Hidden In Plain Sight

Voiceover: 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’s 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 health care 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: Hello and welcome to another episode of Scrubs and Subpoenas: Tales from the Witness Stand. I’m your host, Jannah Amiel. And joining me is Dr. Sally Miller. Dr. Miller, how are you?  

Sally Miller: I’m very well, thank you. And you? 
 
JA: Good. Thank you. Thank you. Now, Dr. Sally Miller, as you know, if you were listening to our first episodes, episodes is a new word. 

I’m going to coin that. She is an expert witness, so she gets to sit in on or review some actual cases that happen in real life practice, where things don’t quite go right. And we all know about that, right? We talk about medical errors. We learn about medical errors. You eat, sleep, breathe it. Right. And in healthcare. 

And these are real things that actually really do happen, right? IRL: in real life. And so we’re taking these cases and taking these stories as an opportunity to work through them to kind of walk through them, identify where some of the mistakes may be made, and help us to learn how to practice better. Right? Help us to remind us how to practice better, making sure that we are advocating as we should be and just the importance of not forgetting or not omitting some of the pieces of the things that we do. In saying that, right? 

We know that mistakes happen. We’ve said that in our previous episodes. We say it all the time. We know that not a single person who works in healthcare, who works with patients, is exempt from it, is immune from it. But we really want to take the opportunity to look at what happens, truly, what really is happening out there in practice, and take that as an opportunity to see how that can enhance us and what we’re doing for our patients. 

Is there anything you want to add to that, Dr. Miller. 
 
SM: I don’t think so. I mean, that’s the whole point here is just to learn from it. We all make mistakes, oh lordy, We could do a whole podcast on my mistakes, but I don’t know if I want to do that, but. But no. And actually, there are some that I will share with you at some point because we do have to learn from them. 

If you ever talk to anyone who says they haven’t made a mistake with a patient, that’s a scary person because they don’t recognize the mistakes they’ve made and they are not able to learn from them. This is all, you know, we go through these each podcast for no other reason than to learn and, you know, try to take something out of it. 

And even if there were bad outcomes for the patient in the case, going forward, we can maybe have better outcomes for other people because we’re now just more in tune and aware.  
 
JA: Absolutely. Absolutely. Alright. So we’re ready. Let’s listen in and see what we got.  
 
SM: So this case, this is from earlier in my career. And actually because of this case, I developed a particular interest or expanded my expertise a little bit in this topic and started doing presentations on it because it is, I mean, it can be so just nebulous or ill-defined in the day-to-day clinical setting. 

So I hope that anybody listening can get as much out of it as I did. It really did make a difference in how I work up this kind of complaint. So, this is a series of events that spans over a year and a half of; the patient scenario was a year and a half. And so in that, you know, when things are slow and steady and creep up on you, they’re not always obvious until much later when we go back. 

In retrospect, much like, wait, you know, a pound or two here or there, you don’t really notice it. And then the next thing you know, you’ve picked up 20 pounds and don’t know where it came from. So, this gentleman was a 42-year-old man with no significant medical history, actually. But he and the family were pretty on top of wellness. 

In fact, one of the real ironies here is that they were actually a family that was pretty health conscious. You know, your average 40-year-old, you can’t always talk them into a routine physical when they feel fine. But in this circumstance, I think it was the wife that really drove care for the family unit. But everybody, they did go in and have regular physicals. 

So this 42-year-old man, he just presented to primary care for his annual wellness examination, he had no significant medical history. He was not taking any medications. His review of systems, you know, a comprehensive review of just general symptoms was significant for fatigue, dizziness, and headache. Nebulous, nebulous-er, and nebulous-ness. I mean, fatigue, dizziness and headache. 

Who among us can’t say that? We’ve had them from time-to-time. Right. So, those were his review of systems at that first visit that’s relevant here. No medical history At the time he was given no specific diagnosis or treatment. These, it appears from the note that these symptoms were attributed to just the hectic career life of a young early forties man who was, you know, on-the-go like he was a he, you know, as a career guy, was developing career apparently worked quite a lot and all that kind of thing. 

