Up until now, everyone who has cared to follow me and my patient’s case since it’s social media debut in 2011 knows how things got started, what the issues are, and where I am now. What people do not know is what happened the next morning with the physician staff, the nurse manager, the dayshift nurse, the case manager, and the patient. I write about it now in the hopes that it will be a learning tool to teach anyone involved with caring for patients in hospital like settings what happens when there is no multidisciplinary model of care that places the patient at the center and encourages collegial discussions and healthy communicative relationships among providers.

The next morning, April 13, 2011 unit secretary, Kristie Reed, reported in her testimony to the nurse investigator that a physician had been extremely loud and upset in the nurse’s station—that evening when I came on for my shift she pointed at me and called out my name. With a smile on her face she loudly yelled out that “Whatever you did to your patient last night really got Dr. Chuang upset, he threw some tantrum this morning and he was MAD!” Kristie later reported to the nursing investigator that she “didn’t know who the doctor was that was yelling.” Kristie also made sure to report to the nursing investigator that I as a nurse “was a know it all” and spent the most time out of any of the nurses “printing out education for the patients.” As if it’s a crime. The case manager interviewed by the nursing investigator felt my teaching of the patient was inappropriate and out of line. (Since when does a case manager who is not a nurse have the ability to judge nursing practice?) The dayshift nurse manager told the nursing investigator that my teaching was “above and beyond what any patient should be able to understand,” and the patient was told by numerous staff, including a transplant educator, how “sorry” they were that the “nurse did what she did.”

Nurse Manager Denise Hebert

The patient, in their testimony, reported seeing everybody who came into their room “angry and upset” and they didn’t know why, but “eventually agreed that the night nurse probably shouldn’t have told me all those things.” The education I provided the patient was then taken out of the room, taken apart, and yes—- later photographed by the state board of nursing for their “official report.” One of the biggest “offenses” was that I had placed extra highlighters and pens for the patient to use in an empty biohazard bag (essentially a ziplock bag with a symbol on the front) so they wouldn’t get lost. I know, it was something out of NCIS. The patient, at that point, verbalized they were no longer comfortable having me as a nursing care provider following the events occurring after my time with them. The nursing director Venus Gaines thought herself quite knowledgeable when asking me where on earth I got the idea that the physicians were even thinking “hospice” as an option, and that no one had been exploring hospice as an option for this patient. Venus was appropriately stupefied when I informed her that there were indeed references to hospice as a viable option within the physician progress notes if she had cared to read all of them as I did before making my care plan for the patient. Her main concern was that “the physicians are really upset that you messed up all of their hard work.” She did not share my ethical concerns about the patient.

John Harrington, FACHE, CEO Banner Del E Webb Hospital Sun City West, Arizona

Here is what I see in all of this. An unfortunate and disgusting display of ego and power that has no place in carrying out the safest, most ethical, patient centric care. (Yes, I know I’m not supposed to know anything about healthcare ethics or how and when to apply them to my practice) This patient went from telling me that they were thankful to me as a nurse for being “the only one who has taken the time to ask me what I understand and whether I had questions or concerns” to “uncomfortable with the nurse” as a direct result of the confusing course of events from the next morning.

The nurse patient relationship which is built on an intimate trust and rapport was breached by ego and priorities that were anything but on the patient and their needs. This patient did not have, on record, any sort of multidisciplinary meeting notes during which different healthcare providers all came together to discuss the progress and goals as they pertained to the patient, or their “vision” for “their future.” I know… I read that chart from start to finish. It’s how I build my care plans. In fact, the lack of multidisciplinary meetings amazed me because of how extremely complex this scenario was and it was the reason I wanted an ethics consultation.

Banner Health President & CEO, Peter Fine

What I found tragic is that one discipline would think its even remotely appropriate to undermine or criticize another one in the presence of a sick and vulnerable patient. That members of the healthcare “team” were so eager to destroy the trust and confidence a patient has in a nurse when there are conflicting interests at hand was probably the thing that nauseated me the most when I learned about all of it. This patient was harmed in numerous ways—they were scared and intimated the next day with the outward display of anger all around them, they were deprived of the ability to trust nursing personnel after being told “I was wrong to teach” them anything, their rights to self determination were taken away when the room was stripped of all patient education, and they were left in a vulnerable state unsure of who to trust and turn to for the truth. No patient should have to feel scared or nervous about who to trust and feel safe with while in the hospital–it should, for all intents and purposes, feel like somewhat of a reassuring “you are in the right hands” kind of place to be in when you are at your sickest and most vulnerable. The staff at Banner Del E Webb deprived my patient of that the next day carrying on as they did. From that point on, its safe to say that anything they had to tell the patient was probably met with quiet submission, rather than a spirit of self advocacy–a concept the patient actually began to take hold of the night we talked together.

