Plot Twist

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. I am your host, Jannah Amiel. And joining me today is Dr. Sally Miller. Dr. Miller, how are you?  

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

JA: Good, and you know what? As I’m staring at us on camera, I just realized that I was trying to be cute for this podcast, and I had, like, makeup dust all over my black shirt. 

I-everybody, just listen to this episode. Don’t actually watch it. I tried. Well, it’s Friday so that’s a plus. That’s actually a plus. Always excited to have you, even when I am covered in my own cuteness that I thought I was going to pull off this morning. Oh, man. So, before we get going, really, I’m always excited to talk about these stories, but we always like to set the stage right. 

We talk about real medical malpractice cases that Dr. Miller served on. And the one thing that we want to make sure is established and the takeaway, right, is that we all make mistakes. Dr. Miller has a great line. It’s those of us-there’s those of us who have made mistakes. Right. And those of us who will. And I believe that wholly. 

And so, listening to this is really a good opportunity for us to learn how to practice better, maybe identify when things go wrong that could be avoided. Right. We just want to be better for ourselves, for our profession, for our patients. You know, make sure that we’re doing the right things every time we can. Anything you want to add to that, Dr. Miller? 

SM: I don’t think so. I mean, I-you know, we talked about this in another episode, but not just doing the right things, but also documenting.  

JA: Yeah, yes. Documenting. Yeah. And if you haven’t listened to that episode yet, The Art of the Chart, please take a listen to that. That was a great one. That was a great one. 

All right. So, when you’re ready, Dr. Miller, we are like, gung-ho, we want to listen to this.  

SM: So, this is a case-and this actually is not about a nurse practitioner or an advanced practice nurse. This is about nursing staff. But there’s a couple of really good takeaways from this. 

And so, that’s why I’m excited to present it to you. So, I’m going to give you a timeline here. I’m going to give you a timeline and events. You know that we try-I try to be non-biased, to not give you any hint about which side has retained me. And as always, I’ll do my best. Sometimes it leaks through, with the expression. 

I’m going to try not to and then, you know, try to think about where do you think I’m coming from? I will tell you that this case involves a young man, this young man with 19 or 20. It’ll probably come up as I go to the narrative here. But the patient is a young man, and that’s relevant only because sometimes that can make a case very sympathetic. 

And when you visualize a jury listening to it and trying to weigh the issues, even though it shouldn’t matter, you know, those sorts of subjective things shouldn’t matter. It’s really about the care. Did it meet standard of care or not? And if it didn’t, did it cause, you know- it should be very objective. But sometimes there are cases where, there are those things, those elements that are sympathetic and it can color the way somebody looks at it. 

So anyway, that’s why I share with you that this is this is a man. So, this is a young man that was arrested and taken to a county correctional facility. This wasn’t a prison. This isn’t somebody that’s been sentenced to serve time in prison or anything. This was a young man who was picked up on a warrant. 

For anybody listening who doesn’t have any experience with the correctional system, and hopefully you don’t either as visitor or a guest of a correctional facility or even a healthcare provider, when we talk about being picked up on a warrant, if there is a bench warrant out for your arrest for any goofy reason- 

And where you see it happened many times is a young person gets a speeding ticket, they blow it off and don’t pay it because you know, they’re young and goofy. And if you don’t pay the ticket, it still goes through the system. And if you don’t pay it, if you don’t pay it, you’re supposed to appear. You know, either you appear in court or you pay the ticket. 

If you do neither one, then you are considered a missed appearance and a bench warrant will be issued for your arrest. And yeah. And you could, grow up, be a responsible adult. And 15 years later, you’re in a car accident that is not your fault. You know, you do everything right. Somebody hits you, you’re on the side of the road, and the police respond, and they call in your license. 

JA: That is so scary.  

SM: And there’s a bench warrant. Oh, girl. When I was started to-you know, I worked in a correctional facility for 8 years. Within the first week of working there, I like-I was searching myself out to make sure that I didn’t have any unpaid tickets. Because then not only-I mean, that’s bad enough, but then suppose this is on a Friday evening. 

