A Friendly Favor

Every minute someone’s life takes a terrifying detour, not down a dark alley, but into the sterile, bright halls of healing. They walk in seeking care and find themselves plunged into a nightmare. Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care, which accounts for more than half of the paid malpractice claims, are related to missed or late diagnosis. 

Now, before you raise a pitchfork at every white coat you see, let’s be clear. This isn’t an indictment. It’s a revelation. Because the truth is, any provider, any nurse, any human being capable of brilliance is also capable of a mistake. This is about understanding why and using that knowledge to build a safer future for every patient who walks through those doors. 

Welcome to FHEA Scrubs and Subpoenas: Tales from the Witness Stand, a podcast where we’ll peel back the sterile sheets and delve into the real stories of medical malpractice. Each episode a cautionary tale, a blueprint for change, a reminder that even in the darkest corners of human error, there’s a light, the light of knowledge, the light of empathy, the light of a future where healthcare becomes not a gamble, but a guarantee. So, join us as we dissect the mistakes, illuminate the flaws, and ultimately learn to heal not just bodies, but the very system itself. 

Jannah Amiel: Welcome to our first episode of Scrubs and Subpoenas: Tales from the Witness Stand. I am Jannah Amiel. I’m going to be your host. And joining me is Dr. Sally Miller. Dr. Miller, would you like to say hi? 

Sally Miller: Good morning or good afternoon, I suppose, or whatever time of day it is you’re listening.  

JA: Yes. So, if you listen to the intro of this podcast, right, that just played before we hopped on, you know that we’re going to be talking a little bit about medical errors. And this is really interesting for me for a couple of reasons. One, medical errors I feel like is one of those things that if you were a nurse of any kind, you have heard this, you’ve seen this, you’ve talked about it a thousand times, because it’s the on CE that we must do forever and ever. But this really does bring a lot of practical light, I think, to what it is that’s so important for us to learn. 

And now when we talk about medical errors, there’s really two things. There’s two ways that I think about it and let me know what you think about this, Dr. Miller. We think about omissions, right? Like not doing something that we should have done. Or commissions, doing something that we probably shouldn’t have done at all. And I read, um, it was with the National Institute of Health, there are some estimates that are up to $40 billion a year is what it costs in the US when medical errors are committed. What do you think about that? That’s a lot.  

SM: It’s huge, and I can absolutely see it. And I’m even, even, even, with a minimal exploration with a malpractice action, just the cost of the initial business of having an attorney review a record and then having experts review a record, even if there is no settlement. I mean, even if it turns out that perhaps nothing did occur that is actionable from a malpractice perspective, it still cost so much money just to get to that point, and then if there is a settlement. So, yeah, I can totally see that kind of money. And it’s just outrageous.  

JA: Yeah, it’s like astronomical, quite honestly. Now, Dr. Miller, you serve as an expert witness, which is why we’re hosting this podcast, right? Because we get to talk about these stories. And again, you know, it’s one thing for anybody to sit down and go through an hour or two or three or four or whatever it is of a medical error CE, right? And we kind of like pooh pooh that. But there is a very real story. There’s very real people and real practitioners and nurses and doctors and whoever that are behind that. And so I think it’s really important that we take the opportunity to listen to some of these cases, these real cases that you’ve served on, and take it as an opportunity for us to learn from it and to really apply what we know. So first, talk to us a little bit about expert witness. How did you even get into that and what does that mean for you?  

SM: You know, I honestly I’m not entirely sure how. I mean, years ago, 20 years ago now, an attorney reached me out of the blue. An attorney just literally called me on the phone. And that was back in the days when we went to when faculty went to offices most of the time. So, I had an office that had a phone that rang, and I actually answered it from time to time or checked voicemail. It was a different world. And an attorney called me out of the blue, and if I remember correctly, he found me on the university website. He was looking for an expert witness, nurse practitioner expert witnesses even now remain difficult to come by. And 20 years ago, it was a lot harder. So, when attorneys needed one, they would often just, you know, look at schools of nursing online, you know, look at the website online, look through the different faculty bios and try to find someone with an area of expertise that matched their need. And as I remember, I think it was actually 20 years ago, I think 2003 was the first time I ever got a call. And it was somebody I’m pretty sure, who saw me on a website at the university and asked if I had ever been an expert witness and if I would be interested in serving as one.  

JA: Wow. And so, what do you do as an expert witness? What happens? Like something terrible happens and then they call you and they say, like what? Tell us about this, fix this. How could this have gone?  

