About six months ago, one early Saturday morning around 2:32 a.m., my critical care transport team was urgently dispatched to retrieve an 11-year-old male patient. He was having recurrent and refractory grand mal seizures, which means he was violently and uncontrollably seizing and not breathing. Our mission was to retrieve him from a small community hospital and transfer him to a large children’s hospital, with hopes that he could survive with as minimal damage to his brain as possible. With ambulance sirens blazing and cautiously driving through red lights to expedite our arrival, I knew the young boy’s life depended on us getting him into the care of a pediatric critical care neurologist at a children’s hospital.

When we arrived the young Latinx boy had just been intubated. I could smell and see vomit near his head. His bed linens were soaked with urine from loss of bodily control. Smears of blood and used medical supplies were all over the floor. There were about six staff members around his bed. At one point, the doctor walked up to me frustrated and said he couldn’t get the lumbar puncture done and walked away; it’s an important test to check the spinal fluid for infection.

Nursing staff members were left to clean up the young boy. His non-English speaking parents were in the waiting room crying and pacing in fear because they could hear all the commotion and chaos around their son but did not understand what was happening. The primary nurse then proceeded to give me a report and as I listened, I could hear the remainder of the staff on several occasions say, “just let them do that there,” meaning let the next hospital take care of it.

Before we began the hospital transfer, I asked what treatments and procedures they were postponing for the next hospital. Upon looking at the young boy, I already knew what hadn’t been done. I was disappointed. I needed to set him up for survival by ensuring necessary devices and medications were in place and administered so I could safely transport him in the ambulance across town. In just a split second, I had already anticipated anything and everything that could go wrong and wanted to be prepared. So, I insisted that certain things be done or started prior to our transport. I also pulled the parents to the bedside so they could see who was caring for their son, but more importantly, that they were able to see their son.

It was important to me that I explain in real-time what was happening via a Spanish translator. And I’m glad I did because some of the young boy’s stomach contents had started to go into his lungs. His temperature was now 103°F and he was becoming severely septic. I wanted his parents to know what I was doing and that I would do everything I could to take excellent care of their son in case this was their final moment with him.

But why did I have to question the staff there? Why did I have to explain the significance of these customary interventions to the white providers in the room? Did they already know what to do and just didn’t want to? Were they being lazy? Did they forget? Is it because the child didn’t have insurance? Was it because they were Latino?

I can’t say with certainty as to why, but those are questions that I too often find myself asking when it comes to patients of color.

In my experience, this has become far too common. To me, this was another example of how complacency, implicit biases and racism contribute to the disregard for life. When providers fail to do what’s right and timely for patients, that’s when people die in the ER. As Dr. Martin Luther King, Jr. once said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Now, what would have happened if this child died?

Would the predominately white medical staff have admitted to the parents they didn’t do everything they could have? Or would they have said they did, thinking the parents would never know? How is a patient or patient’s family to know health care providers are doing everything they can? According to patient safety experts at John Hopkins, it’s estimated that more than 250,000 deaths a year are from medical errors. But medical errors aren’t just doing things like giving the wrong medication or performing the wrong site surgery. It includes errors in clinical judgment, lack of surveillance, failing to act timely and delay in care — and it includes omission of care just as much as it does performing erroneous care.

This brings us to the nationally publicized case of nurse RaDonda Vaught. She was a neuro ICU nurse who was criminally charged and found guilty of negligent homicide and endangerment of an impaired adult. An elderly woman died when Vaught administered the medication Vecuronium, a powerful paralytic instead of the ordered drug Versed, a sedation medication intended to help manage the woman’s claustrophobia while she undergoes a PET scan. If Vaught had stayed with the patient, as she was supposed to, she could have likely caught her error early on. Instead, the woman was found unresponsive and not breathing 30 minutes after the Vecuronium was administered.

The patient would undergo resuscitation efforts and be placed on life support, but had already sustained permanent and irreversible brain damage from the lack of oxygen. The family would later take her off life support and she died. Now, while Vaught didn’t intend to harm this patient, it was her complacency and several missteps that would contribute to her substandard nursing practice while charged with the important role of caring for someone. Now, health care providers and groups all around the United States are concerned that her guilty charges will set a dangerous precedent for future clinicians to be criminally charged for medical errors, which many believe would contribute to a culture of health care providers hiding their mistakes.

As a professional community, is that really the stance we want to take? What’s the message we’re trying to send? What would happen if airline pilots, bus drivers, police officers and other disciplines we rely on to protect our public health and safety acted with a similar work ethic?

As a health care provider, I didn’t have to think long or hard about this, especially considering my father died of a massive heart attack in 2001 when he did not receive adequate attention, surveillance or timely treatment. Complacency may not have been what the doctor ordered, but it was the treatment my father received.

The ugly truth is health care is not exempt from systemic racism and injustice. Implicit biases and white privilege exist, and quite frankly, many of the C-suites of health care systems operate in a profit over patient fashion. If profits didn’t come first, wouldn’t they be as equally outraged and do something about the inequity I see daily that has been adopted as status quo? As a Black woman, raising Black sons, as a consumer of health care myself, as someone who lost their father because of a broken health care system, as someone who has always had to work harder than my white counterparts and knows what racism looks and feels like — this is wrong.

Now the shoe is on the other foot with the Vaught case. Vaught, and many other health care providers and health-related companies who believe her guilty verdict is unfair, is more than white privilege. Many of them think her case should’ve been handled civilly, which is health care privilege trying to buy their way out of repercussions for wrongdoing. At Vaught’s sentencing, she received three years of probation and avoided any jail time. And the health care community thinks this is injustice?

The BIPOC community knows what injustice is. For several years it has been subjected to unfair and unequal standards. Even people with minor offenses have been thrown under the jail for years. We all probably know someone who has committed lesser crimes than abuse and homicide that are serving out a harsh sentence.

The point is that inequality, injustice, complacency and systemic racism are rampant in health care. It’s in the treatment you get and don’t get, and even in the punishments handed out to people who continue to perpetuate the injustices while hiding behind the guise of health care. My goal in sharing this is to help increase people’s awareness of how and why people die in the ER. It’s not always God calling us home; it’s sometimes the providers moving up our homecoming.

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“Nurse Alice” Benjamin is a nurse practitioner, speaker, educator, author and mom.

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