A Whole Handful

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. I’m your host, Jannah Amiel. And joining me, of course, again, is Dr. Sally Miller. Dr. Miller, how are you?  

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

JA: Very good, very good. It’s happy to be here with you again, telling these wonderful stories at the beginning of the week.  

SM: Right? Monday. Here we are. Monday again. It’s just come so fast that the weekends are so short.  

JA: And they really are. They really are. But no, honestly, really, we really do love having these conversations and sharing this with all of our listeners. Every time we have a conversation, I learn something new. I freak myself out in a new way also, which is kind of entertaining, but you know, in a good way that it really makes me thoughtful about things that I probably just wasn’t considering as a nurse and as a patient. 

So, I appreciate these stories. And I have two pieces of paper today. Normally, I have one when I have to make notes about the things that you’re saying, and I’m like, I had to look that up later, but I’ve learned that after a couple of these episodes, I need two pieces of paper to look up some of the things that we’re talking about. 

So, we’re really excited to hear today’s story. And with that said, Dr. Miller, I’m going to turn it over to you. And when you’re ready to rock and roll and give us that first little bit of information, we are ready to be detectives and follow along with you.  

SM: I’m ready when you are. Well, I have-we’ve talked about this before. 

I’ve kind of given up trying to be like really neutral face, neutral narrative and have you guess-maybe you will and maybe you won’t. But as always, I’m just going to-just the facts, ma’am.  

You know, just the facts. Just like that old show- was it Dragnet? Does anybody even know what I’m talking about? Probably not. Anyway. 

Just the facts, ma’am. So, this is a story. This is about a patient who was-for quite a while, lived in assisted living. And then she went to become a long-term resident in rehabilitation facility. And the NP, who is the subject of the conversation, was an NP who makes home visits in those facilities. 

So, this patient, you know, as I read through the chart and read about her, she looks like a really happy lady. And it looks like she was really happy with her life there in the facility, which is always nice to hear because, you know, you hear stories and there’s such a negative connotation sometimes. But this lady, it looks like she was initially, she initially went to the facility in a well, you know-it was like several years ago, she was there for a couple of years. 

She had the usual suspects in terms of chronicity when you get to be, you know, I think she was 79 when she first went to live there. She had a number of chronic medical conditions, but they were well managed. She had some neurocognitive impairment and just needed help with personal care and assistance with daily activities. But for the first 3 years of her of her stay in that facility, her conditions were all managed by all accounts, all notices. 

She was a really pleasant lady. She was notorious for enjoying her food and her snacks. She had a little refrigerator in her room, where she had ready access to all the things that she’d like to eat, and she just-she just sounded like somebody who always had a smile on her face.  

JA: She sounds so pleasant.  

SM: And yeah, she really did it. 

She enjoyed her food and she enjoyed her snacks. Whenever it seemed like-whenever she had the occasional acute complaint. Once in a blue moon that it was evaluated and managed to the satisfaction of her, of the patient and her family. Her daughters were very involved in her care, and there’s numerous notes over the years, you know, in that kind of setting, there’s, at the very least, like an annual meeting and the families are involved and, you know, it’s a multidisciplinary-and all that kind of stuff. 

It just sounded like for the vast majority of her time there, she was very happy. And I can’t share them with you. But of course, as I was going through the chart, I saw some pictures and for an old pictures, like she got a big smile on her face and stuff. Yeah, actually, I wish I was that happy. 

Like, she did seem like somebody who was a perpetually happy lady and yes, living in an assisted living facility as a long-term resident and then progressed to the more, you know, more supervision, but just seemed like she had her food. She had her snacks, she had close interactions with her family and was a favorite of the staff. 

And whenever anything went wrong, that it was managed appropriately. So that’s you know, how we start that. Thankfully for the first year of her life there.  

JA: Yeah.  

SM: But I was just, you know, I was looking at this thinking, ‘Wow, it’s really nice to hear,’ because of course you always hear the horror stories about any kind of facility, but you don’t hear that there are facilities where the staff are really, you know, helpful and positive, and they care and they take good care of people and the patients are happy and all that kind of stuff. 

So, it’s really nice to read that story. So, that’s the way things went for the first 3 years for the majority of the patient’s life there. So the items of interest or the circumstances of interest began on a-I want to say began on a Wednesday. And so, what happened was that the RN, who was supervising the shift, at about 6:00 in the evening or so, was notified by the nursing assistant that this patient was complaining of severe right hand pain. 