Dr. Keng Yu Chuang

Self empowerment—the empowerment every human being deserves to have, was taken from them too. No healthcare discipline has the right to sway a patient in one direction or another with fear or intimidation, or away from trusting one discipline versus another. Its immoral, its unethical, and unfortunately it is what happens when there are numerous people all working with one patient, but each with a completely different goal or belief system. Ever heard the saying “You ask ten doctors in one room what a nurses job is and you will likely get ten different answers?” A case manager who is not a nurse has no right to judge the competency or professionalism of a nurses practice, no physician has the right to decide what information a patient gets or doesn’t get, or define what nurses “do or don’t do,” and no healthcare provider has the right to destroy the fundamental trust a patient has in his/her healthcare team members. In this scenario a very pertinent question to ask every one of the players who took part in the theatrics the morning after my care– “Do you remember who you were when you decided to get into healthcare?” If not…well, then, perhaps you need to rethink the answer. Because no matter how anyone spins this case, a patient was directly harmed that morning. By every member of the healthcare “TEAM.”

I wanted to share the course of events (that can indeed be corroborated) so that it would serve as a learning tool to any healthcare provider that reads it. One of my dreams had been to teach a university course that would begin showing medical students, nursing students, and social work students how to communicate with each other from “day one.” It was to be a two semester university level course that would begin to change how members of the healthcare team would view each other’s contributions, how to effectively collaborate for the good of the patient, and each other, while promoting a healthier more collegial work environment for all. But seeing as the Arizona Board of Nursing thought it appropriate to inform the ASU Doctorate Program (prematurely) about my case before it was even concluded—that dream has come to a screeching halt as well.

Michelle Winters

Hopefully this blog entry is the beginning to change, my hope is that people will examine how this played out and see where things broke down (root cause analysis), perhaps it will even inspire some discussion and debate about how to prevent it from ever happening again in the future……

Information: White v. Advanced Neuromodulation Systems, Inc., 4732 SCCA (1/14/2011)-FL

Summary: The ‘undertaking’ doctrine may not be what you think!

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

We usually hear of lawsuits that, for the most part, focus on physicians and hospitals. In this most unusual case, it’s the nurse that the patient and his wife ultimately held responsible for the injury caused to the patient. What’s baffling…is that the nurse involved was not practicing in the capacity of a Registered Nurse, rather, she was employed as a device technician and was working well within the scope and regulations set forth by her employer Advanced Neuromodulation Systems (ANS). Her careful documentation would become the highlight of a case that should cause us all to think twice about the Good Samaritan Laws in the states we live in, and to what extent they protect us as nurses. Here, it’s referred to as the Undertaker’s Doctrine which “provides that whenever one undertakes to provide a service to others, whether one does so gratuitously or by contract, the individual who undertakes to provide the service—i.e., the ‘undertaker’—thereby assumes a duty to act carefully and to not put others at an undue risk of harm…The doctrine comes into play where a plaintiff alleges a defendant voluntarily took an action which, although statutorily authorized, is not required.”(White, 2011)

Here’s some background on the major players in and unfortunate sequence of events that resulted in the paralysis of a patient. Advanced Neuromodulation Systems (ANS) is the manufacturer of implantable spinal cord simulators used for patients who experience chronic back pain. “PMS” is a separate company that “ANS” contracts with to do the sales and servicing end of the business. “PMS” employs technicians to program the spinal cord stimulators. Some of their employees have nursing backgrounds–though it’s not necessary to have a medical or nursing background to perform the functions of programming the devices. The employees who perform this function have no access to the medical records or health histories of patients. Should a client have health or medical questions, PMS instructs its employees to refer those concerns to a physician. Wendy Bolin was one of these employees, and in fact, was the employee “ANS” assigned to manage the spinal cord stimulator in question throughout this case. Dr. Moyer is the neurosurgeon who initially saw the patient and implanted the device for chronic back pain relief. Dr. Waks was the primary care physician of the patient who had the spinal cord stimulator implanted. Finally, there was a second unnamed neurosurgeon who the patient consulted with shortly before becoming partially paralyzed.

Mr. White initially made contact with Dr. Moyer, a neurosurgeon, early in 2004 for help with chronic back pain. Dr. Moyer recommended a spinal cord stimulator be implanted, explained the risks and benefits of the procedure (which included infection), and Mr. White agreed to the procedure having had the surgery performed sometime in April of 2004. Wendy Bolin, the technician who would be assigned to program Mr. White’s device, became acquainted with him preoperatively and explained her role. It’s unexplained how Mr. White was privy to Wendy’s nursing background, but the court documents emphasize that he was well aware that her role was one of a technician and not that of a nurse. Mr. White first contacted Wendy one day after the device implantation complaining of “seepage” from the incision site. She advised him to call Dr. Moyer, the surgeon who implanted it, for follow up on the issue. He followed those instructions and spoke with Dr. Moyer’s PA who told Mr. White over the phone that the “seepage wasn’t unusual given the circumstances.” (White, 2011) (those “circumstances” were never made clear during the proceedings).

