U.S. at 105).

“Rather, ‘a prisoner must allege acts or omissions sufficiently harmful to evidence

deliberate indifference to serious medical needs.’” 

U.S. at

106). We conduct a two-pronged inquiry, composed of an objective and subjective

component. 
Id. (citing Farmer v. 
Brennan, 
511 U.S. 825 
(1994)). “Under the

objective inquiry, the alleged deprivation must be ‘sufficiently serious’ to constitute

a deprivation of constitutional dimension.” 
Id. (citing Farmer, 511 
U.S. at 834).

Under the subjective inquiry, “the prison official must have a ‘sufficiently culpable

state of mind.’” 
Id. at 1231 (citing 
Farmer, 511 U.S. at 834
).

                                          A.

      As mentioned above, the district court concluded Plaintiff’s “radial fracture

was sufficiently serious to meet the objective prong of the test.” Heidtke, 
2011 WL

1335855
, *3. On appeal, Plaintiff contends the district court erred in identifying the

injury as a radial fracture rather than complications from a radial fracture. For

purposes of this appeal, we will assume, without deciding, Plaintiff’s fracture and

                                          7
complications from the fracture are sufficiently serious to satisfy the objective

inquiry. We turn then to the subjective inquiry. A prison official cannot be liable

for a claim of deliberate indifference “unless the official knows of and disregards an

excessive risk to inmate health or safety; the official must both be aware of facts

from which the inference could be drawn that a substantial risk of serious harm

exists, and he must also draw the inference.” 
Self, 439 F.3d at 1231 
(internal

quotation marks omitted). “The subjective component is akin to recklessness in the

criminal law, where, to act recklessly, a person must consciously disregard a

substantial risk of serious harm.” 
Id. (internal quotation marks 
omitted). And

“[w]hether a prison official had the requisite knowledge of a substantial risk is a

question of fact subject to demonstration in the usual ways, including inference from

circumstantial evidence.” 
Id. (internal quotation marks 
omitted). A serious medical

need’s obviousness “could be evidence of deliberate indifference, although a prison

official may show that the obvious escaped him and avoid liability.” 
Id. (internal

quotation marks 
omitted).

      In this Circuit, we have recognized two types of conduct which may rise to the

level of deliberate indifference in a prison medical case: “(1) a medical professional

failing to treat a serious medical condition properly; and (2) a prison official

preventing an inmate from receiving medical treatment or denying access to medical

personnel capable of evaluating an inmate’s condition.” 
Id. But, our case 
law firmly

establishes that “the subjective component is not satisfied, absent an extraordinary

                                          8
degree of neglect, where a doctor merely exercises his considered medical

judgment.” 
Id. at 1232. Examples 
of such matters “that traditionally fall within the

scope of medical judgment are decisions as whether to consult a specialist or

undertake additional medical testing.” 
Id. (emphasis added). A 
prison doctor does

not violate the Eighth Amendment’s prohibition on cruel and unusual punishment

when he “simply resolves the question whether additional diagnostic techniques or

forms of treatment is indicated.” 

U.S. at 107) (internal

quotation marks omitted). An Eighth Amendment deliberate indifference claim “is

therefore actionable only in cases where the need for additional treatment or referral

to a medical specialist is obvious.” 
Id. (emphasis added). “And 
obviousness in the

circumstances of a missed diagnosis or delayed referral, while not subject to a

precise formulation, requires direct or circumstantial evidence that can arise in

several different contexts.” 
Id. We have identified 
three. First, a doctor may

recognize an inability to treat a patient because of the seriousness of the medical

condition and a lack of expertise, but decline or unnecessarily delay a referral. 
Id.

Second, a doctor 
may fail to treat a medical condition “so obvious that even a layman

would recognize the condition.” 
Id. Finally, a doctor 
could completely deny care

even though he observes recognizable symptoms which could signal a medical

emergency. 
Id.

      If a prison 
physician “responds to an obvious risk with treatment that is

patently unreasonable, a jury may infer conscious disregard.” 
Id. “But where a
                                          9
doctor orders treatment consistent with the symptoms presented and then continues

to monitor the patient’s condition, an inference of deliberate indifference is

unwarranted under our case law.” 
Id. at 1232–33 (emphasis 
added). Accordingly,

in this Circuit, the “negligent failure to provide adequate medical care, even one

constituting medical malpractice, does not give rise to a constitutional violation.”

Id. at 1233 (internal 
quotation marks omitted). As long as the prison physician

“provides a level of care consistent with the symptoms presented by the inmate,

absent evidence of actual knowledge or recklessness, the requisite state of mind

cannot be met.” 
Id. Indeed, we have 
limited our subjective inquiry “to consideration

of the doctor’s knowledge at the time he prescribed treatment for the symptoms

presented, not to the ultimate treatment necessary.” 
Id. (emphasis added).

                                         B.
      Plaintiff has not meet the subjective prong. In the present case, Plaintiff, like

the prisoner in Self, attempts to remove the subjective inquiry from the deliberate

indifference test by suggesting “that a competent doctor looking at [his] symptoms

would have known that [malunion and CRPS, in our case, were] possible and taken

additional steps to confirm such a diagnosis.” 3 
Id. As we discussed 
in Self, “Farmer


      3
         Despite Plaintiff’s concerns that the district court erred in its subjective
component analysis because it identified the fracture itself as the injury for the
objective inquiry, the district court clearly did analyze the complications that
resulted from the treatment of the fracture in its subjective prong analysis. The
district court did not examine the Eighth Amendment claim as if Defendant had
                                                                       (continued...)

