Severed Trust

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 back to another exciting episode of Scrubs and Subpoenas: Tales from the Witness Stand. I’m your host, Jannah Amiel, and joining me is Dr. Sally Miller. Dr. Miller, how are you?  

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

JA: Good, good. I’m glad to hear it. I’m ready to hear your story, even though inside I’m hoping this one has a better outcome than some of the ones we’ve spoken about. 

SM: Well, it does have a better outcome than some of the ones we’ve spoken about. So, this one does not end in a patient dying.  

JA: Okay. Okay. That’s a plus. That’s a plus. Now, for anyone who is tuning in for the very first time on these episodes, you know, Dr. Miller, aside from being actually a bajillion things in the world, quite honestly, and one of our faculty members here at Fitzgerald, she also serves as an expert witness for real medical malpractice cases. 

So, these are actual cases that Dr. Miller has served on, that she’s graciously sharing with us, as the opportunity to learn, because mistakes happen every single day, every single person. We are certainly not immune, especially not in the line of work that we do. So, whenever we can take the opportunity to learn from, you know, things like this that unfortunately do occur in real life, we want to do that because there’s a lot of takeaways that can help us decide, practice better. 

Just be a little bit, you know, better than we were the day before for our patients, for ourselves, for our facilities and really understanding that we’re not here to judge or cast any judgment in that way, but to understand and to see, you know, hey, what can I learn from this? To make sure that I’m not making, maybe, similar mistakes or errors or omissions. 

Anything you want to add to that, Dr. Miller?  

SM: I don’t think so. It is just an ongoing learning curve and I’m always grateful when I when I read through these things and pick up things that I know I have sometimes done-  

JA: For sure.  

SM: You know, and have to make sure that it never happens again.  

JA: For sure. All right, well, we’re ready when you are.  

SM: So, unlike some-like some of the you know, some of the cases we talk about, everything happens within like a couple of days of each other and other times there really is a longer progression and a back story. 

And this is one of those. And I always like to read directly from the notes so that I’m giving you as unbiased a presentation as I can. So, bear with me here. I’ve got a little bit of a narrative, but it really is all relevant. The nurse practitioner in this case is a nurse practitioner that works for a vascular surgery practice. 

Okay, so she’s a family nurse practitioner, I believe, but works for vascular surgery, and is managing patients in the outpatient-in the office. So, with that said, our story actually begins-let’s just say you’re zero-ground zero. This this was a young man. This was a patient who when the story started, he was in his early 40s and he underwent an emergent left fem-pop bypass-femoral popliteal artery bypass for acute leg ischemia, secondary to a thrombosis to aneurysm. 

JA: Wow.  

SM: But what’s interesting is that it took 5 years for anyone to figure this out. He reportedly had a 5-year documented history of intermittent left lower extremity pain. So, it started 5 years prior. It got progressively worse for the first several of those 5 years. He was diagnosed with sciatica. And it-you know, and the way this goes is you get a diagnosis, you get treated, it’s a few months later or, you know, it comes back, you come back and you take something else and like-and the years do go by painfully quickly, actually. 

But it took 5 years from the time he first presented to healthcare with this pain in his leg till he-and then and it was, it was emergent. It was like all of a sudden his leg was ischemic because this, this aneurysm thrombosis. So, he finally had his emergent procedure in year-we’re saying year zero. 

That’s the beginning of our relevant story. So, the pain got so bad. He went to the ER and he had this thrombosis and he had to have a bypass. And he also had to have a fasciotomy because he developed compartment syndrome.  

JA: Oh wow.  

SM: So, it was a rough, rough road for that guy. But it was a young man. 

He recovered well. His bypass healed. He was also diagnosed, as if that wasn’t enough-it wasn’t enough that the artery thrombosed, he also at that time was diagnosed with a deep vein thrombosis. So, he was started on Xarelto®, right? So, on year zero after 5 years of pain, he has an emergent arterial thrombosis, aneurysm, and the DVT. So, he has a bypass and he gets put on Xarelto®. 

All right. That’s year zero. For the next 5 years-and it really is 5-year increments. I’m not making this stuff up or you know, like I mean I can tell you that that that emergent procedure happened in August of year zero and then it on March 5th, that’s my birthday, that’s why I remember that-March 5th, 5 years later, maybe 4 years and 8 months or something. 

