Sunday, March 01, 2009

I so want to retire this blog. I am tired of seeing the same patterns show up at the University of California (UCLA in this case). Elements of those patterns include:

  1. "a culture of noncompliance with the law," (in this case, noncompliance with work safety rulings and OSHA findings)
  2. refusal to address risks (in this case, apparently not warning their employee of the risk of her work, and not training her to ameliorate the risks)
  3. billing for services not performed (government grant awards to run research labs generally include a section to fund proper training, which training was apparently not done)
  4. and possible coverup (claiming safety training had occurred when there was no documentation of such training, when the putative trainee denied receiving such training, and when evidence strongly suggests that no one in the lab had received adequate training)

I am particularly disappointed when these patterns seem to directly cause the death of a 23 year old talented young lady. Ms. Sheri Sangji is only the latest victim of these patterns.

The lack of attention to safety at UCLA does not surprise me in the least. It's apparently routine for lab workers at both UCLA and UC Irvine (the two labs where I've had the most contact) to work without safety equipment in place.

When I was a resident at UCLA, the lack of attention to basic safety protocols for most people was evident. This lack of attention did not extend, of course, to higher ranking personnel. For example, I remember doing anesthesia cases on people who were having extremely bloody surgery done with power tools. Blood spattered well away from the surgical field, and it seemed to be in the air as well. While I was protected only by hospital-issued scrubs, gown, and paper facemask, the attendings either stayed only very briefly in the room (anesthesia attendings), or wore full "moon suits" with battery-powered respirators (surgical attendings). In fact, on the topic of differential safety precautions and infectious disease, I believe it is relevant to point out that one study showed that approximately 20% of low-level health care workers (nurses and residents) seroconverted for tuberculosis every year worked at the Harbor-UCLA ER, while almost none of the attendings did. Not that I'd want more attendings to seroconvert; it's just that seroconversion was obviously preventable for the attendings, and not for others. I think that's a relevant point to make in the context of Ms. Sangji's apparently preventable death.

I don't think that there's any significant American institution, other than the University of California, which could have caused a similar toll of death, ruined lives, large scale fraud, waste and abuse, as documented in this blog and elsewhere over the years, and not experienced at least a major reorganization or perhaps even faded from existence. And yet, the University of California keeps on keeping on.

Update from the LA Times: allegations of possible illegal lab procedures before the fire, and possible evidence tampering after the fire, as well as allegations of a "shoddy investigation." Who would have thought that a story about a 23 year old burning to death could possibly get sadder?

Another update from the LA Times: Cal/OSHA chief to oversee criminal investigation of fatal lab fire. That story contains this statement about Kevin Reed, UCLA Vice Chancellor for Legal Affairs "Reed also accused the family of sending Cal/OSHA a letter 'ghost-written by plaintiffs lawyers' in an 'effort to get some big judgment at the end of the rainbow here.'
Naveen Sangji, a Harvard medical student, told The Times that she wrote the letter."

So, just when I thought this story had reached the limits of reasonably believable tragedy, it just keeps on getting worse. Accusing the bereaved family of ghost writing in order to get a big judgment? I can imagine how that statement would play to a reasonable jury, if the case ever gets to trial. Besides, if those sort of accusations are what Chancellor Reed's states in public, then what is the likely tone of the conversations in the administrative suites overall? Based on Chancellor Reed's public statements, is it likely that safety concerns are paramount in those internal conversations in the UCLA administrative suites?

Update 03/13/10: The bounds of tragedy may have been breached, and UCLA may be well into criminal territory here. Serious lab accident at UCLA in 2007 was not reported. Not only was there a serious burn BEFORE Ms. Sangji was burned to death, but the previous serious burn was not reported to Cal/OSHA, and there are documented episodes of continued unsafe practices BEFORE and AFTER Ms. Sangji burned to death.

