For the past six years, Mr. M had worked as a nurse practitioner in the medical clinic of a large university. Another NP and a physician also worked at the clinic, each covering different shifts.
Mr. M’s typical day involved treating complaints of flu, ear infections, strep throat, and sometimes mononucleosis. On rare occasions, a student would be ill enough to warrant referral to the local hospital. While the work wasn’t challenging, it was reliable and steady.
Late one afternoon, a student showed up at the clinic clearly upset. Ms. H, age 20 years, had been bitten by a tick while hiking that morning. Mr. M examined the bite on Ms. H’s shin and determined that the tick was not lodged in the wound.
When asked how and when she noticed the bite, the student replied, “I felt a sting on my leg and looked down to find this tick biting me. Now I probably have Lyme disease, so I came in to be tested and get antibiotics.”
“How long ago was this?” asked Mr. M.
“About seven hours ago,” replied Ms. H.
Mr. M explained to Ms. H that it was too soon to tell if she had Lyme disease. In fact, he continued, it was rather unlikely considering the tick had been attached for such a short time.
“I can’t give you a blood test for Lyme disease,” Mr. M explained, “because the antibodies don’t show up in the blood for four to six weeks. Seven hours is really too soon to tell anything. Symptoms don’t usually develop for three to 30 days.”
“Then give me antibiotics,” demanded Ms. H. “I don’t want to get Lyme disease!”
“I’m sorry,” replied Mr. M. “I can’t give you antibiotics. There is no reason to prescribe them at this time. In fact, it’s not recommended.”
The patient became increasingly demanding, insisting that she needed antibiotics and was afraid of developing Lyme disease.
Mr. M calmly repeated his explanation and told the student that she was free to seek a second opinion if she wasn’t happy with his answer. The student stormed out of the clinic. Mr. M noted in the chart that he had examined the wound, determined it was too soon for blood tests, and declined to give her antibiotics (despite her wishes). He also noted that she had no symptoms of Lyme disease (e.g., rash, fatigue, or fever).
A year and a half later, Mr. M was notified that he was being sued for negligence by Ms. H. The papers alleged that the tick bite had infected Ms. H with Lyme disease, which then went undiagnosed and untreated for months. As a result, she now suffers from permanent bouts of arthritis, joint pain, and neurologic complaints.
Mr. M immediately consulted with the defense attorney assigned by his insurance company. The attorney questioned Mr. M at length about why he hadn’t prescribed antibiotics and what advice he had given Ms. H. After consulting a medical expert, the attorney advised Mr. M not to settle the case.
At trial, Ms. H took the stand first, tearfully describing her daily debilitating joint pain. She testified that she had gone to the clinic and told Mr. M about the tick bite and her fear of Lyme disease, claiming “he wouldn’t do anything to help me.”
“I begged him for antibiotics,” she told the jurors. “I asked to be tested for Lyme disease. He sent me away with nothing.”
The next witness was an infectious diseases specialist, who described how Lyme disease is transmitted and the physical symptoms associated with this tickborne illness. When asked about treatment, the specialist explained, “Patients treated with antibiotics in the early stages of the infection usually recover completely.” He concluded, “If the problem is not diagnosed or treated promptly, permanent damage may result.”
The plaintiffs’ attorney then introduced a family practice NP. This witness testified that she would have prescribed antibiotics to the student as a prophylactic measure.
Testifying in his own defense, Mr. M explained that he was following CDC guidelines, which recommend against prescribing antibiotics in the absence of known Lyme disease because of concerns about antibiotic resistance, allergic reactions, and the fact that it might give the patient a false sense of security. When asked why he hadn’t ordered blood tests, Mr. M again referred to the CDC recommendations and told the jurors that antibodies which would indicate a positive test result do not appear for four to six weeks. Testing would have been inconclusive at the time that he saw Ms. H.
The defense also introduced its own expert in infectious diseases, who corroborated Mr. M’s statement with regard to the CDC guidelines and the time needed before blood tests would reveal anything.
The jury deliberated for one hour before returning with a verdict finding Mr. M not liable.
To prove her case, Ms. H had to show that Mr. M had deviated from the accepted standard of care. The most common legal definition of standard of care is how similarly qualified practitioners would have managed the patient’s care under the same or similar circumstances. Ms. H was alleging that by not testing her for Lyme disease and not prescribing prophylactic antibiotics, Mr. M had deviated from the accepted standard of care. The plaintiffs’ attorney tried to prove this by introducing an NP witness to testify that she would have handled the case differently. However, since Mr. M was following CDC recommendations, there was really no way for Ms. H to prove her case, despite the fact that she did, unfortunately, develop Lyme disease.
Mr. M did exactly what he should have done. He relied on standard practice guidelines and explained them to his patient, clarified for her why he could not prescribe antibiotics in the absence of a confirmed case of Lyme disease, explained the reasons why a blood test could not be performed at that time, and told the patient that it was really too early to know whether she had Lyme disease. All these points (as well as the patient’s objections) were noted in his records.
Having been informed that Lyme disease would take longer to develop (if it developed at all), Ms. H should have followed up in a reasonable amount of time. Instead, she left in a fit of rage and failed to return for a blood test. By the time she was finally diagnosed, the damage had been done. Though the outcome was unfortunate, Mr. M remained blameless.
Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.