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  • Writer's pictureRebekah Bernard

What happens when hospitals replace physicians with NPs?

In the book Patients at Risk, we discuss the tragic case of Alexus Ochoa, a 19-year-old woman who died when a nurse practitioner failed to diagnose the blood clot in her lungs. The nurse practitioner was unprepared to treat emergency room patients and there was no physician on-site, even though the hospital advertised that physicians were available 24/7. Today we are joined with attorney Travis Dunn, one of the lead attorneys who helped Alexus’s family win a major financial settlement against Mercy Health Systems for replacing physicians with nurse practitioners.

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Rebekah Bernard MD 0:07

Welcome to 'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I'm your host, Dr. Rebekah Bernard, and I'm joined by my co-host and the co-author of our book, 'Patients at risk the rise of the nurse practitioner and physician assistant in healthcare,' Dr. Niran Al-Agba.

Niran Al-Agba MD 0:24

Good evening.

Rebekah Bernard MD 0:26

In our book, we discussed the tragic case of Alexis Ochoa, a 19-year-old woman who died when a nurse practitioner failed to diagnose the blood clot in her lungs. The nurse practitioner was unprepared to treat emergency room patients and there was no physician on-site, even though the hospital advertise that they were physicians 24/7.

Today we are joined by Attorney Travis Dunn. He's one of the lead attorneys who helped Alexus's family win a major financial settlement against Mercy Health Systems. Mr. Dunn, welcome to the show.

Travis Dunn 0:56

Thank you. Thanks for having me.

Rebekah Bernard MD 0:58

Thank you so much for joining us. And we really want to thank you for all the help you gave us in writing the book. And I was just wondering if you could start out by just telling us a little bit about yourself and how you got involved in litigation.

Travis Dunn 1:10

Sure, I always wanted to be a litigator. And there are lots of lawyers, lawyers do lots of important things. But for me, a lawyer was always a litigator, I started working for a medical malpractice defense firm in law school, and I worked there for 10 years after I graduated and then decided to make the change to the good guys - to the other side -and join one of the firms that eventually merged to be the firm I work with now.

Niran Al-Agba MD 1:39

So I would start by saying no offense taken, of course, because we love you guys. And you and Glendell Nix are sort of heroes of ours because of the work you did on this case. And of course, most of the public doesn't know and what I've been dying to talk to you about for a really long time is what a hard time Mercy gave you. And I think that some element that a lot of people don't understand, they think you just ask for records and you get records. And what I ended up leaving out of the book, because it was too convoluted to explain really, was this deletion of medical records after she died.

And that's something we really haven't talked about before, but you really have kind of opened up this opportunity to talk about it, because just to let the story at least have the public so they know. Essentially, after Alexus died, the admitting nurse practitioner -or the hospitalist - and her supervising hospitalist reached out to medical, I guess risk or the risk management people and said, 'you know, what do we do about this, we recognize that this nurse practitioner missed all this in the ER, we documented it.' And they elected to delete the record entirely.

And so there's probably more to it. But if you could tell me a little bit more about sort of, I guess a couple of things, how to get into Mercy and how to get these records and how to find this kind of stuff out?

Travis Dunn 2:54

Well, I think that is one of the two biggest hurdles we have to overcome today in these types of lawsuits and the sort of litigation, and in this particular case, I can tell you the facts, and you can make your own assumptions or opinions about what happened.

But Alexus was admitted by a nurse practitioner - was seen by a nurse practitioner - and then she called another nurse practitioner to admit her into the hospital and told her that she had elevated heart rate, and some other information. And then the second nurse practitioner said 'okay, go ahead, admit her.' Now the second nurse practitioner, the hospitalist or the nurse practitioner who was assigned to be the hospitalist was at home at about 3am. And she made a quick note in the electronic medical record. The next morning, she gets to the hospital, she views the actual chart, she sees that Alexus had basically every textbook sign and symptom of a pulmonary embolism, that that information was communicated to her at 3am in the morning. So she makes a note, we called it the CYA note where she indicates she basically lists all the symptoms that are in the medical record at that time, and specifically notes that she was not informed of the signs and symptoms at the time that Alexus was admitted. And the supervising physician comes into work that morning. He looks at the record, we know that from the audit trail, he then sends an email to risk management is entitled 'urgent contact me immediately.' Then the 8am note is deleted. And then he signs off on the record. So that leaves the original note that didn't provide any symptoms. And then the hospitalist's final note where she was transferred to OU, omitting the note - deleting the note - that lists all the signs and symptoms that were present that second nurse practitioner is not informed.