So, all those 5 years go by and he had good recovery and everything was great. Just shy of 5 years later, he was seen by another vascular surgeon because primary care referred him to this. Like, who knows who operated on him 5 years ago? You know, that person, I guess is no longer in the picture, retired or whatever. 

So now, 5 years later, he presents to his primary care provider, complaining of some leg pain and primary care refers him to this vascular surgeon. So, now we’re in year five and the story now is that, yes, the patient had this remote history of a fem-pop bypass and he was doing well. And then late last year he started to notice just some periods of discomfort. 

So, in the leg and because of the history of the leg, he was referred to vascular surgery. So, now the vascular surgeon does flow assessments, you know, arterial flow assessment and realizes that there has been some decrease in flow. It’s certainly not ischemia. I mean, it’s not blocked, I guess is what I’m trying to say. 

But the flow velocity has decreased. And so, this vascular surgeon apparently doesn’t operate anymore like he does, you know, evaluations and arterial studies and stuff. But he referred to somebody else in the practice finally to treat a failing bypass graft. So, eventually after a few months here we are in year five. He is referred to another operating surgeon for treatment of that failing graft from 5 years ago. 

All right. So, this is in March, like I said, March of year five. So, the patient, they say the patient reaches out to the new surgeon, the one that’s going to do the operation. And he’s got some questions. He’s got some questions about what we do here. I guess he had been advised that they would stent the artery and this patient had some questions about it. 

So, he reached out to the operating surgeon with his questions and what the options were if the stent fails. So, he tried to contact the surgeon. The next day, the APRN who works for the surgeon returned the call. So, the APRN is the point of contact. And she was, you know, she answered this question and she says that, the absence of peripheral vascular disease does not imply longevity of the stent. 

But if it fails, it could be remedied a number of ways. And I guess why that’s significant here is many people get stents and they have arterial disease, like the artery is diseased. So, you wonder how long this stent’s going to work off the arteries anyway. Yeah, but he didn’t have arterial disease. He had a thrombosed aneurysm. So, the arteries-this is a, you know, a relatively young man, early 40s. 

So, his arteries are healthy. So, his question is basically is, ‘Hey, since, you know, I don’t have arterial disease, I don’t have, like, plaque formation and stuff. Will the stent last longer?’ All right. Because he’s trying to evaluate his options here. He wants to know how long this option is going to last. And he wants to know like what if it fails. 

What else-you know then what will we do. And her answer is no, the presence or absence of arterial disease isn’t an indicator. The stent is the intervention. And if it should fail, there are a number of ways to fix it. But she didn’t really articulate what they were. All right. Well, the patient’s gathering information; he finally schedules in the next month. 

In April of year five, he contacts the office. He wants to confirm that the stent will prevent further damage. Understandably, he wants info, because remember what happened to him before? Yeah, he spent 5 years trying to get a diagnosis of his leg pain and never got one until he thrombosed.  

JA: Right.  

SM: So he’s asking lots of questions and appropriately so. 

JA: Yeah.  

SM: So yeah. So, he had more questions and he did schedule the procedure. So, the stent was placed in May. Okay. Right. So, in May of year five the stent displaced. Six days later the patient contacts the surgeon’s office to report he’s having some aching, some stiffness and discomfort in his leg after the procedure. He also reports a reddish-brown patch on his left inner ankle that felt warmer than the surrounding area. 

He even took a picture of it and uploaded it because this is all happening by way of communication portal and, he asked if this was normal and he said he would like to try to have an actual phone call with the surgeon on that day. This is a message he uploads into the portal. Well, he doesn’t talk to the surgeon, but the same day the APRN, the same one that he’s been communicating with- 

And in this practice, it’s like one surgeon and one APRN are pretty much a match set. I think she did a few other peripheral things, but mostly she was like the extension of this one particular surgeon. So, if you want to talk to the surgeon, you go through this APRN first, right? And then usually what will happen is you don’t get to talk to the surgeon, the APRN talks to the surgeon and comes back to you. 

So, the APRN responds to that question and she says it sounds like some post-procedure inflammation. It will probably resolve in a couple days. She says she saw the picture he uploaded. She can’t even say for sure if it’s related or not. She doesn’t think that this needs emergency attention. She does move up his follow-up appointment a little bit faster, so he comes in next week instead of the week after, and she told him to draw a circle around it. 