And so, you know review of systems are those general, across-the-board things we do and in a wellness exam. It’s almost impossible to have someone’s review of systems be totally perfect. I mean everybody’s got something: the occasional headache or whatever. So, no particular significance was attributed to this. The physical examination was documented as essentially normal. 

I mean, all of the systems were there. As with wellness exams, they usually are. The physical is detailed and everything was documented, as you know, no significant findings. A month later, he came in to follow up on his lab test that he had in his routine labs, even though that word drives most of us nuts because routine labs really shouldn’t be a, “Now, what is a routine lab?” 

But, you know, he had a comprehensive metabolic panel, a CBC, you know, thyroid test, a lipid panel, and they were all unremarkable. There was nothing there that was atypical and there was no medication started or plan of care advised because of them. So, that was the first visit. And then the follow up of the labs was a month later, two months after his lab review, he came in complaining of sinus symptoms, trouble sleeping, and depression. 

You know, I mean, that’s almost as weird as fatigue, headache. I mean, you know, like trouble sleeping, sinus symptoms, and depression. You kind of have trouble seeing how they could all go together. It’s almost like, well, he came in for one thing and mentioned the other two, you know, while he was there. Anyway, that’s what his complaint wasrecorded as the chief complaint saying the symptoms, trouble sleeping, and depression, but the exam really focused on the sinusitis. 

And so, he was evaluated for sinusitis and the rest of the diagnostic evaluation went that way. And he was and, you know, this was a few years ago, he was given an antibiotic and that was that. One month later, he came back in for his next wellness exam. I mean, yeah, I said two months later I meant ten months later. 

So, he had his first wellness exam and it was like May of that year. And then he did a follow up in June of the labs, I think I said two months later, but it was ten months later and he came in with the sinus symptoms, depression, and trouble sleeping. So, now we’re you know, we’re almost a year out from the last visit. 

Lo and behold, one month later, it’s May of the next year and he comes back in for his next wellness exam and no complaints were recorded. So, this time there was like, no nothing, no dizziness, no headache, no sinuses, no trouble sleeping, no nothing. It was recorded as a normal wellness exam without complaint, without any abnormal findings. 

That’s it. Come back in a year. One month after that, he came back complaining of dizziness and anxiety. Yeah. And so, you know, the workup really was there. There was a cursory, like a primary care type of neuro exam there, that was insignificant. The anxiety really didn’t get a lot of attention in the evaluation. Again, it was just attributed to hectic work life, etc. 

Okay. Well, you know, again, these are a year apart. It is the same provider, but that these are a year apart and apparently not communicated with any particular level of urgency. It doesn’t sound like from the note anyway. So, file that one away. We’re going to come back and you know, and retrospectively look at all of this. But what we’ve got now was in May of one year, he had a physical with no complaints, normal labs. 

Ten months later, he had sinus symptoms, trouble sleeping, and depression. A month after that, everything seemed fine. A month after that, he’s got dizziness and anxiety. Two months later, he comes back again, complaining of dizziness. So, now they’re starting to be like he came in in April complaining of dizziness and trouble sleeping and depression. He came in then two months later in June, complaining of dizziness and anxiety, he came back in August complaining of dizziness. 

There was really no appreciable evaluation of this year. There was no, not even any defining exactly what dizziness means, just, you know, more sort of nebulous discussion about his anxiety and his busy schedule and not getting enough sleep and things like that. And in the end, no medications, no intervention, no further studies just: return to clinic. 

If it doesn’t improve something like, ‘Follow up if no improvement.’  
 
JA: Yeah.  
 
SM: Again, he comes back the next month now complaining of dizziness and irritability. No further intervention, you know, ‘Return to clinic if it gets worse.’ One month later he’s back complaining of dizziness. So, to summarize up to this point, but see, in April of 2010, he had dizziness and a few other symptoms. 

In June of 2010, he had dizziness. In August of 2010, he complained of dizziness. In September, and then back in October, he complained of dizziness. At this point, he’s referred to ENT. He’s referred. So, after, so between April and October, how many months is that? I’m going to count, like the educated, mature professional that I am: April, May, June, July, August. Six or seven months of repetitive complaints of dizziness. 

