A Shocking Turn

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: Tales from the Witness Stand. I am your host again, Jannah Amiel. And joining me is our expert witness and FHEA faculty member, Dr. Sally Miller. Dr. Miller, how are you? 

Sally Miller: I’m very well, thank you. And you? 

JA: Excellent. Thank you so much. And thank you again for joining me and for sharing these stories. Now, just as a reminder, like you hear in our intro, right, we’re going to be talking about real medical malpractice cases that Dr. Sally Miller has served as an expert witness, either on the-I’m going to mess this up-defense or plaintiff. 

I think those are the right words. Right? Okay, good. So, either of those sides, which is an interesting thing, because as we do these podcasts, as you listen along and hear the story, it is pretty fun to try to figure out what side Dr. Miller was on there, and she will reveal that to us. So don’t worry about that. 

But these are really great opportunities, right, to listen and to learn. Judgment-free zone. We know as clinicians, we know as nurses, as practitioners, as any practicing healthcare provider that mistakes happen. They happen. They absolutely do, because we’re human. Right. And so, these are really good opportunities to look at actual cases that have happened; to kind of dissect this and talk through it and see if we can pick up maybe where these pitfalls where decisions could have been made a little bit differently to change that outcome. 

So, with that said, I’ve set the stage, and I am ready to hear this story, and I hope you all are ready to hear the story as well. So, Dr. Miller, I’ll pass it to you. 

Okay. Well, I think this is the first case that we will have talked about that occurred in a correctional facility.  
 
JA: Yeah.  
 
SM: I don’t think we’ve talked about it in a correctional facility yet. So, this is the first one. And believe me, they do come up. I remember I worked in a correctional facility for, gosh, from ‘96 until ’02. 

So, I guess 6 years I worked in a correctional facility. So, I am intimately acquainted with this practice setting in the nuances, and keeping in mind and we’ve already talked about this with those who have listened to the previous Scrubs and Subpoenas episodes. That standard of care from a legal perspective really speaks to what that license professional would do in a same or similar circumstances. 

So, an important part of this case in particular, and really any case in general, is that when we look at ‘did someone deviate from the standard of care,’ what we’re really looking at was did they do what any reasonable professional would do in the same or similar circumstance. And in a correctional facility setting, one key difference is that safety is first. Safety and security is first rate. 

So, if you can be in a correctional facility now like a prison, you know, prisons that long-term house people for years and years and years, they typically have medical units that really are analogous to any hospital. They can manage all sorts of emergencies and things there. But a county jail doesn’t. A county correctional facility was not intended for long-term housing. 

People typically go there when they get arrested for things like, a warrant or, you know, didn’t pay a speeding ticket and then a bench warrant was issued for their arrest. Yeah, just a word to the wise. Anybody listening? Don’t ever let outstanding tickets accumulate. Pay those traffic tickets, because if you don’t pay it, just automatically a bench warrant is issued for your arrest. 

And if you could get pulled over at like 5 years later for something you didn’t even do wrong, maybe somebody hits you, you’re on the side of the road. The police are running your license and there’s a bench warrant out. You’re going to jail until you can see the judge. And whether it’s a day or if it’s, Heaven help us, it’s a Friday night. 

When I first started working in the correctional facility, one of the first things I did when I learned that system was made sure that I didn’t have any outstanding tickets because you can wind up there. So, I know that’s not what we’re here to talk about today, but don’t have any outstanding anything. You know, you get people that do it like 18, 19, they get a ticket, they blow it off or whatever. 

And then years later, when they are approaching responsible adulthood, something happens that’s entirely not their fault and their ID gets run. And there’s this bench warrant from 5 or 6 years ago. You’re going to jail. They get in front of the judge who will probably just dismiss it. So, county jails, I mean, they house that kind of stuff. 

They have, you know, the DUIs, the domestic assaults, the failure to pay child support. Now, also, it may be that you are arrested on a much more violent crime, even a murder, and are housed. They are pending your trial. And that could be a matter of years. You know that you’re in the jail. But they don’t, they’re not really intended for long-term residency, so they don’t have quite the same medical facilities. 

