Scrubs and Subpoenas
Who’s On First?
Lost in a labyrinth of white coats, his silent symptoms became twisted in “on-call” tangles. Join Dr. Sally Miller, Fitzgerald faculty member and expert witness, for a true patient story that will leave you questioning where the ultimate responsibility truly lies.
Transcript
00;01;20;26 – 00;01;36;29
Jannah Amiel
Hello and welcome to another episode of Scrubs and Subpoenas Tales from the Witness Stand. I am your host, Johnny Amiel. And joining me again is one of our expert witnesses and very amazing FHA faculty, Dr. Sally Miller. How are you, Dr. Miller?
00;01;37;02 – 00;01;39;02
Sally Miller
I’m very well, thank you. And you?
00;01;39;05 – 00;02;00;29
Jannah Amiel
Excellent. Thank you. Thank you. I’m really excited to hear our next story. For those of you that might be joining us for the first time. This is a new podcast that we’ve been running here, and it’s a really interesting new podcast series that we have and a really interesting way to learn. Right. So we want to make sure that we take the time to say that we know, right?
00;02;01;01 – 00;02;19;25
Jannah Amiel
We know that mistakes happen all the time, right? And there no one is immune to it. Dr. Miller actually has a really good phrase, a saying that you used last time. You said that there’s those of us who made mistakes. Right. And those of us who will. And I think that that’s a really good way to kind of like ground us.
00;02;19;27 – 00;02;41;10
Jannah Amiel
Right. So we don’t we’re not throwing out judgment. It’s easy to look at things that have happened in the past and say like, well, this should have gone this way, But it’s a really good opportunity for us to hear real stories that we know, we all know as practitioners, as clinicians and providers that happen and kind of dissect them together and take it as an opportunity to learn, learn how we might be able to to do better in the future.
00;02;41;13 – 00;02;45;02
Jannah Amiel
Right. Is there anything you want to add to that, Dr. Miller.
00;02;45;04 – 00;03;01;16
Sally Miller
I don’t think so. It is definitely, definitely not a judgment oriented approach. It’s really, you know, how you you learn, you go back and learn like all of those, you know, root cause analysis and all of the names of different mechanisms for just trying to ensure that we don’t repeat the same mistakes.
00;03;01;19 – 00;03;23;07
Jannah Amiel
Excellent. Perfect. So with that said, we are ready for our first case. And so those are either listening and maybe you’ve heard this or didn’t hear this for the first time. Listen and follow along. Right. Listen and follow along and see if you can catch maybe where there might have been some room for different opportunities, different decisions. I’m ready when you are, Dr. Miller.
00;03;23;10 – 00;03;47;23
Sally Miller
Okay. And I do so some sometimes time and timeline is really important, the nuances of the timeline of events. So in some cases like this one, I have some notes in front of me just because I want to be very precise on the timeline. And I think what I’m I’m going to try not to tell you who retained to me, whether it was plaintiff or defense may just tell you the narrative of events.
00;03;47;23 – 00;04;07;17
Sally Miller
And then everybody can give some thought to what’s going on here and what they think was the standard of care. And then at the end we’ll we’ll Q&A it so. So the story is this it’s about in the patient is a 60 year old gentleman actually works as a medical assistant and he had been seen in the emergency room on two different occasions within a two day period.
00;04;07;17 – 00;04;33;08
Sally Miller
You know, he had an injury at work. Something happened in his role as an M.A, something to do with moving a patient, you know, a physical thing. And he had back pain, abdominal pain and vomiting. And he went to the emergency room twice in a two day period, like I said. And they diagnosed him with sciatica and he was basically, you know, managed for pain and given some suggestions about, you know, exercises, that kind of thing.
00;04;33;10 – 00;04;58;24
Sally Miller
On the third day, he went back to the emergency room and he was complaining again of back pain, abdominal pain and vomiting. And so the emergency room physician who examined him at this point noted some abnormal findings during the abdominal exam and the lower back examination. So following that exam on this third visit on the third day, the physician ordered some laboratory tests.
00;04;58;26 – 00;05;23;26
Sally Miller
He put the patient on IV fluids, pain medication, an N.G. tube was inserted and 200 miles of blood drainage was drain. So needless to say, they kept him around for a little bit this time. So that that was actually the admission and the initial examination and the energy tube, etc. around four, 430 in the evening at 6:00 an hour and a half later, an obstruction series was ordered.
