29/08/2022
Medical Negligence Coverup in Ontario Promoting No Accountability and Transparency in the Ontario Health Care System
My daughter bled to death less than 12 hours after being discharged from Humber River Regional Hospital. (colon resection breakdown due to necrosis of the tissue surrounding the resection)
After reading this as a citizen in Ontario (& perhaps all provinces) you should be very concerned! If they can coverup this obvious case of medical negligence, imagine how a loved one of yours would be disregarded should an adverse event occur?
Please forward Terra's story and my attempts to as many individuals/friends/relatives as possible so the Ontario citizens are fully aware of what actually occurs should an adverse event occur within one of Ontario's hospital.
For over sixteen years I have contacted every single MPP in Ontario and have been totally ignored by the majority.
SHOULD AN ADVERSE EVENT OCCUR IN ANY ONTARIO HOSPITAL, THE CITIZENS OF ONTARIO WILL BE ENSURED IT WILL BE COVERED UP BY ALL OF THOSE SEEN BELOW:
THE HOSPITAL --THE CHIEF CORONER'S OFFICE--THE DEATH INVESTIGATIVE OVERSIGHT COUNCIL--THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO--although completely independent, the Minister of Health is suppose to ensure they put Ontario citizens first when they investigate complaints and should they not, he/she may intervene to investigate, but won't.
THE HEALTH PROFESSIONS APPEAL AND REVIEW BOARD--
THE ONTARIO OMBUDSMAN--
THE ONTARIO PROVINCIAL POLICE--THE INDEPENDENT POLICE REVIEW DIRECTOR--THE ONTARIO PATIENT OMBUDSMAN- -THE MINISTER OF HEALTH- -
THE MINISTER OF CORRECTIONS- -THE PROVINCIAL PREMIER
ALL OF THE ABOVE ARE IN "BREACH OF TRUST" AS THEY COVER EACH OTHERS' ASSES
A very dangerous precidence has been set by all of the above---
It is perfectly OK for major open abdominal surgery to remove a tumor and have a colon resection performed without the manditory antibiotic prophylaxis being administered.
And when the abdominal incision became so infected that all staples had to be removed, it is still OK to not treat it with antibiotics.
And when test result indicated the "presence of many gram negative bacilli (same category as C Difficile falls into), it was still OK to not treat this with antibiotics! --- the above is just one issue with regard to my daughter's care!
If you take the time to look at the various blogs below you will see I have tried. My daughter's surgeon continues to up his kill rate (5+ deaths after Terra Dawn Kilby) and his record is spotless when you look at the CPSO website. The HPARB decisions do not even use his name--- merely AK vs LK.
Ontario citizens are completely unaware of how corrupt things are in Ontario when an adverse event takes place!
All Ontario citizens should be lobbying for the obvious changes that must be made and to inform as many as possible to pressure our present government and all MPPs to stand up and be heard to protect their own constituents. They are at present completely unware of their own MPP disinterest in changing this.
The institutions and appointed officials exist only as mirages to make it appear we have institutions created to protect and improve patient safety????
Should an unfortunate death occur within an Ontario hospital and is being investigated by the local, district or Chief Coroner’s Office, they will not tell the truth but cleverly skirt around the issues *Remembered they are members of the College of Physicians and Surgeons of Ontario.*
Medical Negligence Coverup!
All have totally ignored the medical facts and refused to question those below:
EVERYTHING below is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
Breach of Trust by Publicly Appointed/Elected Officials who are supposed to serve the Ontario Citizens but failed to do so!
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The medical facts:
A)**--NO ANTIBIOTIC PROPHYLAXIS-open abdominal surgery to remove a tumour and a colon resection
B)**-- ABDOMEN GOING FROM FLAT TO ROUNDED TO ENLARGE
--the enlarged abdomen?---That is a sign of something wrong. Abdominal Distension may occasionally result from the accumulation of fluid in the abdomen, which can be a sign of a very serious medical problem.
C) Abdomen and Resting Pulse Rates Nursing Records
Terra’s Abdomen high pulse rate? 34/38 above 90
Day 1. July 11th
1133 hrs 105
1143 105
1630 flat 106
1709 98
1730 101
2000 flat 104
Day 2. July 12th
0000 flat 104
0400 flat 105
0800 flat 116
1300 flat 194?
This is not a typo from me. It is in the record!
