A Fatal Fib

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 am your host, Jannah Amiel. And joining me is FHEA faculty and expert witness, Dr. Sally Miller. Dr. Miller, how are you?  

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

JA: Very good, very good. The weekend is coming soon, so I am very happy about this. 

I’m sorry for those of you that are actually going to be working. Okay. But anyway, let’s roll into our first story. But before we do, anyone who may be joining us for the first time, or if you’re rejoining us, welcome back. We are going to discuss an actual medical malpractice case that Dr. Sally Miller served as a witness on. 

And this is really a good opportunity for every single one of us, especially as healthcare providers, to listen to this as an opportunity to learn, right, to take these really good nuggets of ‘ohs’ and ‘ahs.’ And, is that you’re going to hear as we’re going through these stories, to help us to practice better, right, to practice better for everybody, for ourselves, for the profession, for our patients, for where we’re working. 

And so, this is not where we’re here just to judge all the things that may have gone wrong or could have gone wrong. But to look at this from a perspective of we’re humans and we practice and mistakes happen. And this could be us, right? We don’t want it to be us. So, here we are, making sure that we learn a little bit so that, you know, we don’t find ourselves in a similar scenario that might be avoidable, right. So, as we listen along to this, one thing that I like to do is try to guess what side Dr. Miller served as the witness on. And I also like to kind of collect some of these-red flags is kind of what I’ve been calling them. The things that stand out in this story that seem a little bit questionable, that may or may not be contributing factor to the outcomes that we’ll hear. 

So, really excited to hear this story. It’s such a good opportunity to learn something new and to put things in different perspectives. Now, with that said, Dr. Miller, I will be quiet. I am ready to hear it. I got pen and paper in front of me. Give it to us.  

SM: Alright. I have a story. So, this story about a 67-year-old woman. 

There’s a lot of 67-year-old women.  

JA: Yeah.  

SM: I don’t like that. This is about a 67-year-old patient and she is getting her-she has a cardiology practice that takes care of her cardiology needs. She had been with this practice-gosh, by the time the relevant events happened, she had been there for over 13 years. 

So, the records review goes back as far as-we’ll say year X. Year X she started being a patient there. So-and it was-I mean, she was clearly in her early 50s when she started being a patient there. And I’m really not sure why to tell you the truth, the first couple of years the records are really sparse. 

And again, you know, handwritten records that were just different back in the day. And she wasn’t there very often but, beginning-well, so, the start plus two. So, about 11 years prior to relevant events, from 11 years earlier, she had a very solid record that we could follow with this practice. She was really-it was like a primary care cardiologist, if that makes sense. 

She was-I mean, they weren’t doing her primary care. She had a primary care provider as well. But this is like her cardiology primary care. Like she saw this person annually for the check-in and then occasionally for medication titrations or whatever.  

JA: Okay.  

SM: But it was definitely an ongoing relationship here. So, over the course of the relevant 11 years, this patient had a total of 21 separate office visits with her, with the one cardiologist, with the same person who was her MD cardiologist, and those office notes for all 21 of those visits, they are either annual maintenance visits or scheduled follow-ups for diagnostic surveillance. 

So, like in other words, once a year she would go in and she would have her whole medication list. And, you know, it’s like, ‘Well, how are you doing? Any chest pain, any palpitations, any of this?’ And is like a very comprehensive-what a primary care provider would call a wellness exam. But from a cardiology perspective, it was, you know, it was-what’s the word I’m looking for here? 

Not focused. It was just a very broad-based, comprehensive, cardiology assessment. And they were typically-I mean, they were typically good. She would have labs done, she would have EKGs. You know, every time you go to a cardiologist, you’re having an EKG done. Over the years, she had from time to time had Holter monitors done, and then she would have follow-ups to talk about the results of that in her labs. 

And so, 21 visits with this single cardiologist in an 11-year period. Throughout those years, all of those cardiology visits were routine, ongoing diagnoses, surveillance, medication adjustments, whatever. Very characteristic of a long-term patient-provider relationship. For those 11 years while she was-she would typically see the one specific cardiologist. There were three times at that practice where she came in for an acute care or an unplanned visit. 