He is referred to ENT. He came back in November, a month later. Back complaining of dizziness. And all we have from ENT is that they think it’s not consistent with benign paroxysmal positional vertigo, BPPV. And so I mean a little bit of a backstory here is that dizziness really isn’t a medical term. Dizziness is a laypeople term. 

Dizziness is usually used to convey either vertigo, you know, the sensation of spinning lightheadedness or near syncope, which can come from like volume contraction, you know, over diuresis, like, you know, anything that would decrease blood flow to the head; or even ataxia, the inability to walk straight, you know, like leaning one way or the other. People will use dizziness to describe all of those things. 

So, we can’t tell from the documentation or referral because there’s really not much there to read. This is really not, does not appear to be explored very much by the primary care provider. So, it sounds like ENT assumed that they were being consulted to evaluate vertigo because that is what you would send the patient to ENT for. And in the world of ENT., BPPV, benign paroxysmal positional vertigo is the most common cause of vertigo, though it’s otoliths, you know, ear stones. 

So, reasonable for ENT to think they were being consulted to evaluate for BPPV and they respond in their consult report that the symptoms were not consistent with that. So, then this is happening at monthly intervals. Honest to God, that was November. The patient comes back to primary care, and the report in hand from ENT is: it’s not vertigo. 

So, one month later, in 12 of 2010, he comes back to the same primary care practice to be evaluated for this dizziness that won’t go away. A different provider sees the patient at this point and refers the patient to neurology and this is when, finally, neurology did head imaging and he was diagnosed with a pineal gland neoplasm and resultant hydrocephalus. 

And by the time he was diagnosed, you know, remember, and you remember because we just had this conversation recently, but anybody who didn’t listen to the earlier podcast, we were talking about compensatory mechanisms and how especially in a young 42-year-old healthy guy, compensatory mechanisms can keep you feeling pretty good for months and months and months. 

So, there’s a problem developing here. Occasionally some symptoms will break through, but then compensatory mechanisms, balance things out, and it’s not that bad. So, the patient can like go home for another month or go home for another two months. But finally, when the person is coming back, you know, boom, boom, boom, month after month after month, apparently no longer, you know, accepting it’ll probably resolve on its own would probably be fine. 

Now, the patient is decompensating, so now it’s going to go downhill very quickly. And it did. So, by the time the patient saw neurology and then had head imaging done and then the head imaging revealed that there was this pineal gland tumor which led to hydrocephalus and it was the hydrocephalus that was putting pressure on the brain that appeared to be producing this worsening, worsening sense of dizziness, which really was probably more a sense of, you know, of lightheadedness or near syncope, ataxia. 

By the time he was diagnosed, he was shunted to pull off the fluid and they were able to pull off the fluid. But at that stage of the game, he had lost a significant amount of cognitive function and it wasn’t going to be returned. And so, the end game for this patient is that the way the attorney communicated it to me, was that he had been assessed with the cognition approximately of a five-year-old, and it wasn’t going to it wasn’t going to change. 

It wasn’t going to get any worse, but it wasn’t going to change. So, you know, going forward, this is a condition that, it was treated and so it wasn’t going to cause imminent death or further deterioration. But neither was there going to be resolution of anything. And so no, another one of those it’s a zebra. And you don’t necessarily see a patient who says, “I’m dizzy.” 

And you say, “I’ll bet it’s a pineal gland tumor. Let’s just get that head MRI and see that.” But, you know, going back and analyzing this, in retrospect, there absolutely are some things that we could, that we can pick up on so that any of us going forward that encounters something similar hopefully can intervene more quickly. 

JA: Yeah. This one is such a tough one. You know, not that any of the cases that we’ve spoken about are not, they are all terrible in their own right. I think sometimes it feels like when we were working through these cases together, it seems quick that you’re like, that was right there, Right there, right there. It’s really obvious for me in my own RN brain, this seemed hard in the sense of just what you were talking about. 

