Spinal Shock Part 2

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. 

Sally Miller: So, alright. So, that was early. That was early in, we’ll say-I’m not giving away too much-I can say August, I say early in August.  

JA: Alright.  

SM: So, apparently the patient does go on. The next day patient has actually-no, that wasn’t-that was late in August. The next day, the patient saw a physical therapist. 

I don’t know how she got in that fast, but the patient saw a physical therapist the next day. Physical therapy actually did a very thorough assessment and documentation. The physical therapist documented the history of the pain over the last year. That it had been intermittent, you know, that it had early on results with non-steroidals. But over the last few months it had become constant and intolerable. 

Physical therapy documents, ‘left leg numbness and tingling, stomach numbness.’ Okay, it’s PT-you know-the anatomy might be a little bit- 

JA: Yeah. 

SM: I’m assuming abdominal numbness because nobody went in there and felt her stomach. But left leg numbness, stomach numbness. And the patient reported a recurrence of the knot in her back. Remember I said a couple years ago, she removed- 

JA: Oh! The lipoma. Yeah.  

SM: So, the physical therapist physically inspected the back and noted the presence of blisters and opined that the patient might have shingles. The physical therapist also documented a cyst-like mass along the region of thoracic pain. So, this is the first like day after the NP saw her. And the physical therapist is documenting cyst-like mass along the region of pain, the presence of blisters, and that the character of pain in recent months has become constant and intolerable, and that there is numbness and tingling. 

So again, this note, it’s really in contrast to the note of the day before.  

JA: Oh yeah.  

SM: And no, it just doesn’t sound good. Yeah, yeah. 

So, you know, of course it makes you wonder now, now, of course, the plaintiff’s attorney just suggested that this all happened overnight. Yeah, but, you know, it’s for a jury to decide. 

Anyway, he recommends an MRI. Remember I said like a consultant-they, I mean, they technically only have to stay in their lane, but if a consultant sees a real need for something, they will usually make that opinion. So anyway, the PT, that was on August 31st of this year. So, I’m not giving away too much here. So, that’s that. So, now the NP doesn’t actually see the patient again for like 2 weeks, but via social media communication based on the physical therapist’s input, the nurse practitioner enters into the chart a diagnosis of shingles, puts the patient on acyclovir and gabapentin. 

And that’s it. So, you know, September 1st the patient–this note is entered into the chart. A diagnosis of shingles is made. The patient is started on acyclovir and gabapentin and follows up in 2 weeks- 

JA: Based on? 

SM: The 2-week follow up from the physical therapist. Yep.  

JA: Okay.  

SM: Two weeks later, the patient had no improvement. 

So finally, at the patient’s request, the MRI was ordered on September-the MRI was performed on September 21st. It was ordered like on the 14th. It was performed on September 21st. So, the MRI-I wrote it down. The MRI demonstrates “two large mass lesions in the thoracic spine, worrisome for a malignant neoplastic process extending into the chest and displaces the thoracic aorta. 

Second lesion is associated with a severe compression fracture of T4. The mask completely surrounds the spine at T3 and T5.” 

JA: That’s nuts.  

SM: So, I mean so the first thing that’s a real takeaway here is the numbness might not have correlated to the location where the patient perceived the pain. But this lesion is wrapped around the cord at multiple intervals. So, clearly there is impingement of the cord lower down to coordinate with the numbness. 

So, just because somebody tells you it hurts like wherever, don’t just assume that that’s got to be where the nerve impingement is, because the process inside can be really different and extensive. She also had a severe compression fracture of T4. So, I mean, the compression fracture, you know, you might be thinking, ‘Really? A lesion can cause a compression fracture?’ 

Well, we’ll get there in a second. But just the fact that she had a compression fracture, they really, really hurt.  

JA: Yeah.  

SM: And if you had palpated that area it probably would have hurt her. I mean I-you know, again, we don’t know what was done versus what wasn’t documented, but it’s just such a discordant story along the way. 

And so anyway, now there’s even more to consider here. The MRI report of the 21st is, as I just read it to you, on the 25th of September, the NP begins to initiate arrangements for a biopsy. So, it’s like the surgeon for a biopsy. But oncology because it’s suspicious for a malignant neoplasm. And it’s like oncology won’t even see the patient till the biopsy is done. 