You can sit in jail easily over the weekend, waiting until Monday when court is in session to go back to court and where it will probably be dismissed. But, you know, for the average garden variety person who’s never been in jail, a weekend in jail for a ticket that you didn’t pay years ago is like pretty rough. So, first off, first takeaway for everyone listening: make sure you don’t have any outstanding tickets or citations.  

I say speeding because that’s so common, but I don’t know. There’s just lots of little minor infractions that, you know, a young-you know, young person will often just like, ‘Oh, I’m not paying that.’ Or they shove it in their glovebox or whatever. And then boom, there’s a bench warrant out for your arrest. 

And if that happens- 

JA: Oh my gosh.  

SM: I know! If that happens, I’ve also seen it happen where there was a, like an altercation at a bar and then the police come, but then everybody there, they’ll just run their ID and then some poor soul that had nothing to do with the altercation. But you didn’t pay a speeding ticket 15 years ago. 

So, yeah. So, everybody listening make sure there’s no outstanding warrants for your arrest. So, okay, so once we’ve gotten past that. So, I just want you to have a sense of we’re not necessarily talking about hardened criminals here. When someone gets picked up on a warrant and taken to a county correctional facility, it might be a hardened criminal, or it might be someone who didn’t pay their child support, you know, and the rights or wrongs of that. 

That’s for another conversation. You know, it could be a speeding ticket, unpaid, not paying a child support or anything like that. So, that’s what-and for this infraction, I really-I believe that there was I don’t remember the details of all of that because that’s not relevant to his healthcare. And in fact, it shouldn’t matter at all if he’s picked up for murder or he’s picked up for not paying a ticket, that’s another one of those things that that could bias a jury inappropriately. 

So, I don’t even know why he was picked up. But I have a sense that there was a warrant. There was a warrant. And then-and that’s why he’s there. So anyway, this young man is picked up and he is escorted to the county correctional facility. And so, I’m gonna give you some timeframes here because they become relevant. 

So he is-he presents to the jail at 5:15 p.m. already, like, oh, no, the workday is over, you know, so if you’re there on a warrant, you’re there at least for the night. So he is first-his first encounter with nursing staff is at 5:15 p.m., and that’s because he has just been presented to the jail. 

And now one of the first things you do is an intake screening with nursing staff, typically an LPN. They do an intake screening primarily to make sure that you are basically healthy, don’t have any acute problems, that you can be processed to the jail because, you know, a jail’s not a healthcare facility. It’s not a hospital or a long-term care or even a rehab or anything. 

It’s just a-more like  a college dorm or, you know, a military barracks or something like that. There are no, there’s no health services there for someone with with more significant problems. So, one of the first things that happens when you come in the door is an intake screening by typically an LPN, just to make sure you don’t need to go to the ER before you stay in the jail. 

This is his first encounter, and it’s at 5:15 p.m. and it was actually well documented. Very easy sometimes for those to just get like check, check, check. Normal, normal. And you know, but this LPN documented that the inmate had a history of depression. He was having some anxiety right then about his brother who was having some mental health problems. 

At this time, the inmate was documented as alert, oriented with appropriate speech and affect, neat and clean and appearance, logical thought processes, appropriate activity, behavior. The receiving screening documented that the inmate reported a chest injury about 10 months prior, for which he did not seek any care. He denied using any drugs or alcohol as part of that screening. 

Visual observation documented by the LPN. There was no tremulousness, no anxiety, no sweating. I mean, it was a well documented intake screening, one of the better ones I’ve seen actually. And so, we can infer from that that she really was paying attention. And, you know, sometimes everything is just check, check, check, check, sign. 

JA: Yeah.  