SM: Well, that was my next question. When he asked me if I would serve as an expert witness, I said, What? What’s that? You know what do you need me to do? And so there are there are several roles for an expert witness. In that particular circumstance, yes, he was defending a case that had been brought against a nurse practitioner. And so, he needed a nurse practitioner to review the record, review the medical record, review the existing depositions, and see if he could find a nurse practitioner that could support his client’s actions. So, in some cases, yes, there is, I mean, almost always there is a patient that has an assertion that has a claim that, you know, has filed a complaint that they were in some way wronged, usually, that the nurse practitioner deviated from a standard of care in some way and that that deviation caused damages. 

That’s usually what’s going on. I have from time to time had attorneys asked me to review a record and just evaluate the sequence of events, if they were appropriate, if there was any ancillary circumstance. I’ve had attorneys say to me, look, we know that there’s going to be a problem defending this case, and we’re just trying to identify what the level of damages are. So, could you look at this and tell us what holes you see in it? So, there’s a little bit of that. And then, you know, from time to time, I will receive a call from a plaintiff’s attorney. So, they represent the client that is making the assertion or making the complaint and asking that I look at it that way. Sometimes it’s that they’re asserting that a nurse practitioner did something they shouldn’t have done. Sometimes they assert that the nurse practitioner didn’t do something they should have done, like you said, omission or commission. Either way.  

JA: Wow. And so does it always mean that you’re always like in the courtroom, on the stand? Or sometimes is it just a matter of reviewing the documents or reviewing, you know, the medical records to see what maybe should have happened, what shouldn’t have happened, what could have happened even? 

SM: All of the above, really. Most of the time, an attorney just said to me literally, literally last week, an attorney called me, someone I had not worked with before, he got my name from someone else. And, you know, he asked about my geography because he’s in a different part of the country. And he said, you know, do you travel? How do you normally do this? He said, because we take every case as if it’s going to trial. They approach every case from the beginning as if it will go to a courtroom, which is the way that most of them see the cases, when in fact, I mean, I don’t know what the statistics are. I know that of all the cases I’ve ever been asked to review, if you go with the presumption that they are all going to go to the courtroom, less than probably 5% actually do go to the courtroom, at least in my experience. I don’t know if that’s a national average or anything.  

But typically, what happens is I will be retained and presented with a set of records and asked to review it. And then sometimes I’m asked to write an expert opinion, to write a written report, and sometimes not. But then usually both sides will have their experts review, review the file, review all the available records of depositions, etc. And then when all of the opinions are in, in my experience, more often than not, a settlement will be reached of some sort. The two sides will come to a settlement and it never goes any further.  

Sometimes I am asked to testify in a deposition, which are almost all via Zoom now or some online platform. So all the expert reports are in, the case does not settle, and then opposing attorneys start deposing the witnesses. So, if I am testifying or if I’m offering an opinion for the defense, the plaintiff’s counsel will take my deposition, and it’s sworn testimony. And that’s the next step. And sometimes it goes there. And then sometimes after depositions, the two sides will come together and reach some sort of settlement. In the vast minority of cases, and as I try to mentally think to the number, somewhere between 5 and 10% actually do go to a courtroom or do go to a trial.  

JA: Wow. That’s really interesting. That’s really interesting. Now, all right, before we hop in to the first case, because I want to make sure that we know that these are real, real cases. Right? These are actual cases that you have served on. You know, we want to, you know, address our audience. I want to address our audience. I’m a nurse. You’re a nurse practitioner. We know that this can happen. Mistakes can happen right to anybody, to all of us. Not a single one of us is immune. Right? So, we want to be sensitive to this, but we also want to be realistic in the sense of mistakes, in fact, do happen. And they happen every day. And probably a lot. We heard that $40 billion statistic, and it’s an opportunity for us to learn, right, to learn from it, to take what we know is true and from what we’ve learned, evidence-based practice, and apply that to real world. 

And so, as you listen along, audience, as you listen along to these stories, really think about it from your perspective, you know, where did you find in this story in this case where maybe things could have gone a little bit differently. Did you pick up on some of these, you know, these errors that could have occurred? Right. But we definitely want to be sensitive to the fact that we know that these things happen. And this really is a time for us to look at it, just really look at it with good clear eyes and say, like, how do we do better? How do we learn from this? How do we grow from things like this? Is there anything you want to add to that, Dr. Miller? 

SM: Just that I mean, 100%. You know, I’ve been teaching since 1995 and I tell my students every, every set semester, every quarter, every class, all of the new grads that I see in review programs at everything and CE, like just one of my basic foundational philosophies is, is there are those of us who have made mistakes and those of you who will. Period. I mean, we all but you know, we are human and therefore imperfect. Not to get too philosophical, but I mean it, there are those of us who have made mistakes, and if you haven’t made one yet, it’s coming. And the reason I really think the value in reviewing these cases is that so we all can learn from it going forward. 