And if it gets bigger, let them know. And she tells him he should walk more to help shake out the stiffness. That was in May. That was 6 days after his stent. No more communication until November, so apparently the leg started to feel better. That patch, whatever it was, maybe, you know, post-procedure inflammation, it went away. No more contact is documented from the patient. 

And in his deposition the patient said, you know, no more contact at that point. So that went from May. Next thing that happens is in November, the patient contacts the office to confirm that he can return to normal activity. And I know it sounds like a long time. Like, why is he not asking this for 6 months? 

But it sounds like number one, he’s really very vigilant about his leg and his artery.  

JA: Yeah. He’s asking great questions. He seems on top of it. 

SM: So, specifically what he’s asking about is like working out. You know, he’s active and he works out at the gym. And he specifically is asking if he can use an incline bench, because the incline bench sometimes compresses the underside of the knee. 

JA: Okay.  

SM: And he’s worried about the bypass. You know, he’s worried about the artery. So, you know, it wasn’t just like, ‘Oh, hey, 6 months later, can I go back to work?’ He was asking very specifically about, ‘Can I do anything? Can I do everything I ever did before, including the workout bench that’s going to press on the underside of my knee.’ 

And so, the APN documents that she spoke with the surgeon and she advised that, yes, the surgeon said he can safely return to all of his usual routine with no limitations, that the incline bench was very safe with regard to both his old bypass and his new stent. Okay, right. So great. The next contact is the next May. 

So, when I said there’s a time lapse here, you know, now we’re in year six. 

JA: May of the next year?!  

SM: So, he first got referred in March. He had his stent placed in May. He had a little concern 6 days later, you know, little stiffness, little patch of stuff. But that was fine. No more contact for 6 months. 

That was in November-and November, he just wanted to make sure he could use the incline bench, and he was told he could. No more contact until the next May or May of year six. So, he has a follow-up appointment. This is just his 1-year follow-up appointment and in the documentation the APN documents excellent ambulatory capacity denies claudication or resting pain. Her note reports that the arterial ultrasound on that date of that extremity indicated no evidence of hemodynamic significant disease, that the superficial femoral artery to below the knee bypass was widely patent.  

So, in other words, everything sounds good follow-up in a year. So, she orders a 1-year follow-up. 

You know, to come back for a year. That was in May of year six, right? Two months later, in July of year six, the patient called the office to say he was having increased cramping and slight swelling that resolves when he elevates the leg. He is concerned because this is similar to the feeling that he had prior to needing surgery last year. 

The APN documents that she spoke to the patient, that she told him he needed an ultrasound and then they would get it scheduled. And so, he’d had the ultrasound, like the next day and 3 days after the call, the APN documents an arterial ultrasound of the left lower extremity was performed, with the results, and this is in quotes right from the chart: “results consistent with no evidence of arterial insufficiency.” 

And I just thought that sounded really odd. I mean, it is neither here nor there in terms of what it means to this case, but-  

JA: Right. Sounds like a double negative. Like it doesn’t make sense. 

SM: “Consistent with no evidence of arterial insufficiency.” Sounds like things-like, I would expect it to be, like, ‘result: no evidence of arterial insufficiency,’ you know. 

But anyway, that’s the way it was documented.  

JA: Yeah.  

SM: So, anyway, so, and the APN discusses the-she documents as she discussed it with the patient. And then 2 days after that, I guess they did-they also did a venous ultrasound at the same time 2 days after that. That was resulted on the chart. And that was fine, too. 

So, everything’s fine. All right. That was July. Okay. July, August, September. About 4 months later.  

JA: Oh boy.  

SM: So yeah, it’s November of year six. The patient calls. This is November of year six, right. The procedure was May of year five. November of year six. The patient calls the office to say he is having constant severe cramping in the left leg only, and he is wondering what to do. 

An appointment was made for him to be seen in the office the following Monday, so he is seen by the APRN. So, there’s-I mean, there’s a history here and this is relevant, you know.  

JA Right.  

SM: So, the patient is seen by the APN for evaluation of cramping of a few days duration. She notes that there was also an episode 3 months ago. 