And the only reason we knew about that was because we had a judge that was willing to look at the evidence and listen to argument. And mercy was ordered to produce the metadata, the audit trail, the audit log, we got that, that's when we realized there was a lot of information that was missing specifically this one note. Had we not had that judge, and we had a different judge that had a different slant, had a different opinion, a different interpretation, we wouldn't have gotten that - that was a pretty key piece of evidence. And the same judge also gave us access to some of the hospital's investigations, and most judges wouldn't have. And that was also another key piece of evidence in the case. But without that audit trail, without the metadata from the electronic medical record, we would never have known that there were pieces of information, pieces of the medical record, and entire nurse's notes that were deleted.

Niran Al-Agba MD 5:46

Now, why do you think hospitals are so... or judges are...? And I don't know the judges are, but why do you think so often it could go the other way, and that hospitals are so protected?

Travis Dunn 5:56

There's two different really - let's talk about the medical records. First, the metadata, judges don't understand. And a lot of times, it's our job to educate them on what the federal law is, what the state law is, and the fact that the privileges don't apply to protect the medical record itself and the underlying information in the electronic medical record. In Oklahoma, there's not a lot of, there's not any, state law that provides guidance. And so you have to look to federal law to provide persuasive authority to the court and allow judges, you know, they have 40 cases on the docket, and they don't want to take the time.

And then there's a natural predisposition to protect the hospitals' privileges. And so you really have to lay it out in black and white, and show them. And it's getting easier, you know, this case was several years ago, the judges in Oklahoma County in Oklahoma are a lot more willing to provide that audit trail information now than they were. Back then it was a very rare thing for us to get that. And it took a lot of work. And, in fact, the investigative part of it went all the way to the Oklahoma Supreme Court on a writ and we had to put the whole case on hold while the Supreme Court looked at it and go argue there, and then come back down and proceed with litigation. So things are easier now.

But as far as the electronic medical record aspect, you just really have to go step 1-2-3-4. And lay out the federal HIPAA regulations to the local courts, and convince them that this is actually the property of the patient, and they should have access.

Rebekah Bernard MD 7:32

You know, Travis, when you talk about, you know, the good side, the bad side, you know, it's such an interesting thing, because, from my perspective, as a physician, I don't want to see any doctors, nurse practitioners or anybody get into trouble. But on the other hand, this seems to be sometimes the only way that there's accountability.

And I think what's so fascinating about this case, in particular, is that you and your firm were able to show the facts, which were that Mercy had a systematic approach of hiring nurse practitioners to work in positions that they were not supposed to work in. And you actually were able to show that it had to do with cost savings that patients were being deceived.

Did you have any idea that any of these things were happening before you had this case?

Travis Dunn 8:15

No. Well, I mean, yes, we knew that there were mid-level practitioners that were being used to save money. But, you know, I didn't know a whole lot about nurse practitioners or their scope of practice or their license or anything.

And when this case came in, we didn't even know it was about nurse practitioners because this particular nurse practitioner, represented herself to the family as a physician.

We had to inform the family. I remember very clearly telling Alexus's boyfriend that the person that he'd been dealing with, that he thought was a doctor was in fact a nurse practitioner. And this was a year after she died. He had no idea.