00;05;23;29 – 00;05;50;26
Sally Miller
And then some of the labs started to come back and the patient of note the patient had a total leukocyte count of 25.9 thousand cells, which is elevated, He had neutral. Well, obviously. Right. He had neutrophils of 90%. He had a serum amylase of 1202 other atypical lab findings included a Biewen of 49, a creatinine of 1.7. Now, we don’t know where he started.
00;05;50;26 – 00;06;19;09
Sally Miller
We don’t know what his baseline was. But that’s that’s what was determined on that night. He was medicated for pain and then again he was medicated for pain a little bit later. So needless to say, shortly after this collection of lab lab test came in, the patient was admitted to an internal medicine service. So technically admitted. But you know how it goes in the E.R. Sometimes you’re admitted to a service, but you can stay in the E.R. for, you know, a day or more pending availability of a bed.
00;06;19;12 – 00;06;53;11
Sally Miller
So he was admitted to an internal medicine service. The internal medicine service to which he was admitted. The internist was unavailable. So another internal medicine service was covering for the admit admitting service of record. The covering internist was out of town. And so the APRN, who is, you know, my interest in this case, the APRN was covering call for the internist that was covering for the other internist.
00;06;53;13 – 00;06;56;00
Jannah Amiel
So it was like covering for the covering of the.
00;06;56;07 – 00;07;14;15
Sally Miller
For the covering. Yes. Okay. You have like what they call like that like six degrees of separation, like the whole Kevin Bacon thing. Right? So boom, boom, boom. So this apron, she was not in she was not in the in the hospital. This was this was I believe it was a Friday night. It was a Friday night. And she was at home and she was she was taking call.
00;07;14;15 – 00;07;33;14
Sally Miller
So she, you know, picked up the phone. So she was the one that got the call. So what we do know now, remember, all of these things always happen years after the event. By the time everybody’s looking at charts and, you know, pleadings have been filed and records are subpoenaed and everybody’s looking at it. It’s years after these events actually occurred.
00;07;33;16 – 00;07;57;21
Sally Miller
So what we do know from deposition of the emergency room physician is that he spoke to the covering APRN by telephone. There is no record of this phone call anywhere. There is no recollection of the phone call. The physician was a he and he doesn’t remember what he told the apron. And she’s a she. So just for the sake of brevity, I’ll probably use the pronouns here.
00;07;57;23 – 00;08;15;18
Sally Miller
He doesn’t remember what he told her. He didn’t. He didn’t write it down. He did document that he called or there was a note that he called her, but there was no nothing to memorialize that conversation. She did not remember this call at all. She didn’t remember anything about it when she was deposed, like four years after the events.
00;08;15;20 – 00;08;37;20
Sally Miller
And so he doesn’t know what he reported to the nature and she doesn’t remember the call at all. And no one else can recall anything about information at this phone call. So. Okay. And just put that on the back burner for a minute. This you know, if nothing else, just a side note here for all of this. You know, to make a call like that, it’s probably helpful to jot down the pertinent stuff.
00;08;37;20 – 00;08;57;16
Sally Miller
And listen, I know that it is difficult and I know when when you’re running late and, you know, the last thing anybody wants to do is sit here and write, you know, a whole five chapter volume on the nature of the phone call. And that’s not what I’m suggesting. But just maybe built like real quickly, like the highlights of the pertinent that you report or whatever and what that person says, okay, so we don’t know.
00;08;57;22 – 00;09;22;21
Sally Miller
That’s what we’re working with now. And that was it about. But that happened around 630. It’s recorded at 618. So the timeline here he comes in at 430, he’s got the N.G. tube with the blood. He’s got some abnormal abdominal findings. Labs are ordered and obstruction series is ordered. The lab started to come back around 6:00 with this very high white count neutrophils, a very high amylase, elevated bone and created him.
00;09;22;24 – 00;09;47;10
Sally Miller
That was about 6:00. The patient was medicated for pain and then at 618 was documented. The decision to admit him. So this is when this telephone call is happening. Now, we do know nobody knows what happened during this call, but we do know that according to the chart, the labs were available at that point. The obstruction series was not because the obstruction series was resulted later on in the evening.