That’s what came to the RN’s attention. So, the RN went to examine the patient and noted that. And it was a good note to like this. It just seemed like a really solid facility. The RN documented that the extremity was cool to touch as compared to the left side, the capillary refill sluggish, there were palpable radial pulses. 

The digits were stiff and tender and that, she noted, ecchymosis toward the base of this thumb that was between 3 and 4 centimeters. A really nicely detailed note for a facility where there’s lots of people and comparatively few staff. So, he makes all that note, he further documents that the patient states the pain started at about mid-wrist and extended to the fingers. 

The patient denied any sort of injury, doesn’t know what happened, just started experiencing the pain. So, the RN does this good assessment, writes a good note and documents that the on-call NP was notified and the NP then ordered a radiograph and said, “I will be in to see the patient in the morning.” So, very typical, especially-although it doesn’t sound like she had a major neurocognitive deficit or major neurocognitive impairment. 

There’s some neurocognitive impairment and you just don’t know if there is an injury that she didn’t recall, or maybe something that didn’t rise to the, you know, to the attention. You know, her attention is injury-anyway, for anyone who’s listening, who’s thinking, ‘Geez, an x ray, do you, you know, do you want to like you know, give radiation to somebody under that circumstance?’ 

But in that circumstance, that’s a very fair assessment. In addition to the fact that there may or may not have been an unidentified injury. She was of advanced years, and she did have arthritis and may have even had an, you know, a pathologic fracture, likely, you know, not-it’s not like the top differential, but it’s very reasonable being off-site to order the X-ray at that point. 

So, the next morning the NP came in, the NP came in to evaluate the patient. And so, here’s what she records. And again for listeners just, you know, like listen to what she recorded and then think about maybe what she didn’t or what she did and how that can impact things going down the line. So the NP, knowing that she was called the night before, knowing that this patient of several years duration in the facility, who’s very pleasant and doesn’t appear to be a complainer or have a lot of chronic problems, was having hand pain that was severe enough to the extent that she notified staff and they went an examiner-and they appreciated the sluggish capillary refill, but the pulses were there.  

Pain, a bruising at the base of the thumb which can be many things. In fact, there is something if anybody is interested in looking it up. Google thumb ecchymoses. There are so many different things, especially in the older adult. Yeah, that can present as like an ecchymosis is at the base of the thumb, and the vast majority of them are very benign. 

There’s like a particular thing in particular-named like person’s name, I think name diagnosis, of course, I can’t think of it right now. But yeah, there’s, I mean there’s lots of things that can produce that finding. 

JA: That’s so funny.  

SM: Yeah. So, that’s the first thing for your paper. Check out the thumb bruising.  

So, yeah. So, she, you know, she documents-and the NP the next morning documents that the patients noted to have this at the base of the thumb, that it is tender to touch. There is otherwise no edema. The blood pressure is 156/80. And the remainder of the physical examination is unremarkable. So, what’s documented is the right hand pain and bruising is a chief complaint. 

The fact that the patient is in no acute distress. She’s sitting up in her wheelchair. She is noted to have ecchymosis. It’s tender to the touch. No swelling is noted. That’s what’s documented. Her vital signs were done and her blood pressure was a little elevated at 156/80, but otherwise the remainder is just documented as unremarkable. 

The right hand radiograph that was ordered the night before is reported as no acute fracture. Moderate osteoporosis. Mild degenerative arthritis. The NP diagnosed-I’m sorry? 

JA: No, I’m saying I’m feeling my hand going-diagnosing my own hand. 

SM: But so she diagnoses right hand pain, negative fracture, continue pain medication, and follow. So that you know, from a SOAP note perspective the diagnosis and plan or the assessment and plan: right hand pain, negative fracture, continue pain medication. So, that’s that. So that’s that. The next morning, the following day the RN documents that the-she writes in her note the right hand radiograph is negative. 

The patient is complaining about range of motion difficulty and pain to the right hand. Now this is-I believe this is Friday right. It was Wednesday night when it started, Thursday when the NP saw the patient. And then the diagnosis, the right hand pain, continued pain meds. The next day, the patient continues to complain of right hand pain and difficulty with range of motion. 

