A Heart Wronged

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 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’m your host, Jannah Amiel, and joining me is my co-host and esteemed guest, Dr. Sally Miller. Dr. Miller, how are you?  

Sally Miller: I am well, thank you. And you?  
 
JA: Thank you. I’m good, I’m good. Thank you. And thank you for joining me, as always and sharing your stories with us. 

For those of you that may have be listening for the first time or rejoining us again because you love hearing these stories, these are pretty exciting podcasts. Dr. Miller serves as an expert witness on medical malpractice cases, and she’s sharing some of these real, actual patient stories with us as an opportunity to listen and learn and really to follow along and see how this really does apply and play into everything that we know as healthcare providers, professionals as well. 

But more importantly, I think the big takeaway that we talk about here is that mistakes happen, right? I think that that’s a big thing that we want to make sure that we drive home. Mistakes happen. We are humans. Unless you are not human and you’re AI listening to this. But for everyone that is human, we make mistakes, right? 

And it’s important for us to really take the opportunity to think about, you know, how are some of the things that we are doing that we do or don’t do? How do these play into some of the outcomes that we hear in these stories? And I think it’s just a good opportunity for us to reinforce the things that we do as providers and to reinforce the protections, right, that we bring to our patients and to our profession. 

So, I’m excited to listen in to this story. And for those of you in the audience right now that are listening, and one of the things I’ll ask you to do is, as you’re listening along, Dr. Miller not only to serves as an expert witness on one side, right, but potentially both, maybe for the plaintiff or maybe for the defense. 

Right. So, it is interesting to try to listen and discern which side she may have been on for this and really to kind of pick up on all these little pieces that play into the big whole of the story and how we got to where we get to. So, without further ado, I’m ready. I’m ready to hear with me. 

SM: Okay, so without further ado, let me see. So, I always have my notes in front of me, you know, because I want to be objective in the information that I present. Not necessarily just the way I see it. So, this is another, you know-really I mean, I think they’re all interesting. I guess I wouldn’t present them here, but this is interesting from a little bit different perspective than some of the cases we’ve seen before. 

So, this is the case of a middle-aged gentleman who has migraine headaches-actually migraine-cluster that like the documentation refers to both of it. But regardless, treatments are almost I mean, they’re very, very similar. And he gets really, really, really bad, disabling headaches. So, he has been in headache care for years. He’s been in headache care, I believe, since his 20s. 

And then he started getting infusions of DHE. Dihydroergotamine (DHE) is a therapy for migraine-been around for quite a while actually. You can take it as an oral pill. You can use it as a nasal spray. And it’s also used injectable both IM and by IV infusion in certain circumstances. So, the headache center that is at the center, no pun intended, the headache center, that’s at the center of this conversation: they do I mean, they have several different treatment modalities, but IV infusion is among them, and it’s well-established. 

It’s been around, I think, by IV infusion since the late 80s for migraine, you know, obviously really for like severe unremitting, you know, migraine. So anyway, so this gentleman had this history, he had a history of having these DHE infusions. 

He had them. Well, just like in 2007, he had them again because they, like you do it in a series. There’s a couple of infusions and then sometimes over a period of weeks, he had them in 2007, and again in 2010, and then now again in 2013. I guess at 3-year intervals, things got bad enough that he needed to come back to the headache center. 

So, he was a well-established patient. He had a documented twenty-three office visits for migraine management in addition to the two previous infusion cycles. So, he was certainly well-known to the providers there. So, on day one of his planned infusion for 2013, it was planned for a 3-day infusion cycle and I believe they did like two of them a couple hours apart, but over a 3-day period. 

So pre-infusion assessment and DHE is a vasoconstrictor. And so, there are some protocols about safety you know and some screenings pre-infusion. So, his pre-infusion assessment documents are sitting blood pressure of 136/81, a pulse of 76, and a standing blood pressure of 127 /78. So-and a standing pulse of 82. 

So, his blood pressure is and his pulse is, you know, clearly the appropriate slight variation with a change in position and certainly within normal limit. He was given his pre-medications. Nausea is a pretty significant adverse effect here, so, patients are usually pre-medicated with Zofran. And he was given his first dose. So, he got his first infusion at 10:50 in the morning. 

