Introduction

In this nonprecedential decision, the Eleventh Circuit applied its recent en banc ruling in Wade v. McDade to uphold a jury verdict finding deliberate indifference under the Eighth Amendment against a prison physician, Dr. Manuel Pouparinas. The plaintiff, former Alabama inmate Canyon Duff Moye, suffered peripheral neuropathy and recurrent foot infections before incarceration. After transfer to Fountain Correctional Institution, his left foot deteriorated; culture results later identified a pseudomonas infection, and after months of treatment missteps—including cancellation of an ordered IV antibiotic—he ultimately underwent partial amputation (all toes on his left foot).

The key legal issue on appeal was whether, under Wade’s clarified “subjective recklessness” standard, sufficient evidence existed for a reasonable jury to find that Dr. Pouparinas was actually, subjectively aware that his own conduct created a substantial risk of serious harm, yet failed to respond reasonably to that risk. Dr. Pouparinas argued the proof sounded in malpractice at most; the panel concluded the record permitted a reasonable jury to find subjective recklessness.

The ruling is significant because it shows how, post-Wade, a plaintiff can satisfy the demanding subjective prong of deliberate indifference—particularly where a physician persists in a known-ineffective regimen, fails to adjust care in the face of clear clinical deterioration and lab data, and cancels effective therapy without a well-documented refusal or clinical basis.

Summary of the Opinion

The Eleventh Circuit affirmed the district court’s denial of Dr. Pouparinas’s renewed motion for judgment as a matter of law under Rule 50(b). Applying de novo review to the sufficiency of the evidence and drawing all reasonable inferences in favor of the verdict, the court held that:

• Wade v. McDade clarified that the deliberate indifference subjective prong requires “subjective recklessness as used in the criminal law”—that is, actual, subjective awareness that one’s conduct creates a substantial risk of serious harm—and that a defendant is not liable if he responded reasonably to the risk.
• On this record, a reasonable jury could find that Dr. Pouparinas was deliberately indifferent by:
  • failing to culture a plainly infected wound at the first visit despite green drainage suggestive of pseudomonas;
  • persisting for weeks with Augmentin and later Bactrim—antibiotics with no effect on pseudomonas—amounting, as one expert put it, to “no treatment” for that infection;
  • cancelling an ordered IV antibiotic (Zosyn) that the culture indicated would effectively treat pseudomonas;
  • delaying or failing to act promptly on diagnostic imaging, specialist referral, or alternative modalities (e.g., offloading), and choosing an “easier and less efficacious” course of treatment potentially influenced by cost.
• Conflicts about whether Moye “refused” the IV therapy were for the jury; the physician’s own admission that cancelling IV antibiotics absent a refusal would be “reckless indifference” supported the verdict when combined with documentation inconsistencies.

Emphasizing the limited scope of Rule 50(b) review, the panel declined to second-guess the jury’s credibility determinations and affirmed the $400,000 compensatory verdict.

Detailed Analysis

Precedents and Authorities Cited

• Estelle v. Gamble, 429 U.S. 97 (1976): Established that deliberate indifference to serious medical needs violates the Eighth Amendment.
• Farmer v. Brennan, 511 U.S. 825 (1994): Articulated the objective/subjective framework: an objectively serious deprivation and subjective awareness amounting to criminal-law recklessness. Also recognized that no liability lies if the official “responded reasonably to the risk.”
• Wade v. McDade, 106 F.4th 1251 (11th Cir. 2024) (en banc): Clarified Eleventh Circuit law amidst prior inconsistent formulations (“more than mere negligence” vs. “more than gross negligence”). Wade requires actual, subjective awareness of a substantial risk and an unreasonable response to that risk.
• Adams v. Poag, 61 F.3d 1537 (11th Cir. 1995): Recognized that “medical care that is so cursory as to amount to no treatment at all” can be deliberate indifference; and a doctor’s choice of an “easier and less efficacious course of treatment” can suffice.
• Waldrop v. Evans, 871 F.2d 1030 (11th Cir. 1989): Quoted in Adams regarding “easier and less efficacious” treatment.
• Hoffer v. Sec’y Fla. Dep’t of Corr., 973 F.3d 1263 (11th Cir. 2020), Keohane v. Fla. Dep’t of Corr., 952 F.3d 1257 (11th Cir. 2020), Swain v. Junior, 961 F.3d 1276 (11th Cir. 2020): Pre-Wade discussions distinguishing malpractice from constitutional violations and expressing judicial reluctance to second-guess medical judgments.
• Rule 50(b) review authorities: MidlevelU, Inc. v. ACI Info. Grp., 989 F.3d 1205 (11th Cir. 2021); Ruckh v. Salus Rehab., LLC, 963 F.3d 1089 (11th Cir. 2020); Bhogaita v. Altamonte Heights Condo. Ass’n, Inc., 765 F.3d 1277 (11th Cir. 2014); Ash v. Tyson Foods, Inc., 664 F.3d 883 (11th Cir. 2011); Equal Emp. Opportunity Comm’n v. Exel, Inc., 884 F.3d 1326 (11th Cir. 2018); Lambert v. Fulton County, 253 F.3d 588 (11th Cir. 2001).
• Eleventh Circuit Pattern Jury Instructions (Civil) 5.8 (2024): The court noted the district judge tracked the pattern instruction, which avoided prejudicing the jury amid the pre-Wade split.