1605 flat 101
2000 103
Day 3. July 13th
0820 rounded 110
1130 rounded 105
1615 rounded 102
2100 rounded
2015 rounded 107
Day 4. July 14th
0500 rounded 126
0815 rounded 97
1200 rounded 95
1500 rounded 117
1600 rounded
1857 rounded
2000 rounded 110
Day 5. July 15th
0530 rounded 94
0910 rounded 97
1300 rounded
1800 rounded 108
2107 rounded
Day 6. July 16th
0530 rounded 98
1130 rounded 105
1310 rounded 96
2000 large 102
Day 7. July 17th
0700 large 93
0951 large 104
1437 98
2200 large 108
Day 8. July 18th
0517 large
0600 large
1000 large 86
1510 large
1600 large 90
2000 large 85
Day 9 July 19th
0925 large 93
1957 large 96
Day 10. July 20th
0039 large
0800 large 88
Terra was released
Lab Test Done June 8 2006 month before operation
White Blood Ct 7.0
(4.2- 11.0)
Haemoglobin 127
(120 - 160)
Hemocrit .38
(.36 - .48)
Red Blood Ct. 4.55
(4.20 - 5.40)
Absolute Lymph Ct. 1.5
(1.5 - 4.0)
Potassium 4.3
(3.5 - 5.0)
Urea 2.9
(2.0 - 8.0)
ALL NORMAL PRIOR TO OPERATION
Hospital Test Results:
D)**HCT Hematocrit Count
Ref. 0.36 to 0.48
July 18 0.35
Day 6 0.35
Day 4 0.32 All 5 tests are below normal
Day 3 0.32
Day 2 0.34
Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies. Further testing may be necessary to determine the exact cause of the anemia.
E)*RBC Red Blood Count
Ref. 4.20-5.40
July 18 4.20
Day 6 4.16
Day 4 3.80 1 test at well low of normal range & other 4 below
Day 3 3.78
Day 2 3.95
Red Blood Cells, sometimes referred to as erythrocytes, are responsible for delivering oxygen throughout the body.
F)**ABS LYMPH # Absolute Lymphocytes Count
Ref. 1.5 - 4.0
July 18 0.9
Day 6 0.7
Day 4 0.5 All 5 tests are well below normal range
Day 3 0.8
Day 2 1.0
G)**many PMN’s (polymorphonuclear Neutrophils) –hall mark of acute inflammatory process. PMN’s are rapidly recruited to tissues upon injury or infection
H)**low Absolute Lymphocyte (type of white cells to fight infection)? B cells, a type of lymphocyte (white blood cells), have an important role in the body's immune system. are responsible for making antibodies T cells, a type of lymphocyte (white blood cells), have an important role in the body's immune system.
I)**HB Hemoglobin Ref. 120-160
July 18 119
Day 6 117
Day 4 107
Day 3 106 ALL BELOW THE STANDARD
Day 2 111
The vital role of hemoglobin in transporting oxygen from the lungs to the rest of the body is derived from its unique ability to acquire oxygen rapidly during the short time it spends in contact with the lungs and to release oxygen as needed during its circulation through the tissue
***********************
Individually, perhaps the test scores may be dismissed but collectively there is an indication of something going wrong and required further investigation!
J)** seriousness of the oozing, infected abdominal incision. Excessive or prolonged serosanguineous drainage could indicate increased inflammation and the possibility of infection, which could in turn lead to wound dehiscence. This is what happened to Terra, her resection broke down.
FROM NURSES’ CHARTS
July 15th
Page 109
853 hrs incision oozing
910 no odour, no oozing
Page 105
1300 no odour but dressing soaked with purulent foul smelling fluid
Page 103
1430 foul odour
Page 98
2000 site #1 leaking
Page 94
2152 foul odour
July 16th
Page 86
1030 foul odour
Page 83
1310 no odour, but larger purulent foul drainage from the umbilicus
Page 78
2000 no odour, but larger purulent foul drainage from the umbilicus
Page 76
2200 foul odour
July 17th
Page 74
0445 foul odour
Page 73
0630 foul odour
Page 71
0700 no odour but large purulent foul drainage from umbilicus
Page 66
1400 large amount of drainage from umbilicus
Page 65
1700 foul odour
July 18th
Page 62
0045 foul odour
Page 60
0900 foul odour
Page 58
1300 foul odour
Page 56
1560 7 staples removed — wound gaping wound oozing copious amount of purulent fluid
Page 55
1600 oozing incision
July 19th
Page 51
0815 foul odour
Page 49
0925 wound oozing copious amount of purulent fluid
Page 48
1500 foul odour
Page 45
1957 oozing incision
Page 44
2100 foul odour
July 20th
Page 43
0039 oozing incision
Page 41
0800 oozing incision
1000 foul odour
Terra was released.
K)**no nutritional supplementation to ensure her nutritional needs were met. Terra was on a liquid diet of juice, jello, broth and tea for 8 ½ days. (last two meals were regular) This diet should not be used for a long period of time unless vitamins, iron, or liquid nutritional supplements are added. Terra received no nutritional supplements.
She was receiving only 687 calories per day that equates to a starvation diet. With no nutritional supplementation!!!
The full liquid diet is low in iron, vitamin B12, vitamin A, and thiamine. It should not be used for a long period of time unless vitamins, iron, or liquid nutritional supplements are added. The full liquid diet does not provide enough energy, protein and many other nutrients. This diet is temporary and should not be used for more than 5 days
TAKEN FROM USDA National Nutrient Database for Standard References 2004
1. LACKING 83.2% OF TOTAL DAILY IRON INTAKE!
Iron is required for the formation of haemoglobin in red blood cells, which transport oxygen around the body. Iron is also required for normal energy metabolism
1. Iron Deficiency = The recommended dietary allowance required by an adult female for Iron is 18 mg/day
Terra’s diet contained: Jello .01 mg Tea .02 mg Broth .06 mg Juice .92 mg. Terra would have received 3.03 (16.8%) mg per day in the course of her 3 daily meals. This means she was lacking 14.97 mg per day!
2. LACKING 99.6% OF TOTAL DAILY VITAMIN K INTAKE!
Vitamin K is not readily stored within the body, thus the importance of the daily requirement. The over riding effect of nutritional Vitamin K deficiency is to tip the balance in coagulation toward a bleeding tendency.
2. Potassium Deficiency =The recommended dietary allowance required by an adult female is 90 micrograms of Vitamin K per day.
Terra’s diet contained: Jello 0 mcg Tea 0 mcg Broth 0.2 mcg Juice 0 mcg. Terra would have received .6 (point 6) (.7%) mcg in the course of her 3 daily meals. This means she was lacking 89.4 mcg daily!
3. LACKING 75% OF TOTAL DAILY MAGNESIUM INTAKE!
Supports a healthy immune system, energy metabolism and protein synthesis
3. Magnesium Deficiency =The recommended dietary allowance required by an adult female is 255 mg/day (milligrams) of Magnesium per day.
Terra’s diet contained: Jello 1 mg Tea 5 mg Broth 0 – 3 mg Juice 12 mg. Terra would have received 63 (25%) mg in the course of her 3 daily meals. This means she was lacking 192 mg daily!
4. LACKING 99.7% OF TOTAL DAILY VITAMIN E INTAKE!
Vitamin E is the major lipid-soluble antioxidant in the cell antioxidant defence system and is exclusively obtained from the diet. Vitamin E significantly strengthens the immune system; supplies oxygen to the blood, which is then carried to the heart and other organs.
4. Vitamin E Deficiency =The recommended dietary allowance required by an adult female is 15 mg (milligrams) of Vitamin E per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth .13 mg Juice .02 mg Terra would have received .45 (.03%) mg in the course of her 3 daily meals. This means she was lacking 14.55 mg daily!
5. LACKING 99.27% OF TOTAL DAILY CALCIUM INTAKE!
Blood coagulation is dependant on calcium.
5. Calcium Deficiency =The recommended dietary allowance required by an adult female is 1000 mg/day (milligrams) of Calcium per day.
Terra’s diet contained: Jello 4 mg Tea 0 mg Broth 4 mg Juice 20 mg. Terra would have received 73 (.73%) mg in the course of her 3 daily meals. This means she was lacking 927 mg daily!
6. LACKING 99.99% OF TOTAL DAILY VITAMIN A INTAKE!
It is also required for cell differentiation and therefore for normal growth and development, and for normal vision and for the immune system.
6. Vitamin A Deficiency =The recommended dietary allowance required by an adult female is 700 mg/day (milligrams) of Vitamin A per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice 2.5 mg. Terra would have received 7.5 (.01%) mg in the course of her 3 daily meals. This means she was lacking 682.5 mg daily!
7. LACKING 91% OF TOTAL DAILY VITAMIN C INTAKE! assists the body in the production of collagen, a basic component of connective tissues. Collagen is an important structural element in blood vessel walls, gums, and bones, making it particularly important to those recovering from wounds and surgery. IMPORTANT: Inflammation in the tissues causes the breakdown and destruction of collagen fibers. Sutures will pull away from damaged tissues whether the tissues are damaged by disease or medical negligence. Any infected tissue which is separated by surgery will be slow to heal, or may fail to heal.
