solutions and teatime county detention officers for failing in their gatekeeper roles and also we're appealing the dismiss supervisory liability against a sheriff teton county as well as manila claims against some accounting and or it's our position that the judge is factual and legal reasoning was flawed and in that he invaded the province of the jury by wayne evidence and making credibility determinations his st wrong turn was he ruled that the nurses made a reasonable considered medical judgment about what the condition was of the deceased  to have a reasonable considered medical judgment you need a diagnosis he showed up and they in a condition with astronomically high blood pressure extremely high blood pressures and they knew that these were life threatening and so the nurse who's just a registered nurse she's a gatekeeper she knew this she knew that extreme hypertension could cause organ failure you know before you get do much of the facts i'm wondering if you've properly stated the issue  you said was whether she made a reasonable medical decision yes the way i understand the test it is whether she was or any of them were deliberately indifferent to the situation that is is it significantly different question sometimes it will be the same answer sometimes it won't but i think we ought to make it clear that our test is whether there was deliberate indifference whether she considered consequences any of them considered as was you know we were you don't care in she was when he showed up she was on the phone and the st thing to be as a gatekeeper she has to understand she is unqualified to make a diagnosis she knew when he was she should understand or she knows them well sometimes this this language is morphing into a negligence standard and i just think we ought to be clear our minds that we're not dealing with a negligent standard here we're dealing with a standard of whether she where she considered a risk is it you know i don't really care what happens absolutely and she was on notice  condition and symptoms that could cause substantial harm and she does regard it in a recklessly disregarded find somebody who is qualified some hours later she pursued ripe and she's on authorized to prescribe medication clonidine which you're not supposed to give by her own company's policy  elevated blood pressure clonidine should not be used she was on authorized to prescribe she prescribed it and she prescribe the wrong medication and so when we say that when the judge says well she treated him she has no ability to treat him or her job is to recognize the conditions and symptoms of a medical emergency medical emergencies in fact he was over a point three which under this policy in procedure is a medical emergency and needs hospitalization so true medical emergencies that she's on qualified to diagnose and treat and she never contacts a physician or it did you bring at a state law and negligence or professional malpractise claim against the nurses i'm sorry did you bring a state reason medical judgment because no physician was ever contacted then they say these are the nurses who need or they both say i cannot diagnose the other nurses i don't do medical exam she didn't even go see him in over fifty hours so he's never seen by a qualified person physician nurse practitioner who by the way a mythical nurse practitioner your honor was on call for c c s their own her own company in jackson wyoming she's a medical nurse practitioner who if on call she didn't call or she disregarded calling her we've taken her deposition she nurses as as being stronger than her case against the guards for deliberate indifference they they blame each other there was a contractor honored that  s only a contracted ry the nurse for some twenty hours a week that means for one hundred and forty four hours a week you had to have the detention officers c c s was was to train the detention officers on how to obtain vitals take blood pressures make clinical judgments they had to make clinical judgments on all of these najah tremors agitation author anxiety blood pressure temperature hosts of the forty nine omissions they didn't take so that they are it's a it's a look i'm just i'm just trying to drill down i mean the are your claims against the two types of defendants are a little different the nurses you're saying they should have known they couldn't handle it and even though they tried to treat him and because they did prescribe medication to him so even though they tried to treat him and they had reasons for thinking he was ok that they articulated you have the guards on the other hand were the guards your allegation is that the guards were were not giving them the prescribed medication and in fact avoiding his cell yes and that's what that's what i want you to drill down and see if there's some difference in the two in the claims against the two people two types of defend your honor both are equally culpable c c s didn't give the nurses they disciplined the nurses for working overtime the nurses said what we're trying to train the officers the we don't have enough time c disciplines of the nurses for working overtime the officers a saying we're not getting trained we have all these jobs so it is an equally culpable situation because it's  failure it's not the fault surely of the individual officers and it's not the surely the fault of the nurses although in this case of nerves clearly it was deliberately indifferent to gnome risks of harm i mean nurse on the phone so she can't diagnose i don't do diagnosis she's in cheesey only when it's time over fifty hours they have a medical nurse practitioner that was never called no i understand that but what you said was that