And so, if you’re having an MI in the jail, the first priority is can, from a security perspective, you be safely transported out. So, the access to things is a little bit different is just what I’m trying to say. So, but that is a backdrop here. Now that may or may not actually be directly relevant to this case, but what’s for sure relevant is that the standard of care in a county correctional facility, which is what this is, is different than the standard of care somewhere else, because you have different considerations in terms of accessibility of services to inmates. 

So, with all of that said, let me tell you the story about this was a 22-year-old female who was arrested and she was transported to the county jail. I don’t even know why; we really never did know why. That’s really not relevant unless it’s a safety issue, unless the staff have to be physically protected. 

And that wasn’t the case here. And so, she went to the medical unit-or she went to the jail. And within the first 24 to 48 hours of being incarcerated, you do have a medical screening typically from the nursing staff, and then you’ll have a follow-up with either a physician or an APRN. So, this 22-year-old female went to jail. 

And when she had her screening in the medical unit, she was complaining of throbbing of her leg and it was radiating to her buttock. The medical assistant documented that she had two linear bruises under her buttocks. She recorded a temperature of 101.8, a pulse of 114, a sat of 92%. But you don’t see every day on a 22-year-old. 

It’s a little bit low, but her blood pressure was normal. As it happens, this young lady had a history significant for methamphetamine abuse, heroin abuse. Her last drug use reportedly had been 3 days prior and that’s important because it really does complicate how you assess everything else. You know, if someone is going through heroin withdrawal, they’re going to have physical signs and symptoms related to the withdrawal. 

And so, like the tachycardia, for instance, is not unusual and it’s not as worrisome in someone withdrawing from heroin, not because we don’t care, but we know why it’s happening. We know it’s an expected anticipated phenomenon. So, there was there was a lot there with the drug withdrawal. She also reported a history of physical abuse, of sexual abuse, she had inside and panic attacks. 

And there was a lot going on for this young lady. And many times when people first are in the correctional facility, one of the reasons people do drugs is because there are all these other things going on in their lives that they’re looking for some escape from. And then when they go to jail and they no longer have access to those substances, not only do they go through substance withdrawal, but they’re more alert and having, you know, relive and deal with all of those reasons why they were using drugs in the first place. 

Plus, they’re in jail now. So, there’s lots of reasons why people that first present to a county correctional facility might be tachycardic or agitated or, you know, tearful or that kind of thing. So, she had a lot going on. She also reported at that time that she had been constipated for 5 days, that she hadn’t had a bowel movement in 5 days, which, again, is very common with an opioid use disorder, because opioid use slows down the bowel. 

So, at that time, she had these she had some discomfort and she had bruises under her buttock. There wasn’t a diagnosis documented, but she was given antibiotics. So presumably someone assumed it was a cellulitis and she was given lactulose for her constipation. And then apparently the next day, she must not have had a bowel movement because she was given more lactulose the next day. 

That’s all the documentation revealed. Just, you know, one day she was given additional 30cc of lactulose. Okay, now this, none of this is uncommon, you know, with IV drug users. You also very often have a little abscesses, areas of cellulitis, things like that. So that was on, we’ll say, let’s just call that day one. She was given her additional lactulose, day one. 

On day three, she came down to the to the medical unit complaining of an unwitnessed fall. She wanted to be evaluated for a fall. She denied any injuries herself. You know, she didn’t knowingly hurt anything during that fall. But while she was there, she also went on to relate that she still had a painful leg, you know, leg, buttocks, all the way down. 

According to the documentation, she was crying during the physical exam and there was documentation of a baseball-sized red area on the front of her thigh. So, a baseball. That’s a pretty big abscess. Baseball-sized red area on the front of the thigh. It was documented as red and painful to the touch. Her vital signs were essentially unchanged from those a few days ago. 

Or was it 2 days ago? A little bit tachycardic. But otherwise, you know, she was normal temp, otherwise normal. But because she had this baseball-sized thing on her thigh and she was clearly agitated and upset and she still had not had a bowel movement, she was sent to urgent care. So, she was sent out of the facility to an urgent care setting. 