Like there was a bunch of back and forth here. And I mean, I’m editorializing. There was actually back and forth with, well, this oncologist, you know, wouldn’t see them for X number of weeks. And then the patient was getting concerned. And the patient had a relative who worked somewhere. So, the patient starts trying to navigate her own thing. 

Finally-anyway the biopsy is done in October, early October. So, we’ve gone from an MRI with this reportin like the third week of September. And the patient’s still out walking in the street, you know, not literally, but just, you know, living life, has a biopsy on ten for, the biopsy along with other records. 

The biopsy result is forwarded to the oncology service, who as soon as they see it, they call the patient. The patient had an appointment coming up, but the oncologist called the patient at home and said, “Go to an emergency room right now.”  

JA: Oh, how scary.  

SM: And the patient went to the emergency room right then. And she had her surgery that day, like immediately. 

And so, she had surgery to try and, you know, dissect out some of this lesion. And then she had radiation. She went on the whole, you know, a whole cancer care phenomenon. She survived. You know, the patient survived.  

JA: Wow.  

SM: She survived. She, you know, she was still alive and you know, functioning and everything and capable of testimony and everything now at the time of this lawsuit. 

JA: But-so I’m like, trying not to be fired up. I’m going to be very honest. We just opened up this whole episode saying that like, ‘We get it.’ We talk a lot about documentation and like these episodes a lot and lot and this really seemed so just based objectively alone, based off that, the documentation and what we know seemed so off. So far away from like any standard. 

SM: I mean-I did I-like, I consolidated some of it, you know, some of these visits. 

But it was like stuff that really wasn’t relevant. The assertion. So of course, you know, the lawyer drafts the complaint, and the complaint is served on the defendant. And the complaint really centered around the back pain not being taken seriously.  

JA: Yeah.  

SM: And so, then the push and pull here as well, ‘Maybe the patient should have been more verbal,’ ‘If the patient was having pain worsening for the last year, why didn’t she come in more often?’ 

Like that’s the-you know, like that’s the plaintiff’s position. The patient didn’t really communicate it this way. But so, here’s the takeaway message for all of us who are listening like, yeah, back pain. Listen, back pain is hard. And we get so much of it and a lot of it is like psychogenic and stuff like that. So, you do have to always be open to a complaint of back pain is having an organic cause. First thing to keep in mind is don’t let yourself fall down that hole of, ‘Oh God, back pain, oh God it’s back pain.’ You just can’t think that way. It’s not unreasonable in the beginning to think thoracic strain. Now the weight I really did struggle with because of the BMI of 24.9. 

Like I said, I can’t imagine 24.9. I can’t imagine attributing back pain to that. But like in general for somebody who doesn’t really, really think about the pathophysiology behind a thing is probably-oh, one of the most common causes of back pain is overweight. So that really is like a more superficial approach and doesn’t really demonstrate truly thinking through the underlying process here. 

But okay, even at the first visit, if you call it thoracic strain, that’s not-that’s a fair miss. Okay. So, fair miss. And the document of the exam might not have been perfect, but it’s a fair miss. But another thing, and I know I’ve mentioned this in other episodes, if the patient persistently complains of the same thing and you’re not-it’s not getting any better, there’s something there.  

Complainers, you know, our Munchausen people or whatever the contemporary term is, our somatic complaint disorder or whatever. It’s always something different. You know, it’s not like this lady, you know, she’d been back a few times with her back pain, and it’s always in the same place. And if you can’t figure out what’s going on, there’s something missing. 

JA: Yeah.  

SM: Now she’s been through Kenalog injections, ultrasound, baclofen, ibuprofen, Toradol. When you have the same complaint and it’s not getting better with all of this kind of stuff, like the take home point is look for more, look for something else. There’s something else going on there. Because if it was somebody who is just beaming Munchausen, it’s like this week, it’s back pain, then it’s my abdomen, then it’s my leg. 

Then it’s my head. Like it’s always something a little bit different. So, there’s that. Aside from that, that final visit in August a year later where she comes back and again, it’s still really pretty perfunctory here. It’s pretty cursory, but the next day the physical therapist appreciates a cyst-like mass, the therapist appreciates blisters. The therapist, you know, supports the numbness. 

So, it really makes it hard to imagine that the evaluation a day before was I mean, was it accurate to our standard of care, you know. Absolutely. Interestingly, remember one of the documentations was tenderness to palpation, but no skin change.  

JA: Yes, and then these disease blisters and- 

JA: Yeah.  

SM: And a mass.  

