THE 911 Truth

What was puzzling to me was news coming out of California that a “Nurse” refused to administer cardiopulmonary resuscitation (CPR) on an 87 year old resident.  

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 A Midwinter’s Philosophical Puzzle:  THE 911 truth.

A mountain blizzard rages outside the windows, classes are cancelled at the University… being socked in for the day, one gets philosophical. 

So I meander over to a philosophy blog where they argue to the point of making reality, which feels so real, puzzling.

What was puzzling to me was news coming out of California that a “Nurse” refused to administer cardiopulmonary resuscitation (CPR) on an 87 year old resident.  Upon witnessing a collapsed resident gasping for breath, the nurse called 911.  The transcript of the 911 call was harrowing.  Over the 7-minute call the dispatcher begged the nurse to administer CPR to save the woman’s life.  The nurse wouldn’t, instead saying that the independent living facility’s policy prohibited her from administering CPR.  The dispatcher appealed to the nurse’s humanity.  She asked if there were anyone around who could save the woman.  The nurse, even though qualified herself, said that she would not ask others because they wouldn’t know how.  Ms. Larraine Bayless was pronounced dead at the hospital.


My philosophical readings this morning had me asking my own puzzling question: “What is THE truth”; which is in contrast to asking the question “what is truth”.  A blogger named Michael Lynch was citing other philosophers saying that they get stuck trying to answer questions that only lead to the frustration of further quarrelsome questions.  He thinks philosophy gets stuck because philosophers are out looking for THE truth (my interpretation); a single truth that can be surmised from reducing some explanation to its core… kind of the way science approaches problems.


For the nurse in California, the moral question of saving Ms. Bayless’ life got reduced down to the company’s policies that seemed to be aimed at reducing liability than acting to save lives.  For her, it was THE truth.

For Lynch, a single philosophical version of THE truth falls short.  The truths of science are truthful because they correspond to the physical world.  But the truths of mathematics or politics conform to different realities; Morality, with yet another truth.


In California, within Brooksdale Senior Living’s facility, a single version of THE truth failed.  Ms. Bayless died, the company is under scrutiny and the target of public anger, and the rest of us are puzzled.

This has happened before in other places, including hospitals.  I remember when I was earning my Lifeguard certification through the Red Cross.  I was taught that the second anyone started a rescue, throwing a flotation device or going into the water or beginning CPR, they are personally responsible (liable) for the victim’s outcome.  Even at my young age I was aware of the paradox of the two realities…the treat to the victim vs. the threat to me.

Our employees face the same puzzle sometimes.  They see risks being taken. Sometimes they take risks themselves.  What is THE truth driving these behaviors 

A production quota

        (as in the case of a pipe manufacturer who recorded an injury per employee over a decade);

Avoiding regulatory actions

          (as in the case of Massey Energy’s coal mine explosion that killed 29);

A delayed schedule costing millions

          (as in the case of the Deepwater Horizon explosion)? 

The list goes on and on. 

I’ve written about it in a couple of previous blogs: “Cowardice”, “Tackling”.


Build an alternate truth.

One where any employee can stop production if they are concerned about a safety issue.

One where leaders adopt a discipline to ask about the safety implications of decisions.

One where employees can report minor injuries and close calls without fear of unjust discipline.

One where employees have decided to encourage peers to coach each other when they see risk.


Do this before having to call 911.


Timothy Ludwig’s website is where you can read more safety culture stories and contribute your own.  Dr. Ludwig is a senior consultant with Safety Performance Solutions (SPS:, serves as a commissioner for Behavioral Safety Accreditation at the non-profit Cambridge Center for Behavioral Studies (CCBS: and teaches behavioral psychology at Appalachian State University, in Boone, NC.  If you want Tim to share his stories at your next safety event you can contact him at



The Discussion:

Tim, what a truly philosophical blog. How nice to see you struggle as the ‘nurse’ and others with ‘what is reality’ and how do we define good, etc. Really beautiful and so far removed from just an R+, R- or P approach.  Certainly rules drive many kinds of bad and not so bad behavior but you did not go down our usual path. You really did not try to solve the problem or judge the woman’s history of reinforcement. Build alternative ‘truths’—speaks so much to how the world and our behavior is seen.  If we then translate the ‘how to build’ we have a whole new way to approach our clients/ the world. LOVE IT.

Darnell Lattal, Ph.D.


ADIAubrey Daniels International


Dr. Ludwig,

Like you (and huge number of others), I was fascinated by the Brooksdale Senior Living incident. As you know it was much bigger than a nurse locked in a Catch 22. Your personal experience with lifeguarding was a great example.

As usual there is no single "root cause" for this incident. Many commenters have expressed outrage over the Nurse's decision. I would suggest that many of them have never faced such a dilemma. As usual the blame gets placed at the lowest level... where rubber and road actually come together.ed

Having been a plant GM for 10+ years, I was placed in similar situations as were the 300+ employees who worked under my direction. The tendency is always for upper part of the "food chain" to want the hides of the lowly person or persons who committed the dastardly crime of violating company policy or for not having the "common sense" to violate company policy when it's suggested that one could have done that without corporation's equivalent to capital punishment. I have witnessed heroic actions that have saved serious consequences  and have been applauded by the CEO. Those actions were, in fact, violations of the company safety rules. I have seen almost identical actions where the "would-be" hero was killed! When that happened the CEO rightly wanted an in-depth investigation to ultimately determine who, in the line of authority, was responsible for the numerous oversights and lack of enforcement of the rules that invariably come out! The results usually led to discipline at the lowest level... never on company policy makers.

Striving for perfection in S&H is mandatory. Fixing the processes involved is also mandatory. Too many winks occur when a risk produces a reward. Example: Removing an obstacle in the nick of time avoided a costly shutdown (production quota you referred to), but the method it was done was a violation of the safety rules. Now we have a dilemma! Damned if you do and damned if you don't. Nurse's case: Scenario one: Administer CPR and patient dies anyway: Nurse guilty of violating company policy and cause of lawsuit to company! Certain discharge. Scenario two: Administer CPR and Patient lives: patient and family happy, nurse happy, nurse supervisor reports her to bosses. Reprimand and discharge. Case never reaches media attention. Nurse knows she did the right thing. She's unemployed and has a blemish on her resume (defied company policy) that may limit her working in her profession again.

You are so right. The Truth is in the eye of the beholder!  

You mention that employees should have the right to shut down the process or equipment if he/she believes it to be an S&H issue. Wow! Talk about a can of worms. While it sounds noble and very common sensical, I suggest it is not always practical. There must be some fences built before the right to shut down unsafe conditions is given to any employee. The employee making those decisions must have knowledge about the process. Along with a vast majority of good, knowledgeable employees, comes a group who are not quite in that league. I've witnessed some amazingly dumb and sometimes deliberate (union troublemaker trying to prove a point) decisions made by employees acting on their own that have caused many more safety incidents than would have been caused by taking the extra time to report the incident to someone more knowledgeable. The unintended consequences of shutting down a piece of smoking equipment in a larger process can wreak havoc and create great danger. Many employees are just not knowledgeable enough to make those decisions. 

As you know the key is trust and communication. In the plant I mamaged all control operators were given the authority to shut down a generating unit without asking permission when they deemed a situation was too dangerous to operate. My philosophy was that I would rather explain why we shut it down incorrectly than why we kept it running until a disaster shut it down for us! The trust we had in the competence and judgement of our unit operators was solid and their belief in management standing with their decisions was just as solid.

I really enjoy your blog. 

Dan Lambert

West End, NC

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