I’ll tell you, you know, I still see patients a minimum one day a week and often more than that. And like people make fun of my notes, my colleagues, my peers, they laugh at me. My notes are so detailed and, you know, they it’s kind of a standing joke about my, you know, how my notes are. But the reason they’re that way is after 20 years of reviewing charts as an expert, I write every note now, and I’m not saying I don’t goof sometimes because of course I do, but I really try to write every note as if three or four years down the line, a couple of different experts are going to be looking at it with that magnifying glass, because that’s exactly what happens when there is an assertion. And I’ll tell you, I mean, I have been named in suits over the years. A couple of times when I used to work in the correctional facility, a lot of complaints just seemed to arise from that setting. And there were two or three times I can think of off the top of my head that I was served with a complaint and every time, every time, blessedly, my documentation was adequate to have me dismissed right away. Because the way it usually goes is when there is a complaint, the plaintiff will engage an attorney, and the attorney will name everybody. You know, a complaint will be written that usually says, like Jane and John Doe one through 20, just to make sure that everyone who could even conceivably be part of the case is covered because there is a statute of limitations, and they want to get the filings in before the statute of limitations expires. Then those Jane and John Doe’s are later amended to insert actual names of all of the relevant providers. 

I’ve been named because in the beginning, everybody that even looked at the patient, it seems like gets named. I am exaggerating just a little bit there, but anyone who even is peripherally involved is usually named in a suit. And then as the experts move through the charting, various people are eliminated when it’s clear that they, that there is no evidence to suggest a malpractice action. And the few times that I’ve been named, every time I have been dropped in that very earliest review, because that particular chart, that patient, my documentation was adequate, at a minimum, adequate to support my care. I cannot emphasize enough how important it is. Listen, I see patients. I know the realities. We don’t all have an hour to write War and Peace in every chart, but you do want to make sure that the most important elements of your documentation are there because anybody could be reviewing it in a couple of years, truly with a fine-tooth comb.  

JA: Yeah, I think that that is excellent advice. That’s really excellent advice. All right. So now I’m geared up. We’re ready. Let’s lay it on us. So, Dr. Sally Miller, give us our first case, and let’s talk about this.  

SM: Okay. So, the first case that I have to share with you, I think it can ring true for so many of us because it’s about an APRN who was trying to help, who is genuinely just trying to be helpful to a friend. 

So, what happened was, this APRN was employed by a facility by up by a hospital facility and within this scope of employment practiced in the ICU and was an APRN making rounds and following a job protocol, working in conjunction with a collaborating physician. In fact, when this occurred, that particular state required a collaborating physician, as many did, even as recently as ten years ago. You know, for the brand new NPs listening, now we have a lot more autonomy and many more states with independent practice. But, you know, as recently as ten years ago, the majority of states did require some sort of collaborating physician. So, this APRN was practicing in the ICU. Per state law and facility protocol, there was an in-house protocol with the physician, and that’s how the APRN, you know, implemented the role on a day-to-day basis. 

Well, this APRN had a coworker. The coworker was another healthcare professional within the scope of the hospital hierarchy. And this was this was a young person. This is a 27-year-old coworker who apparently complained to the friend, the APRN about not feeling well, you know, just sort of feeling washed out, tired, out, feeling uncomfortable and so the APRN deduced that perhaps it might be due to some dehydration and offered to infuse a bag of IV fluids. What we would refer to as off the books, you know, let’s go into an unoccupied room, have some IV fluids. There was a time when that was pretty common. IV fluids are a popular intervention for hangover, because hangover symptoms are the result usually of dehydration and not so much now, like just in general, these off the book things are a little bit less common, but there was a time when it was very common. 

Anyway, this APRN thinks that she’s doing a favor for this coworker, this 27-year-old person. So, as it happened, you know, the first time around, got some fluids, felt a little bit better, and then it just happened a few more times over the course of a four or five-week period. This coworker reported several incidences of not feeling good. I’m sure it became evident very quickly that it wasn’t an isolated incident of the overusing alcohol in one occasion or something, but the APRN was just providing this off the books IV fluid for the patient. And after a few weeks of this going on, the APRN ordered some labs, and the labs were drawn, you know, again, off the books there wasn’t an established patient-provider relationship. There was no independent chart. This APRN ordered the labs be drawn in, you know, in the hospital system in which they worked. And so, some labs were drawn. And apparently the one abnormality that the APRN appreciated was an elevated lipase. So, at this point, the APRN makes the determination that the patient has acute pancreatitis and tells this 27-year-old that this is just something that has to run its course. And so some more IV fluids are given. I think there may have been a prescription for an antiemetic. I’m not certain about that, but I think there was some, you know, parallel prescribing for typical symptoms of pancreatitis, and so the patient just assumed that the APRN was giving accurate information and didn’t take it any further.  