And she told them that she hadn’t had a bowel movement in 10 days. They ordered, the urgent care, ordered a flat plate of the abdomen. They ordered a CBC, a CMP, a urinalysis. They did not incise the abscess. They didn’t drain the abscess, interestingly, but they ordered all these labs and they ordered a flat plate. Yeah. So. And the flat plate reported mild distension of loops of bowel, a moderate amount of stool in the colon.  

It was recommended that further imaging be considered if indicated. Her CBC, at the time though, reported 96% neutrophils which is a lot, you know, that’s appreciably above normal and toxic granulation. So, she clearly had evidence of systemic infection and she clearly had this baseball-sized thing on her thigh. 

And interestingly, you know, who knows why? Again, I think it’s interesting from an academic perspective, but we don’t know why they didn’t drain it. Nothing was documented. In fact, it really wasn’t even acknowledged in the note, the presence of the abscess and the decision not to drain it. A UA revealed some blood and white cells in the urine at the urgent care. 

So, they put her on cipro and they sent her back to jail and that was it. They sent her back to jail on cipro with the report of the neutrophils and the mildly distended loops of bowel, and the stool in the colon. So, she went back to the jail. Now she was transferred after hours. There was no APRN on-site at the jail. 

So, a call is made, you know, the intake staff, very often an LPN. I don’t know if it was an LPN or an RN, but somebody, you know, received her back from the urgent care fund called the on-call APRN who just said, ‘Okay, we’ll continue the antibiotics that they ordered at urgent care, transfer her out if she starts vomiting.’ 

So, there was acknowledgment of that flat plate of the mild loops of bowel. Transfer her out if she starts vomiting and put her on sick call for the next time that I’m there. This is what the APRN says. So, 2 days later, must have been a weekend, and 2 days later is the first time that there is a sick call, and the patient is seen in sick call and she still has the abscess. 

So, this is the first time reportedly that the APRN is seeing the abscess. Urgent care didn’t address it. It appears that when the patient came back to the facility, the receiving nurse didn’t mention it to the on-call provider. So, this is the first time that the APRN sees the abscess. The patient’s blood pressure was 75 over 60 at this point. 

Her pulse is 145. She is satting, however, at 97% and she is afebrile. So now, in addition to her baseball-sized abscess and her leg pain and her hypotension and her tachycardia, she also has some evidence of antecubital cellulitis. So now at this visit, the NP drains the abscess, puts her on a combination of antibiotics to include IV Rocephin as well as doxycycline for broader coverage. Gives her IV fluids and her blood pressure comes up to 86 over 50. 

So, and her mental status was normal. She was, you know, normally mentating, was how they documented it. So, the orders read to be housed in the medical unit in the jail, which I mean, and they do have medical units. It’s not like a prison, it’s not like a hospital setup. But they do have a medical unit. 

They have IV capability, they have IV antibiotics. If nothing else, it’s close to the medical staff so that she can be monitored frequently. And vital signs, you know, as many times a day as needed, stuff like that. So that’s where she went. So that was on day one. Well, let’s jump ahead now. Let’s start all over again. Say we’re on day one. 

That was on day one. For the next 5 days, she appears to sleep well for the first day or two. There is no worsening. And then she very slowly begins to have some improvement. And this, too, is not unusual because she has this long history of drug abuse and typically associated malnourishment. I don’t think I mentioned it, but when the urgent care ordered all of those labs, they also ordered albumin. 

You know, they ordered a whole bunch of studies there and the albumin was low and the indices were consistent with someone who was using a lot of drugs and generally doesn’t have the best nutrition and you know, not having a good nutritional status makes healing in every way really difficult. So, the recovery trajectory is going to be slower on someone like this. 

Also, their compensatory mechanisms will be less robust. So, some things will look more dramatic earlier on. And I say this, you know, this 75 blood pressure, in context someone who has good compensatory mechanisms, the blood pressure probably won’t get that low because they can immediately compensate in other ways to keep it from getting that low. But someone with that level of systemic compromise, they will decompensate more quickly and then re-compensate just as quickly. 