SM: There’s there was call into question, you know, how how truthful is it. But anyway, this is this is pretty straightforward. And for someone who is just arrested, he’s pretty, you know, pretty calm. Is 6’0’’ young man. He’s 212 pounds. His vital signs were normal. Blood pressure 108/84. You know, the 84 of a young man always catches my attention, but, I mean, his vital signs were fine.  

Anyway, during this screening, he was called away by correctional staff, by the officers, the corrections officer, the nurse officers for a personal property inventory. So, the LPN was not able to complete the screening, but she completed that much of it. And then the inmate is taken away by correctional staff to process his personal, you know, get his his wallet and stuff processed in. 

Apparently, while he was with correctional staff, there was some sort of altercation between the inmate and the correctional officers. And we don’t know the details of that, but we do know that the next time he is seen by nursing is 5:30. So, 15 minutes later, he is now presented back to the nursing staff.  

JA: Okay.  

SM: And the nurse documents in her notes. So, he’s gone for 15 minutes and now he is there for it-there’s an injury report. So, the nurse documents in the progress note that the patient was transported back to the medical unit. He has lacerations on his left and right eyebrow and a contusion on his cheek. These were cleansed. The LPN documented that now the inmate was acting aggressively. 

He was spitting and that further assessment and intervention were not possible. They cleaned the laceration as best they could. They were documented as appearing superficial. The LPN was unable to obtain vital signs because of the inmate’s aggressive behavior. She notes that now he is screaming, yelling, screaming. But he’s alert and he’s speaking in full sentences, but he is combative, aggressive. 

And so, she can’t complete a further assessment. That was at 5:30. And safety really is paramount in a correctional facility. Security really supersedes a healthcare thing. So, 15 minutes later at 5:45 p.m., now there is an order written by the social worker, to transfer the inmate to Constant Watch. So, this is an observation. It’s like a mental health observational area where there is a video that will, you know, constantly be watching him. 

And he can be observed by staff, like through a window. So, the social worker orders that he go to Constant Watch and so they have a form, they have a process for this. And it includes filling out a form called the Mental Health Constant Watch Infirmary admission form. And on that form, the nurse documents that the patient is highly agitated, aggressive, and physically harmful towards custody. 

So-I don’t know what happened in those first 15 minutes. You know, after his first physical where he appeared cooperative and then he’s taken away by corrections staff. But whatever happened, now he is aggressive, he is violent, he is spitting, and he is unsafe to the staff. So, that’s documented. At 5:45 p.m.-at 5:54, 9 minutes later, the nurse documents that she is called the the physician who’s not on-site. 

She’s called the medical director and advised of the inmate’s condition, and she gets a telephone order for Ativan 2 milligrams IM. Which is, you know, a very common-I mean, 2 milligrams of Ativan is a comparatively modest dose for a 6’0’’, 212 pound young man with no reported medical history. Because remember, in the intake screening, we got enough of that there was no history reported, you know, except for this chest injury 10 months ago that was never followed up. 

So, at 6 p.m., the nurse administers 2 milligrams of Ativan intramuscularly in the right deltoid. So, the inmate is in a restraint chair. And there is a process for this. And there’s a protocol and there’s a series of forms and they’re all completed. And the inmate is-while he’s in Constant Watch, he’s put in a restraint chair as ordered by custody and a spit mask. 

And I know it sounds sort of archaic.  

JA: It does. 

SM: I know. And people that don’t-people that don’t have any experience  in this kind of setting might be uncomfortable with it, but spit masks are used for the safety of, you know, of the correctional staff, of the healthcare staff, of nursing staff. And they are safe and they are approved. 

And believe me when I tell you in this day and age, ensuring safety of the inmate is also paramount. And those kind of things aren’t approved until there’s all sorts of checks and balances to make sure that they’re safe.  

JA: What is the spit mask, Dr. Miller. It’s just like, someone’s trying to think about it in their head right now. Like, is it a mask from the face all over their head? 

SM: Goes over your head. Yeah, goes over the head. And it’s actually, it’s like-it’s aerated so air can move through it, but it’s-what’s the word I’m looking for? Narrow enough, like, very fine little holes in it.  

