Spinal Shock 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’m your host, Jannah Amiel, and joining me is Dr. Sally Miller. Dr. Sally Miller, hello, how are you? 

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

JA: Good, good, good. Thank you, thank you. Dr. Sally Miller, for those that are tuning in for the first time, of course, is faculty here with FHEA and she serves as a medical malpractice expert witness-that is a mouthful, I should be used to saying it by now, but I’m not-for some of these cases which, of course, gives us an opportunity to talk about them, which is exactly what we do in these episodes. So, we’ve got some real cases that she served as a witness on. 

And we walk through those cases, we talk about what happened, how did it get to this point, right? To the point of actual litigation. And I like to play a little bit of, ‘Can we guess what side Dr. Miller was serving as a witness for?’ And as we’re listening along, right, there’s so many opportunities as you hear the story unfold to identify little red flags or things that feel like an outlier or something strange that happened that we like to dissect and talk about. 

Okay. But most importantly, we also want to set the stage that this is never to be judgy, right? We are all healthcare professionals. We are all very well aware that mistakes happen and they can happen and that they will happen. And if we can learn how to practice the safest of our ability, right. And we’d really be accountable to ourselves, where we’re practicing, to our patients and make sure we’re doing all the things we should be doing, then that just makes us better. 

So, this just gives us an opportunity to be maybe a little bit better than we were yesterday. And with that said, I’m going to pass to Dr. Miller, so we can start to dive into our first case.  

SM: When you were talking, I was thinking about how I’m so judgy. I’m judgy with my sister, judgy with my friends, but definitely not judgy of other clinicians because like virtually everything that I am asked to consult on, I can I just so identify with that. 

I can so see how this could be me. But yes, I can be judgy too. Like I was very judgy to my sister and she’d laugh to hear us say we’re not being judgy.  

JA: Sisters probably deserve it. I have an older sister.  

SM: But it doesn’t count when it’s your family. But I’m not being judgy here because as I look at this case, I’m like, ‘Oh boy,’ this-a lot of this could happen to any one of us.  

So, this is a story over a period of a couple of years, about a 39-year-old woman and the nurse practitioner that took care of her. So, the patient is a young female. She’s 39.  

JA: Oh I hate it when you say my age. 

SM: Well, listen, you like it better than 40 or 50 or 60, so 39 doesn’t sound so bad. Anyway, she was a 39-year-old woman. No significant medical history. Your garden variety 39-year-old. She married, divorced, and she has two kids, so that’s-just no significant background. At one point, a year or two prior to these events- 

So, actually, I guess it was a year prior to the initiation of relevant events, she had been treated for a cyst on her back. She like she had a bump or somebody told her she had a bump. It turned out to be a lipoma, you know, a benign fatty accumulation. It was removed. It was biopsied. It was negative. 

And that was that. And then about 1.5 years later, the patient developed what she characterizes as severe back pain. Now, the notes didn’t characterize it as severe pain, but the patient did in her deposition. So, you know, all of our memories a little bit later could be a little flawed. But anyway, she made an appointment for back pain and she saw the nurse practitioner. 

So, in May of this year, she was seen by the NP for the first time and indicated pain in her left upper back.  

JA: Okay.  

SM: And the NP notes in her notes, documents ‘right thoracic region pain to palpation.’ Now, this is at a time when the practice apparently was just starting to transition to electronic medical records. 

So, some of the note is electronic and some of it’s not. It’s scanned in in handwritten sheets. Those of you that have been around for a while-they’re listening, you know what I’m talking about. Like we had a scan in all those old one page-you know, people would come in for an appointment and you would have a page and just start circling stuff. 

You know, document by exception, circle, circle, circle, a quick note. And then we would scan it in and nobody could ever read it. And that’s what we have here for this first visit. So, she documented right thoracic region pain to palpation. Nothing else. No inspection of the area, like-no nothing. Just right thoracic pain to palpation. The NP then diagnosed that the pain- 

She told her that the pain was due to excessive weight since the patient was started-  

JA: Excessive weight?  

SM: Yes.  

JA: Oh, okay.  

SM: And the patient was put on weight loss medication. She was put on a diet med, you know, like a weight loss med. Her BMI was like 24.5, the patient-which is normal.  

JA: Yeah.  

SM: Yeah, just this is just a little side note. 

I thought it was kind of interesting, and I thought, well, because- listen, if someone is significantly overweight or obese, it can cause back pain. Usually lower back pain. You know, like lumbar sacral strain. That’s very common. I mean, I have certainly told many people over the years that have back pain, that weight loss is really a big part of managing it. 

