Power imbalance killed Brian Sinclair

Hey there, time traveller!
This article was published 17/12/2014 (3980 days ago), so information in it may no longer be current.

Have you ever walked into a hospital, afraid you might die if left alone? Could you imagine being labelled a drug addict because of how you looked? Have you been ignored while a family member suffered and eventually died?

These are whispered stories that indigenous patients share behind closed doors and under their breath. They feel ignored, stereotyped and outright hostility when accessing health care. There is mounting evidence — increasingly conclusive — that this is more than simple perception by indigenous patients. This is their reality.

I believe health professionals do not begin their days wishing harm to patients. But harm did happen when Brian Sinclair died after 34 hours of being ignored in a hospital waiting room, though it started much earlier than that.

Until you experience the health care system, it is difficult to fully comprehend the incredible power health professionals have. We are the points of access. The system is built — for the most part — to accommodate our needs, wants, schedules and habits of work. This is not wholly unfair; our training and experience give us special insight into both the nature of disease and how to triage the immediacy of care. But quite regularly, a darker side to this power imbalance appears.

If patients annoy us, we can ignore them. If patients are aggressive, we can divert or delay. In many ways we coerce, forcefully encourage and lightly lean-on patients to accept our best judgment. We can also deny or withdraw treatment in situations we deem unnecessary.

Brian Sinclair’s inquest report is very clear on several points. His home-care nurse became frustrated with his care and withdrew necessary catheter changes — Brian could not void his urine and required a tube to empty it. This was done unilaterally, with no effort to follow-up on care. It was known this could lead to serious complications. Power imbalance to the home-care nurse.

Brian went to the HSC almost a month later, though there is no indication whether his catheter had been changed in that time. He presented to the triage assistant for care and there is clear video they conversed. There was no evidence of intoxication. Sinclair appeared oriented and of clear mind. He was not abusive in the way he spoke or acted. He followed directions to sit in the waiting room where he remained the full 34 hours. Power imbalance to the triage assistant and the security staff.

From experienced providers to inexperienced trainees, we hear similar testimonies. He was drunk. He was warming up because he was homeless. Someone else was coming to assess him. Power imbalance to the health professionals.

After his referral to the emergency ward, Brian was noticed by many, but approached by none. Many assumptions were made, none with any attempt to find evidence to sustain them. Even in death, staff had to be encouraged to assess him.

In the aftermath of apologies, a common theme is apparent. “We failed Brian Sinclair.” The health care system. The regional health authority. The Winnipeg emergency room.

There is a striking lack of “I failed Brian Sinclair.” At multiple moments before and during that fateful night, many individuals could have reached beyond their assumptions and assessed a human being instead of a caricature.

In taking collective responsibility, we lose the opportunity to take account of our personal failings in treating patients. Worse yet, we further homogenize these situations through bias, discrimination or racism and stop talking about people and instead label patients as problems. We blame language barriers, lack of a patient advocate, poor policies and procedures, insufficient staffing and infrastructure, among others. We ignore our own ability to change the course of our patient’s care and make excuses for our own abuses of power.

In the end, if a single person acknowledged the lack of power Brian Sinclair had in our health care system, his outcome would have been different. There would have been collaborative decision-making. Bias would have been challenged. An emergency room assessment would have been made. A person would have replaced a caricature. Brian would have mattered.

A medical colleague recently shared how power imbalances and bias affected his own care for a ruptured appendix. Having definite First Nations features, his initial assessment by a trainee lacked a physical exam. His perception was that the student was afraid to touch him. Misdiagnosed, he could have suffered significant harm had the supervising physician not done a physical exam himself. “In the end,” he said, “It doesn’t matter what I do or how successful I am, when I put on that hospital gown I become just another Indian.”

Until we acknowledge the very real consequences power imbalances and bias have to patients, there will continue to be many more cases like Brian Sinclair’s. More than likely however, they will remain whispered stories that indigenous patients share behind closed doors and under their breath.

Alika Lafontaine is an anesthesiologist practising in Grande Prairie, Alta. He is vice-president of the Indigenous Physicians Association of Canada and was an Action Canada Fellow in 2013.