JA: Yeah.  

SM: So, air can move in and out, but spit can’t.  

JA: Got it, got it.  

SM: Yeah. Yeah. So, they can definitely breathe in. And it just it goes like, you know right over the head and ends at the chin okay. So, it’s like there’s no concern about the neck or anything like that. Like the airway really just covers it, you know. And different places have different forms of this. But in this particular circumstance, it was a-it was like, it’s a material, it’s like a mesh. 

JA: Okay.  

SM: So yep, he’s in the restraint chair and he’s got the spit mask and almost everybody listening-in fact, I’ll bet that there are many nurse nurse practitioners listening that just came up in the era of minimal restraint. You know, there was a time, I mean, in the hospital, there was a time where somebody got combative, just tied him up. 

You know, you could walk down any med-surg unit, and half the patients were tied up because they were, you know, delirious or getting out of bed or whatever. And then at some point, I want to say the late 90s, there was a huge culture shift in that and lots of regulation and restraints, whether it’s a chemical restraint or physical restraint, they are not advocated unless there is just no other way to protect the patient or the people around them. 

So, like these things are not implemented without clear documentation and clear rationale and reasoning and all that kind of stuff. But in a situation like this, this is a time when it’s necessary. So, he’s in the restraint chair, he’s got on his spit mask, and he’s been given 2 milligrams of Ativan and at 6:00 p.m., the Ativan is administered. 

And so, he’s put in Constant Watch. So, Constant Watch I mean it is a room. If you if you saw the video, it looks like one of those old time, mental hospitals where they have you in this chair that looks, you know, really threatening, and you’re sitting in an empty room and the walls look great. The video is like black and white. 

That’s what it looks like. But he’s just there in the chair. And because he had been so aggressive and physically combative, he was restrained. And so, he’s in the room alone, the door is locked and the lock is maintained by custody, not by nursing. Nursing doesn’t have access because nursing is not allowed to approach a potentially dangerous inmate without correctional staff. 

Now, I don’t know if every single correctional facility in the country has that policy, but that was the policy at this one, and that was the policy at the ones I practiced in. You don’t approach an inmate without any interview, without correctional staff on board, and somebody like this, like they have to be there. So, it’s very typical that the door is locked and nursing does not have a key to it. 

So, 6:06 p.m. while in Constant Watch, let’s see the the nurse documents that the inmate remains agitated. The narrative note indicates that vital signs could not be obtained as the inmate was locked in the cell, and the nurse did not have access to it. That was at 6:06, right? He was injected at 6 p.m. and at 6:06, he’s still agitated and she can’t do vital signs. 

At 6:20 p.m., 14 minutes later, nursing documents that the inmate is resting comfortably, but that vital signs were not obtained as the inmate remain locked in the cell, so she couldn’t get in. And the restraint documentation does call for vital signs every 15 minutes, which is why she’s documenting her inability to obtain them. At 6:35 p.m., the next 15 minute interval, the nurse again documents that the inmate is resting comfortabl-well after 2 milligrams of Ativan he’s probably really resting comfortably. 

The narrative note indicates that she requested access to obtain vital signs, and was advised that a sergeant would be required to be present. So, they reached out for a sergeant at 6:35. At 6:40, the sergeant arrives. The nurse is allowed access to obtain vital signs. As she notes the skin is warm, the color is normal. There is a shallow heartbeat and an absence of respirations. 

JA: Oh God.  

SM: She immediately alerts the charge nurse and the charge nurse-and this is one minute later, 6:41 p.m. the charge nurse instructs custody to remove the inmate from the restraint chair, alerts yet another nurse on the staff that the inmate is unresponsive and that assistance is required. Gathers emergency equipment and instructs custody to call the paramedics. 