Now, he hadn’t called the office about it, so who knows what’s up. But anyway, she also documents that the patient reports that his leg became swollen and the cramps were very bad. This resolved with elevation and warm compresses. Her physical examination records a normal vascular exam with trace swelling of the left leg. Arterial ultrasound performed reveals left lower extremity duplex findings are consistent with no evidence of arterial insufficiency. 

That same funky wording. But, the APN documents that the cramps and swelling are due to electrolyte imbalance. The patient is advised to wear compression stockings and elevate his leg. The APN documents that the post-bypass stent-with regard to the post-bypass and blood flow is excellent with normal ankle brachial indexes bilaterally and open stent. He is also asymptomatic in this regard. 

I don’t really know exactly how to interpret that, like the stent is in the left leg and you know he’s having pain and cramping and swelling.  

JA: Yeah.  

SM: And stuff in the left leg.  

JA: Yeah.  

SM: So I think what she’s trying to specifically document here is that his symptoms-she does not believe are related to the stent or the artery. 

JA: Yeah. It sounds like she’s saying he’s okay, but he’s not okay based on what he’s saying. 

SM: Yeah. Well, she documented that his cramps and swelling are due to electrolyte imbalance. So, she’s saying, yeah, he’s got pain and swelling, but that’s from electrolytes. As far as the blood flow, he is asymptomatic in this regard. It’s odd. You know we’ll tease through all this later. 

But that’s what she’s documenting here. So, she’s acknowledging the pain and the swelling saying it’s due electrolyte imbalance but that the flow is good. The stent is patent. Okay. That was November. Third week in November. Very early first week of December, the patient contacts the office to report that he again experienced the same cramping. He stated he was doing everything he was asked to do, and he wants to know how to find out what’s causing the pain. 

The APN responds by message the next day and says, I don’t think this is something that you need to come in for for a visit. She advises him to “watch for any other triggers that are exacerbating it,” and she opines that since it only happened once since the last episode 2 weeks ago, that it’s being well-managed. So, basically, if you’re just cramping every couple weeks, it’s okay. 

She tells him specifically and documents it is not related to the bypass. So, you’re probably thinking, ‘Well, of course it’s related to the bypass.’ But that’s what she tells him at the-now again, we’re looking prospectively here. She’s not Monday morning quarterbacking okay.  

JA: True.  

SM: So, 2 weeks later, 16 days later to be exact, we’re still in December, 16 days later, the patient messages the surgeon and the APN that he saw his cardiologist to discuss the cramping. 

The cardiologist thought it might be from compression from the original aneurysm. The cardiologist prescribed cilostazol which is old-school drug. What is the brand name for that-Pletal. It’s an old school drug for arterial insufficiency.  

JA: Okay.  

SM: What we used to use. But I don’t even like almost nobody you ever talked to thinks that actually helps in any way. 

But that’s what it’s for-peripheral vascular disease. It’s what we used to use for claudication in the legs. And it’s still available. And the cardiologist prescribed it. But it was apparently producing intolerable adverse effects to the patient. I don’t know what they were. This is what the document-this is what the documentation says. 

So anyway, nobody responded to that call. And later on in deposition testimony, the surgeon said, ‘Well, he didn’t ask a question. He just left a message.’ The surgeon was like, the most stereotypical surgeon. 

JA: Are you kidding me? 
 
SM: Yeah. Nobody returned this man’s call because he didn’t actually ask a question.  

JA: All right. Nice. 

SM: Yeah. Nine days after that, the patient calls requesting a callback regarding the pain in his leg, and he now has a small bulge in the affected leg. It has been there for a week. He is specifically asking for a return call. He does not get one that evening. The pain progresses to the point of emergency. He goes to the emergency room where his graft was found to be occluded.  

JA: Oh no.  

SM: He was immediately airlifted to a level one center. 

He had arterial occlusion from the distal superficial femoral artery to the popliteal stent. Salvage attempts were unsuccessful, and he ultimately underwent a left above the knee amputation in early January.  

JA: No.  

SM: So, he didn’t die, but he lost- 

JA: That’s a bummer.  

SM: He lost his leg above the knee. So, who do you think called me? Did I do a good job of not giving that one away? 

JA: I mean, it’s going to depend on my guess, I’m going to guess. And this is my frustration because I’m feeling frustrated, honestly. I’m going to guess it was the plaintiff.  

SM: That is-I was retained by the plaintiff.  

JA: That is- 

SM: I was retained by the plaintiff. 

JA: This is really long and painful. I am so sorry that, like anybody has ever experienced this over the course of years. 

Oh my gosh. So, all right. So, first things in my brain were like, were those scans wrong because the ER-like it shows up to the ER. Things are really, really, really bad at that point. I can’t imagine it like, everything turned around in 7 hours of a day.  

SM: You know, I mean, it’s just so interesting that, by the time people are being deposed on this, it’s years later. 

Like, this surgeon was just such an arrogant-I mean, he was just so stunningly arrogant, he said-because that was one of the questions. He said that those scans were done by his staff and there is absolutely no way they were wrong.  

JA: Oh that’s it. Point blank period.  

SM: Impossible. It is impossible. He has the best equipment and the best staff, and there is no way the scans were wrong. 

JA: Oh. That doesn’t check out.  

SM: And the like-in the rest of the world, where us mortals live- 

JA: Right? Exactly.  

SM: Sometimes scans are-it was so ironic. Like I’m-the attorney that retained me was like, ‘I know this is ludicrous. What can we say?’ The attorney who retained me for this is actually a physician as well.  

JA: Oh, wow. 

SM: As an attorney, it’s really interesting. I mean, I-you know, he’s, I believe now, like, he’s later in his career, I believe now he practices law full-time, but he is he is an experienced and trained physician and licensed physician. But anyway, yeah, we were like, there’s no way- 

JA: Like give me a break.  

SM: So, these are these are noninvasive studies. 

You know, they’re noninvasive. And there’s two things about studies. This is one of those takeaways, I’m glad you asked today. The takeaway for all of us, number one, every scan can be wrong. So, there’s that. But it is also like really important to give-when you order any sort of diagnostic study like that to give relevant background information to the technician so that they know what they’re looking for. 

In all of the ultrasounds that were ordered, the order was like it was like checked off ‘routine ultrasound.’ Right? There was no history at all. There’s a big difference between a routine ultrasound versus a patient with fem-pop graph that is having progressive pain, right. You know, and the technicians don’t know that. So, they look at it differently the way that I always-like I explained this when I, you know, when I’m teaching a class is that if I just showed you a picture of the  front of a house and the lawn and stuff like that, and said, ‘Hey, check out this house, how does it look to you?’ 

You’re going to look at it differently than if I say, ‘Look at this house. There’s something wrong with that. Front door won’t close all the way. Do you see anything there?’ You’re going to look at that very differently, right? You know, and so one of the things that I mentioned and I noticed in this charting was that the tech was not given any information about complaint. 

So, that’s going to skew your interpretation and even the way that you perform that study. So, yeah. Well, you know, so who knows. I mean the study-nd then the other thing is that to report it is consistent with an absence of whatever I said, whatever convoluted terminology- 

JA: It was so wacky.  

SM: What you really want to see there is ‘patent graph.’ 

JA: Right. Because that’s the issue, right.  

SM: And if the technician was given the right information, then that would have been the lens through which that study was performed. And so that’s an issue; a takeaway for all of us is make sure whether you’re sending somebody for an X-ray or a scan or like whatever you want to have, you want to make sure that the person doing the study has all the relevant info. 

JA: I feel frustrated for that patient because it’s like we all know what it’s like to try to, you know, talk to your provider can be one little thing and like, you know, you’re trying to express it like, I think something’s wrong and you get the no, no, no. But for over the course of years and then to have this type of outcome is- 

SM: And he never got to talk to the surgeon. 

JA: [sarcastically] Well, I mean, he didn’t ask a relevant question.  

SM: So, that’s one takeaway. Anything else jump out at you there? 

JA: You know, there was something that did jump out at me. And it’s actually related, maybe to telemedicine. So, kind of less about like the patient. But I’m curious you kept saying that he was like in the portal. 

I’ve got like a patient portal too for my primary and like, communicating in that way. I-the one thing I thought about, I was curious. He uploaded a picture like he put things in there. Does that come into play if like no one responded to it, no one even looked at it. But he was sending all of this very relevant information for people to see. 

But let’s say no one ever logged in.  

SM: That’s why portals scare me. I don’t use them, I don’t, I’m old. Listen, I’m antiquated now. I’m not going to practice in a few years. But I will not. I will not participate in that for exactly that reason.  

JA: Yeah. 

SM: Because I’m afraid I’ll miss it. In fact, I will give my patients my my email address at my practice.  

JA: Yeah.  

SM: And every time you email me, you’ll get an auto response. And at the bottom in big bold face italicized letters with asterisks everywhere, ‘I am not an emergency provider. This mailbox is not attended evenings, weekends, holidays. You may not get a response for more’ that you know, blah blah blah. 

If you have an emergency, call nine-like that’s in every email. For that exact reason, I am terrified that somebody is going to communicate something to me that’s important and I’m going to miss it.  

JA: Yeah, okay. That’s a good point. So, yeah, this patient, he has a history of clots. Like was he taking anything for that.  

SM: So, he was on Xarelto®.  

JA: That’s right. Xarelto®. That’s right. And he took that. He always took that. That wasn’t an issue? Man. All right.  

SM: He was really proactive about his care. Like he was really on top of things like even just having a primary like half the population doesn’t have a primary care. 

They don’t do anything. You know, he’s really on top of that stuff. But but listen, if you have like some sort of underlying clot dysfunction.  

JA: Yeah.  

SM: You know-and whenever you put anything artificial in a vessel there is, there is always some level of increased risk that it will incite a clotting response. It’s just the nature of the beast. 

You know, risk-benefit certainly favored doing, you know, having a stent. But I mean, there’s-you still have to take something. So the other thing, well, there’s two other things there that I thought were so interesting. One of them is history, I swear, like in every way, the single biggest risk factor that something will happen to you is the fact that it happened before. 

And so, the fact that he had that like one of the one of the calls, he said, ‘This is what it felt like the last time.’ 

JA: Yeah.  

SM: And I think that’s very telling. And then-and we’ve also talked about this in these episodes, if you have a circumstance and then you do a diagnostic study and the study doesn’t match the circumstance, you go to the next level. 

You don’t just say, ‘Oh, okay, study says this, you’re done.’  

JA: Right.  

SM: And so often that happens like everybody was hanging their hat here on these arterial ultrasounds.  

JA: Is it, you know, in your opinion, do you think it-I mean, for my layman opinion over here, it seems inappropriate, I don’t know, for the- based off documentation for the APN to have spoke to the patient about, ‘Yeah. It’s fine. No big deal.’ I’m paraphrasing. Obviously, there’s other options if it doesn’t work, but like not getting into it, not like laying out what are all the options so the patient can make a a decision or really just understand that like this is a risk of a stent. These are the things that could happen. Like it doesn’t seem like those got answered. 

This is just me frustrated.  

SM: Well, I mean that’s what informed consent is though. And it should have been done at some point. Now, we’ve also been in that position where you get five pages of informed consent. You get ready to go to the OR so you sign it. But was anything actually explained to him? 

I mean, clearly this man only got very specific information that he aggressively asked for. That just appears to be the nature of that practice.  

JA: Yeah.  

SM: Even though, like, the physician was like, my NP is the best she could not have made a mistake. If you see her, it’s like seeing me. It’s just so, so funny. I was laughing at that. 

JA: Wow. I wonder how the weather is up there where he lives. Jeez. 

SM: I know. The other thing about this case that’s really interesting- and I know I’ve said this so many times, you’re charting should tell a story. You should be able to follow it from start to finish. So, she attributes his cramping and swelling to an electrolyte imbalance. 

JA: Yeah, I didn’t understand that when you said that. That was my other question. I don’t understand what that means.  

SM: So, like, have you ever like been talking to somebody and you say, ‘Oh, my leg hurts.’ And like, ‘Oh, eat a banana.’  

JA: Oh, yes. 

SM: There’s this laypeople impression electrolyte or potassium deficiency will cause pain in your leg or cramps or whatever. 

I don’t know, I like-I love-I don’t know where this stuff comes from.  

JA: I swear, it doesn’t explain the swelling.  

SM: It doesn’t explain any of it. Like if you have such a profound electrolyte imbalance that you are having pain in extremity, you’re also probably asystolic like- 

JA: Right. Like really-like you-just doesn’t happen. 

