Cleared To Play Part 1

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 Jannah Amiel. I’m going to be your host for today’s episode. And joining me, we have a very special guest, one of our FHEA faculty members and expert witness, Dr. Wendy Wright. Dr. Wright, how are you?  

WW: I’m doing great. Thank you so much for having me today. I’m really excited about our conversation.  

JA: Yes, I’m so excited. We really have come to love doing these types of episodes. You and I have podcasted on before a different topic, but I’m super, super excited to have you on again and to be talking about this, but I want to set the stage a little bit for those who are listening in that maybe haven’t heard Dr. Wright before or haven’t met her at any of our programs. 

Dr. Wright, you do so much more than just work with Fitzgerald and serve as an expert witness. You got a lot going on. Tell us about yourself.  

WW: Thank you. Yes, I do have a lot going on, but it’s all good. I’m pretty blessed. So, I have been a nurse practitioner 32 years and I have been teaching for Fitzgerald Health companies for 27 years. 

But I own my own family practice where I have nine nurse practitioners who work alongside me, 6500 primary care patients that we take care of. We’ve been in business for 17 years, up until about a year ago, I had two clinics. I sold that clinic off. I also own a medical education company, and I fly and travel and speak somewhere pretty much every week. 

And then in my free time, something that I really love to do is I help to work on malpractice cases, both on the side of defense, but also occasionally on the side of plaintiffs. So I have done now, I think, between 125 to 150 cases over the last 27 years.  

JA: Wow. And I like how you said free time and somehow sneak in like, 150 cases. That’s a ton. That’s a lot. 

WW: I think that that’s really for me. You know what the best part of this is that every time I do one of these cases, I always learn something. And I use that into a teach-make it into a teachable moment. Because every time I do a case, I say, ‘You know, that could have been me.’ 

And what can I teach people around this country? What can I teach the NPs that I work with how to prevent that from happening? So to me, it’s just a really interesting way of learning more about healthcare.  

JA: Yeah, and I love that you said that. One of the things that we like to do, we always level set, right in the beginning of these episodes. 

And you said it perfectly. This is a good opportunity to learn, not just for us having these conversations and for those listening in to learn from it. But, you know, truly, one of the things is, this is a phrase that Dr. Miller has given us that we’ve adopted is that there’s those of us who have made mistakes and those of us who will make mistakes. 

And I think that that really does kind of set the tone. And for us, it’s knowing that we’re human, right? We’re clinicians, we’re providers. Things happen. We’re going to make mistakes like humans make mistakes. But if this is an opportunity for us to learn to practice better, to practice safer, to be, you know, the best advocates we can for our practice and for our patients, then we’ve done a really good job. 

So, I’m really curious, how did you end up in this kind of, like, expert witness arena? What was-how does that have even first happened for you?  

WW: Right. So, I bet you don’t know this, but you’re going to learn that in 1997 Dr. Fitzgerald was asked to do a malpractice case, and she was actually really busy at that time. 

I don’t remember the backstory, but I remember her coming to me and saying, “I’d like to refer this case to you. Are you willing to take this on?” And I thought, ‘Sure.’ My motto has always been, ‘Say yes and figure it out later on.’ So I took the case, and that is actually going to be the case that I’m going to talk about today, because it was my first case to work on. 

And so and it has left this print in my brain, over the last, what, 27 years, I guess was the time that I worked on this. So, that’s how it began for me. And then what happens in the world of malpractice is, at least for me, I helped to defend the largest malpractice suit ever filed against a nurse practitioner in the history of this country. 

It was $169 million case. And what happens is the attorneys, if you do your job, often will put your name in a databank, particularly in these large firms. And so when people are looking for nurse practitioners, my name comes up because I did work on that case and we did some really good stuff. And so maybe that’ll be our next podcast that we’ll talk about, because that’s public domain and it’s all been in the media. 

So, I’m happy to talk a little bit about that case as well. We can do that the next podcast.  