00;09;47;10 – 00;10;06;14
Sally Miller
So all you know, he may or may not have shared with her some of these labs. We just nobody knows. And and blessedly nobody was. You know, as you read through the notes and read through the depositions, everybody was just very frank about, look, I don’t know what I did on a Friday night four years ago, just like we don’t know what we did Friday night four years ago.
00;10;06;14 – 00;10;27;28
Sally Miller
I don’t know what I did this last Friday night, you know, but that when you go back and look at the written word, there was very little there. We do know next thing that’s recorded of interest is at 8:24 p.m., the Obstruction series is dictated by the radiologist as suggestive of an early or partial small bowel obstruction. No one was advised of this result.
00;10;27;28 – 00;10;52;03
Sally Miller
You know, usually the radiologist will make a note reported to attending reported to the floor nurse in a reported to E.R., whatever, but there was no note that anyone was advised of this result. So again, was it called to somebody or not? We don’t know. It wasn’t. The report was not transcribed until the next morning. So so that’s just out there.
00;10;52;03 – 00;11;16;13
Sally Miller
It was resulted at 824, but we don’t know if anybody knew about it or not. So the next thing of interest in the record is that at 9:40 p.m., the emergency room nurse calls the apron because she’s covering the covering the admitting. Right. So the E.R. nurse, the patient is now in some sort of status, like they had this a status hold or something.
00;11;16;15 – 00;11;45;06
Sally Miller
So they’re calling the service for orders, but it’s the E.R. staff that’s managing it. Well, you know, whatever. So the E.R. nurse, the E.R. nurse calls the APRN to request a pain medication and Dilaudid. One milligram was ordered. The nurse again called the apron 5 minutes later, asking for an order for severe pain. And so she ordered two milligrams of Dilaudid, PRN, severe pain, Dilaudid.
00;11;45;08 – 00;12;11;16
Sally Miller
At that time. At that time, the apron also ordered a surgical consultation. Nothing else is documented about the content of these calls. We have one one milligram of Dilaudid. 5 minutes later, severe pain, two milligrams of Dilaudid and a surgical consultation. It looks like a routine surgical consult. At least there was nothing, nothing ordered stayed or nothing recorded.
00;12;11;16 – 00;12;46;22
Sally Miller
It was ordered start. So this is now 9:40 p.m. on a Friday night. So the surgical consultation did not happen that night because it was an ordered stop. Reportedly at 11:45 p.m., a new nurse took over. Nothing else was recorded that night. The apron was not called by nursing or house staff. The apron was never called again. This is the entire interaction of the apron with any staff or anyone about this patient.
00;12;46;24 – 00;13;08;25
Sally Miller
She got a call at 618 from emergency room physician. She got a call from the floor nurse at 940 and then again at 945 and gave orders for pain meds and a surgical consult. Again, there’s no there is no discussion or dialog in writing about the content of the call. The nature or any other pertinent findings pointed out was anything requested.
00;13;09;03 – 00;13;27;24
Sally Miller
We just don’t know. And that’s it. I never heard from anyone again. So I guess she went to bed the next day. The attending physician with whom the apron worked, the covering, the covering attending. He was back in town, right? So he so yeah, the person whose service it actually is still has nothing to do with this yet.
00;13;28;01 – 00;13;52;25
Sally Miller
Now, the next morning, Saturday morning, it’s the physician with whom the apron works is now available and he goes to the hospital and he rounds live. You know, he does live rounding on the patient. And he felt during his physical exam that a small bowel obstruction with a perforation was possible. So and apparently at that time, he became aware of the obstruction series result that had been obtained the night before.
00;13;52;27 – 00;14;15;25
Sally Miller
So a stat c.t. And surgical consult were ordered. The patient was taken impotently to the operating room in the O.R. the patient was found to have necrosis and gangrene from the gastro agent ostomy to the terminal ilium that he had that nobody appeared to know about. So by the time that the surgery was over, he was left with about 18 inches of small intestine.
00;14;15;28 – 00;14;17;22
Jannah Amiel
Holy crap.
00;14;17;24 – 00;14;44;06
Sally Miller
So needless to say, he lived. I mean, he. He did. I shouldn’t say. Needless to say, he lived. Not everyone would, but he did. But what I what I started to say was, needless to say, his life has changed significantly. You know, at the age of 60, as a medical assistant who now has 18 inches of bowel it, you know, when you go from something like 15 feet of bowel or I don’t know exactly what the number is, but we have feet and feet of bowel and now he has 18 inches of small intestine.