He was also given Ativan, Solu-Medrol, and Depakote. This is all, you know, like part of the protocol. Yeah, I mean these really are for intractable very, very difficult-to-control headaches. Yeah. So, that’s the collection. And he was given those following his first infusion. His blood pressure was recorded at 170/96. But at 1:40 in the afternoon he was again pre-medicated with his Zofran and he was given his second dose. 

His second infusion started about 2:00. Like the note says, the timing is not well-documented. But shortly after his second dose, this patient developed another headache. It was documented as a cluster headache. He had a blood pressure of 180/120, a pulse of 108. He was noted to be diaphoretic, complaining of his heart pounding, having chest discomfort, and needing air. 

According to the documentation, he insisted upon going outside to smoke two cigarettes. Always a good treatment for your hypertension and chest pain. He went outside to smoke two cigarettes and then he wanted to leave, but the nurse in the center managed to get him to stay and wait for the NP to come evaluate him. So of course, the NP is the person of interest from my perspective in this case. 

So, the nurse testified that she had reached out to the NP three times on this date to talk about this patient and the symptoms that he was experiencing after his second infusion and before coming to see him, the NP gave an order for a 0.2 mg of clonidine to treat the blood pressure. The order was acknowledged, the clonidine was given, the patient was medicated, and his blood pressure came down to 150/106. 

His pulse came down to 98, but he was encouraged to stay until the NP came to evaluate him. So finally, she did come down to evaluate him. And she testified later on when all of this, you know, went to the testimony part, that she suggested he go to the emergency room for evaluation. Later on, she said she insisted that he go to the emergency room, but the patient refused, and the NP then gave him written instructions to restart his blood pressure medication. 

She gave him written instructions for a steroid taper, which is a very common thing with migraine. You know, like that kind of migraine management or cluster management. And so, for him to do this when he got home. So, although she, you know, she said she first said she suggested he go to the ER, then she said she insisted he go to the ER, but he refused. 

So, she then gave him instructions and discharged him to home. So, point of interest for anyone listening here, if you give somebody discharge instructions, you discharge them. It happens, you know, on occasion, the patients really don’t want to do what we really, really think they need to do. And if you then change your plan and support what they want to do, it says you’re endorsing it like you’re the stamp of approval, and if you really don’t think it’s the thing they should be doing, don’t do it. 

Just document that they leave against medical advice. I see this a lot more with nurse practitioners than I do with physicians. And I mean, I’m not giving opinion on the physician work. But when I read whole charts, very rarely do I see a physician say, ‘Basically, I thought the patient should do X, but the patient wanted to do Y. So, I said, okay, yeah.’ 

Physicians don’t do that. But nurse practitioners, I do see it more often. And I think it’s because we genuinely, you know, we are trained to be patient advocates and we really want to support the patient. And sometimes we go too far in that direction. So, point of interest, just on a side note here, since we’re doing this for all of us to learn something, I mean, this is definitely something I have learned from reviewing cases, is that if you don’t think something is appropriate, don’t support it. 

You document that the patient left against medical advice. And I mean, unfortunately, it may not improve the patient outcome, but it might because sometimes though, the patients do really, really kind of push you to support their decision-making. But if you don’t do it, they will eventually do what you say.  

A: Yeah. 

SM: No, if for no other reason, because they’re going to have to pay for it. 

Because if a patient leaves and does something against medical advice, very often the insurance bill won’t pay for whatever the thing was. So, it’s very possible that his insurance would have declined that infusion if he didn’t follow recommendations. So, that’s-I know it’s a side note here, but I thought it was a good a good thing to point out because she testified that she insisted he go to an ER, but then ultimately she gave him instructions for what to do when he got home and she, in her note, she discharged him to home. 

So, he was discharged at home and then-and he wasn’t driving, thank goodness he was taking the train. So anyway, he went home and that was on this date, the second of the month he did not come back for the 3-day cycle after that first day. He didn’t complete three days of the DHE. 

He did, however, show back up on the 15th. So, a couple of days later and the NP interviewed him on that date and he had no recollection of that encounter. He had no recollection of what happened after he started his second dose, after he started a second infusion, he didn’t remember any of the any of the, you know, the chest pain, the diaphoresis, any of that kind of stuff. 