So, you know, you give her some fluid and the pressure comes back up. It’s not as unusual in that kind of setting with that kind of patient as you might think of in other settings. So, you know, hold on to that. And with that context, for the next 5 days, slowly and steadily, number one, she’s not getting any worse. 

Number two, she is slowly and steadily getting better. She has regular changes of the packings in the incision and drainage of that baseball abscess. She is having serial CBCs, which demonstrate improvement in the differential or by the sixth day her white blood cell count is normal, her neutrophil percentage is normal, and there’s no toxic granulation of the neutrophils. 

JA: This is not where I thought you were going. 

SM: I know. All of these are encouraging, actually. Well, hang on, hang on. It’s not and this is what we need to look at when we’re all done with the story, just the way it goes. So, she continues to be housed in the medical unit and for the first 6 days with her, she’s on multiple antibiotics at this point. 

She’s on IV Rocephin. She’s on IV vanco, she’s on oral doxy. She’s getting fluids and, you know, extra like they have double portions to try to beef up nutrition, all that kind of stuff. But most importantly, she’s feeling better. She’s not feeling great, but she’s feeling better. She’s not overtly agitated or tearful during her visits anymore. 

So up to day eight, she does. The inmate reports continued improvement. She still has pain. You know, she’s still not comfortable, but she’s getting better. Her examination is documented as consistent with recovery. And she is being seen on a daily basis at this point by the staff. And she’s in the medical unit. So, you know, they’re evaluating her daily and consistently, daily slow but steady improvement. 

Finally by day, gosh, I said one. Now I’m looking at my dates here for up to a 9 days later. Every day consistently improved. Now, on this one relevant day, she’s feeling good. She is no longer crying. She’s no longer upset. Her vital signs are almost normalized. There is now a clear, consistent trajectory of recovery. So, she is transferred out of the medical unit because she wants to go back to her cell. 

You know, the medical unit, inmates like to be there when they’re really, really sick because nobody’s bothering them. There’s not a lot of noise. Jail pods are notoriously noisy and just annoying. And in the medical unit, you can play, you can sleep, you get food, somebody will respond to you whenever you need help. But when you start to feel better, it’s boring. 

When you start to feel better, there’s no rec. You can’t go outside. You can’t, you know, you can’t be talking to people which when you’re sick is fine. But when you feel better, you know it’s boring. So, when people feel better, they want out of the medical unit. So. And she was sufficiently improved to go back to the medical unit. 

That doesn’t mean that she wouldn’t continue to be checked on and continue to be monitored, but she didn’t need to be in that medical unit. She was in the general population for 5 days. And on the fifth day in general population, she was found to have an elevated temperature and she was complaining of fatigue and, like, systemic symptoms. 

And she was sent back to the emergency room where now this is what you were expecting. She rapidly decompensated into septic shock. 

JA: What. 

SM: She didn’t die. She didn’t die. She you know, she lives. She survived it. But she rapidly, from that slow, steady improvement. And, you know, when you look at the records, actually they’re really good for correctional facility records. I mean, it’s a good series of documentation from the nurse practitioners. She’s being seen every day. 

They documented clear objective indicators like the improving white cell differential, the improvement, you know, the normalization of the neutrophils. They were really a nice series of notes. And when they finally let her go back into general pop, which I tell you, she was in that medical unit longer than would have been my experience to keep anybody there. 

But when they finally let her go, apparently for 5 days, she there was nothing documented. So again, we don’t know who checked on her and she said things were good or, you know, feeling good or better or whatever. All we know is that on the fifth day after she’s back in general population, she was febrile. She was sent immediately to the ED and that fever. 

Remember? And remember, I keep saying remember, as if we all know we all had this conversation. So, for anyone who’s listening, you definitely want to go back and listen to some of the other episodes and then you’ll know what we’re talking about. But we have talked in previous episodes about how people can compensate, compensate, compensate and seem really asymptomatic because your compensatory mechanisms are keeping you near normal. 