So, this was done 1 minute after the original nurse determines that there’s an absence of respirations. Four minutes later, a nurse arrives with the emergency equipment and initiates CPR. CPR is initiated at 6:45 p.m. At 7:08 p.m. the paramedics arrive and assume CPR and the inmate expires. The inmate is transferred to the emergency department and he is dead on arrival, so he doesn’t survive. 

JA: Oh my god.  

SM: So, that’s the story. Now, I really-I tried to be as bland as I could. Any idea who retained me here?  

JA: The defense.  

SM: It was the defense. It was the defense. And like, this is if there was ever a time where you can just see how important documentation is. This is it because this is a very sympathetic case. 

This is a young guym who reportedly had no medical history and- 

JA: He just suddenly dies. 

SM: Comes out of here dead.  

JA: And I will say from like the cases that we’ve done together that you’ve shared, this documentation is definitely one of the better ones. Normally writing that, I’m like, oh my gosh, oh my gosh. Oh my gosh. 

This one’s seems like it’s good.  

SM: This really is. And you know like correctional facility inmates are protected population.  

JA: Okay.  

SM: So, the the the role of documentation is really trill. Now, it doesn’t always happen. I think we talked about another case and another episode is in a correctional facility, young lady. And yeah, documentation wasn’t quite as often, but in this case and-then so of course the, the criticisms here, we’ll talk about that in a minute. 

The so-I’m here to defend nursing staff. Now what happened with corrections. Why there was a fight in the first place, why the inmate was agitated to the extent that he needed Ativan. Those were all bones of contention too. And believe me, everybody was a defendant here. The inmate’s father was suing the state. The county, you know, everybody. 

But, you know, suing agencies of government is hard.  

JA: Yeah.  

SM: They too, are protected from lawsuits. So really, who’s perceived as the deep pocket here is the healthcare side. Because in this instance and this happens a lot in the country, the county contracts with a private company to provide healthcare services. So, the staff are not employees of the county or the state. 

Their employees of a private organization.  

JA: Oh, so you’re like a vendor. It’s like- 

SM: Oh ding ding. Yeah, exactly. You’re a vendor. So-and there’s several of them. There’s several big ones in there. I think they have a lot of them have consolidated over the years and become 1 or 2 big companies. And whenever a county facility or maybe even a state facility. 

But I know when many county facilities, every X number of years, they just put out a call for bids, call for proposals, and the various companies will put together a proposal and submit it. And then the county picks someone and contracts the vendor. But the vendor is a private company, and so they are not protected in the same way that the government is from a lawsuit. 

And because it’s healthcare, you know, they have lots of insurance. And so they are really seen as the target. So, the nursing staff individually were sued and the the organization was sued. Everybody was sued I think. So, I was asked to evaluate the nursing care and see if it was defensible. And so, interestingly, the criticisms of the nursing care, we’ve talked about this, this a little bit beforehand- 

Well, let me back up a little bit. When a plaintiff-when a patient or in this case, inmate patient, whatever you call him when they initiate a lawsuit, they contract with a plaintiff’s attorney who typically works on a percentage of the recovery. Like, you know, you see the commercials on TV. Oh, if you don’t get paid, we don’t get paid. 

And, you know, they’ll just get like X of how much the judgment is for. And that means that that attorney, the plaintiff’s attorney, they have to put out all the money upfront. You know, they invest their time in any money upfront, and then their payday comes when there is a judgment and they recover money from the insurance companies. 

So, you know, solid plaintiffs firms, they typically have lots of money from some of their earlier wins, and they can afford to prepare their case and retain the experts and pay the experts and do all of that, and then they get their money back at the end of the case. I don’t know exactly what the issue was here, but this particular plaintiff’s attorney, I don’t know if it was a small firm or a new firm for whatever reason, or maybe they just thought they had a really great case and they were going to make a bazillion dollars, but they didn’t hire any nurses to opine on the nursing care. 

They didn’t hire any nurses to be critical of the nursing care, which is-it’s an an oddity of many states with virtually every other discipline. Your expert has to be the same discipline. Right? Like if you want to criticize a nurse, you need a nurse and if you want to defend a nurse, you need a nurse. 

