In this episode, veteran charge nurse and supervisor nurse, Julie Reif and I talk about how a deep dive into the medical record led her to discover that the plaintiff's tale of their family member's death in the hospital was not the true story, and which hospital culture issues allowed her to level up the accountability for this tragic outcome to the hospital itself.
In this episode, veteran charge nurse and supervisor nurse, Julie Reif and I talk about how a deep dive into the medical record led her to discover that the plaintiff's tale of their family member's death in the hospital was not the true story, and which hospital culture issues allowed her to level up the accountability for this tragic outcome to the hospital itself.
You're listening to episode 16 of your MedMal podcast, discovering the needle nurse consultants help you discover what you didn't know that you didn't know about how to win your medical malpractice case. In this podcast, we look at anonymized true examples of how a behind the scenes non testifying nurse consultant was able to quickly locate. Isolate and articulate the core issues in common and not so common medical malpractice scenarios using his or her nursing expertise to save the firm upfront costs resulting in higher profits and higher compensation to your deserving client. If you're new to our podcast, welcome, you can learn more about how behind the scenes legal nurse consulting can improve your firm's win rates and profitability. By following us on LinkedIn or visiting our website@wwwdotnplegalconsultants.com. By following our weekly podcast, you can use your commute to sharpen your own standard of care issue, spotting and causation narrative skills. Grow your virtual Rolodex of top nurse consultants of all specialties and discover the med ma plaintiff attorneys secret weapon for slaying the medical corporate giant it's time to discover the nurse consultant advantage. Let's get started. Today our guest is Julie Reif. Julie, welcome to our podcast.
Julie:Thank you for having me. I'm very happy to be here.
Elisa:You and I were both in the same legal nurse consulting coaching cohort, so it's really fun to have you on our show and to just learn a little bit more about you and connect with you more. I'm sure our listeners wanna understand where you've been clinically and how you can help them. So tell us from the start and how you got into legal nurse consulting.
Julie:Okay. I graduated nursing school in 2000. I have always known I was gonna be a nurse. My mom is a nurse. I got my CNA, which is certified nursing assistant, and went to work in a nursing home. Very enlightening. I worked as a CNA through nursing school, and then I took a break from school. Then I got a job at a hospital working in an intensive care unit as a tech. I started on night shift and I actually really enjoyed that. I enjoyed the fast pace of it. And really got to know the patients. I continued to work there in the intensive care unit while I went to the bachelor's program. Then when I graduated in 2000, I continued to work in that intensive care unit. We took everything; we took all kinds of patients. We took medical patients; we took surgical patients; we had trauma patients. You could have a little bit of everything. And I enjoyed that. I became a charge nurse. I have a good level head, a calm sense about me that shown through during times of chaos-- which can happen often in intensive care. And then I took a full-time nighttime nursing supervisor job. And we responded to all the rapid response situations and the stroke team, the trauma team, and the code team. But then, I went back to the ICU, same hospital. I was actually at that hospital for 26 years. My focus was always on the patient, always on making sure that the unit, my nurses that were working with me had what they needed, and that the patients were cared for as best as possible. Being in a facility for that long, you know the way that things run most smooth, and try to get them to run in that way most of the time. So in, March of 2020 we had a thing called"COVID". Come here to the United States. COVID really rocked everybody's world at the bedside. Everything as we knew it in the hospital, and the way that things function, changed. I was affected tremendously in the intensive care unit by the amount of death that there was. It changed me, and allowed me to see that I may need to go in a different direction then to continue to work at the bedside. I really started looking seriously into legal nurse consulting. One of my favorite things to do at the hospital-- besides take care of patients-- was I loved to look into charts; to incident reports. Part of my job as a manager was to figure out what happened; get to the bottom of it. When a code would happen, they always ask the supervisor"what really happened?" And to look into that and to figure that out was very easy for me to do. And so I was very good at looking at medical records, so I took a course on legal nurse consulting. I hired a mentor. Legal nurse consulting has been something that's brought a lot of joy to my life. I really enjoy working on the cases
Elisa:Julie can be reached at her website at forensiclnc.com. That's www.forensicLNC.com. Now, Julie, what kinds of things does a forensic legal nurse consultant consult on, exactly? Can you give some examples?