After approximately 4 to 6 weeks of this going on and not getting any better, the patient finally went to the emergency room and had a formal emergency room visit. What was first, what became apparent at that time in the records was that the patient had had a sleeve gastrectomy about six weeks prior. So, this was, this was a procedure that the patient had, went home the next day, went back to work shortly thereafter. And then it was several weeks in that the patient started having symptoms, you know, that the APRN was treating. 

And so apparently the APRN knew that the patient had had the sleeve gastrectomy. But consistent with this person, the APRN’s deposition just really didn’t consider that a fact or didn’t think that one had anything to do with the other. And just kept giving the IV fluids and based on the elevated lipase, assumed that the patient had pancreatitis and that it would indeed run its course. By the time the patient was seen in the emergency room, there were so many profound electrolyte abnormalities excuse me, there were renal dysfunction. There was just really a laboratory disaster going on. The patient was admitted to the hospital and continued to deteriorate almost on a day-to-day basis. You know, the thing about the human body in sickness is it will compensate, compensate, compensate. So, things seem not that bad until our compensatory mechanisms are exhausted and then boom, you know, downhill very fast. 

So clearly, by the time the patient was sick enough to go to the emergency room, the compensatory mechanisms were beginning to fail. And once they fail, it’s down like that. So once a patient was admitted, just profound deterioration continued to occur, really on a daily basis, and nobody at first could figure out what was wrong. I mean, now the patient is assigned to an attending. You know, there’s rounding, there’s fellows, there’s residents, the whole yard. The patient, in addition to the profound electrolyte abnormalities, the emesis became more and more significant. Cognitive deficits started to occur. There was significant abnormalities of eye movement of vision, cognitive impairment, decreased ability to ambulate. It went downhill very fast. Blessedly, a resident, I believe it was a resident, came up with the diagnosis of a possible thiamin deficiency and Wernicke’s. And so, the patient was evaluated for that did indeed had this profound a thiamin deficiency that was linked to malabsorption secondary to the gastric sleeve procedure. And so now they had a diagnosis. Now the problem was just trying to manage the deficits that were significant, the disability that ensued. I mean, at this point, this is someone you know, we’re consolidating this in a matter of a few minutes. But this went on for weeks and weeks and weeks and even into months. So, by the time a diagnosis was identified, there were deficits that were permanent. There were neurological deficits that were at least predicted to be permanent at that time. The patient had been essentially bedridden. You know, ambulation was difficult and it was with assistance. Once the diagnosis was made and treatment was initiated, then when able physical therapy was started. But this was a long, drawn-out process and at the end of my involvement with the case, which was years after it started, about four years after events occurred, was when it actually went to a lawsuit. To the extent that I was reviewing it, the patients still had deficits and they were expected to be permanent. 

JA: Oh my gosh. Oh my gosh. Okay. So many things. There’s so many things here. Now, you talked about, I don’t want to say the culture, but let’s face it, I worked in the ER, right? And I know I worked in the ER at night. I’ll go ahead and say that, so I know what it’s like that we’ve sometimes you’ll have a coworker or whoever who’s not feeling great, maybe have a little bit too much to drink the night before, whatever the case, and just kind of casually the feeling of we can just run IVs for that person. No big deal. Just do that like you’re all good. Yikes. And on a different level, I think it’s one thing to be a nurse, an RN and then try to administer something. Another thing to be a clinician, a practitioner, aprovider, and trying to help out your friend. What are like what are the rules around that. It’s so… it shouldn’t be foggy. But I’ll be honest, Dr. Miller, it’s kind of foggy.  

SM: But you know what, though? It really isn’t. It shouldn’t be. This is where my black and white personality, this personality that is often seen as a flaw and sometimes it feels like a characteristic I wish I could change, but in this circumstance, it is black and white. No friends. No. I know I was part of the culture too. I remember giving residents IVs, you know, 30 years ago. But you know, nurse practitioners especially, we have worked so hard to earn autonomous practice in most states, to earn the respect of patients, of our peers, of all of our health care counterparts, not just physicians, but everyone. 