If you want to evaluate a PA, you need another PA.  

JA: Right.  

SM: And I’ve been asked to evaluate PA care. And even though the care and the protocol and the job description are identical, I can’t do it because I’m not a PA, you know, so like that kind of thing. But of course, a physician can legally opine against anyone that’s an any other healthcare provider. 

It’s ludicrous and it’s antiquated and outdated. And hopefully, you know, sometimes these things change slowly. But in this particular case, the plaintiff retained a physician to offer all the opinions about the medical care and the physician that they retain is very well known as a as an expert, you know, well known as an expert and very famous. 

But he was opining on the nursing care. And so, some of the-I tried to pull up some of the quotes here. Now, this particular physician is a,-what-spent his entire career as a medical examiner. So, he didn’t evaluate live people. 

JA. Right. Dead people.  

SM: Yeah, he provided care for dead people. I don’t know if care is what you call it when you do an autopsy. 

Anyway, whatever it is, are dead people. I guess certainly nobody’s going to sue you for wrongful death anyway. This physician, like, he, you know, he made comments about how the care was substandard. Physicians should have been called immediately to evaluate the patient. The patient should have been transferred immediately to the ER. All of these things imply a complete lack of understanding about the standard of care in a correctional facility, because those things just don’t happen. 

Remember, standard of care is what the you would do in the same or similar circumstances. And you don’t pick up a phone in a correctional facility and call 911.  

JA: Yeah.  

SM: You don’t have a physician in the on-call room 24/7. So, those things don’t happen. This expert also freely admitted that he had never testified about nursing care before, and now he’s very famous and done a lot of testimony, written books and all this kind of stuff, but never about nursing. 

And in his deposition, he actually admitted that he has never supervised a nurse, which is kind of, you know, it’s kind of hard to find a physician who never supervised a nurse, even in residency, you know. But he said he had never supervised a nurse. And he had not seen a living patient since 1962. I remember that specifically because I was born in 1963, and I’m no spring chicken. 

And I remember thinking he hasn’t seen a live patient since-in my lifetime. However, he was offering opinions about the lack of nursing care, though he said that the fact that she couldn’t get vital signs was more a testament to her substandard nursing care.  

JA: Oh wow. Wow.  

SM: And if you saw the Constant Watch video for the first 6 minutes, the inmate was-he wasn’t knocked out yet. 

So ,he was like, fighting and struggling and shaking his head and stuff like that. He was angry. And this expert asserted that he was having a seizure and that they should have let him out of the chair right then because he was having a seizure.  

JA: But he had Ativan. Isn’t that what Ativan is for?  

SM: So, there’s two things wrong with that, and I did-I was very proud of the rebuttal report I wrote for this one, because this was a circumstance where they really just-I think they thought the name was going to do it. They didn’t think they needed anybody else. They had this famous person, and I did point out that granted, someone who hasn’t taken care of a living patient since 1962 probably doesn’t know what a seizure looks like. 

You know, because dead people don’t have them. But I have seen numerous seizures. This was purposeful movement. Like this was somebody who was ticked off. He was in a chair. He had a spit thing, a spit guard. He was  unhappy about it. And he was like, yeah, he was definitely thrashing and trying to get out. 

But it wasn’t a seizure. In fact, he called it a grand mal seizure. And wow, I-at the risk of sounding catty, I did point out that that isn’t even the terminology that we’ve used in the last 25 years, but that this was indeed not a tonic-clonic seizure. And then I pointed out that Ativan-he was asserting that Ativan caused the seizure. 

And I pointed out that someone whose career centers around taking care of dead patients probably doesn’t realize that Ativan doesn’t cause seizures. It’s used to treat them, right. And that if he had enough Ativan to suppress his respiration, he certainly didn’t have a seizure. You know, I mean, like, is there some case somewhere, like in some weird circumstance where somebody got Ativan and had a seizure? Probably like I, you know- 

JA: Anything is possible. 

