband or her family, but that is not important. Yes, if Laura had a nebulizer treatment at home then perhaps she would have been able to treat her attacks herself. But keep in mind, the cost of these nebulizers varies, and we have no idea if Laura had the monetary means to get one at home. Or perhaps she simply felt more comfortable having her attacks treated in the emergency room.

Everything went wrong as soon as she was unable to get through the doors in Entrance A. There should have been a bright light indicating where the emergency room is at Somerville Hospital. Why was there no light? Why is our nation’s 911 infrastructure not equipped to work with our wireless world? Why was there so much communication breakdown among different providers and responders that Laura had to repeat her story multiple times? Why was information omitted among dispatchers and the nurse?

Why did the hospital not say anything to Laura’s husband and family? How will we protect individuals when they are hurt by public hospitals? Why is it that malpractice law firms fail as advocates for our patients?

Under the Emergency Medical Treatment and Labor Act (EMTALA), Somerville Hospital should have searched for Laura within 250 yards of the hospital, this includes sidewalks, parking lots, driveways, and other buildings. Laura was 70 feet away from the nurse and 30 feet away from the emergency room entrance. The 100 feet between Entrance A and Entrance B should have been searched because 100 feet is approximately 33 yards.

Leaving off with some good news.

Despite all the pain and frustration that Laura’s husband and family endured in the aftermath of her death, Laura’s husband received a phone call from the U.S. Department of Health and Human Services (HHS), Office of Inspector General. Somerville Hospital had been accused of violating federal law by denying Laura access to emergency care. The hospital had to cough up $90,000 to the government.

Our fragmented healthcare system has hurt so many people, and will continue to hurt more people if we don’t try to fix it anytime soon. We need to have robust communication systems where dispatchers can talk to each other and pass along information so that the patient need not to repeat the same lines over again. We need to strengthen our 911 infrastructure so that GPS coordinates are accurate. We need make sure the hospitals’ surrounding environments are lit up and helpful to patients. We need to encourage our physicians, staff members, and nurses to keep looking if they can’t find it. We need a less fragmented system.

Let’s empower patients and put them back in the center of care. Let’s minimize risk and maximize benefit. Let’s be innovative.

Let’s be better America.

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