Teenage nightmare

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 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: Hello and welcome to another episode of Scrubs and Subpoenas. I’m your host, Jannah Amiel. And joining me is expert witness and one of our amazing FHEA faculty, 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, for anyone who is tuning in for the first time, we are looking at, I can say looking at and not really looking at them, but we’re talking about them. We’re talking about actual cases. Right. Malpractice cases that Dr. Miller has served as an expert witness on. So, these are actual cases where something has gone wrong and we’re looking back at them or talking through them, dissecting them to really take the opportunity to, one, identify where maybe these hiccups have occurred. 

What could have been a little bit different and take those learnings. Right. And actually apply it to the work that we do as healthcare providers, because we want to practice faith and we want to practice at the best of our ability for ourselves, for our patients, for the facilities that we’re actually working at. Anything you want to add to that, Dr. Miller? 

SM: I don’t think so. I mean, it’s just so important to emphasize that this is just really for all of our growth and development as it has been for me, and that we all, you know, I mean, we’ve said it before. There are those of us who make mistakes and those of you who will, everybody will. And we just want to try to mitigate it and minimize. 

And when we can learn from others, you know, hurray, then maybe that’s a mistake we won’t make. We can find our own mistake to make that somebody else can learn from. But they happen to all of us. And it’s just for us to learn from it, you know, to review and improve our practice. 

JA: Yes, well said. Well said. And with that, then we are ready for our first case. So, as you all are listening in. Think about, you know, as she’s telling the story. Right. Walking us through the timeline of events and where you identify some of those mishaps, those hiccups, and what you think is going on. I’m ready when you are. 

SM: I’m ready. So, again, timeline really does matter. Sequence of events. And remember that when experts are looking at a case, we’ve got the whole, you know, we’ve got the whole retrospective analysis so we can look back and say, on this date this happened. And then 3 months later this happened. And think about how is it really reasonable to expect that, in the moment, the APRN who is in a patient encounter, how realistic is it to expect that they are aware of what happened 3 months ago and is it realistic to expect that that’s their responsibility to pursue that or not? 

How accessible is the info? So, you know, put that in the back of your mind because that’s part of what’s relevant here to this case. And as always, when timelines are an issue, I made some notes so that I don’t get anything wrong or don’t miss anything important. So, you may see me from time-to-time glance down surreptitiously pretending that I’m not looking at notes, but I am, because I know I just want to get things right here. 

So, this is a case of a 19-year-old female college student. 

JA: Young. 

SM: Yeah, 19 years old. And she was from you know, I got to know a lot of her history aside from these events. And it sounded like she was just a very, really sort of wholesome, you know, young woman. She was a student athlete and was really embedded in the athletic community at her school, which was a big, you know, a pretty big name school and pretty well known for its athletics. 

And she was part of it. At 19, she was fairly new college student. I think she was. 

JA: I hate to tell you. I hate that you keep saying, “was.” I feel like you’re already setting this up. 

SM: Well, no. I mean, she did not die. She did not die. I’ll tell you that. Yeah. So, that’s a plus. But, well, yeah, I mean, I think her athletic ability is not what it was. So, life did change for her as a result of this. So, you know, interesting you pointed it out that I’m thinking of it in terms of what her circumstances were prior to her event. 

But I can see why you thought that was. It sounds like she-thank God that she is alive. And, you know, I mean, of course, recovered to some extent, but her life is not the same as it was before. So, what happened initially, the first relevant medical event here was in January of the relevant year. 

And, you know, in the interest of anonymity that I want to give too much identifying info here. But it was January and this 19-year-old female college student with no known medical history, you know, no remote heart murmurs or any like anything that you might think of as some risk for an occult infection. 

She had no known medical history. She went to a student health center at school because she had what she called a spot on her thigh. She had a little bit of a, you know, of an erythema on her thigh. It turned out to be an abscess. The recommendation at that point was that she had an incision and drainage procedure. 

So, she got a referral to a surgeon. She went right to a surgical office, according to the records, the next day. So, it was a small thing, not an inpatient procedure. She went to an office. She had an I&D of an abscess on her thigh. She was reported as otherwise stable. She was given trimethoprim-sulfamethoxazole, aka Bactrim, to take in follow up for the abscess. 

And that was the initial encounter in January. A couple of days later, the abscess was still a little warm to the touch. It was still tender. It wasn’t what she expected with a recovery trajectory. So, she went back to see the surgeon. The antibiotic was changed to clindamycin, which as a side note, it’s really interesting that this is all very evidence-based approach. 

Right. I&D number one, Bactrim as a first-line thing to cover Staph aureus when you don’t have a culture, but when Bactrim doesn’t do the job, clindamycin is like the cannon that really will step on both strep and staph, the things that colonize the skin. So, it looks like the care at that point was very appropriate. 

A few days later, as I look at my timeline here, the lab results came in of the culture from the I&D and it confirmed that clindamycin was appropriate. You know, the organism was sensitive to it. She completed her clindamycin without incident and experienced resolution of the abscess. But that was that. Young woman. Small abscess took an antibiotic, didn’t heal right away, had to have another one. 

Then 6 months later, in June of the same year, the patient developed a similar abscess on the same leg. This time little bit higher up, closer to the buttocks. Right. She did report pain with this first presentation. She went to an emergency room. She reportedly told the emergency room about the history of the infection 6 months prior and that she had an I&D and they prescribed Bactrim and told her to come back if symptoms worsen. 

So, the first one, when she went back 6 months later, it sounds like this abscess, it was closer to the buttocks. Nobody drained it. They just gave her Bactrim. Which this is not directly relevant to our discussion. So just a side note for anybody who’s listening, this is one of those evidence-based things that really does get ignored half the time. 

Every evidence-based clinical practice guideline will tell you that the primary treatment of an abscess is to drain it. Period. Localized, small, contained abscesses with no systemic symptoms. The evidence-based approach to care is it doesn’t even need an antibiotic that you just drain it, irrigate it well, and it will heal. We use antibiotics routinely when there’s any hint of systemic spread. 

So, it’s kind of interesting. Now, if a patient says no, then you can’t, of course, tie them down and make them let you drain it. But that wasn’t any part of the conversation here. It was just it suggests that they just gave an antibiotic and she was told to come back if it didn’t get any better. 

So, she didn’t. For a month, apparently, she took an antibiotic. It appeared to have taken it down and controlled things a little bit, that she didn’t feel the need to seek care. So, we went from January where she had an I&D, two antibiotics to get rid of it. But then for 6 months things were good. And then in June, another one occurred higher up and she took an antibiotic and apparently for a month things were okay. 

Then in July, in late July, the patient began to experience a significant pain near the bottom of her back near the sacrum and hips. I’m pulling this out of the medical record. Right. This is where she reported pain. In retrospect, she does not have a clear memory of these visits because she doesn’t have a clear memory of a lot of this part of her life. 

But according to the emergency room records, she reported pain near the bottom of her back, sacrum, and hips. She went to emergency room and so between, there was a 4-day span at the end of July, a 4-day span where she went to the emergency room, one, two, three, four times. The first time. So, again, last encounter was June. 

Right. So, really a little over a month later. So end of July. She goes in, first emergency room visit. The documentation reveals lumbar pain radiating to the leg, normal vital signs. She was diagnosed with sciatica and she was given pain management for her sciatica. She was given steroids and whatever else. Just pain meds for her sciatica. Two days later, she went back in. 

She was not having any improvement or resolution with the intervention that she had been given. So, she came back 2 days later. Back pain, the report, back pain, no history of injury. Normal vitals, need to follow up with primary care. Diagnosis, pinched nerve, and she was given more steroids the next day. The next day she went to another emergency care in a different place with acute lower back pain. 

It’s recorded in the chart that she was sobbing in pain in the exam room. 

JA: No. 

SM: She was diagnosed with sciatica and given Norco. The next day. Next day, she goes to the first ER that she had gone to two times. So, day one, day three. Day one, three, four, and five. In this 5-day span. I guess she went in for a time. She missed one day. There was what, the first day she went in called sciatica, took a day off. 

The next day went back no better and then next 2 days in a row. So, the last time she went back to that first emergency room and the documentation says extreme hip, leg, back pain and weakness and tingling, Dilaudid, not much relief. Diagnosis, low back pain and constipation need for follow up. And so, she was advised to follow up with a primary care provider. 

If you look you know her vital signs during that visit. They weren’t even recorded completely all the time. But the blood pressure ranged from the 110s to 70s diastolic. On one occasion, it was 97 over 51. Her pulse ranged between 91 and 113, and we have two temps of 97 on the first two encounters and no temps after that. 

On the last day that she was in an emergency room, remember one, three, four, and five. On the fifth day, they did do a CBC with a white cell differential. Her white blood cells were reported at 12.1 and her neutrophils were 83.6%. So, the white count of 12 is not especially impressive. The neutrophils of 83% is impressive. 

You know, that suggests bacterial infection. Alright. So, that’s the end of that. So, she finally gives up on the emergency room and they do make an appointment with the primary care provider. So, the next day. So, we have days one, three, four, five. On day six, she has an extended office visit with an APRN. So, at this point, her father came down. 

Now the father, you know, the family lives in a different state because she was away at college. At this point she had called her family. Her father came down to come with her. He was worried about her. You know, she was sobbing. Now she’s having this leg pain, tingling, and all this kind of stuff, all these emergency room visits, not feeling like she’s getting any answers or any relief. 

So, father came down to be with her and she and her father went to this extended office visit with the nurse practitioner. The nurse practitioner acknowledged that she saw the reports of the emergency room visits because apparently it was part of a big network, and all of the information was made available on the computer. So, when they told her that she had been in the emergency room all these times, the APRN acknowledges that that information was available to her and that she was able to review the gist of the visits. 

The NP testified in her deposition that at the time of the exam on that last day in July, the extended visit, the patient was diaphoretic, sweating in the office. She had elevated vital signs with a heart rate of 146 and that during the visit she was crying out in pain. The NP further testified at the time of the exam that she-I mentioned this-that she had access to and reviewed those emergency room records, and she knew the following information about the patient. 

She knew that there was a recent diagnosis and treatment of MRSA abscesses on the left hip and leg. She knew that the treatment included surgeries, incision and drainage, and multiple courses of antibiotics. She knew that the location of the abscesses was near the location of the acute pain for which she was now being seen. 

The NP testified that she knew about the elevated neutrophil percentage and the white cells, although 12.1 is not hideous, it is a little bit above reference range normal. Yeah, she knew that the vital signs were skewed and that 146 was not the patient’s baseline and she knew that the patient had been given steroids and ibuprofen that had not helped at all. 

So, on the day of this extended visit, the vitals were recorded as 126 over 64 as a blood pressure, pulse of 146, respirations of 20, and the temp was 97.4. So, you know, this young woman is in your office in this kind of shape with this history of emergency room visits and everything just progressing. 

The NP further testified that she did not physically see or examine the patient’s legs or hips or back, that the patient remained clothed and not gowned through the examination, and that she believed that the patient was in real pain. She didn’t think she was making it up. She didn’t think she was exaggerating it. She didn’t think it was part of a mental health diagnosis. 

She believed the patient’s pain to be real and unexaggerated. With all of that information available to her, the NP diagnosed sciatica and prescribed additional pain medication, muscle relaxers, and ordered an MRI. 

JA: I hate this story. 

SM: Yeah, it doesn’t get much better. The patient went immediately to have the MRI, had the MRI the same day. By close of business on that day the NP received the results of the MRI and knew that there was no acute or obvious cause of the extreme and worsening pain. There was no disc herniation, there was no spinal stenosis, there was no impingement on nerves or anything like that. 

She did not order any additional evaluation, no additional lab work, no additional studies. She called the patient’s father to report that there was no known cause of pain and that the patient needed to be followed up. So, the next day, so we’re still like, except for that one day. Yeah, for that one day till now, there was an everyday encounter, ER, ER, ER, extended office visit with the NP that we just discussed. 

Now the next day they go back. So, after the visit with the NP and the MRI, the patient and her dad went back to the patient’s apartment where the patient continued to experience extreme and unrelenting pain. The father said in his deposition he didn’t think she was making it up, but that the NP explained to him that there was no connection to the MRI, so nobody knew what was going on. 

At this point, the patient was unable to walk. She had to crawl to the bathroom. She continued to be diaphoretic and writhe in pain. She became confused and disoriented enough that she doesn’t know anything about what happened for the next, for a long time. But the father tried to call back the NP. The next day, tried to call but didn’t have any interaction. 

The next day. The next morning he again tried to reach the NP and did reach her and said the patient’s father said he was so concerned. And you know, now the girl’s got a declining mental status. She can’t walk, she’s crawling to the bathroom. What to do next? You know, Dad wants to know what to do next because they’ve already been to this other emergency room so many times and you’re not getting his satisfaction. 

So, the NP then told them to go to another emergency room, one that was further away, and she gave him instructions on how to get there. And so, the father drove her there to this other emergency room that was affiliated with a major, you know, a major medical center. And so, she was immediately admitted in septic shock. 

She spent weeks on a ventilator. She had panic attacks and continues to have panic attacks. I mean, she was in the ICU for weeks with multiple attempts to extubate her. And then she had to be re-intubated again. She had MRSA bacteremia, septic shock. She had hematogenous spread of the MRSA to include pneumonia and osteomyelitis. 

She had acute liver injury just as the result of this overwhelming systemic insult. She wound up with acute liver injury because of the massive antibiotics that were required to try to get that under control. She wound up with fungal infections. She had to have repeated surgical debridement to her hip to remove the infection, drains. 

I mean, all sorts of stuff. She was in the hospital for 6 weeks and on the ventilator for at least four of them. Like I said, they kept trying to extubate her and couldn’t. She finally, you know, after the hospitalization, then she had to go. She went home, but she went home with a PICC line she had to continue for the osteomyelitis.  

She had to have months of occupational and physical therapy. She missed two semesters of school, you know, this former student athlete. And so, at this stage of the game, you know, she did survive. I mean, you know, she was a 19-year-old, otherwise healthy young woman. So, she survived. 

She survived with a profound anxiety disorder and panic attacks. She is absolutely terrified of any healthcare provider, as you might imagine. She has had to learn to eat again. She had to learn to walk. She had to learn how to get dressed again because she also had cognitive impact as a result of this overwhelming systemic sepsis. So, she doesn’t want to go to any healthcare providers’ office because she’s afraid of them, which understandably so. 

She can’t run distances. She you know, she’s got this chronic hip problem now with all the debridement. And then this all happened to her before the pandemic. And so, then when the pandemic happened, you can imagine how traumatic this was for someone with such a fear and distrust of the healthcare system, appropriately so. She remains, I mean, she just lives in fear of getting sick and having to be re-intubated. 

That process of intubation, I don’t think any of us can appreciate how awful that must be, especially for, you know, a 19-year-old girl, but for anybody really. And so, yeah, I mean, she had all this time being delirious and I mean, I’m paraphrasing a lot of the important stuff here and leaving some stuff out. 

But so, you know, immediately this business of anchoring it’s come up before as we’ve talked about these cases. But so, you know I would ask anybody who’s listening, and like I did to think about, you know, the first time somebody comes into an ER with back pain. Sciatica is not unreasonable. And a 19-year-old with no history, a 19-year-old athlete, a little bit less likely, probably, but okay. 

The first time around, not unreasonable. But one of the things about our diagnostic decision-making process is that we take information about how people did or didn’t respond to treatment, and that helps us reformulate our diagnoses. And so, when you look at these records and see day after day after day, it keeps getting attributed to sciatica or radiculopathy, despite the fact that she doesn’t respond to any treatment. 

I mean, listen, if you have sciatica or radiculopathy and you take steroids, it’s going to feel better, right? It’s going to feel better unless that nerve is totally, boom. You know, it may not be forever. You may have to go have something else more definitive done, but at least for a couple of days, it will feel better. This young lady got no relief of pain with steroids, ibuprofen, Norco, and even Dilaudid. 

The pulse of 146. You know, to me, this is another thing. In her deposition, the NP attributed the diaphoresis to a warm office and the pulse of 146 to anxiety. And I mean neither of them, it’s just not possible. So, for anybody listening, you know, can anxiety make your heart rate go up to maybe 100, 105? Sure, but not 146, that just doesn’t happen. 

I mean, at least in those office visits, she clearly had criteria for SIRS. Right. I mean, if she hadn’t had an inflammatory response that pulse alone, and if nothing else, that pulse in a young athlete with no cardiac history and previous reported pulses were in the nineties and sounded high, to jump up to 146 a day later. 

I mean, I think that’s an immediate red flag right there. Now, again, I mean, I’m really not trying to be critical here, but just pointing out things that we all need to be aware of going forward. And so, I don’t know. I do have opinions on this case, but I’m sure you probably have some questions about it as well. 

JA: Like a ton. my goodness gracious. This is a really terrible thing. So, I mean, there’s things that I feel like I didn’t hear done. The one thing that stands out to your point with that many visits like in a row, that many visits I feel like is a huge mess. If there was someone who visited the ER twice, you know, I know some providers are like, well, you’re going to get admitted because, you know, now there’s something else going on that we’re dismissing. 

We’re going to keep you here for that moment. But I mean, like let’s back up too, I feel like, and please correct me right, that Bactrim a second time, like that first time everything started just seemed in the beginning the abscess drained. And I think that made total sense to me that wasn’t working. Okay, another antibiotic that seemed to have been better. 

But then she gets that same type of abscess symptom again, and then we start with that first antibiotic that didn’t work the first time. This is where things start to seem a little like we’re falling off of best practice. Am I wrong? 

SM: No, you’re right. 

JA: Yeah. So, that’s like the first bit there that’s happening. Having then like, hear, sciatica, sciatica, sciatica, sciatica. With something that started off as like, that needed that drain, that MRSA. I didn’t hear anything, like a blood culture happened. None of that. Like, no actual work-up of there’s an infection going on. Like that was just totally missed. And maybe that’s an anchoring you’re talking about or just falling back to sciatica and not at all thinking about all the other pieces that create a bigger picture. 

And I’m sorry, obviously it’s clear now, but it’s a pretty clear picture of like there is a lot more going on here than sciatica not having assessed her physically. Like, not even looking at her leg, not even looking at her hip. When you said she was fully clothed, that there are a lot of things that went wrong. There are a lot. 

What are your thoughts on that? 

SM: I mean, again, I don’t want to sound like I’m criticizing or judging anyone. You’re just making observations about how we can go forward and do better. But to anybody that’s listening and again, we’ve all fallen down the wrong rabbit holes. It’s just so easy in the course of a busy day to see a diagnose and think, ‘Okay, that must be it.’ 

Let’s go to step two. But if you just step back for a minute, I mean, like, you know, some people do come to ER all the time and they always complain. So, they come to the office and all these complaints. This clearly is not that one. One thing that really jumps out here is there was no history of her doing this at all. 

This wasn’t your garden variety frequent flier, number one. And number two, people that are more, not even like purposely, faking it, but people that tend to have more somatization of mental health diagnoses. The symptoms move around like the abdomen, the head, the back, the legs. This young lady had the same exact thing. Boom, boom, boom, every day. And it was just getting worse, worse, worse, worse. 

That’s not mental health. That’s not somatization. Like there’s a problem there. And after like, I don’t know, the fifth time or something, if the ER, I think they could have maybe expanded their work-up. But really, when you look at this APRN who had all of that information available, all of it, knew about the history of the abscesses, knew about knew about everything, knew about all the ER visits, knew about the progression, the lack of responsiveness to the pain. 

The pulse of 146 is a real flag and the normal MRI and the neutrophils of 83.6%. It is, I mean, it’s really hard to, you know, to not put those dots together and think about, you know, one of the biggest risk factors that anything will ever happen to you is the fact that it happened before. 

And so, the fact that in the last 6 months, there were two spontaneous eruptions of infection in the same general area, one needs to consider that there’s the potential that there’s a nidus of infection embedded there under the surface. And remember, the second one wasn’t drained.  

JA: Right. She just got Bactrim.  
 
SM: But what usually happens is it washes it down just enough that it doesn’t create an overt problem and it also creates resistances. 

And now you have a superbug that pops up and it found another way out. It found another way to tunnel and extend itself. So, and it was really amazing how, I will say that the attorney for the defense, she was very good. And I mean, I like I was just so stunned at some of the things that she said, like she thought it was perfectly acceptable, now she’s not a healthcare provider, you know, she’s just a good debater. You know, that’s what attorneys are supposed to be. But this business of not even examining the patient like, you know, this is like at 101, if something hurts, you look at it. If the back hurts, you look at it. If the leg hurts, you look at it. Could be a bug bite, you know, I mean, could be something lodged there that the patient doesn’t know about. 

It doesn’t matter. It’s just assessment 101: when something hurts, you look at it. And so, the, you know, my first bone of contention is not even examining her to see what was going on. And then, of course, the assertion was, well, you know, like, would she have known if she had done the exam? Would she have known that there was infection? 

And I said, ‘Well, we’ll never know because she didn’t examine the part of the body that hurts,’ which I think is a violation of the standard of care.  
 
JA: For sure.  
 
SM: Right. Yeah. This was a time, I mean, you probably figured this out, but in this case, I did testify for the plaintiff and felt strongly about it. I mean, I felt strongly about it because I want all of us to be practicing, you know, appropriately and thinking again, deductively and looking at, well, if something doesn’t respond to four or five different attempts to treat a diagnosis, maybe it’s not that diagnosis. 

You know, I always in all the things that I teach, one of my another one of my catch phrases here is if the patient doesn’t respond to appropriate treatment, there’s a fair chance that they don’t actually have what you’re treating. And you have to go back and revisit your differentials and adjust. And it just didn’t happen here. And what a sad story. 

JA: And let me ask you, the MRI, this is for my own knowledge and for anyone who’s listening who might not have this knowledge. If the patient had sciatica, right, or some type of nerve impingement even in that way, would that be revealed on the MRI? So, meaning like, couldn’t you have ruled that out? Well, it’s not sciatica, it’s not a nerve issue because everything looks okay; or no, can you not see that. 

SM: Yeah. If she had sciatica or any radiculopathy, any of those nerves to cause to the extent that it caused the symptoms she was having. Yes. It would have been evident out of an immediately evident. 

JA: Wow. But that’s just one of the kind of missed opportunities there too. You had that diagnostic that didn’t support sciatica. That is really, really unfortunate. 

SM: Yes.  

JA: And again, I think about things like blood culture like that wasn’t done. Some of those vital signs seems like the textbook stuff that we learn about and we read about that point to sepsis. 

And that way, granted, I will say the temperature seemed okay, but I know that that’s just one of many. And we can’t go by that alone. The heart rate is very high. The blood pressure going up and down. That is very telling. Wow. And so. 

SM: Yeah. And when you have a series of findings and some of them look okay and some don’t, you always look at the ones that don’t. You always work up the ones that don’t, you know, again, just another cardinal rule of patient assessment, like a couple of good findings don’t negate a clearly abnormal finding. 

JA: Right. Wow. 

SM: The body compensates. The human body has this amazing way of compensating for disruption in homeostasis. And you can never know. Like you can have five people in front of you with exactly the same laboratory abnormalities, but they will manifest in five completely different ways, just depending on which of their compensatory mechanisms are trying to normalize things for the patient, because that’s all it ever comes down to. 

There’s a problem. The body’s like, ‘Oh, there’s a problem. How to protect the organism, how to normalize function.’ And then every other body system kicks in to try to compensate and they do it differently from person-to-person. So, in another case, somebody might have cranked up a temperature to try to bake the bacteria and kill it. 

So, somebody else might have had a high temperature, but she didn’t. And still, that pulse of 146 is just so far over and above what you would expect from anxiety or pain that that alone, I mean it you know any in any primary care office of a patient sitting there with a pulse of 146 unless they’re like 6 months old, you know, they’re going to a hospital right then. Pulse of 146, even if there’s no other anything wrong, you’re going to a hospital. So, yeah. 