SM: Yeah. And it’s also very possible that somebody might have had Ativan and it wasn’t enough to suppress a seizure. So, they appeared to have a seizure after having it. But that just-none of this was-all just so ludicrous here. But I think, you know, aside from patting myself on the back for this one, which I don’t usually do, but I’m kind of proud of myself for this one. 

JA: You should.  

SM: Really-and there was no-the judgment was for the defense. Not a dime was paid for this. And I’m telling you, this plaintiff’s team, you could just tell they thought they were going to make a million, billion dollars off of it, and they didn’t. And it really comes down to honestly, the documentation. I love to take credit for it, but all I did was point out the documentation because this did go to trial. Like this was in court and this did go to a trial. 

And when the plaintiff’s attorney was asking about, ‘Well, when he was he was thrashing in the chair, wouldn’t you call an ambulance?’ And I said, ‘No, he was angry. Here’s an angry, angry inmate.’ And and he said, ‘Well, wouldn’t you call an ambulance?’ And I said, ‘For an angry inmate? If you call an ambulance for an angry inmate, you’d be calling an ambulance all day long.’ Because most people who are just being transported to jail are not happy about it. 

It was just such a ludicrous assertion. But the thing that really saved the day here for this nursing staff was that their documentation was outstanding. Really, they had every form that needed to be filled out. They had, you know, they documented why they couldn’t do vital signs. And when she couldn’t get in the room, she documented her observations through the door. 

They documented the trajectory of when the emergency equipment was transported. And I don’t know if you may not have noticed, but it was a couple of minutes before they actually got there because these are big places and you have to get through various locked doors.  

JA: Yeah.  

SM: And you have to have somebody let you through. And so actually 4 minutes is pretty darn good. 

You know, this was around dinner time too. This is around time when some officers are on a dinner break. I mean, I’m not suggesting you can just lay there and expire while I’m eating dinner, but there’s lesser people on the floor. So, when they get calls and say, you know, we need an officer to respond to this unit, you can’t leave your unit until there’s somebody there and it’s harder at the dinner hour. 

So, all of that stuff was going on. But they still-they documented the timing and the actions and their actions were very appropriate in terms of initiating CPR and getting him out of the chair and all that kind of stuff. And I mean, in court, we really-because they put they’ll put the charting up on a big screen.  

JA: Oh, so you can see it.  

SM: And I’m like, look, you know, they did it. 

And she just documented exactly every step of the way what she needed to do. And I really think if that documentation hadn’t been there, it would have gone a different way.  

JA: That’s a good testament to documentation, because that’s always the thing that comes up. That’s the thing that always comes up that leaves something to be desired. But this one sounds really tight.   

SM: In addition to nursing notes-I before I forget this. The policies also you know how we all think policies are such a pain like, you know, when you get a new job and you have to like read all the policies and you have to sign the thing. And then every year if there’s an update, it’s like, oh, it’s policy day. 

But having those policies and following them to the letter when something like that comes up, like that’s the stuff that saves the day in the end.  

JA: Yeah.  

SM: So, I do want to point that out. But anyway, you started to ask a question.  

JA: Well, because I don’t think you said how did he die.  

SM: Oh, I didn’t say it!  

JA: But I’m in my head. Well, wasn’t a seizure or this spit mask, I assume. And this is an assumption that you can definitely correct me on. I always have this assumption that if somebody has no significant medical history or no medical history at all, and they’re like a young, otherwise healthy person, are autopsies always performed? 

SM: Okay. Yes. Yeah. An autopsy. The only time an autopsy is not performed, I think, is if the person is under the care of a healthcare provider who, you know, will attest to the cause of death, and they can under their care. No. Yeah. This is really-this really matters. So, the little exciting truth that almost forgot to share. 

I can’t believe it. So, this inmate who denied using any substances.  

JA: Yeah.  