So we really approached the case from the perspective of understanding that nurse practitioners have a role to play in the emergency room. And that even though this nurse practitioner made a lot of mistakes, she should never have been in that position. Though she was credentialed, she was given assignments, she was scheduled to be the only provider in the entire building at the time. And although she certainly made mistakes, and didn't handle things the way that we think she should have, she should never be in that position. She should have been the only provider in the building, she should never have been required to diagnose a pulmonary embolism. And so we approached it from not necessarily making her the bad guy or blaming her but from why was she there, knowing what should have happened. That's that was our approach.

Niran Al-Agba MD 9:45

And the second piece of that I'm so glad you mentioned that because we've talked a lot about this in our book. It isn't about saying all nurse practitioners are bad. It was that she was thrown into a position she really wasn't trained for and that's the responsibility of Mercy. So the second piece that I wanted to talk to you about so much is that here they had identified that she had, you know, nurse practitioner Thompson had made a number of mistakes on other cases, and they had sort of deemed her as not doing high-quality care. Well, I'm not saying the right words, but essentially, they'd been worried about her and terminated her and then let her work 30 days out. To finish out the shifts for which she had already been assigned on one of those last shifts is where she ran into Alexus Ochoa and misdiagnosed her, and Alexus died. And so the second question I had for you was sort of how can this go on when you identify someone who's really incapable of doing their job for whatever reason, whether it's a doctor, whether it's a nurse practitioner, how are these hospitals able to shield this and continue to do this?

Travis Dunn 10:47

I've actually written quite a bit about that issue. And I'm sure it's not my original idea, probably stole it from somewhere, but I have in briefing compared the way airline crashes are investigated with the way medical errors - and if there's a plane crash by a commercial carrier, the National Transportation Bureau comes in, they do a thorough investigation, it's all a matter of public record. Everyone sees what has happened, everyone has access to that information.

Contrast that with the way hospitals conduct an investigation, everything is privileged, you know, find out any information about any doctor, or provider, all that information is kept strictly confidential. And I think that is the reason airline travel is the safest way to travel and medical errors are the third leading cause of death states.

In Oklahoma, there are two privileges that control those sorts of investigations. And we had, again, we had a judge that was going to look at the law. And we were fortunate in that the peer review privileges in the state of Oklahoma are written about doctors, this wasn't a doc. And so while the hospital believed these investigations were going to be protected and were brutally honest in their internal investigation as a result of that, they weren't because it wasn't a physician, and that these statutes to protect those investigations don't apply.

So we had all their internal documents with regard to the investigation, that's where it was revealed that she had a long list of quality concerns, Misdiagnosing, not making workups, misinterpreting test results, ignoring patient symptoms, working back-to-back 24-hour shifts with different hospital systems, and they decided to fire her. And then we got access to internal emails where there's a conversation about 'well, we if we fire her for cause we have to pay her 30 days. But if we just fire without cause and let her work the rest of 30 days, we don't have to pay to people who do that work.' And so they sent her a letter of termination that was to take effect a month after the letter. And it was her next to the last shift that Alexus came in. So that was an aggravating factor.

And in the lawsuit, also when we depose the doctors who were part of the investigation, they said there were no problem, no problems with her, quality was fine. And then we get to documents where they were on the records, they will not accept any more patients from this person. she doesn't do a complete workup. And it was it turned out to be a lot of really persuasive information. And again, it's because we had a good judge, that was one to look at the law. A lot of judges would have seen that document stamped 'peer review.' And that would have been the end of the inquiry. And it was peer review but this judge took some time to look at the actual records, to the statutes and corrected rule that we should have access to that information. If there were more of those types of investigations that were made public, I really believe we would have a lot fewer medical errors.

When they terminated [Nurse Thompson] and she went off to Iowa to work, they gave her a letter of recommendation because she wasn't fired for cause. And so they passed her on to another hospital system without telling anyone that she had had a long list of complaints.

So I just really believe that I understand the public policy argument by keeping these investigations confidential. But I think the public would be much better served. If there were no sort of privileges of all the investigations were conducted.

Rebekah Bernard MD 14:22

Well, it sounds very much like that 'Doctor Death' case in which, you know, they just kept passing him from hospital to hospital. And, you know, it doesn't just happen to doctors, it happens with all sorts of different professionals. And I'm guessing maybe they're afraid they're going to get sued or something like that for not getting a recommendation?