You know, when I was first an NP, getting the respect of the nurses was a lot harder than getting the respect of the physicians. Oddly, they embraced me with open arms, but it was the nurses who were kind of like, you know, why do you get to write orders? Why do you get to make this decision? I mean, we’ve all worked so hard to earn the respect of the healthcare system, to earn the opportunity for reimbursement, the whole thing. The last thing that we need to do and, you know, rightly or wrongly, we do need to be on our game 100%. We are watched. Let’s just face it, we are watched more closely than some of our peers who also make diagnoses and write orders and write prescriptions. So there really is no room for a gray area. And so, when it comes down to treating friends, we don’t have friends. 

We don’t have any friends. We shouldn’t have any friends. Every nurse practice act in every state, and the associated administrative regulations does have clear laws, rules and requirements about the patient-provider relationship, the role of the APRN, how we provide care, how we document that care. I can’t speak for every state. I’m not familiar with all the state’s laws, but having formerly been the APRN consultant/investigator with the Nevada State Board of Nursing, and I can tell you in Nevada we have a very clear requirements about maintaining documentation, maintaining written documentation, re: the patient provider relationship. And so, first things first, before anybody prescribes anything for anyone, it needs to be your patient and there needs to be a record of that patient-provider relationship. It doesn’t have to be War and Peace. You know, it can be a concise record, but there needs to be there needs to be a record. You need to establish that patient-provider relationship formally, because once you make a diagnosis, in this case pancreatitis, and once you prescribe an intervention, you have assumed the role of the provider. The patient has every reasonable expectation that you are giving them good information. It’s not appropriate to say, well, I mean, it was just somebody I work with. They weren’t really my patient. I didn’t really do the full workup that I would have done. That’s not an option here. Once you even make a diagnosis, we have to remember that the patients believe us. You know, they think that we’re making that diagnosis appropriately. So, if I say to anyone, this is just something called acute pancreatitis. It just needs to run its course. It’s very appropriate and fair for that person to assume that that’s good advice, and I know what I’m talking about, and they don’t need to seek any further care.  

So, so as to the question about what are the, what’s the walls or the guidelines with the friends? I mean, if you choose to treat a friend as a patient and it needs to become your patient, you need to see them like any other patient, do the appropriate evaluation, document it appropriately. And that includes a history, a relevant review of systems, relevant medical history, surgical history, social history, allergies, medication history, review of systems, relevant physical examination. That at a minimum should be performed before offering any diagnosis to somebody in any treatment in the same way that you would for any other patient. And so, if you choose to treat a patient, it’s my understanding that in most states there’s no law prohibiting that you can do it. You just have to do it the right way.  

On a side note, just from the voice of experience, keep in mind that with your friends, sometimes it’s not as easy to get accurate information. Sometimes they’re not comfortable sharing things with you about, you know, a substance use history, a sexual history. I mean, those just come right off the top of my head. But there’s any number of things people aren’t comfortable sharing with their friends.  

And on the flip side sometimes it’s hard to tell our friends something they don’t want to hear. Probably every nurse and nurse practitioner listening has had the experience where your family and friends think you’re brilliant if you tell them what they already think. But if you tell them something different than what they think, well then you don’t know what you’re talking about. You know you don’t know. You’re just a friend. I mean, I mean, the examples, you know, are limitless about, you know, vaccines. You do need an antibiotic. You don’t need an antibiotic. You do need to lose weight. You don’t. When we try to tell somebody something that isn’t necessarily what they think or what they want, don’t want to hear, it’s hard enough if it’s a patient with whom we have a clear professional relationship, but with friends it can even be harder. 

So, see friends as patients at your own risk. But if you do, you need to treat them like any other patient. And that includes all of the relevant assessment and documentation.  

JA: Yeah. And you know, I think that’s really the next thing. It’s like, okay, so how should this have gone? But I think you said it. What I didn’t hear is I didn’t hear anything about actual, like assessment, actual, you know, you know, diagnostic, none of that. It just seemed like we kind of skipped that part maybe because they were friendly in that way and just thought maybe she was doing a favor or, you know, he or she was doing a favor to help. But like, what was missing? Was it just that actual real patient workup?  

SM: There was so much missing here. And again, I mean, I do want to be crystal clear. It’s easy to Monday morning quarterback and, you know, you could look at my notes over the past 30 years and find things that are missing or, you know, find things that I did that weren’t ideal or perfect. So, believe me, when I say from the bottom of my sincerest heart, I am not trying to Monday morning quarterback here. 

First of all, you know, we all know the old adage of it’s not written down, it didn’t happen.  

JA: Yep.  