SM: Or having any conditions or using any medications actually neglected to mention that he was using anabolic steroids for muscle building.  

JA: Oh.  

SM: And so, on autopsy, like the autopsy report said he had the heart of an 80-year-old.  

JA: Oh, geez.  

SM: Because the ana-like, he had all big cardiomegaly. 

JA: Oh, my God.  

SM: He had, like, an enormous heart. His coronary arteries were fried and stuff. So, yeah, in the autopsy report, it commented on the very large size of the heart and the the advanced atherosclerosis, because anabolic steroids, you know, just into building muscle. They build other things too, that you don’t want, like atherosclerotic plaque and, you know, cardiomegaly to the extent that it doesn’t oxygenate well. 

And so, I mean, it was a cardiac event. It was basically a big MI. But the-and really having nothing to do with the Ativan, it’s just that this-like number one, anabolic steroids do give you like superhuman strength.  

JA: Yeah.  

SM: Which was why the altercation got so profound. Like it took several officers to take him down. 

It was like, you know, I editorialized all of that, but it was like four or five officers that were necessary to control him once he got violent. And and it got pretty, you know, it got pretty physical. And then when they took him down and apparently it was just that profound strain on this very old heart. 

JA: That’s a plot twist. That big plot twist.  

SM: Yeah. I’m glad you asked.  

JA: Wow. Yeah. Well, I’m thinking, like he’s-what was wrong? What was actually wrong, but holy moly, it was a cardiac event.  

SM: Ultimately, that happened. And that’s how he died.  

JA: Wow. Yeah. And did like a role in this in the case. Like I’m going to imagine. 

SM: Yes, the autopsy showed like-hey he really did have this pretty serious issue. It did. I mean, it was really important that he had neglected to advise the staff. Now, like, would that actually have changed the outcome?  

JA: Yeah. 

SM: I don’t know. I don’t know. I mean, you know, if somebody tells the nurse,‘Oh yeah, I’ve been you know, I’ve been using whichever one it was, anabolic steroids.’ 

Would I mean-I think if he still got that agitated they still would have had to take him down.  

JA: Yeah.  

SM: But we don’t know-you know, you can’t go down that ‘what if, what if’ game. It’s just-it’s the information at hand. And he did not-he was not truthful in his H&P and he withheld the fact that he had a risk factor. 

JA: Oh my gosh. Wow, I didn’t see that coming. Wow. That’s an interesting case. Dr. Miller, thank you for sharing. That really is-yeah. Gosh, that we should just call this one Plot Twist quite honestly because I didn’t see that one, man. Well, I mean, good for you understanding this one quite honestly because I am really impressed with that documentation. 

And it’s always terrible to hear, of course, somebody, you know, passing  to hear these outcomes, of course, you know, but understanding how it happens, I think is really important. And yeah, not disclosing that information. I love to play the game in my head. I got to be honest of like, if they had no, maybe they would have done this. 

But to your point, as I think about it, just as a nurse, I don’t know personally that I would have done anything differently had I known that this was a steroid user or not. Honestly.  

SM: Yeah, I don’t know either. But it’s just-it’s like, in especially in this day and age, there is a young man and law enforcement, you know, there’s a-we’re like, we’re in sort of that era of law enforcement and, the fact that he initially was calm and interacting with the first nurse and then he goes, you know, disappears for 15 minutes. 

So, like the in other cases, it’s 10 years old now. But the twist that the plaintiff’s attorney seemed to be trying to go with it was that, you know, it was like evil law enforcement.  

JA: Right. 

SM: And this poor, defenseless young man, right. And in to the right jury, that really could weigh very heavily, even though it should have nothing to do with anything. 

JA: Yeah. You know, but you’re right. That’s kind of like the state of today. Man. Wow. This was a case. Dr. Miller, thank you so much for sharing this. We appreciate hearing these stories. Appreciate learning from them. We hope you all enjoyed this episode. And tune in for more every Friday with new releases. And we look forward to seeing you again. 

And bye 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.