JA: That would be awesome. I’m really excited. I’m excited to hear this story. I had no idea the backstory of how you had gotten into this medical malpractice arena. That is really-that’s neat. So alright, without further ado, I know our audience is like, ‘Come on with the story you laid on table!’ When you’re ready, we are ready to hear it. 

And then I just a little reminder, we like to always put this out there for folks listening in, to remember us for working through this story. As we’re listening to Dr. Wright talk about it, I want you to consider what side was Dr. Wright on, right. Not right or wrong side. We’re not saying that. 

Was she serving for the plaintiff or serving for the defendant. She will tell us at the end of the story. But it’s an interesting bit that we like to do as we kind of listen along and see if we can identify those pieces. So, Dr. Wright, when you’re ready, lay it on us.  

WW: Okay. So this is a 14-year-old young man who comes into a clinic and is seen by a nurse practitioner, roomed by a nurse, seen by a nurse practitioner. 

And the patient is there for a well-visit. He’s actually there for sports physical.  

JA: Oh.  

WW: Because he wants to play football and he wants to participate on a high school level. And so he needs a well-visit in order to be cleared in order to practice. And practice, by the way, is about a week from now. 

So, he’s coming in at the last minute, which any of you in primary care, you know, this is what we see all the time. Like my cheerleading starts tonight and I need you to clear me kind of thing. So he comes in, he sees the nurse practitioner. His past medical history is consistent with exercise-induced asthma. But other than that, no other past medical history. 

So, the nurse practitioner uncovers that he does have exercise-induced asthma. He uses albuterol as he needs it for dyspnea, and it’s generally only occurring when he’s exercising. So the NP does his history and doesn’t really find out anything else that’s remarkable in the history. And then does the physical exam and during the physical exam identifies that his lungs are clear. 

The rest of his exam is unremarkable, with one exception. And that is a murmur was noted. And the nurse practitioner noted a systolic murmur, grade two out of six, loudest in the mitral region, with radiation into the left axilla. The nurse practitioner documents that murmur and then, in the assessment and plan documents ‘benign murmur, cleared for sports, exercise-induced asthma stable.’ 

And this adolescent was given the ability to practice sports and go to football. And it was the first football practice that he was running laps around the track and cardiac arrested and died. And so this was before the time-I just gave you the backstory in terms of it being 1997-but this was really the whole time before that movement that every sports field needs the implanted-the automatic defibrillators. 

So, there wasn’t one there. And unfortunately he did not survive. Now, when the autopsy was done on this young man, his heart was five times the size that it should have been. And on autopsy it was identified that he had hypertrophic cardiomyopathy and which for many of these individuals and many athletes, we hear about this in the media of these athletes who are playing basketball, like here in Boston. 

We’ve lost a couple of really well-known athletes to this condition. But it’s genetic. And what happens is that heart gets bigger, bigger, bigger and what and they end up dying often of a ventricular dysrhythmia, often v-fib that will take them and otherwise they’re healthy. So again, that whole reason why these defibrillators are at the side, because if we can get to these kids quickly, we can often save their lives. 

So, that’s the story. It was about a year later that the nurse practitioner received the subpoena that she was being sued and that at that time, 21 defendants were actually named. The NP was the primary defendant, but there were 21 other individuals, including the nurse that roomed the patient, the facility. And back then the NP worked in a state where there was a supervising physician. 

So, there was a number of other plaintiffs named in the case, which is not that unusual in cases. And I’m happy to talk about that, although I know Dr. Miller has spoken about that in previous podcasts as well. And so I was then hired in this case. So, that’s kind of how it began. And, so I’m happy to answer any questions that you might have about it, but it’s obviously a tragic case, right? 

JA: Yeah.  

WW: It’s one thing if you miss a diagnosis, but this was a life-threatening and life-altering, not only for him, but also his family as well.  