Julie:In my mind, having,"forensic" in my title was that I like to be able to gather all the evidence. Be a detective. All the pieces that there are; putting them together, and then being able to tell a story about it.
Elisa:Right. Reconstructing what went wrong, and what occurred.
Julie:It fits in medical malpractice or personal injury. Even at an accident scene; something that has gone wrong in a nursing home. Say like a wrongful death. It really takes keen eye to know all the pieces that you're gonna need because some of them you can't see them. You just know that something should be there and we should be able to find that evidence.
Elisa:Yeah. I love that. And I've always thought of, forensic nursing as being in this box of criminal law. Yeah. But that's interesting, to put that outside that box. You really bring up a good point that all of it is forensics in a sense, because you're looking for what's been covered up here. Especially in the case of medical malpractice, where once that outcome occurs, then there are times where people will try to cover their tracks. And being able to know where to look to sniff that out is not intuitive for the average attorney. It is actually quite intuitive for a nurse to be able to know where the evidence will lie that shows that there's some nefarious behavior of the healthcare providers following this outcome that occurred.
Julie:Yeah. Yeah. When an attorney requests records from a facility you get the records and you just assume that's all the records. But in my experience, most of the time, i t's not all the records. That's not everything. Being a nurse for so long in the hospital, that's where my experience leads me to have a good understanding of what actually needs to be there. It's very clear to me right off the bat if something is missing.
Elisa:Right. And even the fact that something's missing is a violation and standard of care if that piece of documentation should be in place for that particular type of treatment. Attorneys are used to looking for hints: someone making reference to an MRI, for example, and saying,"Hey, this physician in his progress note made reference to an MRI, where's the MRI?" And that's an easy thing to notice if something is blatantly missing; if it's made reference to. But there's things that aren't made reference to in many places. And you think, as a nurse,"Okay, they would not have done this procedure without first doing imaging." Yeah. And there's nowhere in the record where it ever says"we did imaging." But you're not gonna go in blindly. So a nurse with a particular clinical background would be able to know,"Hey, this imaging must necessarily have taken place." And guess what, if it didn't take place, that, right there, is a violation and standard of care. Imaging should have taken place. So there's no way out of that. One way or the other, either the imaging took place and there's something nefarious about the fact that it's conspicuously absent from the records that were given, or the imaging didn't take place. And in either case, there's a violation somewhere. But how would you know that? Like, how would an attorney know that?
Julie:He wouldn't. He just wouldn't. Because, as a nurse, and as someone who has experience clinically in the hospital for certain cases, it is only a nurse who's going to look at it with that eye. If there were a code going on, I can literally see in my mind, all the players; what should be taking place, what should be going on, what the supervisor's doing at the desk, what the tech is doing outside the room, what the respiratory therapists are doing. Was there a pharmacist there? It's a picture in my mind. And so it then becomes fairly easy for me to check mark what is there and what is not there and what we need to ask for if they just left that information out of the medical record.
Elisa:It's kind of a nerdy metaphor for me to pull this one out, but I think most attorneys who do medical malpractice are familiar with the concept of an EKG, and it's essentially a strip-- one piece of paper-- that contains different angles of the same exact set of heartbeats. It's looking at it from, the angle from the right shoulder down to the left hip, and from the left shoulder to the right hip. And it's got all these different angles, but it's the same heartbeat. It's the same set of beats that you're looking at, so that you can understand that heart cycle from all angles. And so as a nurse, you've just described like a code situation where it's not just the person who's filling out the code form that has the only perspective on what happened in that moment, and understanding all of the different players that are there in a code situation, you can say,"Okay, what's the perspective of the respiratory therapist? Where's his documentation? What's the perspective of the pharmacist? Where's her documentation?" And so, you can get that multifactorial perspective of a single event. And that can really fulfill that picture for you. But unless you know the players and what documentation they typically keep, then you know, it's hard to even know where to look to find those different angles and get the entirety of that picture. Exactly. So I know you brought a medical malpractice plaintiff story with you today, and I would love to hear what happened in this story, what went wrong, and how were you able to help the attorney to show her what she may not have seen on her own.