I mean, I can’t tell you how many times I’ve gone to the doctor and it’s been like, “I don’t, I just, I don’t know. I was a little tired. I don’t feel great.” Like, it seems like nothing symptoms. Just a bunch of nothing of nothing. So, I mean, how do you, as a as a provider, especially as perhaps a new practitioner when these symptoms are vague like this, you know, how do you help to really make sure that you are picking up on what’s important here and that you’re not missing the opportunity maybe to probe a little bit deeper. 

SM: So, I mean, there’s not a perfect answer to that. This kind of thing does get missed. But, there are a few things here that that we can learn from. There are a few flags here that we could have identified a little bit sooner. The first one is this man at 42 with absolutely no history at all, suddenly has three distinct separate symptoms, seemingly unrelated. 

The sinus symptoms, the trouble sleeping, and the depression. And except for the sinus symptoms, the other two weren’t really explicated at all in the history of present illness. I mean, trouble sleeping can be many things. And incidentally, the pineal gland is really the gland that manages the circadian hormones of sleep and wake. I mean, the pineal gland is hugely associated with the circadian maintenance of sleep. 

So, again, it’s not like if somebody says to me, you know, I’ve been having such trouble sleeping, and I say, “Oh, you might have a pineal gland neoplasm. Let’s check that out.” Nobody thinks that way right off the bat. There’s just an interesting side note that one of his earliest symptoms was consistent with a pineal gland anomaly. 

Like, even if just to know in the history of present illness if the trouble sleeping was chronic. Did he have a long history of it? Did it happen before? Was it trouble falling asleep, trouble staying asleep, waking up early? Like, they’re all different causes of sleep disorder and they all have potentially different etiologies. So, it would have been helpful to know, like if this is a new onset trouble sleeping that had never been there before and there was nothing in his life to explain it like, you know, a sudden job loss or, you know, financial catastrophe or divorce or something like that, it would have taken on more significance. 

Conversely, depression doesn’t typically just land on you at the age of 42 without a precursor. In this chart, there wasn’t even an exploration of depression as whether it was a symptom of a depressive disorder or a symptom of something else, or just, ‘Yeah, I’m really depressed because this thing happened.’ You know, if I come to you with the chief complaint of depression at the age of 42, you do, first of all, you want to quantify it and see if it really is consistent with the depressive episode. 

And if so, why? Because if there’s not a clear reason to be depressed, then that makes you wonder if there is an organic etiology. I mean, the trouble sleeping and depression, they’re both, you know, brain phenomenon. I mean, if they’re organic, if there’s a physiologic cause, they are both often brain phenomenon and if they’ve never happened before and there’s no good reason for it, it it just raises the suspicion a little bit. 

Even if you don’t further evaluate right now, it’s on your radar, you know? Yeah. Okay. “Well, look, you know, get a little time and if this doesn’t normalize itself in a month or so. Come back and see me.” You know, like that. So, okay, so the first time, it’s easy to go back and say, we should explore this more fully, but we didn’t you know, any of us can go back. 

And that is Monday morning quarterbacking in reality, all of us probably would have said, well, there’s any obvious reason for it. Don’t know what’s going on, you know, but just pay attention. If it doesn’t get any better, come back and see me. But then he did come back like in two months complaining of dizziness and anxiety. Again, no obvious reason. 

Where were these things before? Like, where is this man who never had any problems before? How is it that a couple of months ago he’s having trouble sleeping and depression and now he’s got dizziness and anxiety? If nothing else, that index of suspicion is going a little bit higher. Explore the symptoms a little bit more because all of these can be caused by any number of physiologic phenomena. 

JA: Yeah.  
 
SM: But then again, he comes back two months later complaining of dizziness again. Dizziness and irritability. At this point, you have to say there is something going on here that needs further exploration. And one of the things that really needs to be done at this point is to articulate exactly what the patient is talking about when he says dizziness, because clearly it’s not vertigo. 

ENT picked up on that right off the bat. You don’t often see and come back at you and say, “He don’t belong here.” You know. Yes. So, the fact that ENT did that should really rein us right back in to considering a central nervous system phenomenon here and really quantifying what are we talking about? Are we talking about near syncope? 

Are there any other cognitive changes like we don’t even know because the notes were just so limited. And then keep in mind that the only reason this ever got referred to neuro was because another provider just happened to see the patient that day, Like, the same person who had seen all these visits just either was out of the office or not available or something. 

If that person had been there, you know, who knows what would have gone. It’s pretty telling that the person that did see the patient, the new person that did see the patient looked back at these notes and right off the bat, right to neuro. So, it’s reasonable for any provider to determine at this stage of the game that there is something wrong other than, you know, some ambiguous trouble sleeping. 

So, this, the thing that is a flag for me, there are several. This dizziness that is not in any way explored. Yeah, we just we don’t know. We don’t know what’s going on. Dizziness it’s not a medical term. When somebody says they’re dizzy, we need to know exactly what they’re talking about. I mean, if they’re having vertigo, it is probably an inner ear thing. 

But if they’re having near syncope, that’s more likely a cardiac or neurological thing, you know, And if they’re having ataxia, that is a spinal-cerebellar thing. If I can only say it, that is a spinal-cerebellar thing. So, right off the bat, you’re moving down three very separate diagnostic pathways, just by figuring out exactly what the patient’s talking about with respect to dizziness. 

The other red flag here is the increasing intensity of symptoms. You know, sometimes people worry about patients, you know, overthinking it or, you know, fictitious or what they used to call Munchausen and all that kind of thing. But one distinct difference is when it’s the same thing over and over and over again, something’s probably wrong. People with Munchausen or what we now call fictitious disorder or somatic disorders, that’s a whole family of disorders. 

It usually migrates from thing to thing. You know, it’s all over the body. Today is the headache. Now, my back hurts and that is my abdomen and that is my vision’s off. And then, you know, I don’t know. I have gout. Like it’s all like sort of different things. But when someone keeps coming back to you consistently with the same thing. 

Thing, thing, thing, thing. There’s something going on there. We just have to work a little harder to figure out what it is. And if you don’t know, it’s time to refer them on. So, those are the real red flags for me. The fact that somebody goes from previously healthy, no problems, no conditions, no meds, no nothing, to all of these visits in a short period of time with increasing frequency with essentially the same thing. 

It’s the dizziness and mental status stuff, dizziness and anxiety, dizziness and irritability, dizziness and depression, dizziness and trouble sleeping. You know, there’s just the whole brainpower there is going on. That’s what I think is most useful to take away from it.  
 
JA: Now, you know, one of the things that we had spoken about actually earlier before was, you know, is there such a thing as doing too much? 

Right. I was telling you a story that when I worked in the ER with a doctor and, you know, look, hearing this story because it sounds so vague in the beginning. Right. And I know that there are so many rules that I don’t even know, to insurance, to reimbursement, to all of these different things. And I wonder if it’s ever a challenge for providers or even if you’ve encountered this yourself personally, that you know, you do your interventions, you do the things that are like the first step, right? 

But then you feel like maybe you hit a wall and is there a struggle to say, like, if I do anymore, like this is just way too much, or even if it’s if I do anymore? Like this may not even be covered, but like, I don’t know what’s going on here, so I’m just going to pull out all the stops and try to figure it out. 

Is that like a real challenge that happens sometimes?  
 
SM: It is. Sometimes it is. I mean, there are, it is. You know, the business of healthcare is a business in most circumstances. Unless you have a funded, you know, a grant funded entity, it is a business of healthcare. And so, there is always somebody watching, even nonprofits. 

There’s a business manager, you know, somebody is watching that money. And yet it is an ongoing struggle. This business of ordering, quote, too many diagnostic tests, too much imaging. Lots of times you have to get it approved from the insurer. I mean, sometimes they want us to order things that we know are unnecessary before they will approve the next thing. 

Yes, that kind of stuff. Definitely happens. And I’m not saying it’s an easy fix. So, but there’s a couple of ways to go about it. Sometimes they’ll pay for it, you know, sometimes the insurer will cover it, but the practice gets, “dinged” isn’t the word I want, but it’s the best one I can think of where, you know, there’s all there’s all sorts of quality assessment measures and practices have to police their these health measures and how they meet certain goals and how they optimize the use of resources. 