Legal Reasoning and Application

The panel framed the question narrowly: could any reasonable jury, on this record, find that the physician was subjectively reckless under Wade? The answer turned on a combination of expert testimony, medical records, and the physician’s admissions and documentation inconsistencies.

• Subjective awareness of substantial risk:
  • Green drainage from the wound at intake was classic for pseudomonas. The doctor was an experienced provider who claimed he “does it all” in wound care and had access to records documenting prior pseudomonas and IV therapy successes.
  • Despite these indicators, he neither cultured the wound at the first visit nor adjusted treatment as the wound worsened.
  • Once a culture was taken (by a nurse practitioner), it confirmed pseudomonas and delineated effective antibiotics. Nevertheless, the primary agents provided—Augmentin and Bactrim—were not listed as effective, whereas Zosyn (ordered by the NP) was cancelled.
• Unreasonable response to the known risk:
  • Persisting with antibiotics known to be ineffective against pseudomonas is functionally “no treatment” for that infection, per expert testimony. That is more than a mere malpractice dispute; it is a refusal to act upon clear risk information.
  • Cancellation of IV Zosyn—the agent the culture indicated would address pseudomonas—was a critical pivot from adequate to inadequate care. The physician conceded that, absent a real refusal, such cancellation would be “reckless indifference.”
  • Delays in imaging follow-up, slow referral, lack of offloading or comparable measures, and testimony about cost-conscious choices supported a finding that the response was not reasonable given the infection’s severity.
• Credibility and documentation:
  • The purported “refusal” was reflected only by a computerized “R” without contemporaneous narrative or consistency across notes. Discharge was ordered even before the timestamped “refusal,” and the physician backdated documents after a weekend call-in.
  • The jury was entitled to credit Moye’s testimony—corroborated by prison movement barriers, parental advocacy, and missed appointment explanations—over the physician’s version.

Importantly, the court reiterated that the Eighth Amendment does not require ideal care. But under Wade, the dispositive question is whether the defendant actually appreciated the risk created by his own course of treatment and nonetheless failed to respond reasonably. With testimony that Augmentin had “zero effect” on pseudomonas, warning signs were evident from day one, and effective therapy was cancelled, the panel held the jury had an adequate basis to find subjective recklessness.

Impact and Forward-Looking Significance

Although unpublished, this decision is a practical roadmap for post-Wade medical deliberate indifference claims in the Eleventh Circuit:

• What suffices after Wade: Evidence that a physician:
  • ignored obvious infection indicators;
  • failed to culture promptly and persisted with empiric drugs known to be ineffective against the suspected pathogen;
  • cancelled culture-concordant IV therapy without a documented clinical basis or a reliable refusal; and
  • chose an “easier and less efficacious” course (including cost-driven choices)
  can allow a jury to find subjective recklessness.
• Frequency of care is not dispositive: Regular appointments and repeated prescriptions do not, by themselves, demonstrate a reasonable response to risk if the treatment is misdirected or ineffectual in the face of known dangers.
• Documentation and escalation matter: Post-Wade, defense strategies must emphasize contemporaneous, consistent documentation of clinical judgment and any refusals, prompt adjustments to therapy based on labs, and timely escalation to specialists or emergency care.
• Pattern instructions remain usable: The decision implicitly approves use of Eleventh Circuit Pattern Instruction 5.8, even midstream in the Wade transition, so long as the charge captures the essence of Farmer/Wade and the jury is asked to assess reasonableness in light of known risks.

For prison healthcare systems and their contractors, the case underscores that operational barriers (lockdowns, movement constraints, limited on-site days) do not excuse inaction when a significant risk is known; the physician’s ability to call for guard assistance or emergency transfer—and use it—will be scrutinized.

Key Facts Timeline (Condensed)

• 2015–2017: Pre-incarceration neuropathy; recurrent left foot infections; successful PICC/IV antibiotic courses under Dr. Paul; later care by Dr. Dull with cultures and IV therapy.
• Aug–Oct 2019: Transfer to Alabama DOC; wound reopens; transfer to Fountain on Oct 4; reports green drainage. At first visit, Dr. Pouparinas orders x-ray, wound care, Augmentin; no culture or MRI.
• Nov 15, 2019: Nurse practitioner cultures wound and orders IV Zosyn; Dr. Pouparinas cancels IV and discharges Moye; later culture shows pseudomonas susceptible to Zosyn; Moye receives Augmentin/Bactrim (ineffective for pseudomonas).
• Jan 7–21, 2020: Outside consult with Dr. Paul; orders MRI; suggestion of amputation; MRI reveals severe bony loss; toes later amputated; Dr. Pouparinas leaves post later that month.
• 2023–2025: Jury finds deliberate indifference; $400,000 in compensatory damages; post-trial Rule 50(b) denied; Eleventh Circuit affirms under Wade’s subjective recklessness standard.