He didn’t remember it, but she wasn’t seeing him for an infusion. She was, you know, seeing him for a regular headache visit. There was a-so at this visit, it was just, you know, ‘Your headaches? How are they? Are you doing any better?’ On this date his blood pressure was 100/70. His pulse was 78. 

I suppose he was basically symptom-free. And that was it. The next available documentation is when the patient on the 23rd of the month. So we have: the 2nd was the infusion, the 15th was the follow-up visit where he seemed okay. And then on the 23rd he was seen by a cardiology practice. He was seen by cardiac specialist, and he had a 12-lead ECG that revealed several gross abnormalities, as compared to one that he had in baseline a month prior. 

So, in July of this year, he had an essentially, you know, normal ECG. And then in early August, he had this infusion and these subsequent events. And then on the 23rd of that month he saw the cardiology practice, and he had lots of new abnormalities on his ECG that he didn’t have a month prior. And the only significant event in the interim was that DHE infusion. 

And the way that he felt after it. He experienced a very rapid decline in cardiac function and at the time of the lawsuit was pending transplant. 

JA: Cardiac transplant?! Oh my gosh. 

SM: And so, do you know who I was retained by? Just wondering. 

JA: I’m thinking plaintiff.   

SM: So I really tried to be, like, so objective in the way I present these to you. But yes, I was retained by the plaintiff.  

JA: Okay. By the plaintiff. Okay.  

SM: Now this plaintiff’s attorney, I will tell you the plaintiff’s attorney is a physician who is also an attorney. He has a really, he’s really smart, and he’s definitely not the cutthroat guy that you think of sometimes. He genuinely-I mean, he’s very brilliant. 

He really just-the way he presents cases and puts them together and stuff. He’s just-I just really admire his brain and all of this. And you never get the sense that he’s even deposing the other side. It’s never nasty or anything like that. He’s just really-you can tell that he really just wants to make the patient whole or try to make sure that the patient is appropriately managed. 

So, whenever he calls me about a case, I never worry that it’s unfair. I never worry that somebody is going to be you know, inappropriately targeted. So anyway, another side note there that I guess I really didn’t need to go off on that. But here’s the thing. Here’s the thing. So, the question is, ‘Did this NP-what was her responsibility when the patient had this event?’ 

You know, what was her responsibility when the patient had this event? So, the physician that manages the headache center, the headache specialist with whom this NP works, he too was deposed, and he was adamant that this NP was brilliant. He said, in fact, he cited her as one of the leading headache specialists in the world. 

JA: Wow, that’s big.  

SM: Yeah, that is big. I mean, mind you, it was as big as his ego. This-I’m telling you, this physician in his deposition, this man, the ego was just like, stunning.  

JA: Wow.  

SM: Sometimes I almost envy people who feel that great about them, even though nobody else wants to be in the same room. 

I know, but no, but he did. I mean, I actually, I recorded the quote. Of course I won’t be able to find it now that I want to. Yes. He said, “She was extremely proficient at giving drugs like DHE. She was well-aware and had been trained about the indications and contraindications.” And he said that, and I quote, “One of the world’s experts on the side effects of DHE.” 

He further says that, “She was taught how to initiate, evaluate, differentiate cardiogenic from non-cardiogenic chest pain and that she knew to send to the emergency room any patient in whom reasonable suspicion for cardiac pain exists.” And so, when I’m, you know, looking at this from a standard of care perspective, the questions for me are, ‘Should this NP in a headache center be able to recognize cardiogenic pain, recognize when a patient needs to go to the emergency room, and then send him there?’ 

A, should she be able to? Is that the standard of care? And then like, you know, did she manage things the way she was supposed to or not? And so, I mean, I have no doubt that she’s a brilliant headache specialist, but NPs aren’t trained as a headache specialist or an asthma specialist or in anything. 

We are trained as NPs and we have a foundation, you know, across the spectrum. And then you may go on to work in a specialty setting and learn a lot more about that and be really good at it. But we do still have some responsibility for some of the basics. So, the question again, and not all of your listeners probably will agree with me. 

I mean, I’m sure we’ve got lots of different brains out here in NP world and people will see this differently. But again, it’s not what I think or what any other one person thinks. The question is, ‘Would any nurse practitioner in the same or similar circumstances with the same, you know, training, experience, and education have been expected to recognize that this cardiogenic, that this was cardiogenic or that it should have at least had been evaluated in an emergency room,?’ And I think so. 