So, if there’s a provider in the practice who appears to be ordering more stuff than anybody else, more consults, more imaging, chances are the insurance company is going to send a friendly letter to point out that this person is ordering more stuff than everybody else and maybe they need some education or something and maybe they do. You know, I mean, sometimes there is that because back in the olden days, we used to shotgun people. 

If you didn’t know what was going on, you ordered everything. You know, just ordered everything and it would get paid for and prices went through the roof. And that was that. And but we’ve gotten away from the whole shotgun in philosophy. Now, there does need to be medical justification for what we order. And sometimes the insurance company doesn’t agree with our justifications and then they won’t approve it. 

So, there is that. Sometimes you just have to go through their hoops, like if they want you to order an x-ray before you can have the MRI. Okay, you know, you order the x-ray even though you know you don’t need it, it’s not going to tell you anything because that’s what you have to do to get the MRI approved. 

If they want, you do a CAT scan before an MRI. Okay, we’re irradiating the patient. But if that’s what we have to do, if this problem is more compelling. If you feel like the patient needs something urgently and they won’t approve it, send it to the ER, send them to the ER and have them report the symptoms as they were reported to you. 

Like, I might not be able to get the insurance company to approve an MRI, but if the patient goes to the ER and relates to a recent history of progressive dizziness, whatever you call that, whatever that dizziness is, along with four or five other neurological symptoms, then the ER should do the image right there. And then the ER might say, you have this little tumor, go back to your primary care, you know. So, that’s another way that we can manage it. 

Sometimes you have to get on the phone with their approvers. You know, they do have people like insurance companies, from what I understand of the model here, no disrespect to insurance companies, but what I understand the model is that some things are just a blanket denial and the plan is that the provider just won’t have the time or inclination to pursue a prior authorization process and will do something else. 

And that does happen. You know, sometimes there will be an initial denial and then we call and we try to appeal it to that. They call it peer-to-peer. There’s a clinician on the other end of the phone that you can talk to and try to make your case and convince them, and sometimes they’ll go ahead and approve it. 

Sometimes you’ll find that there was information missing from the referral that made a difference. You know, those clinicals again, or sometimes they’ll just say no. And then you do have to rethink it and think if you really need that study, if you do send them to an emergency room, if you don’t, is there something else you can do first? 

So, yeah, I mean, it is an issue and it’s something we have to consider. And I know it would be so easy to say, “Just order it.” Just order what you think you need to order. The patient comes first, Everybody else be darned, but. But it’s just not that easy because you can order it. 

But if the insurance won’t pay for it, the patient has to. Or if the insurance won’t approve, the patient has to pay upfront and then half the time they don’t get it. So, that’s really not always the answer either. It’s hard.  
 
JA: Yeah and that adds another layer of difficulty to the whole entire, you know, situation. And I am certain I have heard this before, but I don’t remember. 

So, I feel like I’m like today-years-old when I learned about the pineal gland neoplasm. So, can you hit us with that? What is a pineal gland neoplasm and how do we treat that in practice?  
 
SM: Well, neoplasm is just by definition a new growth. You know, some new cells have generated and they can be benign or they can be malignant like you know you can get a little benign nevus. 

Like a little discoloration or something. You know, a neoplasm. A neoplasm can be a cancer and lots of them start as neoplasms and then they become dysfunctional or dysplastic, and then they become cancer. And sometimes neoplasms never become cancer. Their physical presence causes a problem. You know, there’s not much room in the brain for extra stuff. You know, brains are pretty tightly packed in there, in the skull inside the meninges. 

And so, when anything new grows or occurs, even if it’s not cancer, it’s just its physical presence can put pressure on the brain, it puts pressure on tissue, and can change the function of that tissue. And so the pineal gland, it’s a tiny little deep-seated gland. There’s not a whole lot of room around it. And it sounds like in his case, the consequence of the pineal gland, I mean, except for that early trouble sleeping, which is really interesting because that is the pineal gland. 

