Opinion ID: 8414568
Heading Depth: 3
Heading Rank: 1

Heading: The Claim Against Dr. Al-Shami

Text: Collins argues that the treatment he received from Dr. Al-Shami was objectively unreasonable under the circumstances, because Dr. Al-Shami did not monitor Collins’s vital signs, or ensure that his vital signs were monitored, on a regular basis. In support of this argument, Collins points to the deposition testimonies of some of his other treating physicians, to a journal article on the evaluation and treatment of individuals suffering from alcohol withdrawal, and to an “Alcohol Withdrawal Protocol” issued by Dr. Al-Shami’s employer, Advanced Correctional Healthcare. These materials do not demonstrate what Collins urges. Dr. Guffey, the emergency-room doctor who treated Collins when he was first sent to the hospital on August 15, 2012, did refer to vital signs when asked at his deposition about diagnosing delirium tre-mens (an acute form of alcohol withdrawal). Patients suffering from delirium tre-mens, explained Dr. Guffey, typically will have a very high heart rate and a “fairly high” respiratory rate, and may have a higher-than-normal body temperature. However, Dr. Guffey also described more qualitative indicators of acute withdrawal, explaining that patients with delirium tre-mens will be “sweaty, very jittery, [or] shaking.” Dr. Jonathan Light, who treated Collins after he returned to the same hospital on August 23, 2012, similarly described a collection or “cluster” of relevant symptoms, including, on the quantitative side, an elevated heart rate and hypertension (high blood pressure), but also including symptoms that may be observed or discovered through visual inspection or conversing with the patient, such as tremulousness, agitation, confusion, severe anxiety, headaches, hallucinations, diarrhea, vomiting, and excessive sweating. Dr. Grant Olsen, an inpatient specialist who also treated Collins during his second hospital visit on August 23, likewise discussed a comprehensive approach to diagnosing delirium tremens. While Dr. Olsen would often use vital signs to look for delirium tremens, he stated that, for inpatients, he would typically evaluate alcohol-withdrawal symptoms using the Clinical Institute Withdrawal Assessment, or “CIWA,” scale. The CIWA method, as explained in the journal article on which Collins also relies, see Max Bayard et al., Alcohol Withdrawal Syndrome, 69(6) Am. Fam. Physician 1325, 1443-50 (2004), 2 calls for healthcare providers to complete a worksheet that ascribes a numeric score to an array of symptoms typically associated with alcohol withdrawal, such as nausea and vomiting; tremors; “[pjaroxysmal sweats”; anxiety; agitation; tactile, auditory, and visual disturbances; headaches; and disorientation and “clouding of senso-rium.” The more severe the symptom, the higher the score and, collectively, the higher the risk of developing delirium tremens. (The worksheet also includes fields for recording the patient’s heart rate and blood pressure, but ascribes a score to neither.) Collins highlights that the Bayard article lists tachycardia (elevated heart rate), fever, and hypertension as specific indicia of delirium tremens. The article does mention those symptoms in connection with severe alcohol withdrawal; but the article also refers to qualitative symptoms of the condition (e.g., agitation, disorientation, and hallucinations), id. at Table 2. Vital signs are not the article’s sole, or even primary, focus, and nothing in that document suggests that if a patient’s vital signs are not measured frequently, healthcare providers will be unable to assess the severity of the patient’s withdrawal. Collins next points to the Alcohol Withdrawal Protocol created by Dr. Al-Shami’s employer, Advanced Correctional Healthcare. The protocol suggests to jail personnel the actions they should take if they suspect a detainee might be suffering from withdrawal. These actions include: asking the detainee a series of questions (when the detainee last drank alcohol, how much they drink daily, and whether they have a history of liver disease or seizures); examining the detainee — i.e., taking their “[v]itals” (blood pressure, temperature, pulse, and respiratory rate) and looking for other symptoms (e.g., tremors, confusion) that might require treatment; recording the results of that examination; and scheduling a visit with a physician or “responsible medical provider.” The protocol also states that, after treatment with any medication (as directed by a healthcare provider), the detainee’s vital signs should be monitored every four hours for the first day of confinement, and then again during each shift while medications continue. Collins argues that the protocol establishes a standard of medical care, and that the standard therefore includes the regular monitoring of a detainee’s vital signs. On each page of the document, however, is written: These Protocols are designed to assist the staff in the gathering of information to be communicated to the medical staff. The Protocols are not intended to establish a standard of medical care and are not standing orders. All treatments must be ordered and approved b[y] a Nurse Practitioner, Physician Assistant or Physician. (emphasis added). Several jail employees also testified at their depositions that the protocol forms are in general used by non-medical jail staff for the limited purpose of collecting information when medical professionals are not present or available to see detainees in person. At most, the protocol reflects the kind of data that some physicians 3 thought might be helpful in assessing a detainee’s alcohol withdrawal. The majority of those data concern the detainee’s appearance and behavior, not his vital statistics, and in any event, there is no suggestion that acute alcohol withdrawal cannot be treated or diagnosed absent those particular statistics. Vital signs aside, Collins argues that Dr. Al-Shami is still liable under § 1983, because the on-site jail staff should have at least monitored Collins’s overall condition, and Dr. Al-Shami did not advise those staff members about when to contact him should Collins’s symptoms worsen. This argument, too, is unpersuasive. First, it is not apparent from the record that Dr. Al-Shami was responsible for giving orders of precisely this kind. Moreover (and relatedly), Collins points to no evidence reasonably suggesting that the orders Dr. Al-Shami did give were deficient. Dr. Al-Sha-mi. instructed that Collins be observed for signs of withdrawal (including sweating, shaking, and changes in mental state), and Collins was checked — frequently—by on-site personnel, who collectively telephoned Dr. Al-Shami at least four times about Collins’s condition and twice sent him to the hospital at Dr. Al-Shami’s request. Collins stresses that Dr. Olsen was unable to assess the quality of care actually given to Collins during his detention because, according to Dr. Olsen, he did not have a complete “clinical picture” of Collins’s condition. That Dr. Olsen could not opine on the adequacy of Collins’s treatment is not evidence that the treatment was objectively inadequate — and nor do the records from Dr. Light, on which Collins also relies, fill that gap. Dr. Light had remarked in his treatment notes from August 28, 2012, that Collins’s altered mental state was likely symptomatic of delirium tremens that had been “inadequately managed ... with oral Librium at [the] jail.” At his deposition, however, Dr. Light clarified that this comment was not about the relevant standard of care. According to Dr. Light, he had meant to convey only that, despite the Librium treatment (as ordered by Dr. Al-Shami), Collins’s alcohol withdrawal had continued to progress — a possibility even where alcohol-withdrawal symptoms have been managed appropriately. Defendants’ medical expert, Dr. Benton Hunter, reviewed Collins’s medical records and a chronology of his treatment at the Jackson County Jail, and concluded that Dr. Al-Shami’s conduct was reasonable and in accordance with the applicable standard of care. Collins has not presented any evidence suggesting that this conclusion was erroneous. The district court thus correctly dismissed Collins’s § 1983 claim against Dr. Al-Shami.