00;14;44;11 – 00;15;04;25
Sally Miller
So it changes your life in every way. The whole you know, as soon as you eat, you pretty much have to be on your way to the bathroom, you know, as you’re learning how to manage that part of your life. Not to mention the the unbelievable physiologic stress and strain that is placed on a 60 year old body that I mean, it was septic, you know, between the gangrene and necrosis was septic.
00;15;04;25 – 00;15;26;25
Sally Miller
So it was a big deal. He spent a lot of time in health care services and recovery and that kind of thing, and never was able to go back to work. Excuse me. So, of course, a lawsuit ensued and lots of people were named in it. But very specifically, the apron was named in this suit and it was suggested that she violated the standard of care.
00;15;27;02 – 00;15;58;12
Sally Miller
Well, I made some notes, so I made some notes about what was what the assertion was. So one of them was that when the apron took the phone call from the emergency room physician, she failed to ask about abnormal test findings and outstanding tests. It was suggested that it was her responsibility to purposefully ask for any abnormal tests that had been obtained and to obtain the results of the obstruction series that was pending at the time of the call.
00;15;58;17 – 00;16;25;03
Sally Miller
So the suggestion is that she got the call at 618. If she was told the obstruction series was pending, it was her responsibility to call back in and find out what it was. So it was you know, it was suggested that she failed to ask appropriate questions when the E.R. physician gave a verbal report. Keep in mind that the whole you know, most of the time malpractice cases really, really come down to did someone violate the standard of care?
00;16;25;05 – 00;16;44;23
Sally Miller
And I’m sure I’ve mentioned this in previous episodes, but the standard of care for the legal standard of care is very different from the health care providers standard of care. If you ask any nurse practitioner what the standard of care is, they’ll they’ll call the pull guidelines out. They’ll tell you about, you know, this is what this guidelines says, this is what the evidence says.
00;16;45;00 – 00;17;05;09
Sally Miller
And that’s not the legal standard of care. I’m sure I told you before I learned the hard way. The legal standard of care is what a person of the same licensure would do or same licensure experience, etc., would do under the same or similar circumstances. So I don’t even know that there is a an evidence based guideline about what you’re supposed to do on call.
00;17;05;12 – 00;17;26;11
Sally Miller
Know what what do you do when you’re home and you’re answering the phone for somebody and it’s a weekend and they call you about a problem and apprize you of it. And pretty much assuming tell you it’s like we’ve admitted him, etc., you know, what is the responsibility there. So that’s really the question. What did she deviate from the standard of care?
00;17;26;11 – 00;17;51;21
Sally Miller
Did she fail to do what any reasonably, you know, appropriately trained nurse practitioner would have done in the same or similar circumstances? It was also asserted that this nurse practitioner failed to ask appropriate questions when the nurse called her at 940 and 945 asking for orders for pain and then again for severe pain. The assertion is she didn’t ask enough question.
00;17;51;21 – 00;18;21;12
Sally Miller
She didn’t pursue why this pain was happening or why did you need it for severe pain, any of that. And then finally, it was suggested that the APRN should have asked if the patient had a history of gastric bypass surgery or any sort of gastric surgery. But that’s the assertion that that’s the assertion, of course, from, you know, the patient’s attorney, that that’s what they’re asserting that she did wrong.
00;18;21;14 – 00;18;39;25
Sally Miller
So interestingly, I mean, I think it’s I really think it’s an interesting question, actually. So you probably can tell I was trying to be all slick and objective here, but you can probably tell that I was retained by the defense. And that really doesn’t make any difference. I mean, I have turned down defense cases that I didn’t feel like I could support.
00;18;39;28 – 00;19;06;05
Sally Miller
And I have I have testified for plaintiffs and I’ve also turned down plaintiffs cases that I felt like I could support. So I really unlike many of my peers, I really don’t have any particular preference. I mean, I think that if we have a nurse practitioner who’s violating standards of care and being unsafe, I think we we want that drawn to their attention so that they can either remediate their practice or not do it, because it’s no good for patients and it’s no good for the profession.