she said she'd never seen a blood pressure that high before that was the nurse practitioner you know sharon so now we have when you say they there was prescribed medications but the clonidine was the wrong prescription because under c c s his own policy it masked all these vitals that the officers were supposed to be seen but that but doesn't that just sound in bad judgment as opposed to deliberate indifference i mean she was trying to do something whether it was the right thing whether it was the right decision i mean she it's not like she was just like are all turkey case where they were just watching a man die before their eyes right she knows diagnose she knows that and yet she only saw him twice for moments it over fifty hours it's unconscionable that there are nurse experts said that this individual wasn't referred to a hospital or grock nurse practitioner or physician brought in to see him she completely recklessly disregarded known risk when when within that fifty hour period it is but pressure start to decline what what how or who is the test taken that showed a decline it would have been an hour ten circuits application of considered medical judgment i submit cell versus crum shows that the nurses saw fever chills aches cough shortness of breath swelling they referred this is a detainee to a doctor and the doctor made a diagnosis and it was arguable it was a misdiagnosis that was the judgment he made a mistake here there was no diagnosis this man died fifty five hours and that that not that's not exactly right is that they they thought that he they did believe they knew what was wrong with him and they invading the jury she's the nurses are saying we thought he was improving at that same time we have an inmate who is he's he's put into a cell where he has someone who's been arrested fifty five times he psychotic yelling and screaming they violate their own policy by not segregate him out the officers and the nurses don't want any part of that so they don't even go in there and made police the courts council before i began i want to notify the court that i will be splitting the time the other could the fence equally so i want to use my five minutes i like to point about what they knew at the time of the booking they knew from the arresting patrol trooper that he was coherent he could talk that he was functional they knew that he had a high b a c and they knew that he had a high blood pressure so they contacted the nurse to ask about how to proceed and then there's advice them to keep him in the jail and provide medication and when they asked him about the high blood presser he mr  reported functioning with a condition this is so in some i think that the high book the oppressor alone is simply not enough to sow deliberate indifference to a heart attack of any kind he couldn't propose that as per se rule that high blood pressure is not enough to trigger responsibility of course it could be enough depending on the facts it might be telling on the facts but i would point the courts to case law complaining about the high blood pressure and here we don't have anything in the record sewing that he was complain to the deputies that he had chest pains does doesn't record actually show the opposite in this case it says that they knew that he was pale if you taken completely as true it says that he didn't feel good to the deputies not again he was clutching his chest not even that they saw him severing or having trouble eating and in some i think that  as a question of whether they were aware of a substantial risk of heart or heart attack none this terribly of harm by itself and i think the same reasoning is applicable here whether the p d s were aware of a substantial risk of a heart attack in this case did he make any complaints about chest pain or any any other type of symptom that would have given the deputies facts where they could have known he might be having a heart attack i don't think so your honor and to be fair i'm not a medical professional and i think that would be but to me it seems that a lot of those symptoms that he did that they do that they did know about a quarter to their testimony or perhaps could have known been known about could been very fairly troubled all to the uk home after all and i think that that's pretty much it was the fact that he was a diabetic known by to the nurses or was what else did they do they they put him on medication or g m a one million there were some inconsistencies but he was examined there's twice and they would check up on him periodically while i'm in if they were concerned that this man's medical condition there was a severe problem wanted to bother to even contact a nurse and because they knew from the symptoms that they had to contact the nurse not necessarily as far so know that he would die of a heart attack at a point i you're saying that at least they knew something was wrong enough to call the nurse yes that you acknowledge that that's not necessarily sufficient to relieve them from any deliberate indifference i think that in this case it is based on  that they knew and it was not all that they did i'm asking you what did they do you're saying well they didn't do this they didn't do that they were it what did they do because there can also be a negative aspect of this by recognizing either an emergency or a condition that you don't pay enough attention to so what did they do so they would take vital signs that's pretty stuff on the record the record does reflect  pressure is running on one hundred and seventy or two hundred something over something that that is a dangerous condition and i would refer to court to deputy after moyers testimony where he talks about speculative