JA: And what’s that? You know, what’s the responsibility? This is, you know, kind of the big question that I have at the you know, at the end of kind of listening to it, what is the responsibility of the APRN right. 

Refer the client, refer the patient to another level of care? So, if I thought that it was sciatica that was causing these issues and the treatment I’m doing for sciatica is not effective. And still what I think, regardless of all the stuff that’s happening, like what is my responsibility to say like, alright, I need to put you to someone else who’s an expert here who specializes in this, because what I’m doing is not helping. 

What? Like, is there rules around that? 

SM: Absolutely. Any provider, whether it’s an NP, or a family physician in the same circumstance, if you give it everything you’ve got and the patient is not improving, we have to escalate it to the next level of care. Now, what that next level is, it depends on the acuity of the symptoms. 

Sciatica that’s not causing me to be crawling on the floor and writhing in pain and having a pulse of 146 and then becoming delirious. It may not require an ER visit, that may require a referral to neurology or with an orthopod or whomever. But in this case, with this profound acuity and deterioration of symptoms, whether you think it’s sciatica or whatever or whatever, even if you have no idea what it is, with that acute deterioration and such profound pain that needs to go to an ER. And one of the questions that the opposing attorney asked me was, ‘Well, she had already been in that five or three or four times and they didn’t help her,’ and I said, ‘Yes, but this APRN knew of another ER because on the last day they told her, you know, he, she told her the father to take her.’ So, she knew where to send her and in something like sepsis, especially a young girl like that, even just having sent her there a day earlier could have made a huge difference. Again, because those compensatory mechanisms, the body compensates, compensates, compensates, until it can’t. 

And when it can’t, boom, it’s all downhill really fast. So even happened, maybe even having sent her there on the first day that the APRN saw her, which was 48 hours before she ultimately went, those were an important 48 hours, because once she started to get delirious and confused, all her compensatory mechanisms were over and that’s when everything went downhill. 

And so, yeah, I wouldn’t have sent her back to the same ER either. I would have sent her to the other one that I know of that was better. 

JA: Absolutely. Wow. That is that is a really unfortunate story. And there’s a lot to unpack there. Dr. Miller, any major takeaways you’d like to leave our audience with. 

SM: I mean, the big one. The big one really is this business of anchoring. Just you have to be and I know it happened to me. I will share that with you sometime. I mean, it wasn’t a malpractice action, you know, thank goodness, but I mean, listen, I mean, it could have been you know, it wasn’t. 

But I recognize in myself what happened. And believe me, it’s never happened again. But, yes, I have an anchoring story too, as most NPs probably do, until we recognize that and never let it happen again. So, for those of you that it hasn’t happened to yet, don’t let it. It’s better for you and it’s better for the patient. 

Learn from the rest of us. Don’t get so hung up in the diagnosis that somebody else made. Look at it. Consider it. But like in this case, somebody made this diagnosis. And for the next several days, every, you know, progressively more intense approach to treating that diagnosis. Nothing at all. No improvement at all. That’s your clue that it’s not the right diagnosis. 

Neutrophils of 83%. That patient has a systemic infection again, compensation. Like sometimes you look at people and say, but you look fine. I mean, I’ve done that too. I’ve seen patients in front of me. Like if I send you to the ER, they’re going to give me a hard time about it because you look fine, but you’re not fine. 

Yeah, and I’ve learned you send them anyway. Who cares if they like it or not? So, you know, be careful about anchoring. Recognize that, especially in younger people. They can look great, great, great. Until they tank. You know, you want to wait until after they tank. That’s like the antithesis of prevention, you know, a big part of our professional identity. 

And I guess the other thing that I would keep in mind is that a pulse of 146, in that circumstance, something’s really wrong. That alone needs to go to an emergency room. So those are just a few of our takeaways. Yep. 

JA: That was a that was a heavy story. Dr. Miller, thank you so much for sharing that. There is a lot to learn there. I appreciate you sharing the story. I appreciate you all for listening and tuning in. We hope that you found this educational. We hope that you found some good takeaways here that you can also apply to your own practice. 

And if you like this podcast and you want to hear more, check out our other offerings that we have going on at 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.