                                         10
v. Brennan and our cases interpreting Farmer have made clear, ‘a purely objective

test for deliberate indifference is simply incompatible’ with the tenets of the Eighth

Amendment.” 
Id. (quoting Farmer, 511 
U.S. at 839). Thus, Plaintiff “must point to

some evidence allowing an inference [Defendant Sutton] consciously disregarded the

possibility of [complications from the distal radius fracture].” 
Id.

      Plaintiff posits five 
such inferences. Defendant knew of the hospital discharge

instructions in his prison medical chart directing Plaintiff to return to the hospital if

severe pain or swelling beyond the splint occurred.            Defendant observed and

documented Plaintiff’s worsening symptoms and Defendant failed to refer Plaintiff

to a specialist. Additionally, Defendant knew the obviousness of the need for

treatment because the new prison physician noted “obvious” deformity and pain two

weeks later and Defendant took measures to rewrap the bandage and prescribe pain

medications as Plaintiff’s symptoms progressively worsened.

          Taking the facts of the case in the light most favorable to Plaintiff, the facts




      3
        (...continued)
somehow caused the fracture. Indeed, the district court analyzed Defendant’s
treatment of the fracture, acknowledging the issues of whether Defendant fully
appreciated the seriousness of Plaintiff’s fracture and the potential for the
development of CRPS; whether the arm should have been casted and who was
qualified to make that determination; whether the swelling and other symptoms
plaintiff experienced were consistent with his injury or suggested a more serious
complication; and the failure to order a lower bunk restriction. Heidtke, 
2011 WL
1335855 
at *5.

                                            11
do not show conscious disregard of Plaintiff’s medical needs. 4 As discussed above,

an Eighth Amendment deliberate indifference claim is actionable only where the

need for a referral or additional treatment is obvious. 
Self, 439 F.3d at 1232
. And

obviousness in the circumstances of a missed diagnosis or delayed referral arises in

three contexts. 
Id. Obviousness first may 
be found where a medical professional

completely denies care. But that certainly is not the case here, where Defendant

Sutton examined Plaintiff on three occasions, ordered x-rays, prescribed medication,

and monitored Plaintiff’s condition. Rather, Plaintiff contends Defendant missed the

diagnosis of malunion and CRPS and did not refer him to a specialist.

                                          1.

      We accordingly turn to the second scenario from which we may find

obviousness. This occurs where a medical professional fails to treat a medical

condition “so obvious that even a layman would recognize the condition.” Self, 439


      4
         Plaintiff argues the district court acknowledged disputed issues of material
fact existed and summary judgment was therefore improper. Although Plaintiff is
correct the district court acknowledged genuine issues of fact exist, as do
we—whether Defendant fully appreciated the seriousness of the fracture and the
potential for development of CRPS, whether the arm should have been casted,
whether Plaintiff’s swelling and pain were consistent with his injury or suggested a
more serious complication, the scheduling and timeliness of appoints, and the failure
to order a lower bunk restriction—Plaintiff confuses the summary judgment standard.
The district court viewed each of these facts in Plaintiff’s favor, as do we, and
concluded the facts suggested nothing more than the erroneous exercise of medical
judgment regarding the seriousness of Plaintiff’s condition. In other words, we give
Plaintiff the benefit of the doubt these facts are true and consider them in his favor.
But still, Plaintiff cannot succeed in showing a conscious disregard to satisfy the
subjective 
prong.

                                          12
F.3d at 1232
. Plaintiff believes the district court erred in applying this standard.

The Farmer court stated the risk is obvious if a “reasonable man” would realize it.

Farmer, 511 U.S. at 842
. Plaintiff argues under our precedent, a physician, rather

than a lay person with no medical training should serve as our measure of a

reasonable man. Plaintiff cites Department of Labor v. Occupational Safety and

Health Review Commission, 
938 F.2d 1116 
(10th Cir. 1991), in support of his

position. But that case is not an Eighth Amendment deliberate indifference case.

Rather, Plaintiff ignores our decision in Self, in which we clearly stated that

obviousness arises where the condition is so obvious even a layman would recognize

the condition. 
Self, 439 F.3d at 1232
. Indeed, this situation arose in Oxendine v.

Kaplan, 
241 F.3d 1272
, 1279 (10th Cir. 2001), where a prison doctor treated a

severed finger, but missed diagnosing the onset of gangrene. 
Id. The facts in 
that

case easily satisfied the subjective component for the purposes of defeating summary

judgment. Like in our case, the inmate informed the physician his finger was not

healing. 
Id. And although the 
doctor recognized and noted the inmate’s repaired

tissue appeared black and was disintegrating, he ignored the symptoms. 
Id.

      But unlike the 
medical condition in Oxendine, the malunion and onset of

CRPS in this case were not so obvious that even a layman would recognize the

conditions.   A misdiagnosis, even if malpractice, is insufficient to satisfy the

subjective component. But Plaintiff does not view Defendant’s missed diagnosis of

CRPS as a misdiagnosis. As stated by Jonathan Woodcock, one of Plaintiff’s

                                        13
experts, “[t]his case is rather typical in that the problem was not one of misdiagnosis.