Julie:Yeah, I did bring a case. This was interesting because it was described to me during our consultation call in one way, and then once I got the medical records it became a whole nother thing. It was a wrongful death. The complaint from the family member was that the patient died because the nurse did not keep him on the ventilator. And I thought,"My God!" And the attorney had already had a physician look at it, and suggested that maybe we get a nurse to look at it because of the nursing judgment. As I was looking through them, it became something completely different. It wasn't the nurse taking the patient off the ventilator at all. Actually, the patient died because the telemetry alarms were not addressed for about 30 minutes.
Elisa:Wow. So the patient had an arrhythmia that was not addressed?
Julie:Yeah, so a telemetry monitor on a medical unit or a critical care unit is a little portable box. It's five leads that gives off an electrical tracing of the heart. And it's continuous. So the patient puts it on, keeps it with his person, and it is transmitted to a telemetry monitor. So on this particular unit, it wasn't at the bedside. It was at the nurse's station, and then there was also a central monitoring room-- which is more and more common these days-- it used to be, a tech would sit at the nurses' station at the monitor and watch the monitors because nurses can't watch everything all the time. Sometimes the monitor alarms. When a patient's heart rate is too high, a patient's heart rate is too low, a patient's heart goes into a different rhythm. And it is to alert the nurse to go and check on the patient.
Elisa:Yeah, because you don't treat a monitor; you treat a patient, right? You know, there can be artifact, or there can be other things affecting the way that it looks. Maybe something's not showing P waves and you're thinking,"What? Has this person gone into this junctional rhythm?"-- where the middle of their heart's taking over. But in reality, it's just simply the directional flow of the currency and you just have to make some adjustments. So you do have to really know enough, first of all, about telemetry to treat the patient, but also to review these types of cases. You have to know what you are looking at because it may need a second pair of eyes that's familiar with that. Not all nurses are. Only certain nurses are deeply trained in telemetry reading.
Julie:And especially when you get the medical record, cause it's sometimes choppy. Sometimes the quality isn't so good. So you have to take everything else that's going on to continue to paint that story. But the story of this-- looks like, from the medical record-- the patient went into a ventricular rhythm, which means only the bottom of the heart was beating, and this alarm was not checked.
Elisa:That's a deadly rhythm. There's some rhythms that's like you know, when you get a second go check on so-and-so." V-tach is an actual"code rhythm". It really should, initiate a full"code blue". Everybody run-- don't walk--
Julie:Yeah. Run, don't walk. And, typically the nurse would be notified and/or hear the alarm at the nurses' station. According to the medical record, none of that happened. So the rhythm continues to be ventricular tachycardia, and then it goes into ventricular fibrillation, meaning the heart is just quivering.
Elisa:That's really bad.
Julie:There's no blood being pumped from the heart. And then after that happens for so many minutes, the heart then quits beating and goes into an asystole rhythm, which means ceasing all electrical activity
Elisa:Like that Hollywood:"Beeeeep"
Julie:Exactly. Yeah.
Elisa:For all intents and purposes, they're dead.
Julie:Dead. And it had been, probably-- roughly 30 minutes of rhythm strips that I saw until the time that someone recognized that the alarm was going off and was able to then go to the room, found the patient unresponsive blue and not breathing, and did not have a pulse.
Elisa:Oh my. I know. So this was a telemetry unit? Or just a unit that accommodated telemetry? I guess it depends on the the rurality of the hospital.'Cause certain hospitals can have entire units dedicated to people who require telemetry monitoring. And others, if it's rural, then you may have some mix-and-match types of patients and not everyone will have that. And so you have maybe two or three patients on telemetry. But you mentioned something about a whole room that was dedicated in this case.
Julie:Yeah, there was a central monitoring room-- which is just a separate room away from the unit; sometimes it's not even in the same hospital-- but they also have the telemetry that would be seen at the nurses' station as well. So it's a monitor, and it has, maybe eight different rooms on it, but you have 20 different monitors, and there might be multiple techs in that room. So each tech might be responsible for 30 monitors. Sure. So that's 30 different patients, 30 different rhythms that they're watching. So they're watching for subtleties, but-- more than that--they're watching alarms. So if the alarm is alarming, the guidelines are that they will notify the nurse to go check on the patient. And that's about as simple as it is.
Elisa:I worked at telemetry unit for many years, but in the hospital that I worked at, our monitor unit was right there at the nurses' station. And so, if I wanted to go look at my own patient's rhythms, I could. And, in fact, in our hospital, we printed strips every four hours, and you had the monitor tech that knows how to read rhythms, but you also had the nurses themselves assessing on a regular basis, but not a continuous basis. So I, I'm curious-- because I haven't worked in that environment-- how does that nurse do her own assessment on those rhythms every four hours? Not that this would've helped in this particular instance, but I'm just curious about that standard of care.
Julie:Yeah, so if the monitor's on the unit at the nurses' station and there's a central monitoring room, the tech sitting at the monitor is going to interpret the cardiac waveform. They measure the PR, measure, the QRS measure the T-wave. They'll look at the R-wave. They'll identify the rhythm, and then they'll save it in the system. Okay. So then the nurse can either go to the monitor or-- some hospitals, like the hospital I work in now-- you actually log on a different thing on your charting and you can see either in real time and then what they saved. The telemetry monitor tech is responsible for measuring and interpreting the patient's heart rhythm every shift. And then, the nurse... on this computer system, we accept that, or we decline it, and then we just redo it.
Elisa:Because it really is a hierarchy. Techs are techs. And they have in-depth training on this very specific thing, which is the interpretation of heart rhythms. But again they're treating a monitor; we're treating a patient. And really a nurse trumps a tech. Their degree, and by virtue of their license, and their assessment, they have that authority to overturn that interpretation and to say,"No, I disagree. This is what it is. And then of course, you have physicians who can also overturn, yet again that nurse finding. But everybody has a degree of liability commensurate with what license and education and training they bring to the table. So then the question becomes,"what is the standard of care for this individual" and"what is the standard of care for this individual?" And"did they breach that?" Understanding that is critical because, you mentioned in your background that you spent many years as a CNA and then you became a nurse. And so I think what that does for you in your ability to look at cases-- especially cases that involve multiple levels of care-- when you've worked in both roles, then you have this very unique perspective of fully understanding the limits of those two roles. A CNA is a tech-type position. It's a certified nursing assistant.
Julie:They gather the data. It's up to the nurse to interpret it.
Elisa:Assessment is something... as nurses, it's something we do... instantly. And we do it all the time. It is second-nature to us to constantly be assessing. And that is actually a nursing skill. It's something that you have to be trained to do because it's a certain type of thinking. It's a certain way of thinking. Your assessment skills are something that you can hone through your career. But mentally dropping yourself into that environment where a code is going off. You, as the legal nurse consultant, are also assessing based off of what data you have and information you have, which is all these different pieces of the medical record we talked about coming together. And you're doing the same thing that nurse is doing in that scenario. You're just using a different set of data, and a different pair of eyes to assimilate everything that's coming your way, and create your interpretation of that. I hate to go down that tangent. I think it's a good one, and an important one. It is important to know the limitations of where the tech's responsibility and liability is, and where the nurse's starts But something like asystole, something like ventricular fibrillation, ventricular tachycardia, all three of those: unmistakable. I don't care if you are a tech or even a CNA in that environment, you know what asystole, V-tach and v-fib look like. Everyone does. Even Grey's Anatomy watchers know. Some rhythms, you can easily excuse when someone misses a subtle rhythm change, or even atrial fibrillation. Like some of these rhythms that are just really subtle. Yeah. But those rhythms... there's gotta be high-level accountability there for lack of training, I would think.
Julie:And you say high level. When I got my eyes on those rhythm strips, and I was, looking exactly at time of death and then marching it back as to"Okay so what happened?" The patient had been awake and alert and had already been assessed by respiratory therapy and nursing off the ventilator. As I said, in the beginning, the consultation led me to believe that the nurse took the patient off the ventilator, and that's why the patient died. But in reality, what happened was the patient was okay to be off the ventilator during the day and required ventilation at night due to an underlying brain condition.