But once those compensatory mechanisms stop, it just goes downhill really fast. And that’s apparently what happened with this young lady. So, she  was just so nutritionally compromised overall, just her general health. I mean, she had hepatitis C and there was just a series of suboptimal physiologic circumstances that you see in people that have a long history of substance use disorder. 

So, when she decompensated, she fell hard, but she was still 19 or 22. She was 22. And she did bounce back and she recovered however, because of her, you know, her time in the hospital and the whole septic shock experience, of course, a lawsuit was initiated. And I was asked to evaluate the standard of care for the nurse practitioner. 

JA: Wow.  
 
SM: So, as I and you probably are getting the sense that I do, I felt like they did a good job. So, there were several criticisms of them. And we will totally address those. But one other interesting point that I think you know, that anybody listening can take away is that the people that are asked to serve as the experts to review care really should be someone with the same level of professional licensure who has experience in the same general setting with the same circumstances. 

And it’s important for your attorneys to realize that and to know that if they’re looking at expert reports from the other side and these experts are different and they have different experiences and different levels of expectation, it’s not a fair assessment and it needs to be challenged. And the interesting one of the many interesting things about this case was that the plaintiff’s attorney hired two experts to criticize the care of the family nurse practitioner that was practicing in this county correctional facility. 

One of them was a physician who was affiliated with one of the major health systems in the country. And his only experience in a correctional facility was he had worked on a joint-funded investigational program to try to improve the healthcare of incarcerated individuals. So, he, as an agent of this big university system that had all of this funding to articulate with the jail and set up an ideal healthcare, which is a great idea. 

I mean, it was you know, it was an awesome idea what they had in this one county correctional facility. But it was totally not like any other county correctional facility you’ll ever see. It just was not in any way representative of what a regular typical garden variety clinician deals with every day in a jail.  

JA: And it doesn’t sound like he practiced. 

SM: He didn’t. Yeah. I mean, I don’t know if he saw patients at all or not, but I know he didn’t see patients in a correctional facility in any way, shape or form analogous to what the rest of us did. So, that was one expert and then the other expert was an infectious disease specialist who was criticizing the particular antibiotic choices and the pattern in which they were given. 

And I don’t think I have ever seen, in a typical county-now there’s like some big counties like Cook County in Illinois, where they have, you know, all sorts of resources in that jail system. There’s another big one in Texas where they have access to, you know, pretty cool resources, actually. It’s enviable. But for the rest of us workhorses and your garden variety county jail, we don’t have access to things like infectious diseases, like, except for HIV. 

You know, that was a different story. But for something like this, like we might you know, you might request a consult with a specialist and then up in the hierarchy of jail medicine administration, somebody has to approve it. Then you have to find a place willing to accept an inmate who will be transported there, you know, in handcuffs and leg chains and stuff like that. 

And if you manage to find that, maybe you’ll get an appointment 4 months from now. You know, that’s the real world of how that goes. And so as important as it was, really important, in defending her care, that and whenever you’re any expert that’s asked to offer an opinion to write a report, you have to write your opinion. 

And in this case, defending the specific assertions that were made. And so, I have to look at the plaintiff’s expert’s report and the criticisms they make, and then it’s my job to respond to that. And in this case, I mean, the foundation, the response was everything they’re saying here is just-I’m trying to find a diplomatic way to say this. 

It’s just ludicrous, really. It’s just ludicrous in this circumstance. You just can’t even consider that as a valid criticism of this care. And, you know, and I tried to illustrate why I’d do it in as objective of terms as possible. And then by the same token, look at the care that was provided and anticipate the things like, you know, lots of people would say when she saw that blood pressure of 75 over 40, why not right to the hospital? 

In a different circumstance, I would agree. But in this circumstance, we have a patient who is compromised by substance use and lots of other you know, lots of other compromise going on there. In a facility that has medical resources, it wasn’t like being sent home. It wasn’t like an ER where the patient can be discharged home if they didn’t keep them. Here in this circumstance, there was a medical unit. 

There were licensed healthcare providers that knew how to intervene and monitor and, you know, and take care of things. And so, it’s a slightly different story. Also recognizing that when she got fluids, the pressure came up to a reasonable number. And again, some people might say, ‘Well, if anything under 90 is shock, even if it came up to 86 over whatever, that’s still a shock blood pressure.’ 