The problem was a failure to recognize that Mr. Heidkte’s [sic] early signs and

symptoms put him at high risk for the development of CRPS, and that early

interventional treatment which could have impacted his course was not undertaken.”

Aplt. App. vol. II, 443. Accordingly, this situation is more akin to a treating

physician’s “failure to connect-the-dots,” which, by itself, “is insufficient to

establish a culpable state of mind.” 
Self, 439 F.3d at 1235
. “Only when the

symptoms obviously point to a substantial risk of harm can we draw an inference of

the medical professional’s conscious disregard of an inmate’s medical emergency.”

Id. As Plaintiff’s expert 
admits, Defendant failed to recognize the early signs and

symptoms which put him at risk for CRPS.

      Defendant’s failure to recognize the early signs and symptoms highlights the

flaw in Plaintiff’s argument—Defendant lacked knowledge of the complications from

the fracture. Plaintiff argues the Supreme Court’s standard for the subjective prong

is whether a physician “abates the risk” of a medical condition and the district court

erred by not explaining how Defendant’s actions “were reasonable measures to abate

the risk of complications of a fracture.” In making this argument, Plaintiff gets

ahead of himself. Before a physician can abate a risk, he must know of that risk. 5


      5
        Plaintiff asserts the district court “has set up an impossible catch 22 where
a prisoner must be ‘seen’ to establish knowledge of a risk, but the very act of being
seen defeats the prisoner’s claim.” Plaintiff is incorrect. The key is not the number
                                                                        (continued...)

                                          14
As stated above, we may find obviousness where a “medical professional fails to

treat a medical condition so obvious that even a layman would recognize the

condition.” 
Self, 439 F.3d at 1232
. We do not suggest as a matter of law that

medical obviousness is generally to be viewed from the perspective of a layman.

Obviously at times a doctor may be reckless by failing to detect what should be

glaringly obvious to any medical professional—though not to a layperson. We

cannot infer recklessness in this case under either situation.      The presence of

swelling and pain, even weeks after fracturing an arm, would not evidence a medical

urgency so unmistakable that it would have been apparent to a layman or glaringly

obvious to a medical professional. Defendant noted in Plaintiff’s chart that, despite

the pain and swelling, Plaintiff’s fingers and hand had good color and warmth. Aplt.

App. vol. I, 169.    Moreover, Defendant ordered x-rays, scheduled follow up

appointments with Plaintiff, and prescribed Plaintiff medication. 6 Dr. Woodcock

      5
       (...continued)
of times a doctor sees a patient, but instead whether the doctor examines the patient
and treats his symptoms. In arguing Defendant’s treatment methods failed to abate
a substantial risk, Plaintiff disregards whether Defendant even had knowledge of a
substantial risk. Instead, Plaintiff argues the second prong should be simply another
objective prong, based on what a competent physician should know, instead of what
the doctor at issue actually knew when treating the patient. In other words, Plaintiff
must show more than that a risk merely existed. Rather, Plaintiff must show
Defendant consciously disregarded Plaintiff’s condition, amounting to deliberate
indifference.
      6
         Defendant viewed the x-ray of Plaintiff’s wrist and noted, on June 17, 2008,
that the wrist appeared stable and slightly impacted with no angulation. Aplt. App.
vol. I, 241. According to Defendant’s reading of the x-ray, the malunion had not
                                                                        (continued...)

                                         15
stated “[t]he standard of care is to treat the symptoms which may develop into CRPS

as early as possible in order to obtain a better outcome.” Aplt. App. vol. II, 443.

The question of whether Defendant Sutton should have been aware CRPS could

develop relates to the standard of care Defendant owed Plaintiff.            Perhaps

Defendant’s conduct constituted malpractice. But Plaintiff has a separate state law

action against Defendant for that cause of action. As in the past, we refuse to

constitutionalize a medical malpractice claim.      See 
Estelle, 429 U.S. at 106
(“Medical malpractice does not become a constitutional violation merely because the

victim is a prisoner.”). Plaintiff cannot show that complications from the radial

fracture were so unmistakable that even a layman would apprehend it or that it would

have been so glaringly obvious to a medical professional that recklessness may be

inferred. As mentioned above, the subjective prong of the deliberate indifference

prong is exactly that—subjective. Plaintiff must show a conscious disregard on the

part of Defendant, which Plaintiff simply cannot do.

                                         2.

      We turn now to the third and final scenario in which we may find obviousness.


      6
        (...continued)
occurred as of that visit. Plaintiff’s expert, W. Carlton Reckling, stated he did not
believe the x-rays taken on June 17, 2008 demonstrate “an acceptably aligned
fracture.” 
Id. at vol. II, 
344. Even if Defendant misread the x-ray, at worst,
Defendant committed malpractice. Defendant treated Plaintiff and was not
deliberately indifferent, though he may have been negligent. Defendant next saw
Plaintiff on July 7, when he ordered another x-ray. 
Id. at vol. I, 
244. Defendant
ended his employment with the prison the following day.

