I don’t like to pre-judge a legal case before it’s been adjudicated. So instead of pre-judging this case, I’m going to wonder about it out loud in as non-judgmental fashion as I can muster, playing the role of a chatty, colloquial, self-appointed investigator tasked with getting “to the bottom” of the matter, but in a sense of that broader than the narrowly legal.

Suppose that you’re a pre-school given the responsibility of caring for a child with a severe dairy allergy–severe enough to kill him if he eats the wrong thing. Death, I assume, is a serious matter, and merits being taken seriously. So I’d assume that you’d take measures to flag the child during lunch or snack, and make sure he doesn’t eat the wrong thing. If his dietary restrictions were merely a matter of finicky tastes or even religious dogma, you could afford to slip a bit. But if the restriction is a matter of life and death, you couldn’t. So I would make sure that someone was tasked with giving him a non-dairy meal. Or something like that.

But suppose that you do slip, and feed a severely allergic child a grilled cheese sandwich. The child now shows signs of going into anaphylactic shock. Preliminary question, not meant to be rhetorical: do you know what anaphylaxis is?

I’ll assume you do know. Because if you didn’t know, my question would have to be: how is it that you manage to work with kids but don’t know what anaphylaxis is? Which would be too long an investigation for a blog post.

But if you know what anaphylaxis is, you know that an Epi-Pen is the thing to have. So: does your organization have one handy?

Often, Epi-Pens are not distributed in places like this for reasons of liability (or fears of liability). An Epi-Pen wrongly administered can cause serious injury.* So if they were widely distributed, we could with equal ease be reading a story about the kid who got the Epi-Pen shot and suffered severe tissue damage because he didn’t need it. But if that’s the reason, notice that the underlying issue is ignorance. We don’t distribute Epi-Pens because we don’t trust people to know how to use them. So we put up with a few dead kids with anaphylaxis to save ourselves the trouble over the few dead kids who might die from misadministration of an Epi-Pen–treating the high likelihood of misadministration as a given.

Sorry, I was supposed to be investigating, but I’ve been editorializing. Let’s get back on track with our investigation.

OK, so you fed the kid dairy, he’s now going into shock, you know exactly what that is, but for liability or cost reasons, you don’t have an Epi-Pen. What now?

Well, you face a choice. You could call 911, or you could call the kid’s mom. If you call 911, the ambulance comes, and either it has an Epi-Pen or it takes the kid to an ER where they have one. And the kid probably lives, though it’s not a certainty. Or you call the mom. The mom drives there from work, which takes awhile. Maybe she has an Epi-Pen in her purse. I mean, she’s Mom, right? Mom has everything in her purse. And as we all know, the presence of Mom is magic: Mom can soothe away every ache, including anaphylactic shock. But not this time.

So Mom drives in a huff to the ER. In a huff because unlike the EMTs, Mom has an emotional investment in the child. Which could cause an accident! But luckily doesn’t. Or not so luckily, because the child dies. Granted, death wasn’t a certainty, but time was of the essence, and a lot of it got wasted here, so it was highly probable and predictable. So here is my question: yes, Mom is magic, and yes 911 is a bother. But what exactly made you gamble on Mom over the EMTs?

Final question. My significant other Alison used to work in social services in New York City, the self-appointed center of Western civilization, and can’t stop complaining about the incompetence and corruption she found there. “People don’t get it,” she fumes. “They just don’t get it. They’ve never seen it, so they don’t get it.” Well, Ali gets emotional sometimes. But this case makes me wonder. Does she have a point? Was this an “isolated event” or is it par for the course? Not judging or blaming anyone. I just want to know. And so, I suspect, should a lot of us.

*It’s not entirely clear to me whether the use or misuse of an Epi-Pen can cause death.