Elisa:So basically your brain-- certain conditions where your brain just"forgets" to send the signal to your lungs to breathe. It's rare, but in this particular case, it sounds like it was a preexisting condition from home...? They had something going on that prevented their brain to have that natural drive to breathe.
Julie:It was, it had been over five years and the ventilator that the patient was actually using was the home ventilator. And the home situation was that during sleep patient required ventilation. So they would hook up the ventilator at night, and then patient would be able to come off the ventilator during the day. and so that's, Similar to what they were doing in the hospital. So there was no order written by a physician to keep the patient on the ventilator at all times. The order was actually written to continue home routine. Sure. Which would be ventilator at night, off in the day. Yeah. And so the respiratory therapist had been in, assessed the patient, took the patient off the ventilator. Patient was able to be on room air during the day, nurse had gone in and assessed. No distress, as normal for the patient. He was actually getting ready to be discharged. And then, you see the rhythm change. And to go from,"Oh, this nurse, took the patient off a ventilator, and she shouldn't have done that. Maybe we should go after the nurse..." to now it's not really the nurse, it's a higher problem.
Elisa:Sure. There's a system problem. You always have to look at that. Even though, technically, it was--almost always-- one person. But, if you have an individual that made an error, it's always a good idea to dig into what are the training requirements for this role? What are the prerequisites? What is the background education requirement? What is the certification process? What is the training process? All of those things, because that can take that level of accountability up a notch. What is the routine or the system that your hospital is using to train these individuals? You're taking people off the street and putting'em in front of a monitor?
Julie:And also, then looking into the hospital's policies and procedures for the notification to the nurse with an arrhythmia alarm. What is the workflow? Because obviously that's not what happened, right?
Elisa:The more steps in the workflow, the more chances there are for something to be severed.
Julie:That's right. Instead of thinking that,"We're gonna have to go after this nurse, or whatever, actually, going after the facility for not following their protocol or deviating from it, or having a bad protocol to begin with, is going to produce a better outcome. There'll be probably a larger settlement and also fixing a systemic problem. If that's something that's going on in their hospital, that they don't have the right policies and procedures, or that they're hiring people who are not following, or they're not educating them to follow these procedures to prevent things like this from happening.
Elisa:And let's not forget... Really, that, truly, is the legacy trial attorneys and legal nurse consultants are collectively going for... is that there's change that reduces these unnecessary injuries; these unnecessary deaths. It's something that comes up very frequently on the podcast. How I sleep at night being a legal nurse consultant that helps attorneys typically for the plaintiff is that this results in better systems. It results in safer systems. And, at the end of the day, we're all gonna be a patient in a hospital at some point in our lives. Whether it's tomorrow or 40 years from now, we're all gonna be a patient in the hospital system and we need to work together. And I think it's so interesting, actually, that legal nurse consulting is unique in that sense because we work together to help an entirely different industry from our own, which is the legal industry. But in a roundabout way, specifically that arm of the legal industry is working to better the healthcare industry. Yeah. So it's this sort of very unique and interdependent symbiotic relationship that attorneys and nurses and medical legal consultants can have.
Julie:Yeah. Yeah. totally agree and they are so knowledgeable with, how the laws work, how things need to be, how it needs to be said what angle would be most appropriate to come from. And as a legal nurse consultant, working with that attorney, you can literally get on the same page and just be in sync. Yeah. And really compliment one another. Because being. Two experts working together, it just feels so natural.
Elisa:So I'm dying to understand... really, how does this happen? You have monitor techs? Like, where was this person?
Julie:So the deposition read extremely unnerving for me. That this monitor tech took responsibility of not being alert to the monitors. So that, to me, read that she was probably asleep. There were other techs in the monitor room.
Elisa:And"it's not my job." The whole"not my job" attitude. You see asystole, that kind of overrides the"not my job" attitude, normally. But when you combine the"not my job attitude" with"alarm fatigue" you go,"Oh, I hear an alarm, but it's not my job to look and see what that alarm is all about."
Julie:And asystole can be that the patient's heart is not beating, and the monitor sometimes reads asystole when one of the leads has come off, or if the patient is laying a certain way and it's not getting a good reading and it becomes very flat.