SM: And then there’s those of us who see patients that know that’s not like, that’s not possible to write down every single thing. None of us can write down every single thing, or we’d be charting the 16 hours of the day that we are not seeing patients. You know, you see patients 8 hours a day, spend the other 16 charting and don’t, you know, there is definitely a reality check that comes somewhere in the middle. So perfect documentation, it doesn’t exist. I mean, I like to say, because I have had it, I have been on the witness stand and had an attorney say, did you ever hear anybody say that if it’s not written down, it didn’t happen? And I said, yes, I have heard that. And I suspect that that’s somebody who doesn’t see patients for a living because that’s just not reality. You know, in school, we learned the ideal way. You know, the best practice way, the perfect way. And then we go out to work and we have to go out to work with all of the humanistic limited resources that we have. 

So, listen, I know that we can’t have, you know, this perfect long War and Peace kind of record. But, you know, having said that, and again, we can only go with what’s written down. It may even be that this person did do more of a physical exam or a history taking. We’ll never know because there was no written record of it. 

So, in conversation she may have said to her friend, you know, tell me about your medical history. Surgical history. So, you know, that kind of thing. But we don’t know it because it’s not written. So that’s another important point. When it comes down to medical malpractice, the written word is extremely important. It’s what’s written down that everybody’s paying attention to and looking at even things that we as clinicians know probably didn’t happen. If it’s written down, it did. And if it’s not written down, it will be regarded as not happening.  

And so, you know, what’s missing here is, number one, any sort of chart, the only thing that’s documented were the labs that were ordered. And that’s because in this system, apparently, they were pre-populated in because the patient was in the system, but there was no written record of any initial patient encounter. If you’re going to make a diagnosis of someone in this case, it would have been outpatient because the patient wasn’t admitted to the hospital. You need to do your history, your physical, all of that stuff, and write it down. Even if and again, each state has their own laws. So, I’m not trying to give advice here. I guess I should throw in that disclaimer. I’m not an attorney and I’m not giving legal advice, but it may be adequate in some states just to make your own record. It doesn’t have to be attached to a practice. If you are an autonomous provider, you can just type it up in a Word document, and store it in a secure location, and that’s your record. 

But there does need to be the relevant info. The chief complaint, the history of present illness, the relevant histories. That’s how you arrive at your differential diagnosis. What’s also, you know, a question here is that at no point in any of the discussion because the nurse practitioner was deposed, you know, her deposition was taken about all of this and what she remembers. And even though she didn’t write anything down now, she did recollect some discussions with this person, this person who was actually her patient after all. And there was no assessment of abdominal pain. And abdominal pain is a cardinal feature of acute pancreatitis. So, the diagnosis that the APRN did admit providing, you know, telling the patient that he had acute pancreatitis and it just had to run its course, there was no apparent diagnostic criteria for acute pancreatitis. I mean, pancreatitis, there is there you know, there are several things that could be there. But the cardinal feature is the minimal diagnostic criteria are acute, acute abdominal pain like this. I don’t think I’ve ever seen acute pancreatitis without that. But acute abdominal pain is number one at a minimum, a serum lipase greater than three times the upper limits of normal, and radiographic imaging, some sort of imaging that supports pancreatic inflammation. 

Minimum diagnostic criteria requires two of those three. And the only one that was evident here was the elevated lipase. So, to make a diagnosis without acute abdominal pain or alternatively at a minimum ultrasound imaging, it just it really deviates from a very, very minimal evidence-based standards of care. And so that, that’s difficult to overcome right there. 

On the flip side, there was also the business of a collaborating physician and the job description that was part of the employment agreement. I mean, part of the practice privileges in that facility presumed that the practice was occurring in the ICU in conjunction with a collaborating physician, and the collaborating physician wasn’t involved in this at all because the patient was not a patient of the hospital’s service. So that was a problem.  

JA: Oh my goodness. 

SM: And then just to, and I do again, I feel so much like I’m Monday morning quarterbacking here, which I kind of am, for no other reason that we all learn something from it. Because going in going forward, I mean, how many of us have wanted to help a friend? I mean, let’s face it. Yeah. You know, how many of us wanted to help a friend with things over the years? I mean, I know, I know I’ve had in the beginning of my career, there were times when I would help somebody. Oh, yes. You need an antibiotic. Yes, it’s a UTI. I know you don’t have money for it. You know, like in the beginning of my career, I’m sure I did stuff like that as well. But when something goes wrong, well, that’s when it all that’s when it all, you know, comes, comes upfront. So anyway, the last thing that I would that I would comment on about this case is that another evidence-based really indisputable fact is that acute pancreatitis needs to be treated in the hospital. So, even if you’re in the outpatient setting, even if somebody comes in your office with these signs and symptoms that you diagnose as acute pancreatitis, the intervention is to refer them to the emergency room because they need to be admitted to the hospital. You don’t tell somebody with acute pancreatitis to go home and it will run its course. 