Complex Concepts Simplified

• Deliberate Indifference (Eighth Amendment):
  • Objective prong: A serious medical need or risk.
  • Subjective prong (Farmer/Wade): The defendant actually knew that his conduct created a substantial risk of serious harm and failed to respond reasonably (subjective recklessness). It is more demanding than negligence or even gross negligence labels; the inquiry focuses on actual awareness and response to risk.
• Responded Reasonably (Farmer defense): Even if an official knew of a risk, he is not liable if his response was reasonable in the circumstances—even if harm occurred.
• Rule 50(b) Judgment as a Matter of Law: Post-verdict, the court asks whether any reasonable jury could find for the non-movant based on the trial record, viewing the evidence and inferences in that party’s favor. Credibility determinations are off-limits to the judge.
• Culture-directed therapy vs. empiric therapy: A “culture” identifies the pathogens and their antibiotic susceptibilities. Empiric therapy is a best-guess pending data; once culture results return, therapy should adjust. Prescribing agents known to be ineffective against the cultured pathogen is tantamount to no treatment for that pathogen.
• Antibiotics referenced:
  • Augmentin (amoxicillin-clavulanate): Broad spectrum but not active against pseudomonas aeruginosa.
  • Bactrim (trimethoprim-sulfamethoxazole): Not reliably active against pseudomonas.
  • Ciprofloxacin: A fluoroquinolone with antipseudomonal activity.
  • Zosyn (piperacillin-tazobactam): IV antibiotic with antipseudomonal coverage; culture indicated efficacy.
• Offloading: Reducing pressure/weight-bearing on a wound to promote healing, often via special footwear or devices.
• “Refusal” documentation: In carceral healthcare, reliable refusal documentation typically includes contemporaneous notes detailing the patient’s decision, risks explained, and circumstances; a bare “R” code without supporting notes invites credibility concerns.

Practice Implications

• For correctional clinicians:
  • Culture early when infection signs are evident; promptly align therapy to susceptibility results.
  • Do not rely on frequency of encounters; evaluate the efficacy of the plan and adapt when patients deteriorate.
  • Document refusals and clinical rationales contemporaneously; avoid retroactive entries without explanatory narrative.
  • Escalate to the ED or specialist when logistics (e.g., off-site schedule, lockdowns) impede timely care.
  • Be cautious about cost considerations; choosing “easier and less efficacious” options in the face of known serious risk can support deliberate indifference findings.
• For plaintiffs’ counsel:
  • Use expert testimony to connect known pathogen susceptibility to the ineffectiveness of chosen antibiotics—frame it as “no treatment.”
  • Highlight cancellations of effective therapies, documentation gaps, and admissions that such actions would be reckless absent refusal.
  • Develop the movement/lockdown context to rebut “noncompliance” narratives.
• For defense counsel:
  • Ensure robust, consistent documentation of clinical reasoning and patient refusals; train staff on contemporaneous notes.
  • Demonstrate specific, proactive steps taken to mitigate risk once known (e.g., immediate culture, timely adjustments, escalations).
  • Consider expert testimony to contextualize choices as reasonable responses to risk under Farmer/Wade.

Conclusion

Applying Wade v. McDade’s clarified “subjective recklessness” standard, the Eleventh Circuit held that a reasonable jury could find deliberate indifference where a prison physician failed to culture a plainly infected wound at the outset, persisted for weeks with antibiotics ineffective against pseudomonas, cancelled culture-concordant IV therapy, and otherwise chose a less efficacious treatment path as the patient’s condition worsened. The court emphasized that it was not reweighing evidence; the jury’s credibility determinations—especially in light of inconsistent records and the physician’s admissions—were controlling on Rule 50(b) review.

Although unpublished, the decision is a meaningful application of Wade: it underscores that the Eighth Amendment inquiry is not about perfect care but about whether the clinician, aware of a serious risk created by his own course of treatment, responded reasonably. Knowingly ineffective care, delays in adjusting treatment to laboratory realities, and the cancellation of effective therapy without a solid clinical basis are precisely the sorts of facts that can establish subjective recklessness post-Wade. As carceral healthcare continues to face scrutiny, this case offers both a cautionary tale and a doctrinal guide for litigants navigating the sharpened deliberate indifference standard in the Eleventh Circuit.