00;19;06;05 – 00;19;34;22
Sally Miller
So I don’t really I really don’t like I don’t take sides. I’m not, you know, a defense person or a plaintiffs person. But in this particular circumstance, I thought it was really I thought these were some interesting questions. You know, what what who who does have what level of responsibility. And of course, since virtually nothing here was recorded, what they will accept many times what is considered acceptable testimony is when someone testifies, this is my custom and practice.
00;19;34;22 – 00;19;55;06
Sally Miller
This is what I would do if X happens. So so so what she said was not in the paren testified clearly she had no recollection. She didn’t just didn’t remember this at all. She was not in a position to be right. It was years ago. I mean, it’s a Friday night. It was a Friday night phone call and she didn’t have any.
00;19;55;08 – 00;20;11;13
Sally Miller
And, you know, it didn’t memorialize it anywhere. It didn’t happen. You know, I mean, this was a long time ago before we all had ready access to charts and and laptops that had records on them. And even at that, I don’t know, you know, I don’t remember how things were at this time, but it definitely was not that easy.
00;20;11;18 – 00;20;29;20
Sally Miller
And then, of course, you have the whole HIPA thing about you can’t be pulling up medical records on your personal laptop. So this it like it’s just so you know, is it how cut and dried is all of this. So the things that I think that I mean the question for me was did she deviate from the standard of care when she didn’t do those things?
00;20;29;20 – 00;20;58;02
Sally Miller
I mean, it’s the defense’s job to answer, to defend themselves against the assertions of the plaintiff. So the plaintiff is saying she didn’t ask enough questions during the initial report of 618. She she should have called back to check on the obstruction series. If she knew it was pending. She should have asked more questions about why there was pain at 940 at night, and it was also suggested that she should have ordered that surgical consult stat and she did not.
00;20;58;05 – 00;21;28;07
Sally Miller
And all she all she could say in her testimony was, look, I don’t I don’t know what you’re talking about. I have no idea what you’re talking about. Unfortunately, I don’t have any recollection of two phone calls on a Friday night four years ago. But I can tell you my custom and practice would be that had I known about a white count of 25.9 thousand, had I known about an analysis of 1202 and neutrophils of 90%, I would have ordered further evaluate them.
00;21;28;09 – 00;21;50;26
Sally Miller
And and so you know the question and hopefully people are listening are wondering really where you know think about the practical application here you’re at home. It’s Friday night. You’re on call, you’re covering for somebody. Phone rings. Hello? it’s the E.R.. Yes, We have this patient. You know, here’s a dialog, okay? And they hang up and then hours later, three, three and a half hours later, the patient’s having pain.
00;21;51;02 – 00;22;18;20
Sally Miller
Okay, comes. I’m delighted. Having more pain for Dilaudid. Where does the responsibility lie? So who whose responsibility is it to give information? I mean, is it is it acceptable to say that the apron is just the receiver here and whatever information is presented, that’s what she works with? Or is it her job to ask more questions? Is it her job to pursue that a little bit further?
00;22;18;25 – 00;22;39;21
Sally Miller
You know, whose responsibility is it to make sure that information is given to the covering person on call that they can make appropriate judgment calls? You know, that’s one thing to consider. And I guess that’s really the big thing when push comes to shove. So if we only had like mystery music, maybe we could play mystery music now and people would think through this.
00;22;39;21 – 00;23;04;17
Sally Miller
But I mean, you know, really so from from a defense perspective, primarily just because nobody wrote anything down doesn’t mean that information didn’t change hands. You know, Do you write down, do you when when anybody makes a call, is it the standard of care to write down every little thing you say?
00;23;04;20 – 00;23;22;16
Jannah Amiel
Well, it’s like, you know, so it’s two things, right? It’s making me think of and it makes me think of the the the all like line, like passing the buck. Right? And it’s like, well, it wasn’t me, it was you. And it’s like, well, no, it wasn’t me. It was you. I gave it to you. And it’s like one of those things that we talk about sometimes.
00;23;22;16 – 00;23;46;04
Jannah Amiel
But in my mind, writing and I don’t know, this might be not right, but I feel like if you assume this makes you think about one of our episodes, quite honestly, if you assume the role of the provider, right, even if you’re covering for the covering of the covering like and at any point you’re playing provider, then like it seems like you have to be full on provider.
00;23;46;11 – 00;24;06;06
Jannah Amiel
So like what would a full on provider have done? And I hate to make it seem like she wasn’t the full on provider, but she assumed responsibility and seems so if if you assume responsibility for any patient, then I imagine you’re going to do all the things that you would do for every patient and make sure every T’s cross and every I idea started in that way.