                                         16
No evidence exists in the record to show Defendant may have recognized an inability

to treat Plaintiff because of the seriousness of the medical condition and a lack of

expertise, but declined or unnecessarily delayed a referral to an orthopedic surgeon.

Self, 439 F.3d at 1232
. “[A]bsent an extraordinary degree of neglect,” where a

doctor exercises his considered medical judgment not to consult a specialist, the

plaintiff cannot satisfy the subjective component. 7      
Id.   Dr. Woodcock stated
Defendant “ignored [Plaintiff’s] worsening symptoms, making no effort to diagnose

or refer him for further specialty evaluation for over seven weeks.” Aplt. App. vol.

II, 448. Dr. Woodcock believes Defendant “should have been more concerned about

preventing CRPS than in waiting to confirm its diagnosis.”          
Id. at 446.   This
evidence does not establish Plaintiff’s symptoms “obviously required unusual

medical skill or ability thus necessitating referral, or that [Defendant Sutton]

otherwise failed to provide a course of treatment consistent with the symptoms he

recognized.” 
Self, 439 F.3d at 1235
. Rather, Defendant “provide[d] a level of care

consistent with the symptoms presented by the inmate.” 
Id. at 1233. Because 
no

evidence of actual knowledge or recklessness exists, “the requisite state of mind

cannot be met.” 
Id.


      7
        Plaintiff argues 
this language is dicta, but we disagree. Self restated the law
of Eighth Amendment deliberate indifference in the Tenth Circuit. We may not
disregard our case law in which we have interpreted the subjective prong of the
Farmer test. Furthermore, Plaintiff’s contention that Self is inconsistent with Farmer
is simply untrue. The district court correctly applied this Circuit’s case law in its
decision and did not establish a standard inconsistent with that of Farmer.

                                          17
                                          3.

      Finally, Plaintiff asserts Defendant was deliberately indifferent to his medical

needs by failing in his “gatekeeper” role. But this type of deliberate indifference is

rare. 
Sealock, 218 F.3d at 1211
. Where the physician “knows that his role in a

particular medical emergency is solely to serve as a gatekeeper for other medical

personnel capable of treating the condition, . . . he may be liable for deliberate

indifference.” 
Id. (emphasis added). Here, 
Defendant Sutton was Plaintiff’s treating

physician. Although Defendant stated he would need a neurologist to rule out CRPS,

a general practitioner is not deliberately indifferent by failing to make a referral

when he has no knowledge of a substantial risk. 8          Such a result, absent an

extraordinary degree of neglect, would be inconsistent with our case law that a

doctor’s decision to consult a specialist is a medical judgment, which does not satisfy

the subjective component. 
Self, 439 F.3d at 1232
.

      In this case, a reasonable jury could not infer conscious disregard either from

Defendant’s missed diagnosis or Defendant’s failure to refer Plaintiff to a specialist.

Although Defendant’s medical judgment may have constituted malpractice or

negligence, we would simply speculate to conclude Defendant had a culpable state

of mind. Because summary judgment requires evidence rather than speculation that



      8
       Defendant acted in the capacity of a general practitioner at the prison.
Although he had been an orthopedic surgeon in the past, he stopped practicing as an
orthopedic surgeon in 1988.

                                          18
Defendant knew about and consciously disregarded the risk, the decision of the

district court is AFFIRMED. 9



                                      Entered for the Court,



                                      Bobby R. Baldock
                                      United States Circuit Judge




      9
         On March 20, 2012, Plaintiff filed a “motion to strike factually false, ex-
parte letter and for reprimand.” On March 21, 2012, Plaintiff filed an “unopposed
motion to withdraw motion to strike factually false, ex-parte letter and for
reprimand.” Plaintiff’s March 21 unopposed motion to withdraw is granted.

                                        19
11-1205, Heidtke v. Corrections Corp. of America, et al.

BRISCOE, Chief Judge, dissenting.

      I respectfully dissent in this summary judgment case. I disagree with the

majority’s conclusion that Heidtke failed to present sufficient evidence to satisfy

the subjective component of the Farmer test, i.e., whether Sutton had a

sufficiently culpable state of mind, Farmer v. Brennan, 
511 U.S. 825
, 834 (1994).

Although it is a close question, in my view the evidence presented by Heidtke in

response to Sutton’s motion for summary judgment was sufficient to create an

issue of material fact regarding whether Sutton knew about and disregarded a

substantial risk of serious harm to Heidtke. Accordingly, I would reverse the

district court’s grant of summary judgment in favor of Sutton and remand the case

to the district court for further proceedings.

                                           I

      Although the majority opinion provides a brief factual summary of

Heidtke’s interactions with Sutton, it fails, in my view, to do so in a manner

consistent with the standard of review that applies in summary judgment cases.

More specifically, I believe that the majority opinion fails to recount the evidence

in the light most favorable to Heidtke. Accordingly, I shall begin by doing so.

      On June 2, 2008, Heidtke was an inmate at the Huerfano County

Correctional Facility (HCCF) in Walsenburg, Colorado. App. at 217. On that

date, Heidtke “[i]njured [his] right wrist playing softball.” 
Id. at 353. Heidtke
was initially escorted to HCCF’s medical unit, and then transported to the
emergency department at Spanish Peaks Regional Health Center in Walsenburg.

