A Tragic Comedy of Errors–Part 2

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AB 890, the California bill granting nurse practitioners(NPs) the ability to practice without physician oversight, passed on August 31, 2020. With that passage, legislators have now legalized the illegal practice of medicine by nurse practitioners. The only opposition? Dr. Richard Pan, a pediatrician and my senator. His colleagues in the Senate ignored him…completely. I spoke personally to one Bay Area senator whose perspective was that the “only” people opposing the bill were doctors, as if that presented a reason to be dismissive of the opposition. The irony. It should have raised a HUGE red flag to be even more concerned. Every single organization and/or person supporting the bill were non-physicians. This folks, is exactly how medicine became both a business and politicized…the involvement of individuals who know nothing about nor respect the complexity involved in the practice of medicine. Because it appears easy to them, anyone who works in the “healthcare” industry can practice it. All they have to do is lobby ignorant legislators. And that is exactly what the nurse practitioner organizations did in California. Successfully.

The California chapter of Physicians for Patient Protection(PPP-CA), acutely aware that legislators could give two s**ts about our concerns, decided to take the matter to the people and educate them, so they could better protect themselves. We held a Zoom press conference (https://youtu.be/hKp9uGXEtbg), attended by many reporters and journalists, including veteran TV producer and CNBC columnist, Jake Novak. In the press conference we discussed:

-The history of the Balanced Budget Act which led to the medical residency bottleneck which led to the exponential growth of NP degree mills(profit-driven NP programs with sub-par educational standards and poor oversight by regulatory bodies).

-The inconsistent and nonstandardized NP education, citing a specific example of a degree mill by an RN who subsequently left her program after filing a complaint with several regulatory bodies about the poor standards of the curriculum.

-How the pandemic exposed flaws in the medical system and provided a convenient opportunity for the American Association of Nurse Practitioners(AANP) to attempt to seek nationwide passage of Full Practice Authority(FPA), also known as “independent” practice, also known as practicing medicine without a medical license.

-AB 890, the California bill supporting FPA and the myth of NPs working in rural areas and increasing access.

-Malpractice data for NPs in California and nationwide.

-The case report of Alexus Ochoa, a 19-year old who died after being misdiagnosed by a NP who, although unqualified to work in an ED, applied and was hired anyway. A product of a degree mill. The attorneys for the Ochoa family had the presence of mind to question the NPs educational preparation, something most employers and legislators never question. The family received a jury verdict of 6.1 million dollars.

In January 2020, I wrote an article about patients who were grossly mismanaged by unqualified nurse practitioners.(https://authenticmedicine.com/2020/01/a-tragic-comedy-of-errors/). The type of errors witnessed were those one would expect to see when medicine is practiced by those untrained and unqualified to practice it. These clinical blunders are predictable. Physicians and legislators who defend this nonsense with the excuse that “physicians make mistakes also” must be reminded that there is a difference between making a mistake when one possesses the requisite knowledge and is INCOMPETENT and when one doesn’t because they are UNQUALIFIED. The first can be remediated; the latter cannot because they don’t possess the knowledge and never will unless they attend medical school and complete a residency. Period. This absence of logic never ceases to amaze me: If physicians, who are the only ones educated, trained and licensed to practice medicine can make errors, what the hell do legislators expect to happen with those who have limited to no FORMAL medical education? Appropriate medical education does not guarantee perfect outcomes nor error-free practices because medicine is practiced by human beings. What it does guarantee is less risk of errors based on that fundamental, extensive education.

I have decided, in honor of the nutwads in California who passed AB 890 and who were informed by constituents through multiple letters, meetings and phone calls the dangers of enabling people untrained and unlicensed to practice medicine to do so, to periodically remind them of the errors of their decisions. As a general member of PPP, I have to look at these distressing cases that get sent to us every, single, f***ing day. The public, physicians, legislators and attorneys need to see the same. Therefore, I will present cases in Authentic Medicine from time to time–a series if you will. Then no one, especially legislators, can say they did not know this would happen. The malpractice data they never looked at indicated it. The physicians they ignored warned them. The seasoned nurse practitioners who spoke against FPA and who were silenced by their own informed them. So they knew. And passed this godforsaken law anyway. The legislators are 100% culpable for any damage that results by their assistance in perpetuating this travesty of medicine.