risks of high blood pressure not that mr mower is an eminent risk of death not he was going to die in the next two days not even that he necessarily knew go to the hospital but they need to contact the nurse earlier on they rely on the reasonable medical judgment of present medical staff evil's questions because i think it is important to point out when the treatment started to begin to take effect and improve his condition the facts that are relevant to that are that when mr miller did arrive to the jail he refused the drugs that were offered to and that were specifically designed to lower his blood pressure it was not until the next morning that nurse court of told him that if you do not take these pills that i am recommending you take you will die he then acquiesced and took those pills at that time over the course of that next twenty four hours that is when the blood pressure began to come down and by the next morning his blood pressure was down to two hundred and eleven thousand one hundred and thirty one and then even an hour later it was down again to one  was a gentleman who was going through alcohol withdrawal and that the other was medical evidence by the nurses that high blood pressure was symptomatic of coming down from that is correct and that is why nurse courtroom when she receives the call and that st night which is specifically designed to treat out and symptoms of alcohol withdrawal and in particular hypertension so i did want to begin my argument with discussing the qualified immunity issue but regardless of how the court decides that issue a summary judgment can still be affirmed for all the reasons i just stated about that were relevant to developing a difference question is there really was no evidence that supports pla assertion that the that the nurses were deliberately indifferent to his medical condition either at the time he arrived at the jail or at any time following while he was still there they have you're talking about the question about you said you were going to start out with the question about whether qualified immunity is at the question of whether it even applies to your clients that's correct ok and we would submit that it does and the reason why we believe that it does is that there doesn't appear to be any dispute between the parties that that it is available to private parties under the right circumstances those circumstances we believe are present here let me make sure that because you've got two issues going along on that one as i recall the district court said that the it was clear that it was clearly established but he held that your client had not in saying that it was clearly established and is that your argument that it's being made in regards to that that the trial court erred in finding that it was clearly establish yes no i doubt is not part of my argument ok so my argument is  we believe under the richardson factors strong support the extension of qualified immunity for these nurses and in particular i'd focus on the market forces factor because that under richardson is the most important factor and here those same market forces that were present richardson or were simply not present here richardson you have a privately run privately operated joe a staff of the private actors following their own  assuming that they are entitled to qualified immunity the defense of quality munity then how did they not deliberately and differently  to the fact that at each instance where the nurses were contacted about mr millward they did address there is no medical conditions they prescribed him on that st night learning that he had came in and high blood pressure with a high blood out all level they prescribed him medication that was designed to treat those very conditions but they recognized when they took those for readings that this man had an extreme high blood pressure right there that no matter whether it's alcohol related they recognize the man because he was in trouble at the hospital or they recognize that he had i've put pressure and they also recognize that this was his baseline that this was a gentleman who reported to them that he had a history of high blood pressure that he had a history of diabetes that it a those those histories and was refusing treatment for those those conditions and in fact he continued to refuse until the following morning again like to leave my my colleagues some time what did the detention officers do levon thirty at night little christine sanders got the nurse on the phone and said this man has diabetes he has a high b a c i'm worried about it what should i do and they continued to do that michael field difference in fact i would just refer the court to the maoi case i think on page fifty four of the plaintiff's brief where that court said they helped that they did these untrained people that one even our officers that were screening they said even in that situation we're not going to make municipalities and government agencies green for every possible illness and they talked about things you're trying to say to us about not needing to screen for any possible illness just as in have any relevance to the issue in this case at all well i think your honor if i may just i think it does and that he didn't die from alcohol withdrawal he died from a ninety nine percent inclusion of his less left the sending coronary artery and no where he didn't complain about chest pains in fact he didn't complain about anything he was very cooperate if he was ta mobile there was nothing to put our officers on notice and as a gatekeeper the notice they had that st night they got a hold of the medical professional that was trained in correctional care to take care of him they