Travis Dunn 14:37

Well, I guess - I mean, I don't know. I don't understand why they would have done that. But they certainly did. And the other thing that was frustrating, they said they sent her for working her back about shifts. When Mercy was the second shift, they said you can never do this again. Don't ever do this.

But they didn't have any complaints about her going to work for Baptist after working a 24 hour Mercy shift. And when we kind of challenged them in depositions about that, 'well, that's not our responsibility. Those are our patients,' which I thought was very telling, but they didn't even notify Baptist that she was double booking that she was going to work at Baptist, after working a 24-hour shift at Mercy.

Niran Al-Agba MD 15:22

Speaking of responsibility. That was the third aspect I wanted to talk to you about this case in, in that, you know, her supervising physicians sort of number one, they knew she was working double shifts. Number two, I think she was even taking call or working at different hospitals. So different Mercy sites, right. And what kills me is she didn't even know who her supervising physician, she didn't know who he was.

And when I compare that to there's a case I'm sure you've probably heard pieces of it out of Minnesota, where there's a physician who got a phone call from a nurse practitioner. He wasn't even supervising, had nothing to do with, and he was I think, the admitting physician, and he said, 'No, that person doesn't need to be admitted.' And the information had been repeated to him incorrectly, basically, from the nurse practitioner, and, and so in a nutshell, he is being sued for responsibility for this death of this patient, even though he never saw the patient, he wasn't obligated to oversee the nurse practitioner, the nurse practitioner had a supervising physician elsewhere. So I guess that's my long way of asking, Why didn't Brent face more backlash or more dings on his license? I mean, technically, he was supervising her. And why was there why were they able to separate that versus other areas of the country that don't seem to be able to do that, even when they're a supervisory state?

Travis Dunn 16:38

it was actually much worse, because Mercy wanted to use more and more nurse practitioners. And Oklahoma has a specific statute that says a physician can only supervise two nurse practitioners. So they were recruiting physicians who had privileges at the hospital to sign off sign the paperwork as being supervising physicians, for people they've never met, who they never worked with nurse practitioners never heard of. And, you know, to a couple of folks' credit, when got those emails, they were doctors that said, 'I'm not going to sign off on being a supervisor for someone that I've never met.' But there were lots and lots of doctors that did.

So this physician, and was her supervisor position and also was a director of the ER department. He took the brunt of that. But there are a lot of docs that had signed off as being supervising physicians for nurse practitioners, but didn't know their names. They never met him. You know, and I think Dr. Wilson, the main reason that he was assigned some liability was because he had responsibility for overseeing the emergency department. And he really had no, you know, I took this deposition, very nice guy, but

[Nurse Thompson's supervising physician] had no concept of the educational limitations, the license limitations of the nurse practitioners, and was operating under the belief that they had a broad scope of practice, as opposed to being a very narrow scope of practice in a very small area of medicine. And so he thought, I think he pretty much admitted this, if you got a nurse practitioner, they can do anything.

Niran Al-Agba MD 18:18

He did. He did say that his deposition, he said that they can do whatever any other ER doctor can do.

Travis Dunn 18:24

Right? And these folks have a minimum school. No, they haven't had any sort of internship or residency or fellowship or anything. And I think the way the system was designed was just for them to act in a very narrow scope to very few things which they have education and to do with oversight, but they were treating - they were credentialing these nurse practitioners - as physicians, to do anything a physician can do without supervision. And that's why Alexus died. I mean, Nurse Thompson made a lot of mistakes, but she should never have been there. Alexus died because Mercy was just wholesale substituting nurse practitioners for physicians.

Rebekah Bernard MD 19:07

And you know, this is happening with corporations and academic centers, even teaching hospitals across the country, we are seeing this exact same scenario. And this is actually why we wanted to write this book, because just like maybe Dr. Wilson didn't know, maybe he knew, but he didn't know.