So, in the afternoon, the nurse documents that circulation checks to the right hand are continued and she notes positive cap refill. She notes that, she reports to the NP. Do you know how-you know how it is? NP notified that the patient continues to have pain and trouble with range of motion, that the cap refill is present. 

Excuse me. And so, a verbal order was given for a right upper extremity ultrasound to rule out a deep vein thrombosis. And again, some of you might be thinking of deep vein thrombosis, ‘Why are we looking for a deep vein thrombosis. How likely is a deep vein thrombosis in the upper extremity?’ Well, it’s not especially likely, but it’s really the next most likely image-able thing that you can investigate in this setting. 

Like at, you know, at this stage of the game. And I’m Monday morning quarterbacking here a little bit. So, I’m going to stop doing that. I’ll wait till the end. But right now like ask yourself legit, what else would you do? What else would you do? Those of you that work in a rehab or a long-term care, you probably have an idea. 

Those of you that don’t might be thinking, ‘Geez, I don’t know.’ So, you know, just to put it all in context, here’s this patient with no acute problems and she’s 79 and her hand hurts and she tells the aide her hand hurts. So, the nurse comes and looks at it and says, ‘Yep, there’s some bruising at the thumb.’ 

Cap refill sluggish. Pulses are there. It’s a little bit dark, darker in color. I think those are a little less color to the touch as compared to the right, cool to the touch as compared to the right. And you know, that was on a Wednesday night. On Thursday the NP comes in, the patient is still having pain. 

She’s got this bruise. She’s got some tenderness. The X-ray is negative. The next day, she’s having some pain. It hurts to move her hand. There’s good capillary refill documented. What? What else will you do? What else would you do? Well, everybody can ponder on that one. Maybe at the end of the conversation, we’ll talk more about what else you can do. 

But we’ve already done an X-ray, and the only other really thing that is readily available in a facility, an outpatient facility like that, you know, this isn’t a hospital. They don’t have an imaging department where you can wheel the patient down. So, the deep vein thrombosis assessment as you know-look at the potential diagnoses and the risks and the benefits and the availability of assessment. 

It’s really the only other assessment objective in imaging assessment that was readily available. So, she ordered it. The patient’s daughter was notified by telephone because like I said, the family was very involved in the care. The daughter was notified that the radiograph was negative and that her mom was still having pain. So, they were going to order an ultrasound. 

And the daughter actually opined, and this was written in the note, that she thought her mom’s hand hurt because she is like constantly holding her pencils too tight, and I guess she colors and stuff in her chair. Like I said, she’s an active lady. So, between the osteoporosis, the osteoarthritis and perpetual, you know, movement, the daughter was more of the mind that it might be due to that. 

So, everybody is like, fine, okay, order the DVT. So, the nurse at that point also documented the right hand circulation check reveals edema and that the right hand-I’m talking about right hand and using my left hand. The right hand was darker and cool to touch. The circulation checks are being documented on a regular basis to the hand. 

And that’s-that was what was documented right there. The nurse also documented that she had placed a call to MD, which apparently was the nurse practitioner, and that the ultrasound had been ordered. The next note in the chart is Friday night. So, this happened between like one and two in the afternoon. The next note is at night. 

The night nurse is there, and she does a circulation check and says the right hand circulation was examined. The hand was still dark and cold to the touch. The ultrasound that had been performed that evening was negative, that the NP wasn’t notified and there were no new orders. Now, again, to put this in perspective, this is a Friday night and I’m really not trying to steer anybody in one direction or the other. 

This is Friday night, not even evening. It’s late Friday night. This is the night shift nurse. So, she says she notified the NP. We learned later that the NP wasn’t on-call, that there was somebody else on-call. So, the NP that actually follows the patient all day and the one that had seen her the morning before, had, you know, had not been contacted about any of-the last call she had was in the afternoon when she ordered the ultrasound. 

Okay. What else happened that day when we went back to, like, who got this call? You know, what about this call that she said she made to the NP who got it.  

If our NP didn’t-and it turns out that there was an on-call service like a contracted on-call coverage provider that took the call and from there, very limited record keeping and most on-call places really don’t keep a whole lot of detailed records. 

But from their perspective, they just documented that they got a call requesting clarification on pain meds. And that’s it.  

JA: Nothing about a hand or anything like that?  

SM: Yeah, nothing. I mean, you know, the, you know, like a couple years later, of course, this on-call person had absolutely no recollection-  

JA: Right. 

SM: Of that encounter at all. 