But I’ve never really seen it for right thoracic pain, you know. And so, then, of course, when I saw that she was put on a weight loss med and you know told to rest and ice it every 15 minutes, nonsteroidal. Was like a typical, you know, back strain thing. But her-the patient’s height was 6 feet even, and her weight was 181. 

And I thought, that doesn’t sound so bad. And then I did the BMI calculation. It was 24.5.  

JA: That’s great. Oh boy.  

SM: So, normal BMI, of course the listener remembers is between 19.8 and 24.9. That’s a normal BMI. And honestly, 19.8 looks emaciated to me.  

JA: Yeah.  

SM: And there are lots of people with BMI, like in the 25-26 range that you would not glance at and think they were overweight. 

So, 24.5, not only is it not technically overweight, but it really-it’s a stretch to attribute back pain to the extent that someone makes an appointment with you to be evaluated for it. But listen, Monday morning quarterbacking hindsight is always 20/20. The note really was-it was not a good note. Like I said, it was one of those old sheets that we used just to like, just chart by exception and scan in and often tell you nothing, you know, remnant from the day when no one ever sued you. 

So, nobody was ever paying attention to your notes. Right. So anyway-but yeah, she was-so it is attributed to excess weight. Also, at that visit she had symptoms, apparently they were consistent with UTI, and the entire HPI such as it was, the history of present illness, there were a couple of lines on that scanned in form, but it was all about the UTI symptoms. 

There was nothing about back pain. So, all we have about back pain is the document-now, the patient said she was there for pain, but the documentation really focused on the UTI. There was this note about right thoracic pain and then there was a diagnosis of back pain secondary to excess weight. Patient was put on a weight loss med, rest, ice, ibuprofen PRN. Okay. 

That was that. Patient came back to the same practice, same nurse practitioner, a month later complaining of fatigue. Now, the note-the NP writes on her note.-and this is just when they are transitioning. Now that note is electronic documentation. So, the whole note is EMR.  

JA: Okay.  

SM: The NP notes that the patient is there for fatigue, weight gain, hot flashes, night sweats, and menstrual issues. 

And that’s the reason for the visit. And again, I mean, really-I’m really not being judgy because if it’s a really busy day and there’s a lot going on, like you’ll sometimes-you’ll try to throw in just enough that you’ll remember what you have to document later.  

JA: Yeah.  

SM: And then sometimes you don’t. I mean, that’s just the reality, folks. 

I hate to admit it, and maybe I shouldn’t admit it since I’m being recorded for broadcast, but the truth is, sometimes if you’re really, really busy, you just put enough in the note to prompt your memory so that when you go back at 10:00 that night to do your notes, like some of us do, you can remember enough to fill in. 

So, I don’t know. I don’t know if that’s what’s happening or not, but that’s what was in the HPI. She was there for back pain-or she was there for fatigue, weight gain, hot flashes. Now you’ve had some menstrual issues. So, at this visit her BMI is down to 24.3. She’s lost 2 pounds in the last month. 

She’s now down to 179.  

JA: Alright.  

SM: But she’s there for weight gain. So, you see, like, where-now again the charting is not great. But it also is likely that they’re just getting used to electronic medical records.  

JA: Yeah.  

SM: Which is a real pain. You know, like back when you first made the switch from handwriting. 

It’s 10 years later and I’m still complaining about it. So, you know, there’s those definitely all those like real life things that get in the way. But it is interesting that the chief complaint at HPI commented on weight gain. And she actually lost 2 pounds from her last visit. There is no acknowledgment of the back pain at this visit. 

So, the back pain was last month. This month is everything else. And there’s no-interestingly-there’s no comment on back pain now, but later this month, a couple weeks later, the patient comes back for a complaint of back pain. She’s here. So, since last month there have been three visits: last month, early this month, and late this month. 

And the third one, she is now here complaining of back pain. So, documentation reveals a physical exam that supports bilateral thoracic region with tenderness and swelling. The diagnosis for the visit was thoracic strain and enthesopathy. You’re going to say this right: enthesopathy. 

JA: What the heck is that? What are you saying? 
 
SM: Listen, I had to look that one up. 

And I feel like I might have a pretty broad background and I’m well-versed, but I have to check.  

JA: You mean like here? Like thoracic?  

SM: Well, no. So, the thorax when you’re talking about the back it’s usually the thoracic spine. 

JA: Okay.  

SM: But the-I can’t even say it. Enthesopathy is a very particular kind of pain that originates where the ligament attaches to bone.  

JA:Okay.  

SM: And the-whether it’s an inflamed attachment or inflamed or diseased attachment that can cause pain, where the ligament attaches to the bone on the spine is what I’m assuming, based on the way it’s documented. 