We think that physicians all across the country, hospital administrators, patients, don't know what nurse practitioner training is, and that nurse practitioners and physicians are not equivalent. And so we just wanted to make sure that patients were able to ask and say, 'Are you a physician?' If a patient isn't doing well, 'could you please call a physician to oversee my care?' Because it's so interesting - Mercy being a multi-billion dollar corporation, and they have only a nurse practitioner as a hospitalist and a nurse practitioner in the ER. I mean, this to me is crazy.

And this was not a rural area. They tried to make the argument that they were rural.

Travis Dunn 20:01

Yeah, it's a funny story. And I know you guys are limited on time. But it's worth telling when we were trying this case, Mercy brought in their National Counsel, big, big firm from Atlanta, was not familiar with Oklahoma City at all. And during jury selection, he kept saying El Paso instead of El Reno. And he was saying, 'you know, in El Paso is an hour away.' And finally one of the prospective jurors, and I think it was actually a juror that ended up serving said, 'do you do you mean El Reno? Because El Reno is not an hour away.' You know, because the ambulance ride, it's an important point, they tried to paint this as a rural facility.

But when Alexus was transferred from El Reno, to OU Medical Center, Oklahoma City, it was a 22-minute ambulance ride. So it wasn't a rural area, they have access to whatever they needed. They were just trying to save money.

And, you know, when we were going through kind of trying to figure this stuff out ourselves, it was interesting. Their defense was, 'well, she was a firefighter, she was a paramedic, she's worked in the emergency room as a nurse, you know,' and that was, you know, when we're taking those definitions, 'okay, well, how many times you order a test isn't? How many times did you interpret the test result? How many times do you make a diagnosis? how many times - ? ' you know, and it just the comparison doesn't hold up. I mean, nurses are important, provide an important function, but they don't decide what tests are run. They don't interpret those tests, they don't diagnose conditions, and rely on her experience as an emergency room nurse to justify her being in charge of an emergency room and making diagnoses especially, you know, diagnoses like pulmonary embolism. There just really wasn't an excuse for it. It wasn't a way to justify -

Rebekah Bernard MD 21:49

Or even to know that somebody isn't doing well, you may not know what's wrong with them, but you see that they are unstable, they're getting worse, everything you're doing, they're getting worse. And yet you continue to try different treatments, that's when you pick up the phone, and you call somebody who knows more than you do. I'm a family doctor, I'm not an ER doctor. And I would never assume to be and never put myself in that position because I know I'm not qualified. But I can look at a person and say, 'Whoa, this person is sick. And I need to get somebody that knows what they're doing involved.' And I think that's what was so egregious about this case, like 13 hours, with a woman continuously decompensating and no action taken.

Niran Al-Agba MD 22:26

Well, ironically, she did call the other doc at Oklahoma Heart twice. But what's fascinating about that, and that harkens back to this case out of Minnesota as well, the nurse practitioner didn't know the right information to provide. So what I found that was so interesting is when the hospitalist nurse practitioner who said 'I wasn't told this, I wasn't told this, I wasn't told this' in that note she later deleted. That's true of the cardiologists that nurse Thompson called initially because she sort of presented Alexus as an amphetamine abuse or toxicity case, and didn't say more. And as she when she called a second time, like you're talking about Rebekah, you know, she finally provided the information the doctor needed, and he just said, 'Wow, we need a CT scan, and we need a D dimer.' The shame is that while she knew she needed help, she didn't even know what kind of help she needed.

Travis Dunn 23:15

She didn't recognize the signs and symptoms of pulmonary embolism. And you know, that's why that deleted note became so important in the case was because she claimed that she advised the doctor of the Heart Hospital of all the signs and symptoms. And he said, she told me about the elevated heart rate and one positive Meth test. And that's exactly what she told the admitting nurse practitioner.