So, you know, like the visits with her cardiologist were always like, make this appointment. Like, before you leave, make your next appointment. They were all scheduled in advance, but there were three times that something happened that she would like call in and say, ‘I need to come in right now.’ So, like in primary care, we would just call it an acute visit. 

A lot of times in primary care, you hold open a certain number of appointments each day. So, if any of your patients call in the morning and have to come in right away, you have an opening for them. So, this was like that. There were three times in 11 years where she came as an acute visit for very specific reasons. 

One of them was years ago, way back in the beginning, she saw another cardiologist, and it really isn’t clear why. It looks like maybe she wanted to have a-she didn’t like one of her meds and wanted to change it or something that was really irrelevant and old. There were two visits-and there were two visits in the relevant period that were performed by the NP who worked for the practice. 

So, in this 11-year span, obviously from year 1 to year 11, the 11th year is when the events happened that matter, right?  

JA: Yeah.  

SM: So, year 11 is like is D-Day year. The two visits with the nurse practitioner were year 9 and 11. So, there were two times: year 9 and 11 where the patient had a particular event that she had to call in and make a same-day appointment for. 

The one in year 9, apparently the patient was out-of-state. And, you know, again, you know, fairly young woman here in her mid 60s, she was out of state for some reason, and she was in an accident and she had to be hospitalized. And so, in the accident, she sustained cardiac contusion, pulmonary contusion. 

She had some tachy dysrhythmia, apparently transient AFib, like, all while she was in the hospital. So, she was in the hospital for several days, and then she was discharged at home. So, she had been out-of-state. So, she came home. And then they advised her to follow up, which they always do. You know, when you’re discharged from the hospital for any reason, the last thing anybody says is, ‘Follow up.’ 

So, she called the cardiology practice to say, ‘Oh, you know, I was in the hospital and they said, my rhythm, my heartbeat did this thing and I should come see my cardiologist.’ So, that was the first one. So, she came and the NP, did-you know, again, like most NPs, most NPs really do much better documentation than our physician counterparts. 

No diss to physicians, but that’s usually the way it is. There was a detailed note. She documented the entire history, everything the patient told her, she did a physical exam. There was a lot of bruising. There was a lot of bruising still in various stages of healing on the chest wall and stuff. And the NP documented it. The NP noted that the EKG performed at the office, like today on that date, had frequent premature atrial contractions, and that that was consistent with the EKG of 3 years ago. 

And so, the physical exam, other than the bruising, was within normal limits. Of course, there was still some pain to palpation because of the bruising. The EKG was unchanged from 3 years ago. It showed normal sinus with premature atrial contractions. So, the NP at this visit ordered a chest X-ray. She ordered an echo. She ordered Holter monitor testing and had the patient schedule a follow-up with her regular cardiologist for 3 weeks. 

So, you know, the chest X-ray obviously is ruling out any like, occult fractures. The echo is to rule out any effusion. The Holter monitor-because there was this report of the hospital-of the you know, the tachy dysrhythmias and she scheduled follow up for 3 weeks. So, that was that. The patient apparently did her studies. 

She did have the Holter monitor. The cardiologist reviewed all of this with her in her 3-week follow-up appointment. So, when she came back, the cardiologist’s note, you know, notes the Holter, notes that the quality was not well, I guess the automatic interpretation from the machine was atrial fibrillation/atrial flutter for the entire scan. 

And then the cardiologist wrote a handwritten note on top of it saying that the quality was poor, that the rhythm was actually normal sinus with paroxysmal atrial fibrillation. So, paroxysmal atrial fibrillation-I mean, there’s different, you know, subtypes of AFib. But paroxysmal atrial fibrillation typically is regarded as very transient. You know, like a day, you know, max a couple days, but not your sustained rhythm. 

Anyway, that was the cardiology interpretation. Poor quality scan, sinus at 80 with PAF.  

JA: Okay.  

