In 2004, a California prisoner reported to the infirmary with a 2-week history of fever and chills. His condition worsened over the next several weeks. Eventually, he was diagnosed with endocarditis, but never received the appropriate antibiotics. He finally reported to the prison's emergency room with cyanosis, severe hypotension, and a high fever. Despite the objections of a nurse, who wanted to send the prisoner to the emergency department at the local hospital, the physician on duty recommended returning the man to his housing unit. The patient died soon after from cardiac arrest.
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