7. Vitamin C Deficiency =The recommended dietary allowance required by an adult female is 75 mg/day (milligrams) of Vitamin C per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice 2.2 mg. Terra would have received 6.6 (9%) mg in the course of her 3 daily meals. This means she was lacking 68.4 mg daily!
8. LACKING 93% OF TOTAL DAILY FIBRE INTAKE!
8. Dietary Fibre Deficiency =The recommended dietary allowance required by an adult female is 25 mg/day (milligrams) of Dietary Fibre per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice .5 mg
Terra would have received 1.5 (6%)mg in the course of her 3 daily meals. This means she was lacking 23.5 mg daily!
9. LACKING 70.9% OF TOTAL DAILY PHOSPHORUS INTAKE!
protects against infection, and enhances the immune system;
9. Phosphorus Deficiency =The recommended dietary allowance required by an adult female is 700 mg/day (milligrams) of Phosphorus per day.
Terra’s diet contained: Jello 30 mg Tea 2 mg Broth 19 mg Juice 17 mg. Terra would have received 204 (29.1%) mg in the course of her 3 daily meals. This means she was lacking 496 mg daily!
10. LACKING 82.7% OF TOTAL DAILY ZINC INTAKE!
protects against infection, and enhances the immune system; Zinc is also required in wound healing.
10. Zinc =The recommended dietary allowance required by an adult female is 8 mg/day (milligrams) of Zinc per day.
Terra’s diet contained: Jello .01 mg Tea .04 mg Broth .36 mg Juice .05 mg. Terra would have received 1.38 (17.3%) mg in the course of her 3 daily meals. This means she was lacking 6.62 mg daily!
11. LACKING 99.9% OF TOTAL DAILY COPPER INTAKE!
Needed for the formation of red blood cells and body needs copper to be able to use iron properly.
11. Copper =The recommended dietary allowance required by an adult female is 900 μg/day (microgram mcg) of Copper per day.
Terra’s diet contained: Jello .032 μg Tea .018 μg Broth .246 μg Juice .030 μg. Terra would have received .978 μg (microgram) in the course of her 3 daily meals. This means she was lacking 899.022 μg daily!
12. LACKING 81.5% OF TOTAL DAILY SELENIUM INTAKE!
In immune function and infection prevention, and selenium deficiency has been reported in patients after intestinal surgery
12. Selenium =The recommended dietary allowance required by an adult female is 55 mg/day (milligrams) of Selenium per day.
Terra’s diet contained: Jello 1.5 mg Tea 0 mg Broth 1.7 mg Juice .2 mg. Terra would have received 10.2 (18.5%) mg in the course of her 3 daily meals. This means she was lacking 44.8 mg daily!
13. LACKING 84.7% OF TOTAL DAILY THIAMIN INTAKE!
Because of its constant demand and limited storage thiamine is required daily. enhances circulation, assists in blood formation, carbohydrate metabolism and digestion; plays a key role in generating energy acts as an anti-oxidant, protecting the body from degenerative effects
13. Thiamin =The recommended dietary allowance required by an adult female is 1.1 mg/day (milligrams) of Thiamin per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth .004 mg Juice .052 mg
Terra would have received .168 (15.3%) mg in the course of her 3 daily meals. This means she was lacking .932 mg daily!
Thiamine is an essential coenzyme in carbohydrate metabolism. Because of its constant demand and limited storage thiamine is required daily.
14. LACKING 91.8% OF TOTAL DAILY RIBOFLAVIN INTAKE!
Necessary for red blood cell formation, anti-body production, cell respiration, and growth
14. Riboflavin =The recommended dietary allowance required by an adult female is 1.1 mg/day (milligrams) of Riboflavin per day.
Terra’s diet contained: Jello .008 mg Tea .025 mg Broth .015 mg. Juice .042 mg. Terra would have received .09 (8.2%) mg in the course of her 3 daily meals.
This means she was lacking 1.01 mg daily!
15.LACKING 80.9% OF TOTAL DAILY NIACIN INTAKE!
the maintenance of the gastrointestinal tract. It is required for the release of energy from food
15. Niacin =The recommended dietary allowance required by an adult female is 14 mg/day (milligrams) of Niacin per day.
Terra’s diet contained: Jello .001 mg Tea 0 mg Broth .711 mg Juice .181 mg. Terra would have received 2.679 (19.1%) mg in the course of her 3 daily meals. This means she was lacking 11.321 mg daily!