SM: The patient, you know, at that time, the patient and the cardiologist had a conversation about the paroxysmal atrial fibrillation. Was there a risk of emboli? So, the cardiologist, it looks like from his note, was not convinced that the AFib was enduring. 

He felt like it was transient. And, you know, he alluded to this in his note. He said, ‘would consider a loop recorder,’ which is a long-term, you know, implantable under the skin, like the term rhythm recorder, certainly better quality. So, in his note, he put ‘consider a loop recorder, increase her daily aspirin from 81 to 325, consider a loop recorder to see what the AFib burden is and do we need full anticoagulation?’  

Because, you know, there’s the balance of the risk to the unknown progression versus the risk of AFib. Okay. So, he acknowledged the scan. He acknowledged the flaws. He acknowledged with the patient raised her dose of aspirin. And they’re going to consider a loop recorder. That’s it. The note actually says the patient wants to think about it. 

So, a month later, the patient comes back. The patient comes in for a follow-up. The cardiology note says, ‘I have discussed with her inserting a loop recorder. She has not made a decision. For the time being, we will leave her on full dose aspirin.’  

JA: Okay.  

SM: That’s it. the patient saw the cardiologist once more in that visit. 

Two more or once more. That year. Two more. Because remember, this is your 9. This is year 9 I was talking about. I know it’s easy for the listening audience to forget this, but this is the first time the NP saw the patient. She saw her post-accident where there were contusions, the NP ordered the X-ray, the Holter, the echo, etc. 

Physician following up, this is the convo. And then the cardiologist saw her again once more that year, twice the next year in year 10, and then 2018. Well, the last year, year 11, with the cardiologist. And for those visits, there was no further discussion of the paroxysmal AFib. 

No further discussion at all. It was just here’s, you know, our routine maintenance visits. Here’s your meds. ‘How you feel?’ ‘I’m good.’ EKG is fine. No further discussion of AFib later in year 11. So, again the cardiology visit was early in year 11. So, cardiologist was later in year 9, once more in year 9, twice in year 10, early in year 11. 

JA: Okay. 

SM: No more discussion of AFib. Later in year 11 the patient had an acute care visit. So, she came in to see the NP had an acute care visit following a hospitalization. So, apparently the way the story goes is that the patient was hospitalized for several episodes of near syncope that were ultimately attributed to bradycardia and dehydration. So, like the hospital records attribute that she had bradycardia, dehydration. 

So, she had some syncopal episodes and she was admitted for an evaluation of the syncopal episodes or near syncopal episodes. So, then she’s discharged and told to follow up. So, here she is following up. So, the NP reviewed the hospital notes. So, this hospital was in-state and it was actually in the system. So, the practice’s cardiologist that does hospital rounds actually saw the patient in the hospital. 

JA: Oh, okay. 

SM: So, there’s more notes available. Yeah. So, the NP reviews the hospital notes. The notes included serial EKGs, none of which documented AFib. There was some subjective documentation that the patient had paroxysmal AFib by history. And then there was one mention in a note that telemetry reported AFib. But then the cardiologist said no, there were P waves. 

This was normal sinus. So, like the only discussion of AFib in the hospital was in that brief discussion, the hospital also had cardiology come in to see the patient. And a cardiac cath was performed. So patient was cath’d there was no coronary artery disease. Patient was ultimately discharged. Right. And her near syncope was attributed to bradycardia and dehydration and follow up with cardiology. 

So, needless to say, during this hospitalization, nobody documented AFib except the transient mention of telemetry, which cardiology then said no, is not right. There were P waves there. Nobody suggested any anticoagulation other than the 325 of aspirin. So, you probably can guess what might be coming here. The NP reviewed all of these notes. 

In her office note on that day, an EKG was done. She noted the occasional ectopic beat. She also advised a Holter monitor. This is 2 years later, and the patient was to do the Holter monitor and follow up with the cardiologist. The patient had the Holter monitor. She saw the cardiologist again about a month later. Saw the cardiologist again. 

The cardiologist again documented poor quality Holter. They need another company for Holter monitors.  

JA: The heck with the Holter!? 