SM: So, that’s problematic. But then another biggie and a really does it always stuns me when I see stuff like this because I see it fairly often that the NP knows something needs to be done, but the patient doesn’t want to do it. 

So, the NP says, ‘Okay.’ So, you know, remember if people don’t want to do something, we’ve talked about this on numerous occasions. But these, you know, with these cases, if the patient doesn’t want to do it, you can’t make them do it, but you don’t want to give your stamp of approval on it either, because that’s what they’re looking for. 

If you give your stamp of approval, then it’s okay. So, in a case like this, listen, you’re-you know, if you feel numb and you have this pain for over a year, you must have an MRI. And the patient says, ‘Oh, I’m going to have to drive to the city.’ Or, ‘I can’t afford it.’ Or, ‘The co-pays too high.’ 

‘I’m sorry, but you need an MRI. Here’s the referral.’ And then the patient either will do it or well. But you’ve got a document that you’ve advised the patient appropriately. That’s that. That’s a thing there that we all really can learn something from. You can be nice. I mean, I always joke and say, ‘Don’t be nice.’ 

We’re not friends with your patient, but you can be professional and respectful and you can say, ‘Look, I understand.’ Because I have said to people, ‘I get it.’ Like, I totally understand why this is going to be difficult, but it’s what you need. I can’t support anything else. I really think you need to do this. 

And then it’s for that. And then very often that page like, ‘Okay, oh God, I guess I’ll do this.’ And then they do it. Beyond that, the other thing here that, you know, that we all can learn something from is with an MRI report like that, when you see a compression fracture and two lesions that are invasive, displacing the thoracic aorta and wrapped around the spine from T3 to T5, that patient needs to go to an ER. 

They just need to go to an ER. This is not time to be worrying about, ‘Well, it’s a weekend.’ And you know, ‘We will organize and we have to do the referral and I have to hear from them and they won’t see you until this happens.’ They need to go to the ER.  

And I guess that’s all-I mean, that thank goodness that the patient came out of it okay.  

JA: That is really something. I mean we talk so much about documentation and it’s really important, documentation is so much. But this is one of those stories that it is really hard. It’s hard for me, as we like to do in these episodes, to figure out what side you’re on. 

But I can’t imagine, Dr. Miller, that you got this and you’re like, ‘Oh yeah, this this was this was standard of care.’ I don’t imagine that was the case here.  

SM: There was a plaintiff’s expert NP, who supported this and basically tried to shift the blame to the patient, like, ‘Well, why did you know, why did she tell PT that it’s been bad for so many months and that the NP knew it was bad.’ And, you know, like, you know,-listen, yes, in a perfect world.  

But remember, every time a patient comes to you with pain, you say, ‘Okay, it’s a strain. You know, you should sit up straight, take Motrin or whatever.’ You minimize its severity to the patient. So, you know, as the time goes on and the patient’s like, ‘Man, this really hurts more. Oh, well, let me just take some more Motrin.’ And listen, days go by, weeks go by, months go by.  

And you just-you don’t prioritize it because you were never given the impression that was anything serious, that it was just uncomfortable. And you try to like, ‘Oh, don’t make an appointment. She’s just going to give me more Motrin.’ Like, that’s what happens.  

JA: Wow. So, what ultimately ended up happening with this NP in this case? I imagine it the settled. 

SM: Well, yeah. But it’s settled because-I’m sure because they realize that there was just-it was not defensible. So, it settled. But it was a big money settlement. It was very favorable to the patient.  

JA: I can imagine. Wow, this was fascinating. This is one of those things that happen that kind of like, shake you to remind you that, like, come on, we can’t be poo-pooing all these little things I know. 

SM: And it’s so frustrating, though, because most of the time those little things are little things.  

JA: Yeah.  

SM: But that’s our job is to figure out when it’s not. And then we’re not perfect by any means. But there are these like these, these typical axioms-I guess is the word-like if the same thing keeps presenting and it’s the same and it’s not getting any better, despite everything you try, look for something else. 

You can’t just write it off to posture, you know?  

JA: Yeah, I agree. Wow. Dr. Miller, thank you so much for sharing this story. And I hope everyone who’s listening in got some really good takeaways from this. I know I certainly did. I appreciate your time, Dr. Miller. I appreciate you all for tuning in, too. We hope you enjoyed that. 

And if you’re looking for more, check us out at FHEA.com to see what other podcasts that we got cooking for you. In the meantime, 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.