And technically that’s true, but that’s where you have to actually use your, you know, use some critical thinking and say, ‘Yes, under from a textbook perspective, under 90 is shock.’ But in many thin young women, a blood pressure under 90 is not all that unusual. And if it’s an improvement and there is a normal mental status and there are those that are around that can monitor the patient, all of those things go into play here. 

So, it’s a slightly different story. 

JA: Yeah, you know, this one, I will say in comparison to the other stories and you know, we podcast on this together, I’m like, man, that he shouldn’t have done that. That was clearly that, this was clearly this. You know in your mind you’re like, ‘I would never do this. This is the actions that I would take.’ 

But quite honestly, I didn’t expect that turn. Everything seemed pretty appropriate. I would say that as I’m listening, I’m thinking I would do that. I would do that, I would do that. I agree with the blood pressure that did seem kind of shocking. But to your point, like I worked in the ER, in the ICU. So that’s a very different thing than seeing a blood pressure in this type of patient that has this history who’s experiencing these things. 

But I did not expect and this is kind of where I’m stuck and I feel like, shoot, I would be in a lot of trouble myself. I didn’t expect like, you’re doing so great, you’re doing so great, great improvement. And then days later, seeing a decompensation. That is not even how I would imagine the trajectory to go. 

And I guess I’m just wrong. I imagine that you would decompensate pretty fast. Like once you’re good, you’re good, and then that’s that. Like what would have been-how do you prevent that? How do you prevent that? 

SM: You know, sometimes we do everything right and bad things still happen. You know, that’s just the nature of the beast. SSo,I don’t know that there is anything, you know. Now, again, there are those who will look back and say, ‘Well, she should have done this, this, this and this.’ But the fact is there is also the movement toward least restrictive environment. 

You don’t send people to the hospital when you can take care of them appropriately out of it. I mean, that is the standard of care these days. We treat people at the least restrictive environment. So, in that circumstance, as she was being monitored and evidencing improvement and having 24-hour nursing staff around the clock, yeah, appropriate to keep her there. 

But as far as the decompensating 5 days later, you know, it’s just like when you have a bunch of antibiotics and stuff on board, it can tamper things down. It can just keep them under the surface so that they’re not evident and then when they all stop, I suspect that’s what happened. She was, you know, she was on double portions and she was on lots of heavy duty antibiotics. 

And likely when they were discontinued, that’s when she decompensated. But I don’t know that there’s anything anybody could have done here any differently. I mean, you also have to rely on the patient has some level of responsibility. If they start to feel unwell or they start to notice things aren’t quite right. Like there was that 5-day gap there where there was no document patient. 

She was out in the general population. So again, we just don’t know if she really thought she was better and she didn’t reach out to anybody or maybe she checked in, you know, she checked in with the staff and they make their medication rounds and stuff and said, ‘No, you know, I’m doing pretty good today.’ Or maybe she let somebody know she wasn’t feeling well and they didn’t act on it, because that happens, too. 

It’s another one of those we just don’t know. 

JA: What are the guidelines I’m thinking about? Like, okay, so if this person’s doing like better, right? She clearly will say objectively has improved, clinically is good to go. She can go back to general population. Is there like any type of guideline that says like you have to keep checking on the patient for X amount of days after treatment just to make sure everything’s absolutely clear? 

Or am I making that up in my head. 

SM: Yeah, not that I know. I don’t know of any guideline like that. I mean, anybody would tell you that. Sure. Like just from a clinical judgment perspective, you would continue to follow up. But now think about if she wasn’t in jail. Think about if she’d been in the hospital for whatever number of days and got better and better and better and then went home. 

JA: Yeah. 
 
SM: You know, and it would be her responsibility. I mean, I don’t think anybody would check up on her. Tell someone why I shouldn’t say that. You know, a lot of times when people are discharged from the hospital, it’s sort of like a standing joke if you’re in the hospital for any reason, whether it’s an hour in the ER or a month in the ICU, the last thing anybody says to you before you walk out the door is follow up with your primary care provider. 

