A Tragic Comedy of Errors

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And here we go again….yet another article with opinions by so-called “health policy experts” recommending the unsupervised (“independent”) practice of nurse practitioners (NPs), without doing the requisite homework before offering their uninformed perspective. So much for responsible reporting. 

The entire issue of NPs practicing unsupervised is not a new one. What is different is the political agenda on which it is based. With no questions asked by any reporter or health policy expert. Why?

  • The American Association of Nurse Practitioners (AANP) has mandated that 100% of all practicing NPs obtain the doctorate of nursing practice(DNP) degree within a specified period of time. Surely one must ask how valuable is a degree, an online one no less, which can be obtained by 100% of practicing NPs? In addition, all master’s programs for budding NPs are due to be phased out and changed to or replaced by doctorates of nursing practice(DNP) curriculums. Why do these mandates not raise a red flag?
  • Per the AANP, the number of practicing NPs in the U.S. has increased exponentially since 2007. From 120,000 to 270,000 as of January 2019. There were approximately 250,000 in March of 2018. An explosion of 20,000 NPs within one year? Proliferation this rapid does not occur without the rapid expansion of nurse practitioner programs. Now, if programs are developed that quickly, how is it possible that the quality does not suffer?

The fact is the quality does indeed suffer. It is no secret that the AANP is well aware of the unregulated expansion of substandard online (and some brick and mortar) degree mills, yet they continue to push their agenda that ALL NPs should be able to practice “independently”. The only relevant comment by the president of the AANP is to advise NPs to avoid publicizing their deficits in knowledge on social media and use other resources as the information may be used to obstruct their agenda. No solution offered as to how filtering out these unqualified graduates will occur so they are prevented from practicing on people like human guinea pigs. And the Committee on Collegiate Nursing Education (CCNE), the regulatory body responsible for accrediting nurse practitioner programs? Sleeping on the job. No oversight of these atrocious programs and in some cases, actually granting them undeserved accreditation. And not one reporter demonstrating any interest in this unconscionable behavior. Nope. Let’s just continue the rhetoric of physicians protecting their turf, their insatiable greed and their insurmountable egos. 

Physicians for Patient Protection (PPP) is the one organization that is speaking loudly about this issue, regardless of the vitriol directed against us. We did not form out of thin air, we formed out of necessity. None of us needed another job nor did we want it. It came to us by happenstance. Because a few concerned physicians began asking questions about the number of patients they were receiving who had been grossly mismanaged and somehow ended up on their doorstep. Because the mistakes just did not make sense for patients being managed by highly trained physicians. Errors for which a medical student would be reamed. Who else would be expected to address these cases besides attorneys? We did what physicians should do if they honor their oath. We decided to find out what was occurring and why–to protect our patients. We were just as ignorant to the issue of degree mills and “independent” practice as legislators, reporters, health policy experts, physician colleagues and other health care professionals. But we soon found out because we did our homework. No reporter has asked about that either. The stories are dismissed as anecdotal. But to the family that is affected, that anecdote is their father, their sister, their grandparent….their child.

NP runs a hormone clinic in Texas which prescribes thyroid hormone and high doses of testosterone. A primary care physician(PCP) in the community becomes aware of the clinic when one of her patients develops polycythemia due to excessive testosterone supplementation. Supervising physician for NP notified and stops supervising. Complaint submitted to nursing board (BON) who does nothing. NP hires two more supervising physicians miles away and continues to practice. Same PCP informs new supervising physicians and is ignored. PCP reports them to the Texas Medical Board (TMB). Another patient of the hormone clinic subsequently dies from a heart attack. Autopsy concludes contributing cause as excessive testosterone. No action by BON. PCP notifies DEA who investigates and determines NP is not qualified or trained to prescribe some of the hormones dispensed from his clinic. BON finally suspends NP license. Another NP in the same clinic assumes care and the practice continues. Clinic is subsequently shut down after a child develops thyrotoxicosis after being misdiagnosed and given unnecessary thyroid hormone treatment. Second NP surrenders license. All three physicians brought before Texas Medical Board. Child recovers.

**Failure to consult the supervising physician.

**Failure to stay within scope of practice(SOP). https://kfdm.com/news/local/southeast-texas-nurse-practitioner-surrenders-license-optimum-clinic-evicted 

Seven-day old neonate with vesicular rash seen by NP in urgent care. Diagnosed with contact dermatitis and Mom sent home with instructions to treat with calamine lotion. Mom suspicious of diagnosis and goes to ED where patient is seen by a physician. Septic workup performed, patient placed on IV acyclovir for Herpes simplex infection and admitted. Patient did not have sepsis or meningitis and did well.