SM: He documented excessive artifacts and premature leads off. Basic rhythm is at normal sinus rhythm. NRS. And that was the last time anybody in that practice saw the patient, and a month later she had a CVA due to large bilateral cerebral arterial embolic strokes. 

JA: She threw clots.  

SM: A couple of them. Apparently, there were a couple of them. Bilateral cerebral arterial embolic strokes. So, it was a bad stroke. It was a bad stroke. She was no longer independent. She was like in rehab, you know, in the hospitalization and rehab for a long time. And at the time of this, of the lawsuit, she was in, you know, like, an assisted facility, like, not just assisted living, a step up from that, but she needed assistance with ADLs. 

Like, she could not live independently. So, obviously, the assertion here is that she should have been on anticoagulation and she wasn’t. And that’s why she threw a stroke. That’s why she lives-and that’s why she had a stroke. But specifically, of course, you know, my place in the world is because the NP who saw her on these two visits was the assertion was that she should have put the patient on an anticoagulant. 

JA: Was this case just against the NP?  

SM: No, it didn’t start out that way. It didn’t start out that way. But also some states have some really weird laws that protect physicians and not other prescribers. And I don’t remember all the details, but there was something there like that, like they were going after everybody. 

Anybody who ever looked at the patient because there was some weird thing, but I don’t remember the specifics there, but no, she was not the only person named in the suit.  

JA: Okay.  

SM: So, do you know who yet? Do you know who I was called to? Whose side I was called on to? 

JA: Plaintiff.  

SM: So, the plaintiff would be the patient. Do you think I was called to- 

JA: Hmm. I hate it.  

SM: Now, you’re going, ‘Why did she say that?’ 

JA: Yeah, because you never asked me that. Normally, I guess it, and-but now I feel like I’m tricked.  

SM: Usually it’s obvious. Yeah, I really tried for it not to be obvious this time. 

So, I was retained by the defense.  

JA: Defense? Okay.  

SM: I was retained by the defense. So, the defense being that the NP did not deviate from the standard of care.  

JA: Yeah.  

SM: So, anybody who’s listening, all of our NPs, anybody working in cardiology, so like here-I mean, and listen, I have been asked to review cases by both plaintiffs and defendants, and I review them and say, ‘I can’t support you.’ 

And I’ve done that. I mean, I’ve-there have been things I’m like, ‘Well, I can’t defend this, you know.’  

JA: Yeah.  

SM: Or oh, I can’t fault anybody here. But in this case, I mean-this is another one of those cases where it’s sympathetic. You know she was 67 and all of a sudden now she’s, you know, she’s like dependent for ADLs. 

It’s a very sympathetic case.  

JA: Yeah.  

SM: And yes, I do believe that the emboli probably were preventable or at least if she had been on an anticoagulant other than aspirin that the risk that it would have happened would have been markedly diminished. But the question for me was, did the NP deviate from standard of care and you know what I wrote in my report and what I would gladly get on a witness stand and defend is that the NP’s role here wasn’t to be altering the chronic care of the patient. 

The NP was here to see the patient for the reason she came to the office. Like there was clearly an established relationship here between one cardiologist and the patient, and the cardiologist was doing the ongoing management. And in that circumstance, it’s not appropriate for a person covering for an acute visit to say, ‘Oh, well, you should be on this.’ 

JA: You should change your plan.  

SM: Let’s change your chronic-Stop, it’s just it’s not appropriate. It’s-nobody would do that, like, nobody. Nobody who’s seeing a patient once on an acute visit, when somebody else has seen the patient 21 times in 11 years.  

JA: Right.  

SM: And is clearly doing the ongoing management and this patient was just evaluated for this very specifically in year 9. 

And there’s like a lot of documentation about ‘consider it,’ you know, considering a migration loop, the loop recorder, the patient didn’t want to do it. Like clearly the cardiologist has considered here the need perhaps for anticoagulation-  

JA: Yes.  

SM: But did not feel that it was appropriate to order at that point.  

JA: Yeah.  