Id. at 21. There, 
his right arm and wrist were x-rayed. 
Id. The x-ray revealed 
a

“[m]inimally displaced transverse fracture [of the] distal right radius,” with a

“[f]racture line [that] m[ight] extend to the radiocarpal joint, dorsal medially.”

Id. at 544. Dr. 
Rodney Lange, the emergency room physician who examined

Heidtke, treated the injury by placing Heidtke’s right arm and wrist in a splint and

sling. 
Id. at 21, 217. 
Lange also issued orders directing that Heidtke’s injured

arm be elevated and packed in ice for the first few days after injury. 
Id. at 21.

Lange 
opined the fracture would take three to eight weeks to heal. 
Id.

       Defendant Jere Sutton 
is a physician licensed to practice medicine in

Colorado. 
Id. at 218. Sutton 
practiced as an orthopedic surgeon until he elected,

in 1988, to cease his surgical practice. 
Id. Thereafter, he practiced 
office

orthopedics, including various stints as a temporary physician. 
Id. at 232. On
May 30, 2008, Sutton contracted with CCA to work as a temporary general

medical doctor at HCCF until a permanent replacement could be hired. 
Id. at 218,

486.
       On June 4, 2008, two days after his injury, Heidtke was seen by Sutton in

HCCF’s medical unit. 
Id. Sutton noted that 
there was “swe[l]ling of the hand

and pain on palpation and movement.” 
Id. at 240. Sutton 
entered orders that the

arm, which at the time was bound on a splint and in a sling, was to be considered

for casting after the swelling decreased. 
Id. Sutton also ordered 
that Heidtke

                                          2
receive Vicodin for pain, and ordered that a follow-up visit occur within “5 days

for possible casting.” 
Id.

      On June 6, 
2008, when Heidtke appeared at HCCF’s medical unit to pick up

his medication, he was noted to be out of his sling, with his arm dangling. 
Id. at

219. Heidtke 
was seen again in the medical unit the following day, June 7, 2008.

Id. His hand was 
still swollen and he was given Tylenol for ongoing pain. 
Id.

Three days later, 
on June 10, 2008, Heidtke returned to the medical unit and

discussed with staff members the possibility of obtaining a “pass” that would

allow him to wear his sling during trips to the mess hall. 
Id.

      Heidtke was seen 
by Sutton for a second time on June 17, 2008

(approximately fifteen days after the injury). 
Id. at 241. Sutton 
observed that the

“[f]ingers and hand on the [injured arm] [we]re edematous - have good color and

wrmth [sic].” 
Id. An x-ray of 
Heidtke’s arm was taken and Sutton observed from

the x-ray that the fracture “[a]ppear[ed] stable and slightly impacted with no

angulation.” 
Id. Sutton noted, however, 
that Heidtke “complain[ed] of swelling

and pain” and had been “[u]nable to sleep due to the pain.” 
Id. Sutton further

noted 
that Heidtke “[h]a[d] been out of [his] sling at times.” 
Id. Sutton

determined he 
could not cast the arm “at th[at] time due to the swelling,” and he

“[d]iscussed [with Heidtke] means of improving and lessening the swelling.” 
Id.

Sutton prescribed extra-strength 
Tylenol and a four-day-regimen of Vicodin and

directed Heidtke to return for a follow-up visit in two weeks. 
Id.

                                          3
      Following his 
visit with Sutton on June 17, 2008, Heidtke completed and

submitted to HCCF officials an inmate grievance form. Therein, Heidtke

complained that the medical staff at HCCF had ignored his complaints of swelling

and pain, and were deliberately indifferent to his medical needs. 
Id. at 474. The
grievance was denied. 
Id.

      On June 24, 
2008, Heidtke completed and submitted to HCCF officials a

written “REQUEST FOR SERVICE” form stating, “I realize that I finished my

meds on the 22nd of this month, but the pain and swelling is still persisting, it is

getting worse instead of better, if possible I would like to be seen again before my

next scheduled x-ray.” 
Id. at 357. On 
that same date, a nurse in HCCF’s medical

unit responded in writing, “You are scheduled to talk to the doctor.” 
Id.

      On July 2, 
2008, Heidtke completed and submitted another ‘REQUEST

FOR SERVICE” form, this time stating:

      I would like to be seen by the Doctor for my broken wrist. For 4
      weeks I have been experiencing worsening pain and swelling in my
      hand/arm. I have lost almost all mobility in my thumb. I’m getting
      more and more tingling and numbing sensations in my 4 fingers, the
      pain that radiates from my thumb to my elbow is starting to border
      on excruciating. My thumb is terribly painful to the touch.

Id. at 358. Heidtke 
was seen later that same day by a nurse on duty in HCCF’s

medical unit. 
Id. at 242. The 
nurse noted that the “[s]kin on [the] fingers [of

Heidtke’s right hand were] very tight and puffy.” 
Id. Heidtke advised her 
that

“his fingers tingl[e]d much of the time,” and that he was “[u]nable to move [his]


                                           4
thumb and fingers without pain.” 
Id. The nurse “rewrapped” 
Heidtke’s arm with

an “ACE wrap” and noted her observations in Heidtke’s medical records. 
Id.