The insensible losses of fluids are significant. The requirement for pain control is significant. I mean, it’s one of the few times that we still give opioids routinely. So, there were just several key features here that, looking back, really do, do present as a concern.  

JA: Now you talked about Wernicke’s, right, you talked about Wernicke’s encephalopathy and thiamin deficiencies. Talk to us, hit us with some clinical stuff, if we’re not so familiar, if folks are listening and thinking, what is that again? What’s Wernicke’s? Because you mentioned and I keep thinking, unfortunately, that these things sound like they persisted, like the complications of it persisted. But what is that? What are we talking about there?  

SM: It did. You know, and it’s interesting, Wernicke’s is very often one of those things that you learn about, like one little blurb in school. And then if you don’t, if you don’t work in that particular field, you never even think about it again. And let’s face it, it’s often not at the top of everybody’s differential diagnosis list. It is often associated with chronic alcoholism, which is one of the risk factors for it. But it’s not the only one. That’s another trap that it’s so easy to fall into is just being too narrow with the diagnostic reasoning. So, thiamin deficiency thiamin is a B vitamin right? It’s vitamin B1. And as a vitamin, it’s a cofactor for lots of important enzymatic relationships. And the Krebs cycle, you know, in the whole ATP energy generating cycle, and particularly important in both the central and peripheral nervous system. And so, the concern is that a thiamin deficiency can lead to significant impairment of energy generating processes in the brain and the peripheral and the central and the peripheral nervous system. That’s the problem. And it’s not always on everybody’s differential list because it doesn’t always happen. Not everybody with a thiamin deficiency does demonstrate Wernicke’s. I don’t know why some one person would and another person wouldn’t, but we know that they can. So, the classic clinical association is that chronic alcoholism does put you at increased risk for thiamin deficiency, which is why when people, when alcoholics are admitted to the hospital for pretty much any reason, they get the old banana bag, you know, the IV fluids that among other things, has the B vitamins in it for neuroprotection. 

But, thiamin deficiency, yes. Chronic alcoholism is one reason, largely because as alcoholism progresses through the more chronic stages, nutrition isn’t a highlight, number one. You know, we’re not so much seeing a balanced diet. But number two, alcohol does block the dietary absorption of a number of B vitamins. And so, it’s really the absorption that’s the issue, not the alcohol. Right? Alcohol is just one reason why you might not absorb thiamin, but gastric bypass procedures and gastric sleeves are another reason. Another really key feature here for this APRN was failing to consider that the symptoms that were present for the month that she was treating the patient off the books might have something to do with the gastric sleeve that had happened six weeks prior. And for sure some people might say, well, wow, that was six weeks ago. What could that have to do with it? But it’s just a matter of moving through that appropriate history and physical examination. If you have someone who is suddenly just not feeling well, vomiting, you know, just generally fatigued, vomiting and feeling not right, and that’s never happened to them before. And this is an otherwise healthy 27-year-old. And the only significant anomaly in recent history is a gastric sleeve procedure. You have to consider that the gastric sleeve of six weeks ago is producing the fatigue, and the energy loss, and the nausea, and vomiting of now. Really failing to consider that necessary history. So, in retrospect and again, hindsight is 20/20, and looking back retrospectively, it makes perfect sense that as a consequence of that gastric procedure, this patient was not absorbing and was losing weight. But of course, weight loss was expected following the gastric sleeve. So it wasn’t, right? It was it was a hidden finding. But gastric bypass procedures, I mean, one of the big concerns afterward is a variety of dietary deficiencies because of the changes in absorptive and the anatomy of absorption. And so now.  

JA: Wow. 

SM: Yep. So that’s what happened. I mean, it can happen. People with chronic malabsorption syndromes can suffer this, people that are severely malnourished can suffer thiamin deficiency, chronic alcoholics. But in the end, it’s all about not absorbing the thiamin. And so, for this particular patient, unfortunately, the moon and the stars lined up, and the thiamin deficiency did result in Wernicke’s, which is a combination of symptoms that manifest in the central and peripheral nervous system. 

And so, like I said, the last time I had anything to do with this case was four years after the events occurred. And he was still, needed assistance with daily living. He was not able to function independently, needed significant assistance with ambulation, I mean, had some quality of life over and above laying in bed all day, but had to go through just perpetual rehabilitation and had permanent neurologic deficits. 

JA: That is really that is really unfortunate to hear. You know, one of the things, too Sally, thinking about it, is what happens to the NP in this case? I heard that she or he or she, you know, was deposed. What happens is just like a license loss? Is something worse? Like what happens in that case?  

