Freezing to death in Michigan

It was confirmed today that another vulnerable senior citizen died from hypothermia following a utility shutoff. John Skelley lost his life several days after his natural gas supply was disconnected.

Hypothermia caused man's death after utility shut-off, autopsy finds

It was reported earlier that "there are certain circumstances under which the utility companies just suspend shutoffs...[including] when the state experiences extreme cold, like it has for several days in the past few weeks."

This begs the question: Just how extreme does the cold have to be in order for shutoffs to be suspended? Is there a specific temperature limit, duration, and/or forecast used? Is that information available? Why or why not? I'm not asking rhetorically--these are real concerns, given that multiple vulnerable senior adults have already frozen to death due to utility shutoffs in the state of Michigan.

Regardless of the answer, the fact remains that the system is a failure, as evidenced by those who have died under it:

---

2009: Marvin Schur, 93, Bay City

Electricity shut off Jan. 13th; body found Jan 17th.

"Marvin E. Schur suffered 'a slow, painful death' inside his home, said Dr. Kanu Virani, who performed an autopsy on the body."

Bay City, MI, low temperatures:

13 Jan 2009: 7 °F (electricity shut off)
14 Jan 2009: -10 °F
15 Jan 2009: -9 °F
16 Jan 2009: -6 °F
17 Jan 2009: -2 °F (body found)

source: almanac.com: Bay City

---

2012: John Morgan, 86, Flint

Electricity shut off Feb. 17th; body found Feb. 20th.

"He's been in that house for over 60 years," she said. "If they would have just did a little check they would have seen that he was a senior citizen." 

Flint, MI, low temperatures:

17 Feb 2012: 31 °F (electricity shut off)
18 Feb 2012: 28 °F
19 Feb 2012: 21 °F
20 Feb 2012: -16°F (body found)

source: almanac.com: Flint

---

2015: John Skelley, 69, Detroit metro

 Natural gas shut off Jan. 19th; body found Feb. 1st.

"69-year-old John Skelley was discovered unresponsive, huddled under blankets in front of a space heater"

Detroit, MI, low temperatures:

19 Jan 2015: 31 °F (natural gas shut off)
20 Jan 2015: 25 °F
21 Jan 2015: 24 °F
22 Jan 2015: 18 °F
23 Jan 2015: 18 °F
24 Jan 2015: 15 °F
25 Jan 2015: 11 °F
26 Jan 2015: 11 °F
27 Jan 2015: 11 °F
28 Jan 2015: 13 °F
29 Jan 2015: 13 °F
30 Jan 2015: 15 °F
31 Jan 2015: 3 °F
01 Feb 2015: 14 °F (body found)

source: almanac.com: Detroit

The NOAA weather graph for the Detroit metro shows at glance that the daily low temperature dropped below freezing on the day Mr. Skelley's gas supply was disconnected, and continued to be below freezing each successive day until his body was found on February 1st.

---

In the MPSC (Michigan Public Service Commision) staff report, following its investigation of Skelley's death, they recommend that "Consumers [Energy] should identify ways in which the company can communicate with customers, beyond requirements of the rules, about the provisions of the Medical Emergency and how to postpone shutoff of service in the instances of certified medical emergencies." However, this still puts all the onus on the elderly customer, who may not be suffering from a medical emergency -- until an abrupt disconnection of utility service causes such an emergency!

Utility companies are playing a kind of Russian Roulette...

What the utilities are doing in disconnecting vital utilities in the winter months is playing a kind of Russian Roulette. Except imagine the gun is pointed outward, at the customer's head. The probability of a live round being in the chamber is the same probability as that of a vulnerable adult living at the residence who the company is not aware of. The suggestion the communication be improved is a cynical, shameful way of saying, "We're going to fix this by improving the probability somewhat of a bullet not being in the chamber, by getting more folks to communicate with us in advance." What this "solution" ignores -- besides the fact the there is still a real probability of people falling through the cracks -- is that there is a way to eliminate the threat of wintertime utility disconnections causing death: check on whoever might be living at the residence! How hard is that to figure out? Otherwise, you're still playing Russian Roulette!

And why are they not checking on people when they disconnect service?

“When we do go to disconnect service, we go right to the meter now,” Dodd explained. “It’s much safer for our employees because of the possibility of, you know, threats of violence.”

In other words, never mind possible risk to vulnerable residents, it's some vague possible threat of violence toward utility employees that they're worried about. That's apparently their excuse for not making contact to see if anyone vulnerable might be at home and ascertain whether the person can comprehend and be able to effectively deal with a potentially life-threatening loss of utility services.

Michigan isn't the worst...

If you think I'm picking only on Michigan, that's incorrect. It's only by the grace of God that these deaths didn't happen in my home state of Minnesota, which has an even more shameful and risky "Cold Weather Rule", treating potentially vulnerable seniors no differently than anyone else:

1. Can my heat be shut off in the winter?
YES, unless you take steps under the Cold Weather Rule (CWR) to protect yourself.

• You must contact your utility to apply for protection from having your heat shut off.

• This is true for all residential customers, including senior citizens and families with young children. 

The incidence of dementia among the elderly increases with age, but its onset can occur gradually or rapidly at any time, and can interfere not only with daily functioning, but also the ability to navigate complex "rules" imposed on an individual, including the ability to perform some daily activities such as paying bills. That appeared to be the case with 93-year-old Marvin Schur, who was tragically found frozen to death, with money clipped to utility bills sitting on his kitchen table as if he were attempting to pay. To imagine his struggle, consider that hypothermia can further degrade a person's ability to think clearly, as is well-documented in the medical literature.

Many elderly people 'aging in place'...

Most Americans would prefer to age in place, and, indeed, with the Baby Boom population reaching old age, there will be many more elderly people living in their own homes. It's critical that this population is well-protected and looked after.

As these three men bear witness to, their lives were recklessly terminated under pain and uncaring abandonment -- disconnect and dash! -- as the coldness of the grave was imposed upon them before they were even buried, much less ready to die.

 

For Mohammed Zeid of Gaza, Age 15

There is no stray bullet, sirs.
No bullet like a worried cat
crouching under a bush,
no half-hairless puppy bullet
dodging midnight streets.
The bullet could not be a pecan
plunking the tin roof,
not hardly, no fluff of pollen
on October's breath,
no humble pebble at our feet.

So don't gentle it, please.

We live among stray thoughts,
tasks abandoned midstream.
Our fickle hearts are fat
with stray devotions, we feel at home
among bits and pieces,
all the wandering ways of words.

But this bullet had no innocence, did not
wish anyone well, you can't tell us otherwise
by naming it mildly, this bullet was never the friend
of life, should not be granted immunity
by soft saying—friendly fire, straying death-eye,
why have we given the wrong weight to what we do?

Mohammed, Mohammed, deserves the truth.
This bullet had no secret happy hopes,
it was not singing to itself with eyes closed
under the bridge.

source:  The Poetry Center at Smith College

Accretive Health and "unnecessary aggressiveness"

If you haven't been following the discussion on Accretive Health, the commentary has been overwhelmingly negative regarding their aggressive and predatory behavior toward patients in the hospital, behavior which has been documented by numerous patient affidavits submitted to Minnesota Attorney General Lori Swanson. However, there are a few authors who took a different view and needed to be challenged, and you can read more from DeadlyDismissal in the comments sections of the following:

On Forbes:
Why the media can't handle the truth about Accretive Health

Obamacare won't eliminate the need for bill collectors like Accretive Health

On HIPAA Blog:
More on the Accretive Case: Al Franken puts on a show.

Over at the HIPAA Blog, blog author Jeff Drummond did not post my last reply, despite that I submitted it 3 separate times, so I'm including it here:

If one reads through the comments section in the article you cite, including the thumbs ups and thumbs downs, it becomes clear that your opinion is not the mainstream one--in fact, it's decidedly at odds with the prevailing reader opinion. Moreover, one persistent commenter was repeatedly thumbs downed and then corrected for using the same argument as yours. The response was that people who testified at the hearing weren't people who "don't pay their bills" as you both suggested, nor would they agree that the hospital "should never ask them for money." 

I'd ask you to consider that emotion isn't always tied to hysteria or lack of reason. Sometimes it might be a clue that empathy and decency have been too far submerged. I think the leadership at both Fairview and Accretive Health now agree that things might have been better done differently, at least in some instances, and I hope all are working toward changing negative aspects of that former culture. Otherwise, a regulatory nudge in a new direction may be required.

Anna Brown and Appropriate Emergency Medical Care

[My (edited) comments to the following copy of an original web article from White Coat's Call Room blog are highlighted below.]

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. 

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, so let's not be so quick to label her a “frequent flyer”]

She arrived at the third hospital at 11:45 AM. At the third hospital,  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. 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. 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 [because they were called by who?] 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. 

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 the 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 heaven'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 or your 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. Should that be a death sentence?]

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