A big part of what it does is manage the circadian hormones of sleep. You know, we have a circadian cycle where in the morning wake promoting hormones like orexin and histamine they peak and that’s what makes you be awake even if you could stay in bed, you know your brain won’t let you sleep. And then we have our sleep-promoting hormones like melatonin at the peak at night. 

And, you know, calm us down. Despite that very early trouble sleeping, which is really just an interesting retrospective view, that may or may not have had something to do with pineal gland dysfunction. But the rest of it, it really sounds like it wasn’t the actual neoplasm, it was the resultant hydrocephalus. Right. He had the change in physical structure, altered normal drainage of fluid, and he wound up with hydrocephalus, which then put external pressure on other structures and led to all these other things like the depression, the anxiety, the irritability, and the dizziness, whatever it really turned out to be. 

JA: Yeah, okay. Thanks for clarifying that. And that is, again, like all of you know, all of these incidences that happened quite, quite unfortunate. And also, another common thread that we’ve heard before. Time, it seems like there was just a lot of time between, you know, the symptoms, the next follow up, I mean, not even coming back for the wellness check in a year like you normally do. 

But to your point with all of those symptoms and then they were kind of becoming more and more, you know, not following up on that, seems like that was another opportunity that was missed.  
 
SM: And that comes back to where the patient, we’re the professional, they’re the patient. They trust our judgment. If we tell them, it’s probably fine. 

This is typical. It’s not unusual, you know, to go through these spells of trouble sleeping or feeling depressed when you’re building a career. Then the patient goes home and thinks it’s okay, so that even if it happens again, maybe like they feel that way again in a week or two, they think, well, you know, they just said, give it some time, it’ll go away. 

And I mean, you know how this goes. The older we get, the faster the time goes. All of a sudden that those couple weeks became a month and then another month. And but you see how the the intervals become more narrow over time.  
 
JA: Absolutely. Wow. That was. Yeah, that was really unfortunate. Wow, wow, wow. Yeah. Thank you for sharing this story. 

And if there’s any other takeaways you’d like to share with us, Dr. Sally Miller, on this.  
 
SM: I mean, you know, hindsight is always 20/20, but the two big takeaways are, number one, when somebody complains of dizziness, you want to make sure you know what they’re talking about. And if you’re not sure why, we just happened to have a dizziness, vertigo, syncope program at FHEA that, like I said, I developed that. 

I’ve developed that whole line of expertise, really after this case and knowing I had to dig into it, learn more about it. But really, you know, CE program or not, if you don’t really understand the nuances among those things you do want to be familiar with, because dizziness is a very vague term. You know, people always hear things through their filter and then the other person says things through their filter, and somebody might tell you that they are dizzy and they know that, you know, that’s vertigo, because what else could it be? 

But you hear it and might be thinking it’s a near syncopal, a lightheadedness kind of thing, you know, in your often too divergent circumstances. So, you want to make sure that you know what dizziness means, really try to quantify it in a medical term, vertigo, near syncope, or ataxia, that’s usually what people are talking about. That’s one thing. 

The other takeaway is, like I said, if you’re thinking, “Oh, somebody’s overreacting.” They’re, you know, being a bit of a hypochondriac, not when the same thing keeps coming back over and over and over again. Could it happen? I mean, I guess. But hypochondriacs are usually more,  “It’s my head, it’s my stomach, it’s my back, it’s my this, it’s my that.” 

When somebody keeps repeatedly coming back over and over again with the same complaint and the intervals are narrowing, there’s something wrong there. And if you’re not sure what it is and you’ve exhausted your diagnostic evaluation, refer it on.  
 
JA: Yeah, that’s good. That’s good advice. Thank you again for your time. Thank you for sharing these stories. It does give us all an opportunity to remember, to listen, to learn. 

Right. And to continue to advocate for our patients and for our profession, quite honestly. We hope that you found this story helpful, hope that you found this interesting, and you have some good takeaways to carry with you in your practice and if you’d like to hear more check out the rest of our podcast that we have in our other key offerings on FHEA.com. 

Goodbye for now.  
 
Voiceover: 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.