SM: And so, the plaintiff, it was suggested that the NP should have said, ‘Well, that’s wrong,’ that the cardiologist is wrong and that we should tell the patient that she is at risk for a stroke and that she, you know, should take this medicine. 

And I would assert that that is not the NP’s role in that circumstance. Now, I have seen things and I have experienced circumstances where, yes, it’s somebody else’s patient, but there is an immediate imminent threat.  

JA: Yes.  

SM: And it’s clear. And then I will jump in. I mean, I have jumped in and done things in opposition to the person who’s doing the ongoing management. 

But this isn’t that, because at this visit, the patient wasn’t in AFib, right? She wasn’t in like-I mean, her rhythm wasn’t AFib. So, even though there may have been some discussion in the past, on this day at this hospital follow-up visit, the notes from the hospital, like I said, there was no AFib from the hospital notes. 

There were serial EKGs that showed normal sinus with PACs. The EKG in the office on that day did not show AFib and none of the-even the consulting cardiologist in the hospital didn’t allude in any way to AFib or anticoagulation. So, because the patient didn’t have AFib in the office on that day, it’s just not appropriate for the NP to come in and say, ‘Well, I think you should do this and that.’ 

And I would defend that position very strongly in court. As it happened, the NP actually was dropped from the case.  

JA: Wow. Really?  

SM: So, because her notes were good, her notes were awesome.  

JA: That’s interesting.  

SM: I mean, her actions were defensible. And she did what she was supposed to do. She did function in accordance with the standard of care. 

So, you know, so that-so this is like, this is one of our, our good stories from the NP perspective. When like attorneys have things that they do during depositions like, ‘Yeah, well, wouldn’t you say that you should always on the side of safety, you know, wouldn’t you say that you should always do this?’ And the answer is no. 

You wouldn’t always do that. The answer is that you always err-with-along with the patient. I’m not saying this well. It’s the patient’s wishes. You know, unless the patient is an imminent danger to self or others, it’s up to the patient. And the cardiologist had clearly discussed loop recording and anticoagulation with the patient in the past, and it just wasn’t for the NP to jump in at this point, I don’t think. 

Given that the patient was not-you know, if the patient had been in AFib in the office appointment on that day, then I’m not necessarily saying she should jump in and anticoagulant the patient. It might have been, you know, worth reaching out to the cardiologist and not just waiting for the next follow-up. 

But those are all ‘what ifs’ that didn’t happen. And that’s fair.  

JA: You know what? I think that’s totally fair. And it makes a lot of sense. But I do have a question. I am sitting here thinking, ‘Okay, well, we’ve heard AFib come up a couple of times for this patient.’ And of course, the immediate thing I think of is anticoagulants. 

Should this patient have been on anticoagulants a long time ago? Not unlike some. Maybe we’ll think about it. Consider. But like what’s-I guess maybe my question truly is about AFib and kind of what the standard is? Like, when do providers determine you need to be on anticoagulants or this is not an actual thing yet you don’t need to. 

SM: It also depends on who you ask. If yes, that’s it. It depends on he asked. But yeah like there-I mean there are tools for this. Like there’s the classic CHADS tool where you can evaluate the patient’s risk and then if you score a certain thing and that’s what like plaintiff’s expert said, ‘Well, the patient’s CHADS score is high enough that she should have been on anticoagulation.’ 

Well, number one, it’s not that the patient should be on that; it’s should we recommend it. But the downside is that anticoagulants do have their own risks, you know, and again we’re going back some years here. This isn’t today-this, guys, this was a few years ago. And even in the world of anticoagulation, even in the last 10 years things have changed hugely. 

And there is some concern about atypical bleeding or abnormal bleeding, particularly with a fall. And remember that this patient was hospitalized for near syncopal episodes  

JA: Yeah.  

SM: And that’s somebody who is at-risk for falling, more at-risk for falling than the average bear. Attributing it to bradycardia and dehydration isn’t really curative at all. 