So, now, like I said, I didn’t-I have a pretty broad background, but I had never even seen that term before. I mean, I don’t work in, you know, in musculoskeletal or in orthopedics, but had never seen that term before. So, I had to look it up. Enthesopathy is the right way to say it, but there’s an H in there that’s silent. Enthesopathy. 

But yes, it’s a particular kind of pain. Reportedly, though, is most profound when you either palpate those joints or stretch them in some way, because it’s at the ligament insertion. Anyway, that was a diagnosis. And the patient was given a trigger point injection with Kenalog. So, she was given injection of steroid, told to take baclofen and tramadol for her back pain. 

And that was at the end of that month. So, like I said we got a month. And then the next month there’s an early month, a late month visit. This was a late month visit. The next month, apparently, the patient messaged the NP on her Facebook page that the back pain was better. Note to self: not a good idea to interface with your patients on social media, unless it’s the practice’s social media site, I guess. 

And maybe there’s a mechanism for that, but it’s just a good idea to confine your communications to your patients that had anything to do with their healthcare issues, to a recordkeeping system that is readily accessible to anybody else who sees the patient to you in the future, and, of course, to the subpoena when it comes a couple of years later. 

You know, it’s just not good to be messaging, ‘Oh, hey, you’re on Facebook.’ ’Oh, hey.’ ‘Hi. Let’s be friends.’ Now, this was like in a small community, in a rural part of the country, a small community. So, I mean, no doubt that the patients know the provider from church and stuff like that, and you could see how they- 

But just-you don’t want to do it. Not the professional stuff anyway. The patient messaged the NP. So, they clearly had like-they were friends on Facebook or whatever that-I don’t know. I don’t know what social medium it was, but they apparently had a reciprocal communication on a social media site, and that’s how the patient responded to the NP,  

‘My back pain’s better.’ 

Okay, so between that month and the next 5 months, the patient was seen in the office three times for appointments of fatigue. Now, this is a 39-year-old woman with no significant medical history right now.  

JA: Right, why are you tired?  

SM: And now her BMI is down to 22. I wish my BMI was 22. 

JA: You and me both.  

SM: I mean, 22. Like, there is just absolutely no way to be calling anything overweight in any way. So, BMI is 22 and she’s fatigued enough that on three separate visits she comes in. So, there’s really never-like it’s always attributed to there’s like not a good evaluation of it honestly. 

And I’m not trying to be judgy here. When I say good, I mean a written documentation of the things we think you would evaluate for fatigue. Is it psychogenic or is it organic? Does it start in the morning? Like there is a progression to evaluating fatigue and none of this is diagnosed here. And but you can see like in the notes where a patient is advised to try to sleep better or, you know, be sure she gets plenty of rest. 

There’s no real-not even any laboratory assessment, like that you would do a CBC, you know, for anemia or renal dysfunction. None of that there. I said there was a 5-month spell where there were three visits. So, in the last one, the patient now complains again about the back pain. She says, ‘It hurts. It’s hurting more. It hurts more in the evening than in the morning.’ 

At that time, the NP did document no numbness or tingling. She diagnosed thoracic strain and she discussed posture issues with the patient, like, you know, sitting up straighter, stuff like that. So maybe her back pain is due to her-like in her note she says the back pain, which the patient describes as eight on a scale of 1 to 10-it’s eight out of ten. And the NP notes that it may be overworked, that her back may be overworked, like, because I guess at work she’s leaning forward in her chair. The physical exam documented that the patient appeared tired and overweight. 

And I thought, ‘Man, if a BMI of 22 is overweight.’  

JA: Oh my God, we’re still on this number. 

SM: Anyway, I don’t know. I’m really trying not to be judgy like it is very easy for me to sit here with all the time in the world and look at these notes. But to everybody listening, that’s what experts do. 

So, when you write a note, you do want to think about how it reads. And listen. I know it’s hard. I know it’s a pain. I mean, I find myself like last night doing this, you know, my clinical day is over. I want to be done. But I’m looking at these things one more time because I always look at my notes at the end as if somebody else were picking them apart, just like this 3 years later. 

JA: Yeah.  

SM: And that’s really just what you want to do. I mean, you want to make sure things make sense. It is very hard to say that, that there was a good evaluation of what’s going on here when you have overweight and a BMI of 22 in the same sentence.  

JA: Yeah.  

SM: She also notes that the patient is limping secondary to the back pain. 