JA: Yes. And, you know, one of the things is that’s wildly unfortunate. And my background is pediatrics as a registered nurse. So that hits, you know, one thing that we think about to like when we hear these stories, sometimes it’s really easy to identify like or you think it’s easy to identify that, this is where the practitioner made a mistake or didn’t do what they should have done or, you know, admitted in that type of way. 

But I’d love your opinion, you know, on the sports physical and ECGs, you know, as we kind of talk about this. Right. And we do this, we try not to do the Monday morning quarterback thing, but you kind of can’t help doing it sometimes in this way. Now it seems like that’s practice, like that’s standard practice. And I often wonder if it’s because of like, a case like you’ve been on, doctor. 

Right. For instance, where we hear these pediatric cases and it’s like sudden cardiac arrest and they collapse. And now the sports physicals, you know, I remember working in the clinic didn’t used to include ECGs, but now they include ECGs on the children or, you know, the pediatric population. I wonder, is that as a result of something like this, was it happening so much in practice? 

Like what pushed that? And-or maybe was it just a complete miss for the NP? Like once they identified a murmur, should you have done more about that?  

WW: So, let’s talk about this, because one of the videos that I have in the Fitzgerald bank is sports physicals. So, I encourage anyone who wants more information about standard of care and sports physicals to listen to that video that I have developed. 

But in any event, there has been a big discussion in this country. Should we order chest x-rays? Should we order echos? Should we order EKGs or ECGs in patients wanting sports physicals in other countries? I think it’s Italy. They do ECGs on sports physicals, but that is not standard of care here in the United States, because studies have shown that these cases, while we hear about them and they garner a lot of attention. 

I think there was a study that came out of the Mayo Clinic where it was something like 0.4% of adolescents have a cardiac anomaly that could be harmful to them. And what they said after that study was, it’s not enough to do this on every athlete in America. And then what you get is a lot of false positives. 

So, you find something abnormal on the EKG. It ends up being nothing, but you’ve chased it down to the tune of thousands and thousands of dollars. So, today in this country, ECGs, echos, and chest x-rays are not standard of care. But what is standard of care is the American Heart, what they often refer to as this 5-point check where you listen for murmurs, where you check femoral pulses to make sure that there’s no coarctation, where you check radial pulses. 

What you’re doing is you’re really trying to identify in the physical exam, and then you ask certain questions: any a premature heart disease, any sudden death in the family, any history of a heart murmur. And if any of those are positive, then your suspicion goes up and you can take it from there. But these cases have gained a lot of attention in the media. 

The good news is they’re not significant numbers, but when they happen, they’re tragic, right? They’re tragic.  

JA: Right. And we never ever think about, you know, like it’s not the teenager you’re expecting to have this cardiac arrest episode, right? Like in our minds, we’re thinking it’s going to be the older adult with a history, you know. Then in this case, for the nurse practitioner, were those steps taken or was it just simply noted, documented, and that was it. 

Were there any physical pieces that weren’t done that should have been? 

WW: Well, so we’ve got exercise-induced asthma.  

JA: Yeah.  

WW: So one of the conversations that is now happening in the world of asthma-now again, this was 27 years ago and we’re Monday morning quarterbacking.  

JA: Yeah.  

WW: But today about 2% of people who have been diagnosed with exercise-induced asthma truly have an underlying cardiovascular abnormality. So the recommendation is when we hear exercise-induced asthma to get spirometry to at least make sure that we are ruling in what we think we have and maybe trying to identify other things. So I think that’s rule number one that I want our audience to take away is that we’re 27 years post-this case. 

We now have tools in our toolbox that we can use. And if they say we’ve got exercise-induced asthma, then let’s make sure it’s been properly diagnosed and let’s make sure we’re doing that comprehensive cardiac exam to make sure that we’re not missing anything. And the other big takeaway here is murmurs are the sound of turbulent blood.  

JA: Right.  

WW: And they’re the sound that the heart makes as the blood is going through the heart. 