00;24;06;08 – 00;24;30;07
Jannah Amiel
And then without the documentation, it this makes me think of every single time a professor has like drilled documentation into our heads as like nurses, how freakin important it is to document because that’s the whole thing. If you didn’t document it, then like something happens, how do you go back and show anything you don’t? But then I think about that was so many years ago.
00;24;30;08 – 00;24;41;04
Jannah Amiel
Even if you did document it, how long does documentation live now? That’s like the new thing I never even thought about. There is there’s like a lot of layers to that.
00;24;41;07 – 00;25;08;10
Sally Miller
All the above. I mean, now it’s like documentation just lives to infinity. I guess unless we have some major, major devastating cloud crashers, something and everything will be gone. It’s like everything is available on the cloud. So, I mean, I really I tell you, I, I listen, I was retained by the defense, so I mean, I don’t know how to say this because I do want to be I want to accurately represent my thought process.
00;25;08;10 – 00;25;29;04
Sally Miller
It’s not like I go, I’m going to say whatever I have to say for the defense. You know, like I said, I’ve turned down cases when I feel like I can’t defend them. In this one. I really had to I really had to think about what what is that the legal standard of care, what the same licensed person would do in the same or similar circumstances.
00;25;29;06 – 00;25;52;21
Sally Miller
What I you know, I’m like, what did I do when I was on call? And I got a call from a facility and they told me something and I had to give a response to it. How, you know, how much digging do I do? A typical like what someone would do in the same or similar circumstances. I’m I’m kind of jaded now because I see things like this.
00;25;52;28 – 00;26;02;20
Sally Miller
So my documentation has changed over the years. My approach to anything has changed over the years because I’ve seen how these questions arise. You know, I.
00;26;02;20 – 00;26;06;24
Jannah Amiel
Feel like you are hyper documenting now.
00;26;06;26 – 00;26;23;08
Sally Miller
I’m sure I said another episode. Everybody makes fun of my documentation because it’s like, you know, it’s like almost reading War and Peace. It takes time. I really do go back and I just write every note as if as if three or four people are going to be scrutinizing it with a magnifying glass a couple of years down the line.
00;26;23;10 – 00;26;58;07
Sally Miller
But, you know, I hope it doesn’t happen, but it could be. In this case, though, I really did struggle with this this envisioning this dialog in a real world Day today. I mean, I definitely do not think it is the responsibility of the receiver of the call whose, you know, at 6:00 or Friday night, probably home having dinner or something gets this call from the air from the person who is on site, the person who evaluated the patient, the person who ordered all of these things, like that person presumably knows all the relevant info and is calling to give report.
00;26;58;09 – 00;27;19;26
Sally Miller
So I definitely believe that that the the primary onus of responsibility is on the person who’s made the call to admit the patient and then is passing that on to someone else. I mean, when you give report, you tell the person who’s going to take over the that what you what they need to know. Right. I mean even nursing report was that way.
00;27;19;29 – 00;27;26;18
Sally Miller
But and so the APRN we don’t know what she was told that that’s the.
00;27;26;18 – 00;27;27;24
Jannah Amiel
Thing we don’t.
00;27;28;00 – 00;27;50;00
Sally Miller
Know what she was told if I mean we don’t know And so it all becomes what if what if what if so remember, this man had been in there three times in the last three days after an event at work and got some back pain and for two days had been diagnosed with sciatica. So we don’t know if when he gave report, he said, look, this is, you know, man’s third day here.
00;27;50;06 – 00;28;08;08
Sally Miller
You know, he’s been treated for sciatica. But I’ve seen little a little off in his back. So I ordered these other things. We don’t know what results he gave her or not. Right. You know, we don’t know. I mean, you might say, well, don’t you think he would tell her about the blood? Don’t you think he would tell her about the white count?
00;28;08;10 – 00;28;26;29
Sally Miller
Well, yeah, but I have learned don’t ever assume what somebody else did or didn’t do because also vision, those emergency room nights, 5 million things are happening. Somebody is coding here. There’s a femur sticking out of somebody’s leg over here. Somebody else is out sick. Everybody’s overworked. This E.R. doc is in the middle of, like some other major thing.
