please the court counsel objective of objective of the unreadable treatment and dealing with his detainees under kingsley we believe that under shiels which we've raised that the liability have a specific expert dr al shawnee placed mr collins in a padded cell naked eye matt suffering from severe d t s no final signs were taken for five days no medical charting occurred for five days dr l shammy advocated his role of primary care provider and his responsibility to actively monitor the vital signs leading to the emergency condition of mr can you speak to this issue of the protocol sheets and who was responsible for them signed and the impact they have as it relates to the standard of care yes the protocol sheet this is often an issue raised by attention to it i be disavowed if i use the best medical standards well the best medical standards are set forth in this protocol sheet and if you look at one this is every four hours vitals get checked the first day and then at least once every shift slips takes yes and it actually goes on to explain exactly what that means when you say monitoring it says follow up medical file science monitor every four hours just obvious that there was a violation cause the vital signs were taking and the reports were given in terms of how his condition was deteriorating vital signs are the only way you can measure a deterioration you can do it by observation observation with a repeatable in this case a video camera but the vital signs of the only way you can tell about a person's temperature he was taken to the hospital with a body temperature eighty four point two in another case that preceded this in henry county that person died and died of hypothermia in two thousand and ten the same kind of problem mr collins could have been that five percent of severe d t and eight patients who die visited twenty trails a week do the math pretty hard to see anybody you spend ninety seconds the only time you saw mr collins was on the seventeenth and he saw ninety seconds in the south korea attached by physically firing the video that the records show is that there was no medical chart and whatsoever for five days after he came back from the emergency room the first time and until dr el shawnee saw him on the seventeen so from the physicians as experts and i use a treating physician about growth from it and the problem is none of the treating experts said it breached the standard of care enough to monitor or direct others to monitor him and so on back to my original question your case says you're  resting it all in the absence of following those the monitoring in that checking and saying that it's just obvious given what his medical history was given what his condition was that these medications simon multi vitamins and let them necessary and you monitor his just post it they're supposed to monitor his vital signs because that's what they say in their title testimony so you have to go reason they sent him back is they don't have a facility to take an inmate who has to have security they sent him back so what do they do in this case they just go already so they don't have to worry about security and they don't have to worry about paying the bill and yet he's  emergency care this is a for profit business this is a cottage industry but people make money off the misery and the medical problems complicated medical problems that ended by joules in their custody so if you look at just the  just the testimony cited by the defendants you can probably conclude that there was no assertion that the requirements are there for constant monitoring but if you read the whole testimony judge williams you will find that they said that's where you start out but obviously it can deteriorate if you don't monitor and monitoring has to include taking the vital signs and so like dr like he's one of the people you rely on the right data show at the deposition he stated he could not opine whether doctor z dr eyad just got our throat right whether or not he had met the standard of care because he didn't have access to the dosing  duration or how often he'd been checked that's right because he didn't have that because there was nothing to look at and guffey says the e r doctor who treated collins said the vitals help him determine whether an individual has d t s and then thank you may it please the court and it doesn't matter what standard you apply or whether we're sticking with deliberate indifference or whether we're going with objective and reasonable first argued that i believe we are sticking with deliberate indifference because post kingsley there have been several decisions from this court that have still applied deliberate indifference to fourth amendment claims regarding medical care for pretrial detainees and specifically burton v downey which was october twenty fifth tina davis the cook which was august twenty sixth teen based on convicted because it doesn't make any sense in the medical context you know to me it doesn't matter whether they're convicted or not or had their gerstein period are not objective and reasonable is the exact same thing as breaching the standard of care and under indian a law to breach the standard of care you've done what can be  physicians in the community find objective way and reasonable and this court has held as has the supreme court that federal law is not supposed to merely constitutional like state law plaintiff admits in his brief on page twenty five that objectively and reasonable in the federal context is identical to breaching the standard of care under indiana tort law but that's not what we're supposed to be doing there supposed to be a difference between tort law and federal law let me ask you about the standard of care because this case turns on whether the standard of care requires a physician to check a patient's vital signs at regular intervals why isn't this a case where the standard is obvious enough that a medical expert on behalf of the defendant isn't necessary and when you  the expert or what the doctor said that actually treated him when you sort of extrapolate their testimony that that's not sufficient at least to go forward beyond summary judgment lay people cannot look at any patient under any circumstances and say whether or not his or her by the planes need to be checked and whether that's a requirement of the standard of care when you look at his behavior in the cell doesn't that suggest that he was