Like there’s no assurance that this can’t happen again, and I do-I mean, I have had patients on anticoagulation that fall and develop hemorrhagic bleeds in the brain. So, there’s that risk. So, it’s risk of benefit. Is the benefit of the anticoagulant worth the risk? If she had sustained AFib, I think most people would say, ‘Yes, the benefit is worth the risk.’ 

But by all accountable documentation, she didn’t have sustained AFib. And she was put on 325 of aspirin, which is like the step before you go to full anticoagulation. So, it wasn’t like nobody was paying attention to it.  

JA: Right.  

SM: But so, I mean, this is the question and I don’t know how it I mean, once the NP is out of the picture, then then, you know, I don’t know what happens. 

I don’t know how-whatever happened beyond that. But, if she had been in AFib consistently, then, yeah, I think that it would have been appropriate to have a conversation with her about the risk of stroke, the risks of anticoagulation, and, you know, how it could evolve. And then in the end, it’s always for the patient to decide, yeah. But yeah, the difference is the AFib. 

JA: And I’m so curious like if at all-and you might not know this since the NP was out and you were out, but like the amount of times that it sounded like there was just like not great quality printouts of the Holter or the ECG. Look, just like, how much is that way into the case if you’re just kind of like, I can’t really tell, I think it’s this. You know, like, where’s the responsibility there? 

SM: Well, and I don’t remember-I don’t think I had the actual strips, the actual whole day reports in my file. I should go back and look, it would depend on what it looks like. Like it’s very possible, this happens all the time. That electronic stuff will pick up artifact. 

Yeah. And a trained eye can look at it and go, ‘Oh, no, it’s not that.’ I mean, I’ve looked at EKGs that had certain reports, and as soon as you look at it, you know, it’s just artifact and that the interpretation is way wrong. So, it could have been a case where anybody would look at the Holter and go, ‘Oh yeah, that’s artifact. That’s not AFib.’  

You know, look, here’s a place. Or it could have been questionable. So, I don’t know how they looked. Yeah. But I definitely would after two bad reports it’s probably time for another company. Or maybe just the patient. You know, it does. The patient does. You know, there is some role for the patient here. 

Like if you know the leads get there, the stickies get displaced- 

JA: Or they’re moving around in a weird, they’re doing something. Yeah.  

 
SM: But I don’t know if the interpretation of the Holter is clearly just artifact, or if there are those who would call it AFib. I do remember, like, you know, I do get to read the other reports in those kind of cases. 

I don’t-I only try to pay attention to the stuff that matters to me because I bill these people by the hour, and I really try to be responsible with that. So, I don’t get too far into things that don’t directly affect my opinions. But I do recall that there was some controversy over that. 

JA: Wow.  

SM: Was the patient really in AFib or not?  

JA: Wow. Yeah. So, everyone listening right now who gets like a janky printout or something, they’re doing that thing 4 or 5 more times. Now this code. Yeah. Oh my gosh. Well that’s it. I’m sad to hear the outcome for the patient. Truly. That’s terrible. I will say selfishly biased. 

I’m happy that the NP, you know, had an outcome that that she did because that is really frightening. And I really do agree with your assessment on that. I mean, it sounds to me like when you see your primary doctor, I’m making up a scenario, right? When you always see your primary doctor, but once or twice you come in for some off thing and you see the PA or the NP or something else, like, you know, they’re just going to treat you for that specific thing that was happening then. 

And that’s-they’re not like, you know, going back in history. So, that is  

SM: And even any other physician would do that, a covering physician would not start because it’s a different kind of visit, you know, an urgent or an acute care visit is shorter. I mean, you get a shorter time for it. You’re expected to focus on the one reason the patient’s there and, you know, dig back into their chart and start making chronic changes. 

Putting somebody on anticoagulant is not a-it’s not a one-time, short-term thing. And yeah.  

JA: Wow. So, well, thank you for sharing this, Dr. Miller. I appreciate you. I appreciate your time in these stories, and we hope that you enjoyed listening and got some really good takeaways from it as well. and if you want more, check us out at FHEA.com. 

We have a lot more podcasts and different courses for you to check out there that you might be interested in. And in the meantime, until we see you again, 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.