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The Expert: Dr. Byron Thompson, an emergency medical physician based in Georgia, testifies for the defense, and concludes the jail house physician rendered appropriate treatment under the circumstances.
During a 2017 medical malpractice trial out of Atlanta, Dr. Byron Thompson, an emergency medicine expert, testifies regarding the treatment a jail house physician rendered to an inmate. The patient’s family claimed that his death from liver failure could have been prevented by earlier transfer from the jail and treatment.
The discussion begins with questions regarding the treatment of alcohol withdrawal. Thompson assures jurors that mild alcohol withdrawal does not require hospital admission, and is frequently treated on an outpatient basis after ER observation and follow-up by the primary care physician. He opines that treatment of alcohol withdrawal in a jail setting can be accomplished safely, if the jail has an equipped infirmary. While not all county jails have infirmaries, this one did.
In this case, Dilantin was ordered to treat a possible seizure that occurred earlier in the day. If this was truly a seizure it could have been caused by alcohol withdrawal, or especially in alcoholics, can be caused by a healing trauma site in the brain. Such sites are frequently noted in alcoholics, since they fall and hit their heads, then can’t remember that this happened. Over time, it heals but leaves a scar that can be the initiating focus of a seizure. Treating this seizure with Dilantin was perhaps being overly cautious, but was within the standard of care, according to Thompson. The patient also received IV fluids and had blood tests performed, all of which, the expert felt, were also within the standard of care.
The attorney then directed a discussion of the labs performed on the patient. The CBC includes the red blood count to check for anemia, the white blood count to check for infection, and the platelet count to check on clotting capabilities. The AST, ALT, and AP are all liver enzymes that are released into the blood when the liver is damaged or dying. Thompson had created a chart that documented the sequential results of lab analysis in this patient. The elevation of these three enzymes were consistent with alcoholic hepatitis. The elevated bilirubin level is also indicative of a dysfunctional liver or a blocked bile duct. Apparently one of the plaintiff’s experts had stated that the elevations in these enzymes and the bilirubin indicated that the patient should have been transferred to a hospital. Labs were drawn four times while this patient was being observed in the jail infirmary. Despite the abnormal liver enzymes and bilirubin level that would be consistent with alcohol abuse and hepatitis, Dr. Thompson insists that this is not enough to warrant observation in an acute hospital setting. These lab elevations are not unusual in a chronic alcoholic, he explains, and their treatment is to withhold alcohol.
An explanation of other lab results included the BUN, or blood urea nitrogen that is produced by the liver, and the creatinine, a measure of kidney function. The ratio of these two values is followed as a measure of the patient’s hydration status. If the patient is dehydrated, his kidneys will stop producing the urine that is used to excrete the BUN and creatinine. This leads to an increase in both values, but at a maintained ratio that is expected if the liver and kidneys are working properly. Over the time of observation, these as well as the liver enzymes improved, although the bilirubin continued to worsen until its last measurement, when it also slightly improved. Dr. Thompson felt that the clinical picture and this pattern of improving liver and kidney markers spoke in favor of continued treatment at the jail infirmary.
The expert felt that the treating physician had successfully treated the alcohol withdrawal as well as the alcoholic hepatitis, based upon the laboratory values that were examined. Eventually, the last labs drawn even demonstrated that the elevated bilirubin had begun to trend lower. The patient was then started on a liquid diet and eventually returned to the prison population. This was all appropriate since he had improved clinically, improved according to his labs, and was tolerating oral feedings.
It was not known until more than two weeks after he was admitted to the acute care hospital, once he had had a liver biopsy performed, that he had stage IV cirrhosis of the liver. The expert felt that the treatment provided by the jail house physician was appropriate, helpful, and within the standard of care under the circumstances.
The jury concurred with a verdict for the defense.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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