      Heidtke returned to 
the medical unit on July 5, 2008, complaining of arm

and wrist pain. 
Id. at 243. The 
nurse who saw Heidtke observed that the splint

and sling were in place on his right arm. 
Id. The nurse provided 
Heidtke with a

five-day regimen of acetaminophen and noted that he was scheduled to be seen by

a physician later that week. 
Id.

      On July 7, 
2008, Heidtke was seen by Sutton for a third time. 
Id. at 244.

Heidtke 
advised Sutton that he was experiencing swelling and pain in his right

thumb and was unable to move it. 
Id. Sutton observed that 
Heidtke’s right hand

and fingers “[we]re slightly swollen,” but had “[g]ood color and [we]re warm.”

Id. Sutton “[r]emoved [the] 
outer ace wrap and reapplied [it] and allowed it to be

less tight at [the] base of [the] thumb.” 
Id. Sutton also directed 
that Heidtke

receive an x-ray of his right wrist, and he prescribed Heidtke a twenty-day

regimen of Naprosyn for his pain. 
Id.

      Following his appointment 
with Sutton on July 7, 2008, Heidtke completed

and submitted to HCCF officials an inmate grievance form. The form stated, in

pertinent part, “The medical staff is aware of my worsening condition, yet they do

nothing but change the bandage on my arm and take me off the only medication

that was allotted.” 
Id. at 475. Heidtke 
alleged that these acts constituted

deliberate indifference. On July 9, 2008, HCCF officials wrote that “[t]here [wa]s


                                          5
no evidence to support [his] claim [of] insufficient treatment.” 
Id.

      Approximately two weeks 
later, on July 22, 2008, Heidtke was seen in

HCCF’s medical unit by a different physician, Dr. David Paz, who had been hired

by CCA as a full-time employee and effective replacement for Sutton. 
Id. at 245,

414. 
Paz noted that Heidtke was “7 ½ weeks post fall” and fracture and was

“[s]till [experiencing] severe pain and inability due to pain to extend his thumb.”

Id. at 245. Paz 
removed Heidtke’s splint and observed a “deformed dorsum of

[Heidtke’s] right hand.” 
Id. Paz also observed 
“[g]ood pulses and neuro intact.”

Id. Paz noted that 
“[p]ain in [Heidtke’s] snuff box [was] obvious,” 1 and that

Heidtke was also experiencing “pain [in his] right elbow.” 
Id. Paz noted in
Heidtke’s medical chart: “Need to rule out scaphoid fracture and fracture or

dislocation of elbow and carpal bones. Ortho consult important and needed!” 
Id.

Accordingly, Paz ordered 
an “[o]rthopedic consult ASAP,” as well as an “X-Ray

(outside of this facility if necessary within next couple of days right hand, wrist,

scaphoid view of wrist and right elbow for fracture/dislocation[)].” 
Id. Paz also

prescribed 
Heidtke pain medication “until [he was able to] see[] ortho surgeon.”

Id.

      Heidtke was examined 
by an orthopedic physician, Dr. Shawn Nakamura,

      1
        “The anatomical snuffbox is a triangular deepening on the radial, dorsal
aspect of the hand—at the level of the carpal bones, specifically, the scaphoid and
trapezium bones forming the floor. The name originates from the use of this surface
for placing and then sniffing powdered tobacco, or ‘snuff.’” Wikipedia, Snuff Box,
at http://en.wikipedia.org/wiki/Anatomical_snuff_box.

                                          6
on August 28, 2008. 
Id. at 24, 363. 
Nakamura noted that Heidtke had decreased

range-of-motion “in all planes of the [right] wrist,” decreased “dorsiflexion,

“[r]adial and ulnar deviation,” “[p]ain with [range of motion] of the thumb,” and

“[t]enderness throughout the wrist and hand.” 
Id. at 363. Nakamura 
concluded

that Heidtke had suffered a right distal radius fracture, and “ha[d] elements of

RSD,” 
id., i.e., Reflex Sympathetic 
Dystrophy (otherwise known as Complex

Regional Pain Syndrome (CRPS)), 
id. at 346. 2 
Nakamura stated in his medical

notes, “I’m . . . getting a referral to Neurology and getting an MRI of the R[ight]

wrist. Worried about tenderness to palpation of the snuff box.” 
Id.

      In early 2009, 
Heidtke was seen by a neurologist, Dr. Sunku, who

concluded, after running various tests, “that the results . . . [we]re consistent with

moderate carpal tunnel syndrome and that [Heidtke] possibly also had” RSD. 
Id.

at 457. Later 
in 2009, after Heidtke was paroled to a halfway house and was

responsible for his own medical care, “he was definitively diagnosed with RSD by



      2
        CRPS “is a chronic pain syndrome most often resulting from trauma to a
single extremity.” Oldham v. Astrue, 
509 F.3d 1254
, 1255 n.1 (10th Cir. 2007)
(internal quotation marks omitted). “The most common acute clinical manifestations
[of CRPS] include complaints of intense pain and findings indicative of autonomic
dysfunction at the site of the precipitating trauma. Later, spontaneously occurring
pain may be associated with abnormalities in the affected region involving the skin,
subcutaneous tissue, and bone.”          
Id.   “[T]he degree of 
pain reported is
[characteristically] out of proportion to the severity of the injury sustained,” and,
“[w]hen left untreated, the signs and symptoms of the disorder may worsen over
time.” 
Id. Notably, “[a] diagnosis 
of RSD is based upon complaints of persistent,
intense pain that results in impaired mobility of the affected region, coupled with
other complaints . . . .” 
Id. (internal quotation marks 
omitted).