The failure to report the previous serious burn to Cal/OSHA suggests collusion by two different groups within UCLA. Firstly, UCLA, as the employer, is obligated by law to report serious workplace injuries to Cal/OSHA. Secondly, the doctors who attended to the burned patient would have been required by law to document that this case was a "reportable" (i.e. required to be reported to Cal/OSHA) case. A workplace burn that required hospitalization -- or, indeed, that required anything other than non-prescription treatment and a single follow up visit -- would have been required to be designated by the attending physician as something that would be required to be reported to Cal/OSHA.

The fact that the reporting was not done, even after an injury serious enough to require hospitalization ... well, it appears that the "culture of noncompliance with the law" is alive and well at the University of California.

Update 12/28/11: looks like criminal charges may actually be filed. UCLA calls these charges for events which led to Sangji's burning to death, "outrageous."

Update 7/28/12:

UC regents strike plea deal in UCLA chemistry lab death


Anonymous said...

Does anybody ever "get it"? Do you think?

Anonymous said...

Unbelievable that nothing ever gets
done to remedy so much!!

Jubal said...

Yes, I am sure that someone gets it. Somewhere out there, there's a student, or lab tech, or patient, who decided to avoid the University of California after reading this blog, and is somewhere safer as a result. Perhaps that person even managed to avoid death by avoiding the University of California. Too bad Ms. Sheri Sangji couldn't have been warned in time.

As for anyone "getting it" within the University, or the State funding agencies, or State or Federal regulatory agencies: I think only a very few people in a position of authority really get it at all. There have been a few temporary changes in the aftermath of some of these scandals, but things soon revert to form. A relevant quote from the aftermath of the Neuchterlin-Gitlin experiments, which led to death and multiple ruined lives among people who apparetly didn't know they were being experimented upon, is “from all appearances, the controversy over the Nuechterlein-Gitlin study hasn't caused any deep soul-searching at UCLA.” I predict that a similar sentiment will soon be obvious in the aftermath to the death of Ms. Sangji.

Anonymous said...

just off-top
when you were at UCLA did you come across Dr. Mark Ghobrial? what do you think of him as surgeon?

Jubal said...

Name doesn't ring a bell.

Anonymous said...

Yes, most of them don't "get it"
because they don't have a clue and since it doesn't affect them they ignore it whether they are in some position to change the circumstances or not.But the ones that do, don't want to bother because they don't think it will happen to them and so the travesty goes on....APATHY is abundant either out of stupidity or
just not caring...
You are so on target with your observations and statements, aren't you afraid that YOU may become the target of some of these

Anonymous said...

Mark R. Ghobrial was a director of liver living-donor transplant program at UCLA from 2000 - 2008 under R.W. Busuttil - who is chairman of Surgery Dep. now.

Anonymous said...

Did you retire your blog?

Anonymous said...

We admire you for your honesty
integrity in these matters.
You are a hero!!

Jubal said...

Thanks for the kind comments. Of course, the standard thing to say when someone says you are a hero is "I don't think I'm a hero, just someone doing my job." That's a well-worn phrase, but it's true in this case. I'm just trying to, as the title of the blog says, make sense of it all, and trying to help others see the patterns that emerge.

As for me becoming a target: well, that's already happened in some ways. Still, I haven't fallen off a building, or died while waiting for a surgery that was never going to come, or had my children stolen from me and sold for research. Whatever has happened to me pales in comparison to what has happened to others.

As for retiring this blog: I think the blog so far has made it's point. The barrier to new postings on this blog (which has, admittedly, become somewhat focused)has become somewhat high. After I've posted about large numbers of deaths, hundreds of millions of dollars of apparent embezzlement, and large scale violation of patient's rights, it's my guess that those who are able to understand the underlying situation will have already done so.

Anonymous said...

It would be very useful if you organize the information you have posted on this blog along with a summary of the current situation along with the patterns. Basically a tight version of your blog and the implications. That would be very helpful to others and might reach more people.