All we had were her records to go by. And she briefly documented that she had been called to clarify, like it was like a 1 to 2 tabs kind of thing.  

JA: Yeah.  

SM: And the nurse that was on-call wanted clarity there. So, that was that. So, next we have the weekend. We have the Saturday. On Saturday there are orders to give hydrocodone-acetaminophen or Norco or something like that TID for moderate pain. 

Where those orders came from is that nebulous and ill-defined. We don’t know where those orders came from.  

JA: Really? 

SM: These were entered. Yeah, but they weren’t there. So, assuming it was from the night before that call.  

JA: Yeah.  

SM: Interestingly, there’s no paper trail to that, so who knows. So it’s pain orders were entered. There was only one circulation check that day. 

It was recorded by-at night again like late evening when the 11 to 7A person came in. The-I think it was an LPN, documents that the right hand is dusky, cold, and painful. That MD is aware, no new orders left. A message for the full-time NP, our NP, to evaluate. So, again this-the nurse documented this on Saturday night. 

The NP is off until Monday morning. So, she wasn’t-who was notified presumably the on-call service. Like we don’t know-just the note says NP X was notified. But we know she wasn’t because she wasn’t there and she wasn’t taking call. So, that was Saturday night. Sunday, there is actually no documentation of the assessment of this patient at all. 

There’s nothing in the note, which again, you know, this is not an inpatient facility. It’s not a hospital. You know, in a hospital, we’d be like, you know, doing a circulation check frequently and all that kind of stuff. But this, this isn’t that. And so, if the shifts coming in was not and we don’t know what happened. 

But if the shift coming in wasn’t advised that there was any problem at all, well, they wouldn’t go in there proactively. So, there’s just no documentation. So, we have no idea what happened on Sunday or what didn’t happen. What we do know is that the next documentation about this patient was on Monday, and a nursing note Monday morning documents that the hand is dark, cool to the touch, and that the NP will be in to evaluate the patient. 

The NP, our NP, comes in to see the patient, and the patient is immediately sent to the emergency department. The NP on this day notes in her progress note that this is a right hand follow-up. The history of present illness summarizes events that she knows of since she was first contacted on Wednesday night. On this date, on this morning, Monday morning, she finds the patient to be in acute pain, holding her own hand, holding her right hand. 

The physical examination was documented as very limited because the patient said it was just too painful and she wouldn’t allow a proper assessment. The note did document that the hand was dark, that the capillary refill was there, but rather that, the hand was dark. But that cap refill, strength of pulses could not be checked. She diagnoses right hand pain, reports color change and concern for vascular occlusion. 

So, the patient was sent to the emergency department. The nursing supervisor was notified. The family unit was notified. The patient goes to the ER where she is diagnosed with an acute arterial occlusion. And the family at this point opted for conservative management. Like the answer was revascularization or embolectomy or some invasive arterial surgery. And at this point, the family opted not to do that. 

They wanted conservative management, so the patient was transferred back to the facility where she lived for another year, and then she died. And so in, you know, so she died at the age of, I guess, 80, 80 at that point, 80 years old. She died almost a year later after the events of this Wednesday till Monday occurred. 

And so, the NP is being sued. So, the assertions against her were that she failed to perform an appropriate circulation assessment on the first visit on Thursday morning because she did not document pulses, cap refill, color, or temperature of skin. So, that was the first thing. And, well, let’s revisit that in a minute. The next thing that was asserted of her is that it is very likely that the expert goes on to say, it’s very likely that given the findings documented on the 27th and the findings documented by nursing on the 29th, had the NP done a proper circulatory assessment on the 28th, it would have revealed signs of circulatory compromise, requiring prompt transfer.  

And so, the patient would have had intervention, what 3 or 4 days earlier. And so, that was a criticism that she didn’t do that. There was also a critique of her offering the venous ultrasound and-although what the expert said was that she shouldn’t have ordered the ultrasound because that wasn’t appropriate in response to the nursing staff reporting continued right hand pain, dark color, and cold to touch. They didn’t suggest what she should have ordered, just that she should not have ordered that ultrasound. 

JA: Convenient.  

SM: Yeah, yeah. You know, I mean, like, it’s just the same old. It’s just like the old school. Don’t tell me what’s wrong.  

JA: Right. 