And so when we're able to get access to that metadata and show the original note where she says, she told me she had all that heart rate, but she didn't tell me all these other textbook signs, it lined up perfectly with what the doctor at the Heart Hospital has said, 'This is what she told me.' And so that's why having access to that sort of metadata and those audit trails is so important. Had it had we not had that it would have been really a battle of credibility between nurse practitioner and doctor 'he said, she said,' But but but when you had when you see it written down in the note, she had the symptoms, and she didn't tell the nurse practitioner and tell me about it. And then that recitation is precisely and I mean, exactly lines up with what the sworn testimony of the doctor and hospital, it really kind of shows you what the truth is.

Niran Al-Agba MD 24:32

Well, and you know, it's interesting. I've looked at two other cases where children have died, and they were and were either managed by PAs or nurse practitioners and so far the records have been altered in those cases as well. And I find it fascinating that when you get into this metadata, which I think is really important for probably trial lawyers, although I don't know much about that. But I think really getting the metadata, which is it's so important, because in both cases, so really all three cases I'm aware of where we've had this situation, they go back and they alter the record. And of course, we're trained as physicians not to do that.

I mean, I'm on paper. And so my alteration of the record is two lines with a ruler. And I'm sure you're very familiar with that, where you can still see what we wrote. And it's like, Oops, I made this or that, I put down the wrong height or the wrong weight. And cross with two lines and then initial, and then you write the proper answer. And generally, if I'm going to do what I call a late entry, let's say I didn't fix a dictation, or I made a mistake somewhere and I find it a year later, I put the new date like a year later, I say 'this is a late entry error on this prior dates, here is what it should have said' or whatever. So there, there's a trail of it, where 'Yes, I did this here. And here it is.' But I think essentially, that's hidden in this electronic record system, except when you get into the metadata. And they all and I'm sure physicians probably alter it to I haven't come across that yet. I'm sure it happens. But I think this idea that after a person dies, you go back and fix the record is really kind of scary, to me,

Travis Dunn 26:00

it is scary. And like you said, the way it used to be it was all paper. So if there was a late entry or an alternate entry, you can see it, even if it was even if they tried to hide it as the know will be on a different page. So, it was easy to see. The way that these electronic medical records are set up now, they can hide anything, you know, if they're willing to do it. And I always believed, even after this case, that if I got a record, and there was a note, or an op report, or whatever it said version one of one, that that was it, there were no other versions, because I thought that was at least one check on it. But now I've learned that they can print the third version of the record, the third version of the op report, and make it read version one of one.

And so there is no way without getting the audit trail in the metadata to authenticate the record to know that this is the care that was received, actually received, as opposed to something that was put in the record yours later. And that is it's a fight. I mean, we have multiple Mercy cases right now. And in every single case, we have to file a motion with the court to get the audit trail. Now we're starting to get it, it used to be we didn't always but now I think the courts have kind of caught on to what it is. And we're getting those now. But at the time of this trial, you know, which dates back a few years this is one of the first ones we got.

Rebekah Bernard MD 27:31

Travis you guys won a $6 million verdict for the Ochoa family. And that's a lot of money. But then when I think about how much money Mercy makes, I wonder and I ask myself, 'does this even hurt them? Does it make them change their behavior? Is this going to hold these corporations accountable?' What are your thoughts on that?

Travis Dunn 27:50

I go back and forth. You know, I feel like what this was Mercy, this is this was a paid out of Mercy's operating, their self-retention. It wasn't insured. And there were actual, and I think to give Dr. Wilson who, you know, I gave a hard time on deposition, to give him some credit, I think he was actually instrumental in getting some policies changed regard to supervision of nurse practitioners. And I think, hopefully, Mercy is doing these a little differently now with regard to that.

But you know, it's one of those things in the closing argument, and this is probably in the minutia that you don't really want to know about, but we had it set up to get into punitive damages. I think if we got into that, and we could have told the jury how much money that Mercy was saving by doing this, the verdict would have been very different. And the defense counsel said, 'Well, you know if you check punitive damage, we're going to have to come back and do another trial.' And I, you know, and that that comment slipped past me at the time. You know, I think looking back, if I just said, you know, 'it's one witness, you've been here for two weeks. Give me another two hours.' I think they would have- because I believe that they would have awarded punitive damages, I believe the jury was headed in that direction. But they're human beings, too. They have their own lives. They just spent two weeks in this trial. You know, and I think that was a key point that I wish I'd go back and do it differently. I would have addressed that.