Up to 50% of us at some point in our life will have a murmur. And what we need to decide as clinicians is, is it benign or are there findings that suggest that this murmurs pathologic? And pathologic means that there’s a valve or structural abnormality. So, I see a lot of kids, I hear a lot of murmurs, but there are certain things we have to do when we hear a murmur. 

One is what happens when I take you from a laying down position to a sitting up? Because in general, that’s called dynamic cardiac auscultation. We’re going to move you. And in general, murmurs get softer when they’re benign. They’re going to get softer when we stand them. The only murmur that gets louder generally, or the big murmur that gets louder, is hypertrophic obstructive cardiomyopathy. 

So, when we sit them up or stand them, it actually gets louder. So that’s one thing that would have been helpful to that NP to say, ‘When I stood him up, it got, you know, softer or it got louder.’ That would have clued that NP into a different pathway of where they needed to go. But then the other point that I often say when I’m teaching is benign murmurs don’t radiate. 

That when a murmur radiates into the carotid, it’s often an aortic pathology. When it goes to the left ventricle-to the left axilla, it’s often a mitral pathology. So, when I hear a murmur that radiates either into the carotid, into the left axilla, or through/between the scapula, it’s often more likely to be pathologic, because in general, benign murmurs don’t radiate. 

So, the fact that that was heard in the left axilla, what that NP heard was actually mitral regurgitation. Mitral regurgitation, systolic radiation to the left axilla. And the reason that she heard mitral regurgitation was that that left ventricle was so big, filling space was all taken up. There was an obstructive outflow issue. The blood was backing up through that mitral valve. 

And what she was hearing was mitral regurgitation and not a benign murmur. So, I think those are some really important teaching points to walk away with. And I think that had the NP at that time recognized that benign murmurs don’t radiate, and that when I hear it in that left axilla and it’s in the mitral region of the chest wall, I have got to move and get an echo. 

JA: Yeah. 

WW: That would have I would have at that point, based on the guidelines today, I would have disqualified him. I would not have cleared him and I would have obtained an echo. Now, I had a very similar case to this and so this I had a child come in who’s mom said every time he’s on the hockey up on the ice rink, I’ll see him and he’s all winded and he’ll go sit down and he’ll squat. 

Now, you remember your cardiac pediatric background. Remember the squatters had one like they were trying to return blood to their lungs and in their brain. And so when I evaluated, I heard this murmur. Now, he had had a murmur for years, but it was louder and it radiated. And I said, “No more sports.” And let me tell you, that family was not happy. 

But I ordered an echo. And back when this happened, it was about 15, 17 years ago in New Hampshire. We had one pediatric cardiologist.  

JA: Oh my gosh.  
 
WW: I ordered this echo. And I was so scared of the cardiologist because he was really not a friendly man. And he always would say, “You’re taking up my time from kids who really need help.” 

So, I was so scared and I was in the office and they called and they said, “The cardiologist wants to speak with you.” They’re knocking on my door. And I’m like, oh, I’m going to have a chest. But he got me on the phone and he said, “Great pick up, great pick up. This is hypertrophic. This child has a subaortic stenosis.” 

JA: Wow.  

WW: And his heart is pretty darn big. So no sports for him. He’s going to need some surgery. But, you know, those aren’t-it was just that getting louder, radiating associated symptoms. That doesn’t suggest that it’s benign.  

JA: Yeah. So that was definitely one of my questions. Now, is that a today thing as far as we know that today. 

But we didn’t know that 27 years ago like that we shouldn’t just call it benign without following through with those extra steps.  

WW: Well, I think we knew it because I’ve been teaching the board here for 27 years, and I remember Dr. Fitzgerald teaching me, she was my mentor. I was the first NP she hired me to teach this course. 

I remember her teaching me that in graduate school. So, I think we know. But I also think when you’re busy and when you’re-I don’t know how long this NP had been out of school, I don’t remember the history of this-but I think there’s so much that’s going on and it’s hard to know everything. 