The physical exam documents paravertebral tenderness, which is again a classic phrase. You know, we palpate the posterior thorax and if it’s  tender next to the vertebra, you know, it’s a common phrase for back pain assessment. No skin discoloration or abnormalities. The diagnosis is thoracic strain. The patient is given instructions about posture and 5 days of Toradol, you know a pretty powerful, non-steroidal. 

So, now I mean with this back pain-so, now this has been going on for a grand total of about 7 or 8 months. The pain is eight out of ten. The pain is causing the patient to limp. She’s already been on-she’s had Kenalog, you know, trigger point injection. She’s had tramadol. She’s had Ultram. 

She’s had non-steroidal. Today she’s getting Toradol. And a discussion of posture. 

The next time that this NP sees this patient is a year later. The patient comes back a year later.  

JA: Okay.  

SM: Now she’s there because of back pain. Not only does her back hurt now, but she’s numb from the waist down.  

JA: Holy crap.  

SM: So, she tells the NP that she’s numb from the waist down. 

Her BMI is now 20.6. She’s obviously not taking weight loss medication anymore. At least it’s not-not in the record that she’s taking it now. Her weight initially was 181 and now, and this is about a year and 3 months after that very first encounter. Yeah, her weight’s down from 181 to 152 and her BMI is now 20.6. 

She told the NP that her back really hurt and that she was numb from the waist down. And the NP told her that she could not be numb because the location of the pain didn’t correlate to the level of the numbness. So yeah, I mean, again, I’m just looking at the documentation here, but, now it is true that you do associate certain neuropathic symptoms with varying levels of the spinal cord, you know, like-you know, like so for whatever reason, she, the NP, felt like the location of the pain didn’t correlate to the level of where the nerves were. 

So, okay. So, that’s it. The NP documented on this visit that the patient had had back pain intermittently for over one year. It would get better with anti-inflammatories and then it would come back. The pain is documented as upper mid-back between the shoulder blades, tender to palpation, but no skin change. That’s what the NP documented. 

Though, nothing about like the appearance of the skin. But just no-no change. The NP documents-and I actually pulled up the note so I could be very clear, because this is another point I want to address for the people that are listening-the NP notes, “I would like for her to have an MRI, but she wants to try therapy first, and will let me know if an MRI is necessary.” 

JA: “Let me know.” Oh, so the patient has a license like- 

SM: But again, like, some nurses are nice. I don’t know where like-I know every time somebody looks at me and says, ‘We thought we’d get a nice nurse.’ I’m like, ‘Oh, boy, are you in for a disappointment.’ But really, like, something like some NPs just-we want to be patient advocates and we want to not be the authoritative, ‘You must do this.’ 

And sometimes it just goes a little too far. And so, we’ve had this conversation before on Scrubs and Subpoenas. I mean, you can’t beat the patient over the head and make her have an MRI. No, but what you say is, if you think the patient needs an MRI, you tell them they need an MRI. 

If they choose not to, that’s on them. But then the documentation is against medical advice. Patient declines to have an MRI. I have advised her of the risks.  

JA: Yeah.  

SM: I think this is a concern in this note. This is a-now the patient says she’s numb from the waist down, but the NP says she can’t be down from the waist down. 

Now, we all know that if you have back pain and you’re numb from the waist down, this is an emergency. This is an ER visit. I mean, that’s like basic nursing 101. And now there is no documentation of a sensory neurological assessment below the waist, it would really have helped if the NP started doing like sharp, you know, point discrimination or something and documented sensation below the waist. 

Then there would be an objective foundation for saying she wasn’t really numb. I was not concerned that this was an emergency, but with no assessment of whether or not she was really numb. If somebody tells us back pain and numb- 

JA: Yeah, it’s like telling someone you can’t be in pain. Like that’s nuts.  

SM: Yeah. So it’s just, you know, I don’t know. 

I don’t know if there is actually something from the care that’s missing or if there’s documentation. I mean, of course I have an opinion, but I mean, you know, like in the spirit of not being judgy, we don’t know if she didn’t do it or she didn’t document it. Either way, not having this documented, it doesn’t support the position later on. 

And I can also-I can tell you firsthand it feels very different when you’re living it than when you’re looking at your notes 3 years later, you go like-I mean, I’ve looked at my own notes sometimes and said, ‘Oh my God, how did I not document this or what?’ Oh yeah, who wrote that? Who wrote that with my license, you know, and so we can all do it. 

But this is the way the note presents and it is troublesome. The patient says, ‘I’m numb from the waist down and my back hurts.’ And the NP says, ‘It can’t be numb.’ Like that’s a problem. And then-like the MRI sounds like a good idea, like, if you’re not going to go to an ER, the next step is an MRI, but it’s not for the patient to say, ‘Let’s try something else.’ 

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.