00;28;27;03 – 00;28;45;18
Sally Miller
And so he says, hey, that that internal medicine in the phone for this guy. hey, look, Sorry. I just want to let you know we’re meeting this guy to your service. Blah, blah, blah. See you. Right Or not, you know, we just. We don’t know. So, you know, when it comes down to something of this magnitude to say things like, Well, don’t you think he would have done this, this and this?
00;28;45;23 – 00;29;08;00
Sally Miller
A lot of times people reviewing this stuff suddenly get very, you know, like high horse and I would have done this and I would have done that and everybody should have done that. And that’s just not real life. So at the end of the road, if it’s not written down and nobody remembers it, you really can’t you can’t say what somebody did or didn’t do or what they should have done, all they can say it’s their custom in practice.
00;29;08;00 – 00;29;30;13
Sally Miller
So the physician may very well have testified it would be my custom in practice to pass on this info. And the apron I know she testified well, would be my custom in practice if I received this info to do X, Y, and Z. And since nobody can support what went, we’re like, we just don’t know. 3 hours later, she gets a call about the pain.
00;29;30;16 – 00;29;53;20
Sally Miller
So what is how, how much how much do you ask? So now at this point, we’re not talking about like a peer to peer report. We’re talking about the apron getting a call from the covering nurse asking for more pain meds. At this point, does the APRN have the responsibility to dig any further? Like, well, why is he in so much pain?
00;29;53;24 – 00;30;17;08
Sally Miller
Or, you know, I mean, again, I’m I don’t know. I’m not sure we don’t know what the nurse said. We don’t know what the APRN said. Nobody knows because nobody wrote it down to some extent. I still do believe that the person making the call is the person on site, on board with whatever information prompted them to make the call.
00;30;17;10 – 00;30;35;15
Sally Miller
And you would assume that they would pass on appropriate info. But again, like nobody knows. So it almost reads it almost reads like so-and-so is having having pain. Can I have a pain order? Yeah. Give one milligram Dilaudid, right? Is that right?
00;30;35;18 – 00;30;52;27
Jannah Amiel
You know, and it’s like maybe. But you don’t have all the right information. Right. And I think that that’s like that’s a really interesting point because you’re right. I am honestly sitting here going like, well, she could have asked this and she could have asked this and she could have asked this, But that does now feel like a slippery slope, right?
00;30;53;05 – 00;31;10;24
Jannah Amiel
That makes me even think about every single time I’ve received report I counted on the the nurse to give me all the information. Granted, there will be some things I will find out during my own assessment in my own care. But I didn’t also go, well, what about this and what about that? And what about that? And what about that?
00;31;10;24 – 00;31;40;13
Jannah Amiel
Like you know what I mean? We didn’t do that because I assume that you gave me all the information I needed to carry on and take the next step for the patient. So that is so tricky. And then so are there not real best practices that exist around things like this? Like what is the responsibility? If you’re on call and you get a call on a Friday night, they super late like, what is your responsibility?
00;31;40;20 – 00;31;49;03
Jannah Amiel
I think everything is like this checklist, you know, to go through to make sure like you’re nice and safe. But I know that we’re not cut and dry like that. We’re just not.
00;31;49;05 – 00;32;12;10
Sally Miller
Know. I mean, there’s there’s no evidence based standard like that, like there is with a hypertension algorithm or an asthma algorithm or something like that. It really more much more generic. You know, the the on call provider, which, you know, should provide, you know, you know, the kind of language that doesn’t really provide. And and for the most part, I think the the facilities might have their requirements for on call.
00;32;12;11 – 00;32;44;03
Sally Miller
But even that is just very esoteric and you know covers all bases. So, I mean, the one thing that I think was absolutely absurd was that she should have purposely called back hunting down the obstruction. Sierra’s report, if she even knew one was pending. And we don’t know. But if she knew one was pending, it is it is reasonable to assume that if there was an alarm finding on the obstruction series that someone in the hospital would have passed along that information to people that needed to know it.
00;32;44;03 – 00;33;04;16
Sally Miller
You know, you don’t you don’t just expect somebody on call to start making calls, you know, hours later to hunt down the result of a report. So I thought but that one was clearly absurd. But the others. But so I will I will share with the listening audience at home that this opinion was not found liable for malpractice.
