Opinion ID: 6800285
Heading Depth: 2
Heading Rank: 3

Heading: Second TB Disclosure and Reactions

Text: On January 9, 2016, before any action had been taken on her employment, appellant read a PPD result for a second youth in DYRS custody. The youth had a 12 millimeter “induration,” which appellant testified she had “been trained to know is positive.” 13 Apart from taking the youth’s vitals, appellant did not perform any clinical assessment but referred the youth to a nurse practitioner, who ordered a QuantiFERON blood test. 14 The nurse practitioner then sent the youth back to the youth’s residence in the DYRS community without ordering a chest X-ray. 13 In the 48 to 72 hours between appellant’s placement of the PPD skin test and her taking the reading, the youth had not been isolated from the general population. A minimum of 48 hours are required from administering a PPD skin test to reading the result. 14 See supra note 8. 13 At 2:00 p.m. on January 12, 2016, appellant sent an email to Nurse Jackson, copying Dr. Bellard, about a call-back she had received from Constance Williams, the Supervisor Nurse Coordinator at the D.C. Department of Health TB program. Nurse Williams had agreed to appellant’s request to organize a TB clinical practice training session for DYRS staff. In this email, appellant also mentioned that she had consulted with Nurse Williams about a youth whom appellant had seen over the weekend with a 12 millimeter induration for whom a follow-up QuantiFERON test had been ordered. In the email, appellant added that Nurse Williams had informed her that a QuantiFERON test was “not the appropriate follow-up for this youth,” and that the youth instead should be evaluated by a primary care provider, receive a chest X-ray as well as an assessment of symptoms, and then “begin treatment for latent TB.” 15 15 It is not clear whether this email was the first time appellant’s concerns about the second youth were disclosed to Nurse Jackson, who testified that she had not been aware of this youth before receiving appellant’s email discussed above. During cross-examination, appellant testified that she “believe[d]” she had made the disclosure to Nurse Jackson regarding the second youth via email but was “not sure,” and that she could “not remember exactly” what she had said to Nurse Jackson in reference to her concerns about the second youth’s treatment. But, she added, she knew that she had “voiced concern that we had another TB that had not been possibly treated per protocol.” 14 Eight minutes later, at 2:08 p.m., Nurse Jackson sent an email to Dr. Bellard: “So now she had made us look bad to the outside TB clinic.” 16 At 5:30 p.m. the same day, Dr. Bellard sent an email to the entire nursing staff with the subject line “positive PPDs,” stating that “[a]ll youth with positive PPDs should be treated as such” and, therefore, must have a chest X-ray and medication, without awaiting results of QuantiFERON testing. The doctor’s email further stated that “[w]e should also refer these kids to the TB Clinic on the campus of DC General Hospital for follow-up.” The email, however, did not mention what PPD reading qualifies as “positive.” The next day, on January 13, Dr. Bellard sent an email response to Nurse Jackson’s email from the day before, stating: “I’m so sick of her.” At trial, however, Nurse Jackson agreed that appellant had been right in bringing the issue about the second youth to the attention of Dr. Bellard. 16 Nurse Jackson testified at trial that, by saying appellant had made them look bad, she did not mean that appellant had made the DYRS medical staff look as though they didn’t know what they were doing but, rather, that appellant had not informed her bosses that she was reaching out to the TB clinic to get recommendations on how to treat kids with TB, which would have been the “proper etiquette.” 15 In his testimony, Dr. Bellard took issue with appellant’s characterization to Nurse Williams that a PPD reading of 12 millimeters was “positive.” He explained that, “in order for the test to be positive in our healthy kids, [the PPD reading] has to be 15 or greater.” And yet in his deposition, Dr. Bellard had stated that, according to DYRS TB policy, if a kid tested positive on the PPD, “meaning, you know, generally speaking, if it was . . . ten millimeters of firmness that you felt a couple days afterwards, that means it’s positive.” When presented at trial with this deposition testimony, however, Dr. Bellard explained that “it would be 15 millimeters in an otherwise healthy kid,” and that ten would be used “[i]f the kid had any chronic illness.” Dr. Bellard also noted that while the clinician’s decision to order a QuantiFERON blood test after the PPD test was not DYRS policy at the time, it did not cause any harm to the youth, “was just a different way of screening and actually was the way that several other facilities do tuberculosis screening,” and thus “was the action of one individual practitioner, one event.”