                                          7
a neurologist” at Denver Health Medical Center. 
Id. at 26. Heidtke 
was also seen

by Dr. Timothy Muratore, an orthopedic doctor at the Denver Health Medical

Center. Muratore made the following recommendations after examining Heidtke

in late 2009:

      At this point, due to the patient’s complex regional pain syndrome,
      he is unlikely to benefit from any surgical intervention at this point.
      In fact, he will most likely have worsening of the CRPS if there were
      to be any surgery performed in the near future. For that reason, we
      feel that the best course of action for the patient is to be sent to the
      pain clinic or anesthesiologist for potential sympathetic blockade of
      his right upper extremity. If we are able to obtain better control of
      the CRPS, he may be a candidate for wrist arthroscopy for diagnosis
      as well as debridement. However, at this point, the CRPS is
      uncontrolled and any surgery would cause a flare.

Id. at 365.

                                          II
      The majority opinion also fails, in my view, to recognize and give proper

weight to the expert evidence presented by Heidtke in response to Sutton’s motion

for summary judgment. That evidence, which Heidtke attached to his response to

the other defendants’ motion for summary judgment and then incorporated by

reference in his response to Sutton’s motion for summary judgment, provided as

follows:

      • Dr. Carlton Reckling. Reckling, an orthopedic surgeon retained by

Heidtke as an expert witness, considered the steps taken by Sutton during each of

his three visits with Heidtke. With respect to the June 4, 2008 visit, Reckling



                                          8
opined that Sutton failed to provide Heidtke with even the “minimal accepted

treatment,” which Reckling described as a referral to an orthopedic surgeon for

evaluation and possible surgery, and a follow-up evaluation by Sutton within five

days. 
Id. at 436. Reckling 
further opined that Heidtke’s “clinical presentation” at

the June 17, 2008 visit “[wa]s not ‘normal’ for a simple distal radius fracture,”

and that the proper course of treatment was “referral to an orthopedic surgeon for

evaluation and possible surgery. 
Id. As for the 
July 7, 2008 visit, Reckling

opined that Sutton failed to provide Heidtke with the “minimal accepted

treatment,” which Reckling described as the removal of Heidtke’s splint and the

evaluation of Heidtke’s wrist and hand, new x-rays taken and compared to the

first two sets of x-rays, evaluation of the x-rays by an orthopedic surgeon, and

application of a “[n]ew well padded and well molded splint.” 
Id. at 437. “In
summary,” Reckling opined that “when . . . Sutton saw . . . Heidtke on June 17

and on July 7, 2008, he should have known that there was a problem that required

evaluation by an orthopedic surgeon, and he either should have acted in that

capacity or referred . . . Heidtke to an orthopedic surgeon for treatment.” 
Id. at

438. According 
to Reckling, “Sutton’s treatment of . . . Heidtke’s fracture was

the equivalent of no treatment.” 
Id.

      • Dr. Jonathan 
Woodcock. Woodcock, a neurologist retained by Heidtke as

an expert witness, opined that it was well-accepted that “the key symptom” of

CRPS was “continuous, intense pain out of proportion to the severity of the


                                          9
injury, which gets worse rather than better over time,” 
id. at 441 (internal
quotation marks omitted), and he noted that “[w]ithin two weeks of . . . Heidtke’s

fracture on 6/2/08, he was exhibiting this symptom coupled with edema, another

key symptom” of CRPS, 
id., “both of which 
worsened over time,” 
id. Woodcock

further opined 
that “[w]henever this occurs following peripheral injury,

particularly a radial fracture, the pain must be investigated thoroughly and steps

taken to ensure that CRPS does not develop.” 
Id. “In other words,” 
he opined,

“early, persistent, severe pain must be taken seriously . . . because . . . without

early intervention[] it may develop into CRPS.” 
Id. (emphasis in original).
      Woodcock noted that in this case “Heidtke’s early symptoms of severe pain

and swelling were worsening when they would have been expected to be

improving,” 
id. at 446, yet 
“Sutton left . . . Heidtke in a sugar tong splint,” 
id. at

445-46, for 
“seven weeks,” 
id. at 445, causing 
“his fracture [to] heal[] in a

malunion and his CRPS [to] worsen[],” 
id. at 446. And, 
Woodcock opined,

“[h]ad . . . Heidtke been referred to an orthopedic surgeon within at most several

weeks of the time it had become clear that his recovery course was considerably

atypical, it is more likely than not he would have received appropriate, and surely

more aggressive treatment, and that he would have experienced either a

considerably more benign course or a full recovery.” 
Id. Woodcock effectively

agreed 
with Reckling by opining that “[i]n the absence of [a] referral” to an

orthopedic surgeon for evaluation, “Heidtke did not receive treatment for his

                                           10
developing CRPS under . . . Sutton’s care.” 
Id. at 447.