00;33;04;16 – 00;33;27;15
Sally Miller
She there was a settlement. There was a settlement from other providers to this patient and family, but she was not among them. I like to think it was because of the expert witness who defended her in deposition. But honestly, the I mean, the fact is, when push came to shove, there was just absolutely no record of what she was or wasn’t told.
00;33;27;17 – 00;33;54;26
Sally Miller
And all you can I mean, the one thing that I think everybody did seem to agree with was the people on site, the people that make the call to bring you into it do have the primary responsibility for ensuring that all relevant information is communicated and if they don’t and if nobody writes it down and you and you can’t know, well, you know, how do you how do you make that judgment?
00;33;54;28 – 00;33;59;17
Sally Miller
And in this particular case, yeah, so she was not found liable.
00;33;59;19 – 00;34;22;01
Jannah Amiel
And I wonder and what do you think about this? You know what it makes me think about? Like our rights of delegation, like we learn about, like, you know, as a nurse’s right in, like, the right way to delegate. And part of that, as you’re talking, is making me think about like, you can’t just give somebody something to do or to carry out without all of the right information so that they can actually perform that.
00;34;22;01 – 00;34;42;28
Jannah Amiel
So that’s actually kind of interesting for me because I feel like that puts it into perspective in a way that I never thought about that. Like, of course you’re qualified to do this, you’re a provider, You’re you’re no, you can do all of these things. But also there is still a responsibility and an onus of everybody on that team, on that conveyor belt to keep passing along all that information.
00;34;43;01 – 00;34;45;26
Jannah Amiel
Unfortunately, you know, there’s a patient at the end of this.
00;34;46;01 – 00;34;52;02
Sally Miller
Exactly. A patient, a patient whose life changed.
00;34;52;05 – 00;34;55;25
Jannah Amiel
my gosh. That is really that is really interesting.
00;34;55;27 – 00;35;08;19
Sally Miller
Wow. I mean, like I said, when I call somebody now, I do just a few. Just a few, just a few pertinent, but I make sure that it’s in my note, you know, who I call what happened or that they didn’t call me back because that happens a lot, too.
00;35;08;21 – 00;35;30;28
Jannah Amiel
Yeah. No, that’s absolutely that’s a great takeaway to ensure that that’s still account and that’s still part of documentation, that’s still part of, you know, patient documentation that’s really important. Wow. Dr. Miller, That was a really interesting one. Is there anything that we haven’t covered with this? An important takeaways, something to think about that you’d like to leave our audience with?
00;35;31;00 – 00;36;03;14
Sally Miller
I don’t I mean, other than what we’ve talked about, I mean, number one, it is a really interesting hole in our well documented standards of care. Maybe somebody doing a DNP project or something like that really might explore what what is the is there any evidence based foundation for the responsibilities of an on call provider? And if there’s not, it may be it might be a need that, like I said, a DNP student or somebody building a career might look into it sounds like publishable work and then for the rest of us, it’s just just the little things.
00;36;03;14 – 00;36;17;21
Sally Miller
I mean, none of us have time to document war and peace. I know, but if I mean, I will say if I tried it like I you know, the work that I do now, I might reach out to a specialist or I might, you know, send somebody to an and call in to to let them know they’re coming.
00;36;17;21 – 00;36;29;13
Sally Miller
And please don’t send them home or let them sit there for 5 hours and just, just the highlights, just the most important things that you shared at least does document what you did. What you did do.
00;36;29;15 – 00;36;50;06
Jannah Amiel
That’s important stuff. I didn’t really thank you so much for sharing this story, for sharing all of your stories. It is a really good opportunity to learn and and listen in and every single time. It challenges something that I thought, like I was so strong and firm about. And then you realize, like, you know what? Real life is really different than what we learn in the textbooks.
00;36;50;06 – 00;37;02;19
Jannah Amiel
In real life is really different than, you know, all the things that we have to do as we’re learning. That’s not wrong. But there are these pieces that just don’t capture until you’re in it.
00;37;02;21 – 00;37;06;08
Sally Miller
that whole human factor. Human piece. Yep.
00;37;06;15 – 00;37;23;10
Jannah Amiel
Wow. Thank you so much. And thank you all for tuning in. Listening. We hope that you found this story interesting and that you also found it helpful and learn something that made you like this episode and any of our other ones. Check out our podcast offerings that we have going on on FHA dot com. Good bye for now.