21 year old shows up to the ED with her mother “who has had enough.” Patient is tachycardic, has paroxysmal atrial fibrillation with rapid ventricular response and is visibly jittery. KNOWN history of hyperthyroidism, has never seen nor been referred to an endocrinologist and has been exclusively treated by her nurse practitioner. Reports compliance and brings all meds with her. She has had a 100lb weight loss in the last year. She has lost all muscle mass (she was a competitive weight lifter), developed anxiety, frank confusion and memory impairment so great she was forced to drop out of school. Her TSH hasn’t been checked in nearly a year. NP places her on Risperidone. She also has dry eyes because she cannot fully shut her eyes. Patient gets progressively more confused during her ED stay. She is eventually admitted to the ICU for thyroid storm.

**Failure to manage known hyperthyroidism appropriately

**Failure to refer to or consult an endocrinologist, internist or family medicine physician for appropriate management

**Failure to recognize decreased quality of life related to untreated hyperthyroidism

** Inappropriate treatment of worsening hyperthyroidism with anti-psychotic

4 year old child presents to an urgent care on the weekend with pain and redness of scrotum for several days. Nurse practitioner documents “red hot scrotum”. Instead of sending patient to the nearest pediatric medical facility(15 minutes away) to r/o testicular torsion, NP sends patient to small, remote, community hospital without notifying ED staff. Community ED doc, recognizing urgency of situation, convinces ultrasound tech(who is off and not on call) to come in emergently. Patient found to have cellulitis of scrotum and epididymitis. Urologist on call, although not peds uro, agrees patient can be sent home with antibiotics and close follow up. Urologist sees patient the next morning. Patient recovers well.
**Failure to follow medical standard for management of potential testicular torsion(time is testicle)

**Failure to consult supervising physician or medical director


**Failure to notify ED of transfer; thereby missing the opportunity to redirect patient to more appropriate pediatric hospital and further delaying care

80 year old with hypertension, obstructive sleep apnea and congestive heart failure undergoing ORIF of right hip. 2.0 liters of blood lost intraoperatively and patient becomes hypotensive with low ETCO2 and dampened A-line wave form. CRNA fails to notice markedly enlarged right lower extremity and assumes source of abnormal findings is related to other causes. Anesthesiologist rounding on patients in the OR notices the situation, takes note of the patient’s enlarged right leg and immediately orders PRBC transfusion and vasopressors. Patient survives the operation and a code is averted.

**Failure of CRNA to recognize hypotension/low ETCO2/and flattened A-line waveform were the result of blood loss

**Failure to request assistance by supervising anesthesiologist

A pediatric nurse practitioner(PNP) assesses a 1-week old neonate with persistent tachypnea in a hospital-associated outpatient clinic. Patient has an abnormal chest X-ray and is sent home with a prescription for Amoxicillin. No other work up done, including labs. Three days later patient is admitted to hospital by pediatric resident for persistent tachypnea. Labs and blood cultures are drawn. Blood culture grows out gram negative rods in less than 12 hours. Patient ultimately transferred to NICU with worsening respiratory distress and required 5 liters humidified high flow oxygen by nasal cannula. Echocardiogram demonstrated an AP window. Neonate most likely aspirated feedings because of tachypnea and developed sepsis. Neonate survives and is transferred to a tertiary care hospital for cardiothoracic surgery.
**Failure to appropriately work up and admit a neonate with tachypnea 

**Inappropriate medical management of tachypneic neonate

**Failure to consult with a pediatrician or supervising/collaborating physician 

4 month old seen in ED with multiple seizures–daily. Infant has had generalized seizures(documented on video) for several weeks. Parents have seen the pediatrician many times and were told the seizures were “breath holding spells”. “Pediatrician” is a nurse practitioner. Patient admitted from ED for work up of new-onset seizures. 

**Failure to recognize seizure activity

**Failure to admit for new-onset seizures

**Failure to consult a neurologist or pediatrician for assistance

**Delay in care–potential long term brain damage remains to be seen

40 year old previously healthy female seen by NP at UC with history of nausea, vomiting and lethargy for one week. Also with cough, fever and h/o known COVID exposure. Husband states wife can only stay awake 2-3 hours/day. Physical exam by NP simply states patient is not ill-appearing and documents review of systems is “within normal limits”. No labs are done and no vital signs or diagnosis are documented. Patient is sent home with instructions to return if worse. Patient presents to the ED a few days later in frank DKA and with a creatinine of 5.0. Patient ultimately diagnosed as new onset DM with urosepsis, acute renal failure and possible COVID infection. Patient survives.