      • 
Dr. Lynn Sander. Sander, a board certified internist retained by Heidtke,

opined that “Heidtke’s complaints were consistent with known complications of a

radial fracture which include fracture of the scaphoid bone, disabling arthritis,

carpal tunnel syndrome, radial shortening and angulation deformity which limit

range of motion, chronic pain, non-union and reflex sympathetic dystrophy

(RSD).” 
Id. at 454. She 
further opined that “Sutton’s lack of treatment” in light

of these symptoms “was especially egregious because he knew of the risk of

serious complications of radial fracture by virtue of his [orthopedic] training, yet

he did not take any action to mitigate the risk on multiple occasions.” 
Id. Like

Heidtke’s other 
two experts, Sander opined that, “[i]n essence,” Heidtke “received

no medical treatment for his injury for 7.5 weeks until there was a change in

providers.” 
Id.

                                         III

      Construing all 
of this evidence in the light most favorable to Heidtke, I am

persuaded that reasonable jurors could have found that Sutton was “aware of facts

from which the inference could be drawn that a substantial risk of serious harm

exist[ed].” 
Farmer, 511 U.S. at 837
. In particular, Sutton (a) reviewed the

medical records and x-rays from Heidtke’s visit to the Spanish Peaks emergency

room, which clearly suggested the possibility of a complex fracture extending into

Heidtke’s wrist joint, (b) reviewed Heidtke’s medical records at HCCF, which

                                          11
included notations of Heidtke’s complaints to the nursing staff of increasing pain,

swelling, and lack of mobility in his right wrist and hand, (c) personally met with

and evaluated Heidtke on three occasions during June and July 2008, during

which he not only observed Heidtke’s wrist and hand, but also heard directly from

Heidtke regarding his symptoms, and (d) obtained and reviewed an additional x-

ray of Heidtke’s wrist and hand on June 17, 2008. In short, Sutton was well

aware that, following Heidtke’s initial injury, Heidtke’s symptoms continued to

worsen, rather than improve.

      In turn, I am persuaded that the evidence, again construed in the light most

favorable to Heidtke, was sufficient to allow a jury to reasonably find that “the

need for additional treatment or referral to a medical specialist,” i.e., an

orthopedic surgeon, was “obvious.” Self v. Crum, 
439 F.3d 1227
, 1232 (10th Cir.

2006). All three of Heidtke’s expert witnesses testified that Heidtke’s steadily

worsening pain and swelling established an obvious and urgent need for Heidtke

to be referred for evaluation and possible surgery by an orthopedic surgeon, yet

Sutton not only failed to do so, but effectively did nothing to address Heidtke’s

symptoms over the course of three visits spanning seven-and-a-half weeks. 3

      3
        Had Sutton not seen Heidtke on the last occasion, my determination may
have been different. In other words, I am not persuaded that a jury could reasonably
find that Sutton was deliberately indifferent based solely on the steps he took with
Sutton during the first and second appointments on June 4 and 17, 2008. But, in my
view, it is particularly egregious that, at time of the third appointment on July 7,
2008, when Heidtke’s symptoms were clearly worsening rather than improving,
                                                                       (continued...)

                                          12
      Based upon this expert witness testimony, a jury could reasonably find that

Sutton, in effect, completely denied care to Heidtke, at least at the time of the

third and final appointment on July 7, 2008. See 
id. at 1232 (noting 
that

obviousness can arise where a medical professional completely denies care in the

face of recognizable and serious symptoms). Alternatively, a jury could

reasonably find that Heidtke’s steadily worsening symptoms were so “glaringly

obvious to a medical professional that recklessness may be inferred,” Maj. Op. at

16. In other words, a jury could reasonably find, based upon the evidence

presented by Heidtke, that Sutton exhibited “an extraordinary degree of neglect”

by failing to refer Heidtke to an outside specialist for evaluation and possible

treatment, particularly by the time of the third appointment on July 7, 2008. 
Self,

439 F.3d at 1232
. Thus, in my view, a jury could reasonably find that Sutton

satisfied the subjective component of the Farmer test.

      In concluding that Heidtke failed to present sufficient evidence of

obviousness, the majority focuses most of its attention on the question of whether

“the malunion and onset of CRPS in this case were . . . so obvious that even a

layman would recognize the conditions.” Maj. Op. at 13. But Heidtke has never

relied on this “obvious to a layman” standard. Instead, he argues that, under the

circumstances of this case, the proper “measure of a reasonable man” is a trained

      3
       (...continued)
Sutton continued to take no serious steps to either determine the precise cause of the
problem, or to alleviate Heidtke’s symptoms.

                                          13
“physician, rather than a lay person with no medical training.” 
Id. Although the

majority 
concedes that “at times a doctor may be reckless by failing to detect

what should be glaringly obvious to any medical professional,” 
id. at 15, it
summarily concludes, without any mention of Heidtke’s expert witness testimony,

that Heidtke cannot prevail even under this standard. As I have explained,

however, all three of Heidtke’s expert witnesses agreed that, based upon the

symptoms presented by Heidtke and clearly observed by Sutton, the need for

referral to a specialist or additional treatment would have been obvious to any

medical professional. In light of this unusually strong expert witness testimony, I

believe it is quite clear that Heidtke presented sufficient evidence to survive

Sutton’s motion for summary judgment, and that the district court erred in

concluding otherwise.




                                          14