Wendy Bolin and Mr. White had no further contact between June 2004 and January 10, 2005– when he called to advise her that the pain stimulator was not working properly and that there was a cyst next to the site. She made arrangements to meet Mr. White at Dr. Moyers’ office within the hour of his phone call. While reprogramming the stimulator she saw purulent discharge coming from the incision site. She told Mr. White he needed to see Dr. Moyer for follow up immediately. He responded that Dr. Moyer was refusing to see him due to an unpaid medical bill but that he would go see his primary care physician instead. Wendy again insisted he follow up with Dr. Moyer.

Concerned about Mr. White’s inability to see the neurosurgeon, Wendy speaks with the scheduling staff in his office and explains that Mr. White must have a follow up appointment as soon as possible to have the incision site evaluated. She leaves her programming documentation as well as note with her concern about the “purulent discharge” at the surgical site for Dr. Moyer before leaving. Despite Wendy’s efforts, Mr. White is still unable to get an appointment. Three days after meeting with Wendy at Dr. Moyers’ office he presents to his primary care physician, Dr. Waks, who assesses that there is the presence of yellow drainage at the surgical site. He prescribes an antibiotic and strongly advises Mr. White to return to Dr. Moyer’s office for an evaluation. Mr. White returns to see Dr. Waks two weeks later for a follow up appointment —still having been refused an appointment with Dr. Moyer…Dr. Waks would not come into contact with Mr. White again until April of 2005 when, at that time, he advised Mr. White that the site had become infected again. He again urged that the patient return to Dr. Moyer so the device can be removed.

On May 24, 2005 Mr. White makes contact with Wendy, at which time she inquires about the incision site. He mentions that its still oozing now and then but that it’s “okay.” As she has previously, Wendy advises him to make an appointment with Dr. Moyer. He sets an appointment to have the stimulator reprogrammed on June 1^st, 2005. Wendy is unavailable for the visit so a “PMS” colleague, Dawn Dunham, steps in for her. After reprogramming the stimulator, her concerns about the incision site drive Dawn to seek the assistance of Dr. Moyer’s PA—who reassures her and Mr. White that “there isn’t anything to worry about.” The PA then sets a follow up appointment for Mr. White to be seen in two weeks. Dawn then briefs Wendy Bolin about the office visit with Mr. White, adding that an appointment has been set.

**Court records do not reveal who did it….but Mr. White’s appointment was cancelled**

Exasperated, Wendy Bolin pays a visit to Dr. Moyer’s office by herself to investigate what is going on. After speaking with the scheduling staff she learns that Mr. White has been denied a visit with Dr. Moyer because of an unpaid medical bill and that it must be paid before he will be able to schedule any further appointments. She goes one step further and meets with Dr. Moyer himself to plead Mr. White’s case and relay her concerns about the surgical site. Dr. Moyer refuted the notion that he would deny any patient needed care. She left his office feeling as if something would finally be done to help Mr. White…

Mr. White begins seeing a new pain management physician just a few weeks later. Wendy meets him at the office to program the stimulator and is present for the consultation. The physician also advises Mr. White to go back and have the device removed by Dr. Moyer. He again turns to his primary care physician, Dr. Waks—only this time Mr. White is complaining of new “numbness in his legs.” At this point he is referred to another neurosurgeon for further evaluation—during this visit Mr. White is given the unfortunate diagnoses of peripheral neuropathy. *It’s unfortunate because the diagnosis was WRONG*

Wendy Bolin was updated about the new diagnosis on August 12, 2005. Just two days later, Mr. White became partially paralyzed due to an infection at the surgical site that caused compression on his spinal cord. When Dr. Moyer was made aware of Mr. White’s condition he remove the stimulator immediately, lamenting that had he knew about Mr. White’s symptoms and complaints it would have come out sooner. The Whites felt Wendy was obligated to do more– and thus held her responsible for not making sure—herself—that Dr. Moyer provided care to the patient. The court was appalled, applying the “Undertaker’s Doctrine,” and entering a judgment “for the nurse”: “THE FLORIDA COURT OF APPEALS AFFIRMED THE JUDGMENT ENTERED BY THE LOWER COURT. The court held, inter alia, that Nurse Bolin’s voluntary actions in urging that the patient be seen by the neurosurgeon who implanted the neuromodulation system in him did not impose an affirmative duty on the nurse to do any more than she had already done. The court held, inter alia, that Nurse Bolin had gone far beyond the call of duty in imploring the patient to make certain that he was seen by the doctor who implanted the device. Through no fault of Nurse Bolin, despite her extraordinary effort to have the patient seen by the doctor in question, the patient was never seen by him. Ironically, Nurse Bolin found herself among the defendants when the patient finally brought suit. Justice was done when Nurse Bolin’s motion for a directed verdict was granted by the trial court and the trial court’s order was affirmed on appeal. IN VIEW OF WHAT THE COURT PERCEIVED TO BE A GROSS INJUSTICE REGARDING THE INCLUSION OF NURSE BOLIN IN THE SUIT, THE COURT SAW FIT TO DISCUSS THE ‘UNDERTAKER’S DOCTRINE.’ “ (Tammelleo, 2011)