SM: Tell me what needs to be right. You know, I mean, it’s certainly easy to sit there and call, but-so, I wish I could share with you. I have the picture of this lady’s hand. I mean, acute artery occlusion. Now, the picture I saw was many months later, but, I mean, it is like from about halfway through the dorsum, you could take a Sharpie and draw the line. 

And from here up and the thumb up, it is completely black.  

JA: Oh my God.  

SM: Black. Completely black. Not, you know, red or dark or dusky, not faded. It’s like a black-it’s like a black glove. It’s a black glove that starts right here.  

JA: Like frost bite like that? Kind of like look where it’s just like to death. It’s just dead. 

SM: It’s just an absolute-like somebody-it is like somebody took a black glove and, like, cut it short and put it on. So, it just covered her fingers and oh, my God, you know, the mid-what’s that thing called a hand goes way down the hand and then the rest of the hand looks fine.  

JA: Wait a minute. You just sprung on everybody that.  

SM: Yeah.  

JA: So, a year later she died. But how did she die- 

SM: Hand had nothing to do with her- 

JA: Well, all right, this is gonna sound really jerky, but why are we talking about this? Why was she suing? 

SM: Because it’s just-because, unfortunately, it’s the-it’s the world we live in, the circumstances we live in, and if the-just somebody whispers the word lawyer. But there we go again. I don’t-I sound like I’m hating here. I’m really not. But that’s what happens is that, you know, people will say, oh, it’s like there’s a whole psychology thing of, you know, not getting all psyche on you because I’m a psych NP, but there’s this whole thing that when something bad happens, we want to find a reason. 

We want to have something to blame it on. We want to have something extrinsic to blame it on. And that’s just human nature. You know, we don’t to just say, ‘Well, you know, it’s just that time.’ So, there’s that. And then when you’re, when you, when the family has that and they’re struggling and like I said, by all accounts, this was a happy lady. 

So, I’m sure they really-I’m sure that her death was a loss to the family and stuff like that. And so, you know, you’re looking for something to blame it on, and then all it takes is for somebody else to say, ‘Well, you know, I bet this is all like, ever since her hand, she hasn’t been well, ever since that happened to her hand.’ 

Now, like eventually like for a period of time there it did hurt her. She was in pain. Dying tissue hurts. Dead tissue doesn’t, you know, dead tissue doesn’t hurt. This is the cardinal rule of debridement. You know, when you’re dead-breeding dead tissue, you don’t need to anesthetize anybody. You just start cutting stuff away because dead tissue doesn’t hurt. 

So, once the family opted to let the hand die, and I’m not being critical of that, either. Somebody with arterial disease, you know, we don’t know what the underlying arterial disease was, but doing revascularization or doing arterial surgery, it could have been extremely difficult for her to heal. I mean, it just it could have made things worse. 

So, a conservative approach wasn’t an unreasonable one at all, but it was their choice to not intervene and allow the hand to die. And they were advised of how that goes and the potential consequences. Honestly, I’m stunned that she spent like a year with that much dead tissue and didn’t get septic.  

JA: Me too. Me too. Nuts.  

SM: But, she didn’t. 

In fact, the picture I have of her with her-and like again sitting there, a big smile on her face, you know, in her like, and stuff. So, yeah.  

JA: So, I have a silly question-do those things, do those, does that get amputated? Like partially or quite honestly, she would just had these kind of dead fingers. 

SM: No. In a different circumstance, like the definitive intervention would have been to amputate. Yes. The definitive intervention would have been to try to either like lace the clot or revascularization, depending on exactly where the artery was. I’m not-I don’t know either. I’m not-you know, I don’t know all the specifics of the revascularization, but in the immediate phase, just take age and chronicity out of the picture. 

In the immediate phase, the conversation would have been about the risks and benefits of lacing the clot or removing the clot, or revascularization the hand. But then, once they ought not to do that, the tissue is going to die. And once the tissue dies, then it’s either do you amputate and have the associated risks and consequences of amputation, or do you leave it there and take the chance on sepsis? 

JA: Geez.  

SM: And so yeah, there’s I mean-I’ve seen-there was a time I haven’t done it, done it much for a long time, but there was a time where a significant part of my practice was rounding in long-term care facilities, and it definitely was. I mean, that was always the question, like if a digit went necrotic or something or the toes went necrotic, the question was always risks and benefits of amputation, you know, and the risks are poor healing. 