I think so, even if headache is your specialty. I mean, I do get that sometimes when you’re in a specialty setting, you become so laser-focused on that specialty. I mean, you don’t treat cardiology, you don’t treat blood pressure, you don’t treat, you refer them to somebody else to manage it. But do we need to recognize an impending emergency? 

And I think that we do, especially when you throw DHE into the mix. I mean, DHE is a well-known vasoconstrictor, just very basic literature about it. I mean, because, I mean, because I teach pharmacology, I just know the basics and I know that, I mean, there are certain cardiac, you know, cardiac history is a contraindication to it. 

And even the patient that has any significant cardiac risk factors should at the very least have an ECG as a baseline assessment before going forward. Now, this patient had a baseline ECG in a in a cardiac practice. But the NP didn’t know it-like didn’t have that available. So, this middle-aged gentleman was obese, he had hypertension documented-history of hypertension. 

He wasn’t hypertensive on the day of his visit, but he had a documented history of hypertension, dyslipidemia, and type 2 diabetes. So, these are like cardiac issues. 

JA: Like it’s a trifecta.  

SM: It’s a trifecta of cardiac risk. And she testified in her deposition that she didn’t know he had diabetes, which in its own right would be a concern. I mean, if you’re going to order DHE for somebody and knowing their medical history and identifying the cardiac risk is one of those things. 

But then in one of her notes in a chart, like she something-and I may have written it down, but like she has some instruction that she had given him in the past before any of this happened, there was, oh yeah, some instruction. Yeah. Here it was, the prednisone taper should be held unless his clusters were out of control since he is diabetic, because, you know, steroids can exacerbate blood sugar. 

JA: Yeah. 

SM: So. Yeah. So, she knew or should have known. I mean, she knew at one point and would reasonably have been expected to know that he had these historical factors. So, the dyslipidemia, the type 2 diabetes and, you know, the hypertension. Again, I am not here to-I’m really not trying to point fingers. 

Anybody could look at my charts and say, ‘Well, why didn’t she know this? Why didn’t she do that?’ You know, ‘Why didn’t she consider this?’ We all, you know, we can all make mistakes. But the question is, ‘Should an NP have the same or similar background, education, etc., be reasonably expected in this circumstance to have referred that patient?’ 

JA: Yeah.  

SM: And you know, so again I would ask, you know, ask everybody listening like what do you think that that patient, who after an infusion of a known vasoconstrictor, developed profound hypertension, chest pain, diaphoresis, with all of those risk factors, should he have been allowed to go home or should she have, you know, maintained that he go to an emergency room? 

JA: Yeah. You know, I love and hate when you bring cases like this.  

SM: Yeah. 

JA: No, it does sound like them. These are the ones, honestly, that are like, this is an easy, ‘Yes.’  

Look at all the things that were right in front. Right. Like, look at all the information you have to look at all the things. But then also to your point, we just know that’s not the reality. 

We are looking at it on the other end. Right. And it is very really so, so easy to say like, ‘Well, this shouldn’t have been a miss because some of these things seem bright and loud in front of your face that you couldn’t have missed.’ Yet you did-you totally missed that. What happened to the patient?  

SM: Last I heard, he was on the transplant list, so beyond that, I don’t know. 

I mean, I do know, I know that he, you know, there was a settlement and they were-that the plaintiff was confident that the settlement was a fair settlement, given the circumstances. So.  

JA: Wow. Wow.  

SM: Yeah. But I mean, as far as I know, at least at the time that the case came to a conclusion, he was still alive. 

JA: Oh my gosh. And talk to me a little bit about this medication. So, can all NP administer this medication or do you have to be-to your point like specialized in any type of way to be able to give it IV anyway as an infusion?  

SM: Well, legally, any NP can prescribe it, but-and we’ve talked about this in other Scrubs in the previous episodes as well. 

Like, just because you legally are authorized to do something doesn’t mean that we should be doing it. So, you know, the first question for any intervention is, ‘Is it legal to do it?’ And if the answer is no, that’s the end of that. Boom. 

JA: Right?  

SM: But if the answer is yes, it is legal, then the next question is, ‘Are you competent to do it?’ 