**Failure to perform a complete physical exam with vital signs and ancillary studies-history is very concerning for COVID 19 infection

** Failure to document a complete physical exam and vital signs

**Failure to consult a supervising or “collaborating” physician

60-something year old presents to UC of a major hospital for chest pain and is seen by a NP. EKG displays a clear STEMI. NP, unsure of the EKG’s findings, advises the patient to drive to the nearest ED for further evaluation. NP does not notify the ED attending that she is sending a STEMI. SIX HOURS LATER patient gets seen in the ED. ED physician accesses the EKG from the UC which is in the same hospital system and instantly recognizes the obvious STEMI. Patient sent immediately to cath lab but unfortunately dies the following day.

**Failure to recognize a STEMI on EKG


**Failure to activate STEMI protocol; therefore, delaying care and increasing risk of mortality/morbidity

**Failure to consult supervising physician

Pre-adolescent child seen at an UC by a NP for abdominal pain. NP documents RLQ that is tender to palpation and that patient is guarding. Patient is diagnosed with constipation and sent home with stool softeners. 4 days later, patient presents to the ED and is diagnosed with ruptured appendix. Several milliliters of purulent material are removed from child’s abdomen, at bedside, by interventional radiology. Patient admitted to PICU for ruptured appy with abscess and sepsis. Patient survives.

**Failure to diagnose appendicitis, despite concerning exam

**Failure to consult supervising physician

30-something patient seen by NP in clinic for fever and RUQ pain. Patient with obvious jaundice. NP swabs patient’s throat despite patient having no complaint of throat or neck pain suggestive of pharyngitis. Swab was positive for strep. Patient treated for strep and advised that strep can cause abdominal pain. No reference to patient’s jaundice. Three days later patient presents to ED with worsening abdominal pain, is diagnosed with choledolithiasis with cholelithiasis and transferred by air ambulance to a tertiary care center.

**Failure to address jaundice in an acute setting

**Failure to consider a broader differential diagnosis besides acute pharyngitis

**Failure to consult a supervising or “collaborating” physician

As I have stated in the past, these cases are not representative of authentic medicine….they are a TRAVESTY of medicine. A tragic comedy of errors. And no one is paying a greater price than the patients.

***The photo is of Betty Wattenbarger and is provided courtesy of Jeremy David Wattenbarger, her father. He contacted Physicians for Patient Protection(PPP) and asked us to share Betty’s story, which is in the link below her picture. Although I am a general member of PPP, this Authentic Medicine article, “A Tragic Comedy of Errors-Part 2”, is not associated with that organization. I am the sole author.***

***DISCLAIMER: THE CASES PRESENTED IN THIS ARTICLE 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.***

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Natalie Newman MD

Dr. Natalie Newman is a residency-trained, board-certified emergency physician who has been practicing for over 20 years. She graduated from California State University in Sacramento, California with a degree in Biological Sciences. She then attended medical school at Case Western Reserve University in Cleveland, Ohio on an Army scholarship. As a graduating senior, Dr. Newman was presented with the Marjorie M. and Henry F. Saunders award for her compassionate care of patients within the family structure. After her graduation, she was accepted into the Emergency Medicine Residency at North Shore University Hospital in Manhasset, New York. Upon her graduation, Dr. Newman entered active duty service with the U.S. Army. Her first assignment was at Womack Army Medical Center in Fort Bragg, North Carolina. During her stint in the Army, Dr. Newman was deployed to Bosnia-Herzegovina(formerly Yugoslavia) where she was Chief of the Emergency Department at Eagle Base in Tuzla, Bosnia. She had the honor of serving under the command of Colonel Rhonda Cornum(now a retired brigadier general), a urologist, pilot and former prisoner-of-war during the Persian Gulf War. While in Bosnia, and as the only American female physician in the Balkans at that time, Dr. Newman was assigned as the official physician for Queen Noor of Jordan during a humanitarian visit to a local hospital in Bosnia. After her return home to the U.S., she was promoted to Major and completed the rest of her Army service at Fort Bragg. Dr. Newman subsequently returned to her home state of California. She has worked in rural facilities, community hospitals and trauma centers. She has also served as a ship physician for a major cruise line and also provided physician services at the Coachella/Stagecoach Festival in Indio, California for three years. Dr. Newman participates in public speaking engagements discussing the value of education, of which she is passionate. She continues to practice clinically as a traveling physician. 