having medical problems nobody disputes he was having medical problems the only issue plaintiff has raised is whether his vital signs needed to be monitored make no mistake he was being monetary there were two nurses on site there were officers and doctor actually was a phone call away he was being monitored for some of your out as addition is the vital signs  irrelevant or wouldn't make any difference you know just as a cause i'm just trying to see how one gets to ninety eight point six this is a normal temperature and we get to eighty four and so obviously i mean i'm not a doctor i'm not an expert so i don't know how quickly that happens i don't know what kind of behaviors exhibited by the patient when there's that kind of dramatic drop but i'm pretty dramatic i'm not saying vital signs are irrelevant or unimportant what i'm saying is dr ben hunter who's an emergency room specialist at indiana university hell has mistreatment orders which did not include regular monitoring of vital signs was within the standard of care and i was objective lee reasonable if you do what plaintiff asked you to do and read the entire deposition transcripts of doctors might be an olson none of them said that the treatment or the standard of care requires by the signs be taken they said the patient needs to be monitored but that can include is visible signs like shakiness sweating this is he eating is he drinking is his mental status absolutely no evidence in this case not one document not one witness that testifies that document means what plate of claims it means to nurses to correctional officers and doctor all show me have all testify consistently that document because rule jails in indiana and they are small enough to where the doctors are only there wendy a week sometimes one day every two weeks there for a lot of times patients are being monitored not even by nursing staff just by correctional officers the all the testimony of the two nurses the two correction officers and the doctor that document is created for when medical staff is not on site a nurse looking at mr collins can communicate his condition to the doctor in a much more educated much more in a much better way much more meaningful way that a correctional officer because she's trained but when officers are and are there and there's no nursing staff a c h wanted to make it easier for officers to communicated inmates condition to the doctor or the nurse so the created the sheet that said you know what before call the doctor before you call the nurse tape vitals do this do this so that she is a guide just like it says at the bottom for non medical staff because the whole point of not being deliberately indifferent to someone is that you're not basing your c plaintiff had so many treaters specially didn't really have a valid federal claim against any one person and didn't have a proper male claim against the company so judge him bilton thought well this might be a fair situation because there's nobody else to pin it on and he doesn't have an adequate remedy at law that's not the case here dr all shammy is not in any way says he was the only doctor responsible for mr collins while he was at the jackson county jail other than the two times he sent him to the hospital in twelve days so he mr collins has an well and just just to reiterate objective leon reasonable if it's so obvious that vital signs need to be taken i would ask the plaintiff why didn't you just go get an expert to say that that's all they had to do was find a doctor to not and reasonable and whether it was and whether it makes sense to do it is not the same with whether it's required by the standard of care when it had been crate for his vital signs to be taken every day absolutely but that is a completely different question than whether it's required by the standard of care and it's simply not according to the undisputed evidence and plaintiff is no evidence to rebut that thank you mr thank you  we have cited in our brief a number of expert well respected journals or medical sources and this court has often recognized that that is very survivable available source for offering medical testimony of the three doctors who treated him in their entirety as well as dr al shaab niece testimony that vital signs are essential in monitoring a person's condition so that you can detect at the earliest point when that person is deteriorating there was evidence of deterioration from the monitoring but the monitoring was by the correctional officers the correctional have no duty to report this to dr l shammy and in fact they have no duty to report it to the nurses and in fact we have no evidence that they did so when they attempt when a c h attempts to delegate this to the staff it is a mistake i was involved with the other case in which i sued a  and jackson county jail several years earlier when they first came on board that contract contrary to dr l sham his testimony is used as every contract package that a c h has with all the other trails they impose upon him and they quote supposed to train him but they really don't when i deposed the c e o and president of that corporation their power point talked about cost containment and didn't even instruct in any of the of the protocols secondly we found that they had missed a whole shift and in fact if you look at the testimony of the other officers their training is spotty because when they come on they're not always included in the training program they sort of learn on the run so it's not a real professional training as to how to use protocol that information was not in this case that was in the another case that you try well incorporated by reference in this case with it there was not but the part about training for other words if you look at the testimony of the individual officers that were part of the case you will see that they did not have the kind of training necessary to understand protocol so that's that's the thing  released he was released but he could barely walk he was in a wheelchair and he had a great deal of problems because of his deterioration one has to wonder whether or not it was because it was alcoholic but pacifically believe it was because he was allo near death condition and that's what happens when you walk somebody in a room and you don't monitor them and that's exactly what they did and that is punishment here and simple any other questions thank you very much a lot better now with us he