Questions for Consideration

At what point (s) in time did Wendy cross into the role of a nurse—provide examples of action to support your opinion. (this is a trick question)
You’ve taken a job in the healthcare setting that does not use nor require your nursing skills, yet you still keep an active RN license. Are you still required to abide by your oath and the Code of Ethics for Nurses when you see or are aware of unethical situations that place the lives or well- being of others at risk? Explain your rationale.
The Whites, in their complaint against Wendy Bolin, state that she should have “warned Mr. White that an infection at the incision site could result in paralysis.” Do you agree? Why or why not.
If Wendy was acting in the capacity of a Registered Nurse, should she have been held liable for, or had the duty to make sure Dr. Moyer provided care to Mr. White? Is there a line at which the responsibility falls to a physician?
Who, in your opinion, is ultimately responsible for the injury caused to Mr. White? Why?

Discussion

We’ve all done it and if you haven’t— you’re either lying or haven’t been in the profession long enough: Keeping the “Nurse” on the “DL” (the down low) when out in public. Whether it be the gym, the county fair, a restaurant, or the mall– we like to stay off the clock when we are—off the clock. I’ll cop to it. When I used to frequent the gym I stayed away from any equipment operated by someone who had skin pallor that screamed “major coronary blockages within.” Cardiac & ER nurses—you know what I’m talking about. Would I do CPR if I had to? Of course I’d do it– But that doesn’t mean I’m about to tempt fate by putting myself in the path of a potential tornado. We live and practice in a litigious society and even the best intentions/efforts to help your fellow man may not go over so well should the outcome be less than satisfactory to the patient and/or family. Hell, doctors even have the ability to destroy your livelihood and future if you do something they do not like or agree with.

Mr. White’s case is a perfect example of what happens when a nurse—who wasn’t “on duty” as a nurse, sought to help him by tirelessly advocating for his best interests throughout the course of care. I wonder if it was Wendy herself who made the mistake of sharing her nursing background with Mr. White. Here’s a hint—if you’re not working in the capacity of a nurse, don’t share that you have that background for this exact reason! The two roles can easily become blurred in the eyes and mind of the patient. Although the lawsuit named the two companies involved, and each physician that came into contact with Mr. White, the court documentation clearly stated that their focus was on “the nurse.”

Once the coveted RN is placed after your name it would be wise to take a breath, relax with a glass of iced tea or a cup of coffee, and explore your state’s legislative website to learn more about the Good Samaritan Laws in your state. How are you protected legally should you help render aid with a motor vehicle accident or when breaking a few ribs performing CPR in front of the McDonalds at the local mall? It’s important to know these things. There was recently a bad car accident here in Phoenix that involved children. The bystanders were afraid the car was catching fire and worked hard to pull the young children out of their car seats and out of the car before first responders got there to assist. First responders later advised the community via the evening news that because the children were taken out of the car seats they hemorrhaged and coded (trauma code)—the close compartment of the car seat and the belt holding them in place was actually keeping them somewhat stable. There is no fault, lay people don’t know these things—and genuinely want to help. But let’s play the devil’s advocate here—what if those bystanders were nurses and the family found that out? There is a really good chance that they would have been subjected to a lawsuit. The reason why? Well, one could argue that a nurse is trained to assess for potential internal injuries resulting from trauma and should understand the basic principles behind maintaining homeostasis. He/she could be accused of causing harm or death in the process of rendering aid.

I’m not saying don’t stop and help—I do all the time—but be smart about it and practice defensively–know what, if anything, your state has on the books to protect healthcare providers while they are engaged in those crucial moments of caregiving…

Resources

White v. Advanced Neuromodulation Systems. (2011, January 24). Retrieved May 31, 2013, from LEAGLE: Debate, Cases, Regulations, Statutes, and More: http://www.leagle.com/xmlResult.aspx?page=1&xmldoc=In%20FLCO%2020110114132.xml&docbase=CSLWAR3-2007-CURR&SizeDisp=7

Tammelleo, D. (2011, January 1). The ‘undertaking doctrine’ may not be what you think! Retrieved May 31, 2013, from The Free Library: http://www.thefreelibrary.com/The ‘undertaking’ doctrine may not be what you think!-a0249390289