**Failure to recognize potentially life-threatening infectious disease in neonate.

**Failure to follow national medical standard for treatment of neonate with HSV.

Elderly patient with long-term psychiatric illness that had been stable for years is admitted to nursing home. Primary care NP for nursing home abruptly discontinues psychiatric medications based on advice by an inexperienced pharmacologist with no review of records, no discussion with family and without consulting the psychiatrist on call. Resultant decompensation psychosis occurs. The patient continues to worsen. NP subsequently recognizes the error and restarts the patient’s medication at the previous doses prior to discontinuation which not only did nothing for the acute psychosis,but also led to a severe movement disorder. Ultimately patient is admitted to a psychiatric unit for stabilization and management by a psychiatrist. Unfortunately, the patient has not reached the clinical and psychiatric stability they had prior to the inappropriate discontinuation of their psychiatric medication.**Failure to recognize the risks associated with abrupt cessation of psychiatric medications.

**Failure to consult psychiatrist on call.

Middle aged individual seen in the ER by an NP for severe eye pain. No eye exam, visual acuity or eye pressure documented. Pt sent home with diagnosis of corneal abrasion and instructions to follow up with ophthalmology. Seen by ophtho days later and diagnosed with acute angle closure glaucoma. Multiple interventions performed immediately without success and patient was emergently transferred to glaucoma specialist at a tertiary center. Patient treated with IV mannitol and admitted. Patient subsequently had surgery; however, they were unable to save the patient’s vision and patient is permanently blind in one eye.

**Failure to recognize the signs and symptoms of acute angle closure glaucoma.

**Failure to perform an appropriate eye exam.

**Failure to consult supervising ER physician.

Older patient seen by an NP in a rural, critical access hospital that uses on-call physicians. NP notifies the on-call physician at the insistence of a staff member and advises physician that patient “is not that sick” but needs to be admitted. Physician requests vital signs which are grossly abnormal and informs NP they are on their way in to see patient. Physician then calls ER nurse and instructs nurse to provide certain emergent interventions until physician’s arrival. Ultimately, patient is admitted to ICU and treated for septic shock. Patient survives. Physician lodges complaint which results in enactment of strict policies on when MD/DO should be notified by NPs of patients in said ER.
**Failure to recognize the signs and symptoms of sepsis, including abnormal vital signs.

**Failure to institute rapid intervention for septic shock.
**Failure to notify on call ER physician expeditiously regarding critically ill patient.

Well appearing neonate seen by NP at an urgent care for fever. Patient subsequently discharged with instructions to mother to give Tylenol and Motrin for fever. No other instructions given. A family friend, who happens to be a physician, calls to chat with Mom and is informed of infant’s fever and that rectal temperature was high. Physician advises mother to take patient to the ER immediately. Patient is seen by an ER physician who performs a sepsis workup. Patient is discovered to have meningitis and is admitted to PICU. Infant nearly dies; however, subsequently recovers without residual sequelae. Physician friend notifies medical director of urgent care who enacts changes so that no child under the age of 2 is seen by the nurse practitioners.

**Failure to follow medical standard of care regarding neonates with fever.

Elderly patient seen by NP at an urgent care for angioedema. Patient is on an ACE inhibitor. NP advises patient that reaction is most likely due to something patient ingested and discharges patient home with a steroid pack. Patient never instructed to discontinue ACEI. Patient returns later to ED, requires emergent cricothyroidotomy and is admitted to ICU. Unfortunately, patient has anoxic brain injury and care is withdrawn. Pt subsequently dies.

**Failure to recognize ACEI angioedema, an emergent condition.

Young child brought to outpatient Family Medicine clinic and seen by NP for increased urinary urgency and frequency. Urinalysis demonstrates glucosuria. No history of diabetes. Patient diagnosed with urinary tract infection (UTI) and sent home. NO ANTIBIOTICS GIVEN. Patient seen again a week later by another NP with complaint of polyuria, polydipsia, wetting the bed and 10 lb weight loss. U/A demonstrates urine very high glucose and large ketones. Point of care test (POCT) reveals glucose of >300 and a high Hbg A1C. NP correctly informs guardians patient has diabetes. Because patient appears stable, child is sent home with instructions to drink more water. Endocrine consult placed. Clinic calls endocrine group the next day and is instructed to send patient to ED. Clinic unable to get hold of family but contact the following day. Child is taken to ED and is admitted in diabetic ketoacidosis(DKA). Patient survives.
**Failure to recognize the signs and symptoms of new-onset diabetes.

**Failure to consider the potential deadly signs and symptoms of DKA.
**Failure to consult supervising physician.

Young adult patient with cancer seen by NP at clinic. Discovered to have critically low sodium. NP arranges direct admission to medical floor with no order for telemetry monitoring. IV NS ordered as only intervention. Patient was subsequently seen by physician who makes arrangements to transfer patient to ICU expeditiously. STAT chemistry reveals a drop in patient’s already critically low sodium level. While in transport to ICU, patient codes and dies.
**Failure to recognize severe hyponatremia.

**Failure to transfer patient to emergency department for acute management of electrolyte disorder.

Older patient with chest pain seen by NP at a clinic. Patient advised that they may be having a heart attack and to go to ED to get “checked out”.  Patient is allowed to drive to the closest hospital(which is not a PCI center). Patient seen by an ER physician and informed that they are having a major heart attack. STEMI protocol immediately activated and patient transferred to a PCI center; however, care is unfortunately delayed due to missed diagnosis at urgent care. Patient dies two days later. ER physician obtains EKG from urgent care which clearly demonstrates a STEMI. 