Elisa:So you get these alarms all the time. What are the odds this person's actually dead? If the monitor tech in charge of that particular monitor had watched the progression from V-tach to V-fib, and then to asystole, they would've said,"That's legit asystole."
Julie:Yeah.
Elisa:First of all, they
Julie:wouldn't have let it get that far. No. Yeah. The nurse would've been at the bedside to evaluate that V-tach and would've intervened much sooner.
Elisa:The whole"not my job thing"-- I mean-- to the extreme, because I'm sure somebody at some point looked over and was like,"Ugh, stupid asystole alarm. The lead's off. Whatever." If the patient was dead, somebody would've told me by now. Yes. But that's the irony is you have this loop of not my problem". If the patient were dead, I would know about it. But if you're the one that's supposed to call the code, then that's not necessarily true.
Julie:Yeah. Looking at a grander picture of it. It's a broken system as far as how many patients we put on telemetry, the qualifications to have a patient on telemetry. Yeah. It just increases the whole alarm fatigue syndrome, if you wanna call it. And they have a wrongful death case and the hospital was liable, and it's a sad deal, but, they are now putting in different systems to avoid this happening again.
Elisa:Yeah. And I think you said the case settled. Yeah. Substantial amount. Yeah. It's good in a lot of ways because then that family can move on, and the the hospital can make changes that need to happen to prevent this from happening again. Maybe change their ratios, maybe look at the qualifications and the training and the certification of their techs, look at that workflow between what happens when a monitor alarms and exactly what is that sequence of events that happens before the nurse is notified, and how can we shorten that? How can we compact that and make it faster, and how can we reduce this alarm fatigue? Yeah. And also fatigue. Can we shorten the shifts? Can we make sure that people aren't working more than a certain number of shifts? So many things that you can begin to look at from a culture perspective, from a policy perspective.
Julie:All of it. Yeah.
Elisa:Okay. I hope this results in some changes for the hospital. And you were a part of that and I commend you for that. Thank you so much for coming on the show. This has been a really fascinating story. Loved learning about your background and also this really cautionary tale that you brought to us. Thank you so much. Thank you for having me. You're welcome.
Julie:Alarm fatigue is tired of hearing the alarms. There's so many alarms on a monitoring system in the hospital. Something is always alarming. Whether it be an IV pump, a bed alarm, a call light, the telephone nurses pagers, something is always alarming. And when you are talking about the cardiac alarms or the telemetry alarms, there are caution alarms that nurses tend to call"yellow alarms" that have a certain tone. And then there are red alarms that have a different tone. And if you have a unit that has 20 patients on it, doing 20 different things, you are going to hear alarms all day long. And so it becomes a lot to handle and you can have alarm fatigue there in the central monitoring room with the monitor tech. And, it's just a real thing. Your brain becomes numb or immune Like a screaming kid. It's like crying wolf. When is real, you know? And I don't have the answers to it.
Elisa:I think the average person can relate to that with smartphones these days. The number of notifications on your smartphone and certain apps, if you don't hone your notifications, they can just really get out of control. And at a certain point you just don't even care anymore. When you customize your settings on what you wanna be notified about, that can tone down the notification fatigue. You have to re-train yourself. But once you've done that, then you know, if you're getting a notification it's because it made the cut. And so I think there are things that can be done to reduce notification fatigue, and you just have to think outside the box and brainstorm on that as a facility and try and find out what can we do to change that threshold and things like settings on when those alarms do go off, and reducing the frequency of false alarms is really helpful. But also giving your brain a break. Are our technicians getting breaks during the shift to cleanse their palate and go back in with a more alert mentality? Because it really is physiological when your brain turns off and becomes numb to these things. So in some sense, we've all experienced notification fatigue, if not alarm fatigue. But at the end of the day, it doesn't change the liability. You've been listening to discovering the needle nurse consultants help you discover what you didn't know that you didn't know about how to win your medical malpractice case. This podcast is a production of discovery, NP legal consultants. Discovery is the largest unified growing force of specialty nurse practitioners offering consulting services to medical malpractice attorneys who take cases for the plaintiff
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