SM: The outcome as far you know, the last I heard the outcome of this case. Well, so there was a settlement. This never went to a trial. The insurance company settled with a patient, you know, clearly. And the NP did lose her job. You know, she lost her job at the facility. I don’t, was still licensed you know, was still a licensed NP. So, I don’t you know, board actions are separate from malpractice actions, and the fact that the NP was licensed, the last I heard of it, four years after these events, clearly there wasn’t a permanent loss of licensure. I suspect that there was probably a discipline of some sort, like a public reprimand or perhaps a period of supervision. But yeah, the NP remained licensed, and the insurance company did make a settlement.  

JA: Wow, what a story. What a case. Really unfortunate all the way around. You know, is there anything that you would like to leave us with that the listeners? You know, something that we haven’t thought of or that we haven’t mentioned? Just some kind of parting words of advice?  

SM: Oh boy, I mean, I don’t know, only to reiterate a few things that we’ve already mentioned that are so critical: Avoid the temptation to help a friend, or even to help a patient by doing something that you know isn’t quite the right thing, but you want to help. You know, you could see an analogous situation where the patient is sitting in your office, and you think that the patient has pancreatitis, but they don’t have insurance or they can’t, you know, they can’t afford to go to the hospital. They’re afraid to go because of the big bill. They can’t really afford the labs. They definitely can’t afford an ultrasound like we’ve all heard. You know, this thing, too. We’re talking with a patient. We tell them what we think they need and they’re like, but I can’t afford it. I can’t afford it. I don’t have insurance, you know, etc., etc. And so we want to be helpful like that. That’s the sadness here. The APRN was just trying to help. Probably a little bit out of the wheelhouse in terms of experience. And so maybe from an ICU perspective, that elevated lipase was enough to make her think about pancreatitis because in an ICU patient who is perhaps comatose or intubated and can’t respond to the pain thing might not be that overt or apparent. And the laboratory result takes on a greater significance. I mean, and I’m just supposing there I don’t know, but we just we need to do we need to do things the right way, at a minimum, the evidence-based way. And when somebody is your friend, it just makes it harder to do so. Yeah, I mean, that temptation to be helpful. 

I’ve also reviewed cases where NPs will document that they knew something wasn’t necessary, but ordered it because the patient wanted it, or they thought something was necessary, but the patient didn’t want to do it and then just proceed along. And I mean, we can’t make patients do a thing they don’t want to do, but we don’t have to endorse it either. You know, sometimes they will want us to give a stamp of approval to their approach. And if we give that stamp of approval, then they think it’s okay. So like if you say to the patient you have acute pancreatitis, so you really have to go to the hospital. This has to be managed in the hospital. And the patient says, I can’t go, I’m not going, I just can’t. I’m not going. Nobody’s home to watch my kids. I don’t have any money. I’m not going. If you say, well, you know, okay, well then, well, you know, I’ll give you a bag of IV fluids now and we’ll try to manage your pain. That that’s a stamp of approval that it’s okay not to go in. That’s not the right answer. 

The answer is, look, I mean, I need to document that you are you’re against medical advice not going to the hospital. And then at least you have, you know, made a record that you have tried to implement the appropriate approach to care and advise the patient of the consequences of not following it.  

So, I mean, you know, in closing, the one thing is just that whole friend thing, be very careful. Number two, with any patient, with any patient, remember, at a minimum, that the history of present illness and the rest of the diagnostic evaluation exists to rule out all potential causes of the chief complaint. We don’t want to get narrowed in there too soon. And, you know, keep in mind that sometimes these things, these zebras do happen. And there is that old adage, when you hear hoofbeats look for horses, but it doesn’t mean that they don’t need a cursory glance for a zebra and a moose and an alpaca and whatever else might be out there. So, you at least need to consider those things.  

JA: Yeah. Well, Dr. Miller, thank you so much for sharing this case. That was very, very interesting. Unfortunate to hear, but very interesting. I think that any of us that work in any of this type of healthcare space really can understand and relate, and see where these things can happen. So, it was a good opportunity for me to hear and kind of apply it in that way. And I hope that all of our listeners found something, you know, within that story that’s helpful for their own practice. 

And if you found this interesting and you’d like to hear more, please definitely check this out on FHEA.com or more of these cases, more of our podcast stories. We hope you have a good one. Goodbye for now.  

Thank you for listening and learning with Scrubs and Subpoenas: Tales from the Witness Stand presented by Fitzgerald Health Education Associates. Please rate review and subscribe to this podcast and for more NP resources, visit FHEA.com. Join us again next time as we dissect more medical malpractice cases.