  8 comments for “A Tragic Comedy of Errors–Part 2

  1. Roger
    September 19, 2020 at 1:58 pm

    Sorry, MD training does not “guarantee” (your words) “less risk of errors.” There are legions of bumbling, clueless people who take pride in their many years of education and fancy degrees. Incompetent, overconfident graduates get accepted to and complete residencies all the time. One could just as easily come up with a long list of horrible mistakes by physicians. What is bizarre is that you seem to think your wall of anecdotes proves anything.

    Sadly, it may reveal more than you realize about the inadequacies of the very training you seek to defend. Medicine is an inward-looking culture where the ability to rattle off long lists of facts with lots of jargon is too often accepted as having self-evident value. Learned people in other professions far less insulated by government-imposed barriers to competition know that this simply does not reflect reality.

  2. Eleanor Sniegowski, RN,MS
    September 16, 2020 at 3:24 pm

    As an ED nurse for over 40 years (now retired), I respect the NP’s for what they contribute to our current state of medical affairs. But, a nurse or NP is NOT a doctor and should confine their practice to work under supervision of an MD or DO. Who once said, “A little knowledge is a dangerous thing”, must have had a crystal ball. The education received by physicians is much more extensive and should be respected as such.

  3. Steve O'
    September 14, 2020 at 8:10 pm

    It’s not just in medicine, it’s corporatism in general. Whom do you trust more – The Mayo Clinic or some doctor who says that a patient was treated poorly there? Hint – who spends millions of dollars on spinvertizing to put their label out there? Or the American Board of Medical Specialties? They spend buku dollars extorted from their members to stick a label on their foreheads.
    One of the core elements of 21st century business is that you (the stupid consumer) cannot tell what good or bad quality care is. It’s all about the fictitious choices that consumer is encouraged to make. Coke or Pepsi? Doctor Pepper?
    I saw an intriguing statement on COVID by an independently-practicing physicians’ assistant. This PA is a hospitalist-specialist PA.
    Corporations are distinctly aware of morality. They will give you only the quality of product that you care about. If you don’t care what sort of service you get – why should they? If you prefer billboards with flowers and rainbows over smiling babies, to someone who knows what to do in a breech presentation at home – why should they?

  4. L. Ammerman
    September 14, 2020 at 7:36 pm

    Medicine is now being run by cut throat businessmen. Just like our nation.

  5. Dr Bonz
    September 14, 2020 at 12:09 pm

    So how much are these newly independent NPs going to have to pay in malpractice premiums?

    • ABS
      September 21, 2020 at 8:35 pm

      I don’t care who you are or what you do for a living. We will ALL be patients at some point in our life. And we are losing our RIGHT as patients to choose and losing our right to consent to treatment.

      When I am a patient I want someone taking care of me who is not practicing at the top of their license. I want them to know how to treat something or process information in a split second or do a procedure with one hand tied behind their back.

      I am afraid of what is going to happen to me when I am hospitalized or in the ER or intubated in the ICU.

      The last surgery I had I asked for an anesthesiologist for an elective case. But I was knocked out with fetanyl and versed. Woke up to realize the anesthesiologist hand me over to a CRNA.

      This is so terrifying.

  6. Diane
    September 14, 2020 at 11:38 am

    How does this information get to the persons that have authority to revoke NP practice in the ED. I would gladly sign a petition. I’m a retired RN and my daughter is Residency trained EDPhysician that lost her job to a NP in the ED. It is outrageous

    • Natalie Newman, MD
      September 15, 2020 at 12:53 am

      Unfortunately, it is not that easy. The C-suite has decided that NPs/PAs are cheaper and more pliant than physicians and therefore are more desirable to hire. Docs get terminated and NPs/PAs are hired to replace them. That is why this fixation on the physician shortage is a joke. It doesn’t require a physician shortage to replace docs. It simply requires a lack of ethics and abject greed.

      I believe there are legal grounds to challenge the practices of some NPs, many of whom practice outside their scope. IMO, those in states that permit FPA are practicing medicine without a medical license. Hospital and departmental leaders generally have no idea what is entailed in the NP curriculum and just how inconsistent it is. The quality of NPs varies greatly because their education is non-standardized and poorly regulated. Much is presumed about their qualifications, hence there are no barriers except those NPs set themselves.

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