JA: Yeah. And sepsis, you know, that’s the other thing that’s funny. That’s the first thing I think of that you wouldn’t want to do that. But honestly, I didn’t even think of the other side. Like, how is she going to heal? Like if there is to your point, underlying issues, what if she had more clots and then now you’re back in like the same exact scenario, something else dies, you know? 

SM: Exactly. I mean, you just don’t know. Like, she may not have had that bad of an underlying arterial disease and she might heal beautifully, or she might have had significant arterial disease and it wouldn’t have healed, you know, just side lateral note here. When I was first an NP, my very first job was in an acute care first. 

I mean, I was in acute care. And before we had that name, but that was my job. I went to work, picked up my beeper, made rounds on the inpatients all day. So, all my patient decision to whatever that was it and I my service had all of the admissions from the 14 long-term care facilities in the system. 

It was a big healthcare system. And they had these 14 facility-long-term care facilities in the city. And whenever one of the residents typically would have a change in mental status or any acute thing, they would send them to our hospital and my service. So, I managed a lot of people from long-term care when they were admitted in the hospital. 

And in the very beginning, when I was still learning my way and didn’t know my job very well, I did notice very quickly that if somebody came in with like a gangrenous fifth digit, you know, on the toe, like a gangrenous little toe, I would do it. So, I would consult surgery to take them off to the OR and come back with an above the knee amputation. 

And I was like- 

JA: What?  

SM: And it happened. So, now this was, you know, this was helped me over 30 years ago. Now, like-and these were patients where there just wasn’t a lot of, resources for really aggressive care. And this was end game-like this was palliative stuff. And so, I am a consult surgery, the same surgical team, these two surgeons that work together, they trolled the halls, always joined at the hip. 

But I would refer a patient with a necrotic toe and they come back with an above the knee amputation. And finally I said, ‘Guys, what are you doing? What are you doing with all these legs? You know where they are going and why does it have to be above the knee?’ And they were like, ‘Sally’ but you know, you’re going to feel stupid when somebody says, ‘Sally.’ 

‘The answer is that the problem that led to the necrotic toe was vascular disease that extended so much further up.’ He said, ‘If we just cut off the toe, it wouldn’t heal, and then we’d have to take off half of the foot and then that wouldn’t heal, and then we wouldn’t have to do it at the ankle and that wouldn’t heal.’ 

And it would be-and you would see surgeons do that too, you know, or families wouldn’t consent. And it’s just like progressively chopping off the leg. If in that circumstance, taken off the leg above the knee, afforded the best opportunity for real wound healing, even if they would never be able to ambulate, it was the best way for healing. 

Because up there, you know the femoral artery is like the size of a turnpike and usually not affected by the things that get the smaller ones. So anyway, I digress a bit, but those are the issues here. So, I totally get why the family-and I’m sure the patient was part of the conversation too. But you know, this was like I said, this was a solid facility. 

There were lots of meetings and stuff. And everybody knew what the risks and benefits were. And this is what they opted to do. So then, you know, a year later when the patient dies, it’s like the end in that this is what happens. Everybody looks at these charts for the fine to come. And is there any way and you can almost always make an argument for one side or the other, but in this particular case, the assertion was that she failed to appropriately diagnose and evaluate the hand after that first visit. 

And then there were assertions that she didn’t respond to contacts by staff over the weekend. She didn’t order aggressive enough monitoring. I mean, all the things. And what else could you say? I mean, that’s of course-that’s what they’re going to say. But when you take this, just when you take it at face value and you look at it proactively, which is what the NP has to do. 

Yeah, she’s got this patient who’s, you know, basically she’s a stable patient. She has chronicity, she’s an older lady, she’s got some impairment, she is wheelchair-bound and she has to live with assistance on a day-to-day basis. But she’s stable. She’s happy, she’s interactive. She likes to eat all the things you want in that circumstance. 

JA: Yeah.  

SM: And then her hand starts to hurt. So, you get a call about her hand hurting. And the first call is like, ‘Well, she says it hurts. It’s cool to the touch, you know, cool isn’t cold, right? Arterial occlusion makes really, really cold the hands. You know, that wasn’t what the description that just that just wasn’t what it sounded like. 

There was always a documentation of a pulse. There was always documentation of a capillary refill. One person said it was sluggish. Somebody else said it wasn’t. But the nurse practitioner gets a call that night. She comes in the next day. She sees the patient. She evaluates the patient. I think we’d all agree that it doesn’t sound emergent. 

