Dr. Steven Miles was asked to review the former Attorney General’s expert report for comment:
a.Opinion of Dr. Miles
1. Comments Regarding Allegedly “Stable Patients”
Several of former Attorney General experts, all but one of whom were not treating clinicians, referred to some of the patients as “stable.” The stability of any ill patient reflects a balance between the patient’s condition and the hospital’s capability. As a sequestered staff burn out or are diverted to evacuations or as material resources are consumed, the hospital’s treatment capacity falls and the patient becomes frailer and has less margin for cure vis a vis the remaining hospital capacity. Time matters. The longer a patient in a collapsed hospital goes without customary monitoring with laboratory tests and radiographs, the more likely it becomes that a latent problem with become a crisis.
2. Comments Regarding Lack of Record Keeping
Medical records including clinician’s notes, consent forms, care plans, records of vital signs, drug administration sheets, orders and discharge summaries are also integral to the modern hospital. The lack of consent forms and orders played a key role in each of the state’s expert’s opinions. None of these Attorney General experts seemed familiar with how the dynamics of a collapsed hospital changes record keeping. (Emphasis Added)
“Given the highly degraded hospital environment, I do not feel that it is possible, as the Attorney General experts presume, to assess clinical charting on agitation, vital signs, or drug administration without comparing such to a sample of other patients from the same ward at the same time.”
3.Comments on the Morphine Forensic Evaluations
Three tacit and unsupported assumptions underlie the former Attorney General experts’ conclusions that the morphine or morphine-midazolam drugs were lethal.
4. Preliminary Conclusions of Dr. Miles
a. Memorial Medical Center from August 29 through the deaths of these patients was a profoundly compromised hospital that lacked customary clinical, data, staffing and environmental services.
(i) The Attorney General’s medical and bioethics experts do not provide sufficient support for the claim that the presence or absence of orders for morphine or midazolam is material to the conclusion that the cases that they discussed were homicides.
(ii) The compromised hospital environment suffered a substantial and prolonged loss of treatment and monitoring capacities for profoundly ill persons. The medical experts’ conclusions that some or all of these persons were stable or did not die of a fulminant medical condition are not supported by reference to outcomes and clinical courses in this particular hospital environment.
1. The Attorney General’s medical experts do not provide sufficient support for any conclusion as to the lethality of the morphine levels seen in these cases.
2. The Attorney General’s medical experts do not provide sufficient support to conclude that the drugs were given in doses that were higher than customary in these cases.
1. Dr. Steven Miles
Dr. Miles is a Minnesota licensed physician, who is board certified in both Internal Medicine and Geriatric Medicine and he practices and teaches hospitalist medicine at the University of Minnesota. Dr. Miles has: