FHEA’s Scrubs and Subpoenas: Tales from the Witness Stand is back with an all-new season. Dr. Sally Miller returns alongside cohost Dr. Wendy Wright, Fitzgerald faculty member and adult and family nurse practitioner. Both serve as expert witnesses in malpractice cases across the country.
Wendy brings 34 years of NP experience and owns a New Hampshire family practice with 11 NPs and 6,000 patients. The premise of the show hasn’t changed: no judgment, only lessons. As Wendy puts it, every case she reviews makes her think, “but for the grace of God go I.”
The Season 2 premiere follows a 10-year-old boy whose diagnosis was missed across more than a dozen visits. It’s a hard lesson in pediatric diagnostic reasoning and medication history.
The Case: Persistent Right Upper Quadrant Pain in a 10-Year-Old
A 10-year-old boy came to his longtime PCP with a few days of right upper quadrant abdominal pain near his rib cage. He had no fever, nausea, vomiting, or stool changes, and was laughing and talking during the exam. His history included asthma and short stature. An endocrinology NP outside the practice had started him on growth hormone one to two months earlier.
The physician diagnosed a musculoskeletal myalgia and recommended heat and ibuprofen. Over the next three weeks, the boy returned again and again:
- Day 3: Same pain, a worried mother, and the same myalgia diagnosis.
- Day 5: Severe pain prompted an ER visit. He had anaphylaxis during an abdominal CT with contrast, and the scan was unremarkable.
- ER follow-up: An NP took a thorough history, ran a urine dip and CBC, and consulted a physician. Both results were normal.
- Around day 19: Severe neck pain, still afebrile with no rash, diagnosed as torticollis.
- Final visits: Right eye pain, headache, and then light flashes in his vision.
The ER finally found papilledema. He was diagnosed with pseudotumor cerebri, now called idiopathic intracranial hypertension (IIH), and needed a shunt within 24 hours. He lost vision permanently.
Two years later, nine defendants were named, including the NP who saw him once. Wendy worked on her defense. Every other provider settled, and the NP, carrying her own policy and standing alone, ultimately settled too.
The Clinical Lesson: Growth Hormone and Idiopathic Intracranial Hypertension
Intracranial hypertension is a recognized adverse effect of recombinant growth hormone. It most often appears early in therapy. Neither host knew of the link before this case, and Wendy had to research it herself.
That’s the point. Few primary care NPs prescribe growth hormone, but many will see children who take it. IIH can present with:
- Headache, often worse when lying down or in the morning
- Visual changes, including transient visual obscurations or flashes of light
- Neck, shoulder, or retro-orbital pain
- Nausea or vomiting
- Papilledema on funduscopic exam
Abdominal pain is not a typical IIH feature, which is part of why the belly drew everyone’s focus. When the neck and eye symptoms arrived, though, the picture shifted. A funduscopic exam in any child on growth hormone with headache or visual complaints can catch papilledema before vision is lost.
The stakes are high. Untreated IIH can cause permanent vision loss, and Wendy noted that persistent cognitive changes may follow as well.
Look Up the Medication You Don’t Know
The growth hormone was right there on the medication list. Wendy’s advice is simple: if a drug on the chart is unfamiliar, look it up. Sally added a broader rule. When a patient has a new, persistent complaint you can’t explain, and something new was recently started, consider that the two are connected.
Ask directly: “Did anything change before this started? A new medication, a dose change, a new supplement?” That question doesn’t appear in this record.
Red Flags in Repeat Pediatric Visits
The mother brought her son in or called 12 or 13 times in 21 days. Wendy’s rule: the less specific the complaint and the more often the patient returns, the more aggressive the workup should be.
- Repeated calls for the same problem are a signal. Persistent “he’s not getting better” calls are often a desperate attempt to be heard. It’s time to bring the child in and take it seriously.
- The same complaint points to something physical. Sally notes that a different complaint every week may suggest a mental health component. The same complaint over and over usually means a physical cause nobody has found yet.
- Evolving symptoms need a fresh look. When abdominal pain becomes neck pain, then eye pain, then headache, step back and reconsider the whole picture.
- Listen for the bell. Wendy urges NPs to trust that first instinct. If the thought “I hope this isn’t something serious” crosses your mind, act on it.
Documentation and ER Referral: Protecting Patients and Yourself
Wendy has seen cases where a clear “go to the ER” recommendation would have kept the NP off the hook. When symptoms escalate, document it. Write down that you advised emergency care if anything changes or worsens.
Sally adds a caution about empathy. NPs often try to work around a patient’s reasons for not going to the ER, such as work, insurance, or childcare. If you know the patient needs emergency care, say so firmly and chart it. If they refuse, that is their informed decision. A note that says “we agreed they would go home instead” means you endorsed the plan.
The hardest lesson in this episode is that an NP can do nearly everything right and still be named in a suit. Documentation is often your best protection.
Listen to the Season 2 Premiere
Hear the full conversation with Dr. Sally Miller and Dr. Wendy Wright on Scrubs and Subpoenas: Tales from the Witness Stand. Subscribe so you don’t miss an episode this season, and visit FHEA.com for more NP resources and continuing education.