It sounds like she doesn’t. It hurts, but it didn’t sound emergent. Her vital signs were stable. The ANP documents that there was no acute distress. One of the criticisms, and this is for just all of us to think about as we keep harping on documentation, one of the criticisms was that she didn’t document a detailed vascular exam, and she didn’t document a detailed vascular exam. 

She documented that there was a bruise. She documented that it was cool. But she documented the way a lot of us do, charting by exception. So, you note what’s wrong or atypical. And then the remainder of the exam is within normal limits. And in her deposition, she said the remainder of the exam was normal. The pulse was good, cap reveal was good. 

If I didn’t document something, that’s because it was normal. And that’s a very typical standard of care kind of way to approach your chart.  

JA: I feel like how we all chart.  

SM: However just learning point, you know, a little teaching moment there. In retrospect, if you’re seeing a very specific complaint, the pertinent negatives are just as helpful to document as the pertinent positives. 

And so, even though I would never say it was a deviation from standard of care, because charting by exception is what we all do. But, you know, going forward, I can tell you that I always do now, not just because of this case, but because I’ve seen it so often. If there’s a specific complaint like this, like the hand, even if like if the pulse was there and the color was good and the cap refill was good, it were really best served to chart those things just because. 

Then in retrospect, there is absolutely no doubt about the fact that it was done. So, it’s-I mean, it’s a line here. It’s not a deviation from standard of care not to do it. It just-but boy, would it have helped. This would have helped in general to want to go back and see it. So, think about the time it takes to check those things off in your note. 

And there’s that. So anyway, that’s the only time she saw her or the X-ray was negative. The hand hurt. It was not acute. There were no concerning findings. And then she goes on about her day. She gets a-I guess she gets a call later on about continued pain. So, she orders the ultrasound, which is the next thing that is readily accessible to her. 

And that’s the last she hears of anything, right? She was the last she hears. Right? She wasn’t on call. The next thing she knows, she comes in on Monday morning. The patient is acute, and she sends her to the ER.  

JA: So where is the-you know about that ultrasound? Doesn’t that check-I mean, it’s a venous ultrasound, but to your point, they didn’t even offer like, this would have been better. But does-am I like being goofy? A venous ultrasound only checks veins. We’re not looking at arterial blood flow at all.  

SM: Yeah, you don’t there. It is different, they’re different assessments. If you want to look at the artery. If you want to see the artery you could order an arterial ultrasound.  

JA: Okay. Dang. 

SM: And it’s different. It’s different the way that study is performed is different.  

JA: Was that the like case that that you didn’t check the right vessel?  

SM: Actually nobody commented on that. Nobody commented on that oddly enough. But-and somebody could have asked the question. But in this, in the scheme of things, arterial clotting is so much less common than venous clotting. 

JA: Yeah.  

SM: Like in your list of likely and the upper extremity both of them are really uncommon but arterial much more so. And again, you know the fact that the pulse is anytime anybody checked a pulse that was there.  

JA: Yeah.  

SM: The skin and the skin like the documentation is that the color. The color is darker, but you know, what does that mean? 

JA: Right.  

SM: You know, we can look back now, now that we all know it was an arterial problem, we can look back and say, ‘Oh, that was artery.’ But in the moment, there were two options for this. And either do the things she did or send her to the emergency room.  

JA: Yeah.  

SM: And of course, you know what they say about hindsight being 20/20. 

You know, everybody says, ‘Well, she should have sent it to the ER. She should have sent her to the ER.’ Did I mention this was 2020? This was May of 2020. Oh, remember what happened in May of 2020?  

JA: Yes.  

SM: On March 13th, 2020, the world stopped, right? Like the world just shut down. And by May of 2020, when we were in, like, totally high gear, remember? 

You know, I mean, everything’s-all the resources were being mobilized. The hospitals being set up in convention centers and stuff like that. It was just-that was like the peak of the madness. And you didn’t send somebody to the emergency room then unless they had COVID.  

JA: Yeah. Really.  

SM: I mean, you were encouraged not even to send them for an MI. 

I knew that you didn’t send them to the ER unless it was really, really an emergency. Not only because there were just no resources. But then a lady like this is more likely to get COVID there than anywhere else, right?  

JA:: Exactly. I know that now you’re in big trouble, right? And I’m trying to be like, you know, not know the case, right? 