It doesn’t happen to an otherwise healthy person that they have such a profound electrolyte imbalance. And I don’t even know what the deal is with this potassium in the banana thing. Like, I never really-like if you inject potassium in a way to really, really hurt. Yeah, that’s like too much potassium and that’s like, you know, like a potassium. 

But I don’t know where that comes from. I mean, there’s no-yeah, there’s no electrolyte imbalance is going to cause that level of pain and edema in the extremities, coincidentally, and without the rest of the body.  

JA: Yeah.  

SM: Like you’re going to have pain and edema in just the leg that just so happened to have had a problem before, but no problem anywhere else. 

So, that on the face of it, that’s just a no. And okay, even if you want to think it’s an electrolyte imbalance. There’s no metabolic panel ordered. If you think it’s electrolyte, and if you put that in your note, then what do you do? You either order the labs to support it or refer the patient to primary or like do something. 

But you don’t just attribute it to an electrolyte imbalance and do nothing. And I’ve been documented and do nothing about it in the leg that just so happens to be feeling like it did before he had a problem before. So like, that’s- 

JA: I hate this. So, what happened in this case? I’m really curious. Like how did this case settle for the patient? 

Obviously he had a terrible outcome. Sad to hear that he lost his lower limb.  

SM: Yeah. I mean, it’s settled. It’s settled. I’m never allowed to know amounts.  

JA: Yeah. 

SM: But according to the attorney, they were all very happy with the settlement.  

JA: Okay. So, okay. Yeah, I mean that’s important. That’s the least you can do to-I mean- 

SM: You know, there’s the whole prosthesis, I mean, and there, you know, he did go on to get a prosthesis and then there’s that- 

And then the attendant problems, you know, sometimes there’s a whole-oh there’s just issues. It’s just not as easy as putting on your prosthetic leg and not look at a day in therapy and all that. So it was a long road for him. But fortunately he’s an otherwise healthy, you know young man from where I’m sitting for sure. 

And so, I mean he you know, he got back a lot of function and everything, but yeah, he lost his leg and, but got a big settlement that, you know, most of which is going to go to, you know, paying for the best care.  

JA: Yeah. It makes me sad. I hate to feel like as a patient myself, like you got to fight for, like, just fight to be listened to sometimes. 

And that that is so frustrating. It’s really frustrating when you know, because don’t really learn unless this is like a cheesy thing. That’s not true, that like, we’re the best historian, you know what I mean? Like, listen to me. I know my body right better than anybody.  

SM: Absolutely. I have no objective data to support this. 

But I would bet the farm that this man was being perceived as like, ‘Oh, it’s him again. Oh, it’s him again. There he is worrying about this again.’ Because there are patients who have now-we call it anxiety about illness disorder. We used to call it hypochondriasis. You know, there are people that fixate, and it’s when you can’t figure out what’s going on, it’s easy to attribute it to that. 

But I think we’ve talked about this before. Hypochondriasis does not fixate on one thing, but somebody consistently complains about one specific thing repeatedly. If you can’t figure out what’s going on, something’s missing. We’re missing some piece of information. And that’s not even to say we’re necessarily doing anything wrong. It just means there’s something missing and we have to look harder or look elsewhere. 

And in this case, I mean the whole the whole business of the arterial studies and the way they were reported and the way they were ordered. I personally am not trusting of the study. But, you know, listen, of course the defense hangs their hat on, ‘Well, look, the study is negative. So what do you expect them to do?’ 

The study is negative. And then, of course, you know, we were like, ‘Well, the study is reported as negative, but the study wasn’t done with good info.’ And we don’t know about the technical. And that’s where all of this kind of stuff comes in. But blessedly, anyway, they finally-they didn’t have to go to court. 

It settled in favor of the plaintiff, but yeah. Yes.  

JA: Well, that’s a bummer. I mean, he didn’t die, so we got a patient story where that happened, but, I mean, some serious defects as a result. Yeah. Wow. Yeah. Well, Dr. Miller, thanks for sharing this with us.  

SM: And you’re welcome. So always these takeaways, it’s, you know, horrible for him, but we can all all pick up from that. 

JA: 100%. 100%. 

And there were great takeaways for this. I appreciate your time, Dr. Miller. As always, we appreciate you all tuning in and we hope you’ll join us again for our new releases next Friday. In the meantime, goodbye for now. 

Voicevoer: 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.