Niran Al-Agba MD 29:16

Are you allowed to say how much they saved?

Travis Dunn 29:19

No, I don't think so. Because it's not - everything we talked about thus far as a matter of public record because it was evidence admitted. The stuff that we were prepared to admit in the punitive session we didn't get to. So I don't think I'm allowed to talk about that.

Rebekah Bernard MD 29:34

So, the idea being though, if you had sought larger damages, maybe that would have made a larger impact on mercy and made them change their ways?

Travis Dunn 29:42

Well, that's the idea, but it's not larger. So there are two types of damages. There are compensatory damages that are designed to compensate the family for their loss. That's what the jury awarded. If we can show that the corporation acted with reckless indifference or with malice, then we can get into what's called punitive damages which are intended to punish the defendant. And I think we were really close there. And if we had got to that point, we would have been able to show the investigative documents where they were still using nurse practitioners in the same way, we would've been able to show how much money they saved, we would've been able to show how much money they make, we've been able to argue, 'if you want to change this behavior, you have to hit this billion-dollar corporation hard enough for them to change.' And so we weren't allowed to get into that, because the jury did not find that they acted with reckless indifference.

Niran Al-Agba MD 30:41

Can I ask just how else we should hold these hospitals accountable?

Travis Dunn 30:46

I think you just have to get, we have to take this next step. And you have to be successful in convincing juries that they need to. It's not just about compensating the family, which they did. But it's about punishing the defendant is about changing behavior. And once you get past that hurdle, and you're able to admit to the jury to show the jury, this is a $6 billion corporation, they still you know, they're doing this, they're continuing to do the same thing today. You know, we had testimony from one of the higher-ups that they would hire, they're still doing the same hiring practices.

You know, if we could have got that in the second stage of trial, I believe the jury would have awarded punitive damages. And that would have been a function of not having what it takes to compensate the parents of Alexus, but what it takes to change versus behavior, and that would have been much bigger.

Rebekah Bernard MD 31:38

Yeah. And I think that is going to take that. I can speak for myself, and a lot of physicians that I know, we've often been pressured by administrators, by managers, by supervisors, to practice outside of the correct bounds of medicine and our oath of medicine. And we're told, 'Oh, just sign off, and it'll be okay.' And just work without functioning electronic health records and just work without a proper - like, there's an obstetrician right now that's being sued, because she delivered a baby when all the systems were down. And instead of taking responsibility for their systems, being down the hospital said, 'Well, the doctor shouldn't have delivered her if she thought it was dangerous.' So I mean, but this is the kind of behavior that is so common, and it's, and if you complain, or you say, you're not going to do it, they fire you. And so then you have very little recourse. So I think the only thing we can do is to find these cases and try to bring them public and try to get accountability.

Travis Dunn 32:30

I agree. And I think one of the most important steps to get to that point is to limit the privileges associated with investigations because that's where you get, that's where you find out about Dr. Death. That's where you find out about all the other incidents that this nurse had, you know, if you can get if you can make the investigations public, if we can get access to that information, then you can show a jury, 'hey, no, this wasn't her first rodeo.' She had lots of other problems and they kept sending her back, or they passed her on to a facility in Iowa and didn't tell them about this. You know, that's where you think you can really create damages for the system - for Mercy system, for Integra system, for those sort of health care corporations as opposed to focusing on individual actors.

Rebekah Bernard MD 33:22

Absolutely. Well, I want to thank Mr. Travis Dunn for joining us to discuss this really important case. If you'd like to learn more, we encourage you to get our book. It's called 'patients at risk the rise of the nurse practitioner and physician assistant in healthcare.' It's available at Amazon and at Barnes and Noble. Of course, subscribe to our podcasts and our YouTube channel. And if you're interested in helping out you can join physicians for patient protection our website, Thanks so much.

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