Not Monday morning quarterback, but like, I never-it never sounded like this was a life-threatening emergency early on that like sending to the ER may have even been perceived as like, what are you doing? You know, like you’re wasting resources, you know?  

SM: Absolutely, absolutely. If she’d gone to the ER, she probably would have got COVID there and died sooner than she did. 

JA: Yeah.  

SM: I mean, we can all probably-man, now. But, you know, now this is all about opining. But really in in May, I mean, I don’t know that I would have sent her to the ER anytime. I don’t know, you know, based on the things I was reading now, had this gone on for like several days, even if it wasn’t acute. 

But remember, you know, the NP gets a call at night, she sees the patient the next morning not looking emergent showed her an ultrasound for that night. The ultrasound is negative. That’s the last year of it.  

JA: Yeah.  

SM: So, at any point in that discussion, would any of us have sent her to the ER? You know, it always cracks me up when I hear people say, ‘Oh, I would have or I would have known or she should have known.’ 

You know, it is always really easy to be brilliant when it’s not. You’re a patient and you’re not in the moment, but I don’t-I wouldn’t have sent her at that point. I wouldn’t have sent her even if it wasn’t Covid, just based on what I-but I would have followed it, I would have followed it. And if it continued to deteriorate, okay, now we have a negative X-ray, we have a negative ultrasound.  

And it still really hurts her. So yes, then I probably would have sent her, but not in this circumstance. So, at the end she had on board. Then throw in May of 2020. There’s no way that they would have taken to the ER. Wouldn’t have seen her.  

JA: I’m so interested. 

How like-how did this play out for that? And in this case, considering two was a year later, I’m assuming when she died, it was unrelated. I’m just making that assumption. But I was like, you know, cardiac arrest secondary to various chronicity and stuff.  

SM: Yeah. It was dismissed.  

JA: Okay. Wow. She was dismissed from the case, but, I don’t even-I don’t know if anybody- 

I mean, there are, you know, there are like, they there’s always everybody that they’re taking a look at here. So did-was it that the staff didn’t communicate well? Did the on-call person, you know, did they not do what they should have done. Like there’s other errors. You know, there’s of course other people that were being if I even the even the NP’s collaborating physician who had nothing to do with nothing, I was when I was reading his deposition, at one point he said something like, he’s like just offered the opinion that maybe they could have communicated better. 

And I thought, who asked you? Be quiet, you weren’t there. Like, this is also 101. You don’t start offering opinions that are counter to the position. I mean, I’m not saying if there was actually something contributory that, you know, share it, but that’s just an opinion, right? We could have done this better. Well, yeah. Thanks. 

Thanks for another name. Great. Pipe down. Sir. I mean, that is you know, that is a classic. Oh, in retrospect, of course could have done this or this, but that’s not the way or look at these. It’s prospect of it’s contemporaneous. What were the circumstances and what was available. And what did the employee know at that time. 

We all play that game, man. Only we were so good at like being able to forecast into the future and not make mistakes right now. And we know that when we got I’d have a lot less divorces under my- 

JA: Oh my gosh. Well thanks for sharing this, Dr. Miller. This was an interesting story. I honestly, I didn’t see this a year later. I’m like, what hap-this is a turnout that I didn’t expect. I appreciate you sharing that. Isn’t it just crazy, though? How, like, you like anything. Like every everything we do. And, you know, in a couple years we can be getting served with the complaints going, ‘What? What? What? What are you talking about? What?’ 

SM: Yeah, we can and it’s true. I mean, honestly, I think it is a testament to the importance, the gravity of one, the work that we all do as healthcare providers, as practitioners like yourself, who are really doing all they care for, for patients. I mean, listen, this is not like an easy job. 

It is in no way, shape or form is it? And I think at dealing with people at all, caring for people at all in any way, you know, there’s that factor, but here you go. You know, dealing with health and life and death.  

JA: You know, it’s a good job. It’s a good job. Wow. Thanks. Thanks for that. 

And we hope you guys enjoyed the story listening into this. And if you want to hear more check us out on FHEA.com. We got lots of different episodes for you to enjoy and to learn from, right. And help us to maybe forecast a little bit better looking into what we’re doing and, and how we’re doing it and why we’re doing it. 

And everything helps, right? Everything helps. So, we take everything does. Yeah. Well, thanks for joining us, everyone. And until next time, 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.