**Failure to recognize STEMI on EKG.

**Failure to activate STEMI protocol, further delaying life-saving care to patient.

**Failure to follow national standard for treatment of STEMI.
**Failure to consult supervising and/or “collaborating” physician.

PPP receives cases like these DAILY. This is not authentic medicine. This is a travesty of medicine. And should be a crime. Every single case described above involves a physician who is also a PPP member. And the case somehow ended up in their lap. Some of our cases occur in supervised states, some do not. Although we get cases involving physician assistants, naturopaths, chiropractors, PharmDs and psychologists, the overwhelming majority of these cases involve NPs. NPs are not held to the medical standard of care, they are held to a nursing standard, although they are permitted to practice medicine without a medical license, thanks to legislators. It will be the supervising physician, or in unsupervised states, the “collaborating” physician, who will be held the most accountable, whether or not they were aware the patient existed. Why are reporters/legislators/health care policy experts not interested in this? Why do patients not matter? Where is the concern for them? 

These are actual phrases and words documented in posts, charts, referrals, texts, etc. by NPs. Nonsensical terms in lieu of correct medical terminology, with which some NPs are unfamiliar. NONE are dictation or voice recognition software errors. Combined with the several mismanaged cases, it is as if we are in multiple episodes reminiscent of the Keystone Cops slapstick comedy. Except this is not funny…it’s tragic. 

  • “Rule out Alzheimer’s Dimension”–Alzheimer’s dementia
  • “Asymmetrical ass crack”–asymmetrical gluteal cleft
  • “End-stage psoriasis”–end-stage cirrhosis
  • “Pre-ear infection”– “in case” of an ear infection
  • “Microstones”–kidney stones so tiny that they cannot be seen
  • “Loss of great-white junction”–loss of gray-white junction
  • “Protein-pump inhibitor”–proton-pump inhibitor
  • “Blueing of the toes”–cyanosis of the digits of the foot
  • “HBP”–hypertension
  • “SOE(SOB on exertion)”–dyspnea on exertion(DOE)
  • “ATPPT(alert to person/place/time)”-Alert and oriented x 3
  • “Lipoma follicular”–follicular lymphoma
  • “Alagesic”-analgesic
  • “Propothol”–propofol
  • “Nodipine“–amlodipine
  • “Oxygen stats”–oxygen sats or saturation
  • “Growth on the neck”–enlarged lymph node
  • “Audio hallucinations”–auditory hallucinations
  • “Whelps”–welts

Medicine is about minimizing risk. That is not to imply that physicians do not make mistakes, of course we do. We are human. However, that fact should not sanction the unsupervised practice of NPs. One does not beget the other. Common sense dictates that those trained and licensed to practice medicine are less likely to commit malpractice/negligence/egregious errors compared to those untrained and unlicensed in it. Attorneys make errors; yet, when defendants in a criminal case wish to avoid the death penalty, how many choose a paralegal to represent them? It would be ludicrous. A defendant understands that his best chance lies with the individual possessing the most expertise in law. It is absolutely astounding to us that legislators, reporters, physicians, etc. think it is perfectly logical to allow people with no training in medicine to manage patients without any oversight whatsoever and no expectation that their practice will be held to the accepted medical standard of care. While those with the actual expertise are devalued and held to exceptionally high standards(as we should be). The commentary that no one has “heard” of any bad outcomes in unsupervised states is absurd. We’ve said it once and will say it again…absence of evidence is not evidence of absence, it simply indicates no one has looked. Maybe, just maybe, a legislator will scrutinize this most unpleasant side of “independent” practice. Or perhaps one day an investigative reporter will get off his/her a** and do what they are paid to do…investigate. Until then, patients are destined to remain in this pathetic comedy of errors.

***DISCLAIMER: THE CASES DISCUSSED ARE FACTUAL. CERTAIN DETAILS HAVE BEEN ALTERED TO PROTECT THE IDENTITY OF THE PATIENTS EXCEPT IN CASES IN WHICH THE STORY HAS ALREADY BEEN PUBLICIZED.***

(Editor’s Note: For twenty years this blog has allowed others to post their opinions here from time to time. This is a physician site so that is who it is geared towards and that is who we allow to post. The opinions expressed by these guest authors do not necessarily purport to reflect the opinions or views of Authentic Medicine or its members. Lastly, any nasty comments by extremists will be deleted. Do not waste your time posting those comments).

UPDATE: The AANP has attacked the PPP due to this blog entry. That is fine. The PPP, of which I am not a part of, can and probably will respond. The members of Authentic Medicine that they mention in their editorial had NOTHING to do with this entry and therefore they should retract their names. This is the definition of slander as their members are known for trolling. As you can see, it was written by select members of the PPP, as the listed right on top, as well as below.

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