You know, that’s like the last thing in the stack of paper that people get. So, everybody is instructed to follow up with their primary care provider. But I would venture to say that unless you have a primary care provider with whom you are established and have a relationship, you’re not going to get in within 5 days. And even then, you know it’s a crapshoot. 

So, for somebody, you know, now an analogous patient, this patient with this history of substance use and who doesn’t appear to have any outpatient primary care provider, if that person was discharged from the hospital and instructed to follow up with primary care, I guarantee you it wouldn’t be within 5 days. So, then she would just have to go back to the emergency room if she felt unwell. 

But either way it would be completely her responsibility to reach out when she didn’t feel well.  I mean, listen, I know I’ve seen similar cases where that exactly that’s what happened. Not necessarily somebody with a drug abuse history, but I’ve seen patients in the hospital very sick, recovered, get discharged, be instructed to follow up when they, you know, follow up as an outpatient. 

But then even before their regular follow-up is scheduled, I have saw one die, you know, really tragic problem. Nobody really anticipated it, you know. So, it does but, you know, there’s there are unknowns here, like there are unknowns in every case. But the question for me really was the APRN, what was her care? Was her care consistent with the standard of care? 

Was it consistent with what any reasonable entity would do in a same or similar circumstances? And I honestly found it to be better than I would expect very often in those circumstances. 

JA: That’s so interesting. Yeah. The one thing I didn’t hear was about, I know that eventually she had the I&D done on that abscess, but I didn’t hear about like, was there a result, like did they check to see what was growing in there that she had go, it was culture? 

SM: Yeah, it was cultured. It was MRSA. And then she was put on vancomycin. 

JA: Wow. You know, stories like this, I got to tell you, I want to be honest, they kind of freak me out because it’s like, here’s the good ending. And then all of a sudden, it’s not. And again, it’s a big shout out to you providers who live this every single day and have to feel very confident and secure in the actions that you’re taking and the implementations that you’re giving, you know, so that you can predict quite honestly, you have to be able to predict the trajectory. 

SM: It’s just our best judgment, I mean, just our best judgment on any given day. But this is the human factor. You know, a textbook would tell you, blah, blah, blah, they get better. But then you insert the humanoid piece and then we go that way. 

JA: You’re totally right. And thank you for the, you know, I was thinking about this in the beginning, and I’m glad that you clarified this about the standard of care and the type of expert witness that’s appropriate, because I think about something this is our first correctional case that, you know, would have been appropriate to have an expert witness who was, let’s say, didn’t work at all in corrections and came on try to review this. 

You know, of course, I’m thinking no, because there’s very different things that happen in the corrections facility. So, thank you for clarifying that. They really need to be on par. 

SM: I mean, that’s not to say that attorneys don’t try. Yeah, you know. 

JA: Yeah, yeah. Dr. Miller, thank you for this. Are there any major takeaways that you want to leave us with that we haven’t covered in the story? This was interesting. Normally we can hear the story going like this and we’re like, no, no, no. This time it felt like this is not a story at all. 

This seemed fine. 

SM: Until it wasn’t. I know. 

JA: It wasn’t. 

SM: I know. My gosh. I mean, the take the takeaways, you know, they I guess they start to sound the same from one podcast to the other, of course, documenting your care, because in this case, it was imperative that the APRN document, the things that she did and she did document it well, thankfully. The document that daily follow up, the daily CBCs, you know, clearly documenting the trajectory of recovery. 

But for all of this, people do. I mean, they can appear better because of the meds they’re on. And then as soon as those meds are, stop, you didn’t you know, they didn’t really get better. It just sort of kept things smoldering below the surface. So, we definitely want to assume that just when the meds are finished, boom, it’s over. 

We keep an eye on them after that as well. 

JA: Thank you so much, Dr. Miller, for this. I appreciate you joining me for this story. And thank you, everyone for listening in. We hope that you found this interesting. And if you’d like to hear some more of our podcast and some more of our stories, check out our other offerings that we have going 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.