And I know, I mean, I don’t know every state board of nursing’s law and every state’s administrative regulations, but I’m familiar with a few, and I’m very familiar with Nevada, and I can tell you that that’s like the law speaks to that specifically, that you need to be competent, you need to assert competency in whatever therapeutic assessment or intervention it is. 

So, just because somebody-like we could all-gosh, we could all legally you know, inject Botox or do fillers or, there’s all kinds of things that we can do. I mean, yeah, you know, there’s some NPs that should not be prescribing blood pressure meds because their practice is so specialized and they don’t do that. And like, like NPs that specialize in esthetics, right? 

They could legally manage blood pressure, but they probably shouldn’t be doing it because they probably are not competent to manage that condition, you know, and the consequences, adverse effects and all of that. So yeah, and I mean NPs, any NPs can prescribe it. But then the next question, is, ‘Are you competent?’ And it’s not that we necessarily have to demonstrate competency with a certificate or anything, but if you are ever held accountable to it, the question will be, you know, ‘What is your basis for prescribing this?’ 

Now, in this case, you know that the competency was presumed there, somebody who works in a headache center and has been mentored by a headache specialist and gone to see-I mean, this this physician espoused all the training involved and all of the things that this NP knew. And presumably, one of those training things said that if somebody has multiple cardiac risk factors, you know, we might be aware of the heightened risk of a cardiac event and what would happen. 

JA: Wow.  

SM: All drugs are poisons, right. Drugs are poisons. That’s like that’s pharmacology 101. Every drug is a poison. The question is, ‘Does the benefit of the poison outweigh the risk?’ And, in many circumstances, it does. I mean, this is like a life saver for some people who otherwise can’t get relief from their migraines or clusters. 

But just like any other med, we have to ensure that they’re safe to take it. And even at that, I don’t even know that it’s, I mean, I believe based on what I know, that the clinic should have had an ECG on file in recent history before the DHE was infused. But even at that, once he developed those symptoms, that’s where I think, you know, really, I think it’s pretty clear that he should have been not advised to go to the ER, but ultimately discharged to home. 

He should have been required to go to the ER as a condition of being administratively discharged from that practice.  

JA: Yeah, absolutely. And I think that that’s a really big point. And I think a lot of us have been there. I’ve been there just as a nurse of, you know, patient doesn’t want to do what it is that you are recommending or they don’t want to stay or whatever the case is. 

But I mean, this is probably something I’ll hard line on. I feel like there is no budging on that. There’s just-there is no budging. There’s not that patients can’t choose to do what they do. But like I can’t change my tune to appease you.  

SM: Right.   

JA: If I know or even think that there’s a potential that this can go very wrong for you, there is no budging. 

Like there’s just no budging on that. No. Wow.  

SM: I know I’ve done it in retrospect, yeah. In years past I’ve done that with like, ‘Oh man, they just don’t go and they’re going to go home and nobody’s paying attention. Okay. Well, if you’re going to go if this happens, please call.’ 

Like there was a time but not anymore because a lot of the time, if you put your foot down and don’t give your stamp of approval to the thing they want to do, then many times that they will do what they need to do. 

JA: Yeah, yeah, absolutely. And I wonder too, I think about cases like this. And there’s-this is just one example of a case like this. 

But I wonder how many guideline, like, changes, recommendations, new standards, right, have been put into place because of things like this, a case like this, you know, something like this. That now before you even touch that infusion, before you even get there, like have this, that ECGs done, check this. If this happens, if that happens, if that happens, go here. 

You know, these types of things-and hopefully these are the like positives that come out of experiences like this.  

SM: And no doubt at the very least at that center I would guarantee you that there are now policies in place to keep something like that from happening again.  

JA: Oh yeah. Good point. Wow. Dr. Miller, thank you so much for this story. 

Thank you for sharing with us. You know, these are these are really good learning opportunities. These are good reminders. A good just kind of like, knowledge busters for my own self. And so, I really appreciate, you know, listening to that. And I hope you all appreciate listening to it, too. And you find it helpful. You find it helpful for yourself, for your practice, for your patients, right? 

As you move forward and do the amazing work that you all do as providers. And if you enjoyed this episode, you want to hear more? We got lots more. Check out what we have, what FHEA.com, our podcast and courses and we hope that you join us soon. 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.  

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