I don’t know everything. And I’m 32 years into this career, so this is why I think doing these is so helpful, because we’re not just talking about, you know, testifying. What we’re talking about is practice and improving care. Right.  

And I always say when I do these, “Open for the grace of God, go I,” because that could have been me. 

And so what can I do that other people can learn. And I think the big takeaway is benign murmurs don’t radiate. If they do, you got to get an echo and just make sure that there’s nothing structural going on in that heart.  

JA: Yeah, absolutely. And, you know, one of the things that we talked about and you mentioned it and I think you really phrased it well was, you know, for the clinicians that maybe are apprehensive about kind of like throwing everything at the patient, they don’t want to do all the diagnostics they’re worried about maybe something like insurance and approval, you know, cost, time, whatever it is. 

But you know, to your point, there are some of these like physical steps, right? That we miss, that get skipped. And quite honestly, some of the stories we tell, we recognize that that just got skipped, that if you heard something and you thought it was radiating, maybe the next thing wasn’t to do a diagnostic. But there were still some more physical assessment pieces to be done to help to, you know, confirm if you should do that next step or not. 

And that gets lost often when we hear these stories.  

WW: I often say in my clinic that we spend so much time in our brain trying to deny what we think, that we need to embrace the thoughts that come into our brain first. What I mean by that, and I know that that probably sounds weird, but I’ll evaluate a patient. 

I’ll say to myself, ‘No, that can’t be a pulmonary emboli.’ Then when I start thinking that, I now say to myself, ‘You need to embrace what you just thought,’ because sometimes it is an intuition, is it intuition and knowledge? Is it a combination of both? Stop arguing when that bell goes off in your head. Listen to the bell. 

And so, in hindsight, what could someone who’s listening to this do today? If you’re not sure there are really cool things out there now, one is you can just grab a provider, a colleague and say, “Will you come in and listen to this? What do you think?” We do this all the time in our clinic, “Hey, will you look at this ear, I don’t know what to do with this.” 

I think that is so incredibly helpful. But there’s actually now apps that people can use as a stethoscope. The stethoscope transmits the sound into the app, and the app interprets what that murmur could likely be. So, there’s technology out there because they recognize that so many of us are in rural America. 

I don’t have another set of ears. Or maybe there’s not someone else there. So if we can make some of these great tools available, that can be really helpful. 

JA: Now the, you know, the tool bit. I didn’t know about that. I think that’s a great idea. And I love the like well, what do I do if we don’t know. Because that comes up too, right. Some of the times you’re going to see patients, you’re going to hear a thing, see a thing, feel a thing, and you’re going to have no clue. 

It’ll be your first time. You’re going to have no clue. And there’s no shame, right? There’s no shame in asking somebody else to come and check or calling a friend. We’ve had those conversations, calling a colleague, maybe that works somewhere else to ask them, you know, their thought on it. And I think that that’s a really important takeaway. 

WW: I think there’s no shame. And in fact, I tell NPs, when you’re looking for your first job or you’re looking for a job, find a place that is supportive of team and education. And can I run this by you? Because that is so critical. None of us practice in a silo and none of us know everything. So reaching out, phoning a friend, one of the strategies we use to teach the new NPs in our clinic is develop a base of resources. 

JA: Yeah. 

WW: You got to develop your resources. If I don’t know what this is and I’m not sure about this EKG, let’s call cardiology. And they’ve got someone on-call. Will you read this for me and give me some help? Because I think that developing that kind of strategy can really help to protect a lot of us.  

JA: Yeah.  

WW: Not be afraid to ask. 

JA: Yeah.  

WW: Because if you don’t, it could be harmful to you or the patient. Yeah.  

JA: And in this case, I mean, a child lost their life. And that is absolutely tragic. That is tragic. And there were parents involved. 

Tune in next week for the conclusion to this case and to hear some insightful malpractice pearls from Dr. Wendy Wright. 

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.