16. LACKING 83.6% OF TOTAL DAILY VITAMIN B-6 INTAKE!
Vitamin B6, also called pyridoxine, is essential in the breakdown of carbohydrates, proteins and fats. Pyridoxine is also used in the production of red blood cells.
16. Vitamin B-6 =The recommended dietary allowance required by an adult female is 1.3 mg/day (milligrams) of Vitamin B-6 per day.
Terra’s diet contained: Jello 0 mg Tea .002 mg Broth .024 mg Juice .045 mgI. Terra would have received .213 (16.4%) mg in the course of her 3 daily meals. This means she was lacking 1.087 mg daily!
17. LACKING 100% OF TOTAL DAILY VITAMIN B-12 INTAKE!
Helps in the formation of red blood cells Vitamin B12 deficiency impairs the body’s ability to make blood, accelerates blood cell destruction
17. Vitamin B-12 =The recommended dietary allowance required by an adult female is 2.4 mg/day (milligrams) of Vitamin B-12 per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice 0 mg
Terra would have received 0 mg in the course of her 3 daily meals. This means she was lacking 2.4 mg daily!
18. LACKING 65.9 to 68.8 % OF TOTAL DAILY CALORIE INTAKE!
Calorie intake for a Female at Terra’s weight
Daily Requirement
Sedentary 1,816 - 1,982 Carbohydrates 130 grams per day
Low Active 2,016 - 2,202 Protein 46 grams per day
Active 2,267 - 2,477
Very Active 2,567 - 2,807
Jello 84 calories 19.16 g carbohydrates 1.65 g protein
Tea 2 calories .53 g carbohydrates 0 g protein
Broth 29 calories 1.76 g carbohydrates 5.35 g protein
Juice 114 calories 28.2 g carbohydrates .25 g protein
Total = 687 calories 148.95 g carbohydrates 21.75 g protein
Protein = Terra was lacking 21.75 g of protein per day!
Terra was only consuming 687 calories daily. A starvation diet is listed as below 1200.
19. LACKING 57% OF TOTAL DAILY CALORIE INTAKE BASED ON HER BASAL METABOLIC RATE **TERRA WAS OBTAINING ONLY 687 CALORIES PER DAY AND THAT IS IF SHE CONSUMED ALL OF HER LIQUID DIET FOR THE DAY.* A starvation diet (Starvation diets (less than 800 calories per day) does not mean the absence of food. It means cutting the total caloric intake to less than 50% of what the body requires.
20. LACKING 47.3% OF TOTAL DAILY PROTEIN INTAKE!
Nutritional depletion has been demonstrated to be a major determinant of the development of post-operative complications. Gastrointestinal surgery patients are at risk of nutritional depletion from inadequate nutritional intake and surgical stress.
L)**ALL THE STAPLES BEING REMOVED FROM THE ABDOMINAL INCISION AND THAT TEST RESULTS INDICATED THE PRESENCE OF MANY GRAM NEGATIVE BACILLI (SAME CATEGORY AS C DIFFICILE)
Many species of Gram-negative bacteria are: pathogenic, meaning they can cause disease in a host organism. This pathogenic capability is usually associated with certain components of gram-negative cell walls, in particular the lipopoysaccharide (also known as LPS or endotoxin layer). The LPS is the trigger, which the body’s innate immune response receptors sense to begin a cytokine reaction. It is toxic to the host. Gram-negative bacteremia is today's hospital scourge. Although antibody prophylaxis does not lower the infection rate, it prevents the serious consequences of gram-negative infections and thus improved the overall prognosis.
Did the expert ever consider endotoxin shock due to release of endotoxins by gram-negative bacteria? Or hematogenic shock which is the loss of fluid from the circulating blood volume, so that adequate circulation to all parts of the body cannot be maintained. This results in reduction of oxygen transported to the tissues thus explaining the necrosis of the tissue surrounding the resectioned colon. ---according to the autopsy report
Breathing - - It should be noted that Terra’s breathing to the most part indicated concern. (see hospital records)
Also comments regarding eating.
July 11
1133 short of breath on exertion, occasional cough
July 12
0000 eupnea, air entry decreased, occasional cough
800 eupnea, air entry decreased, short of breath on exertion
1300 eupnea, air entry decreased,
1605 nutrition—probably inadequate
1605 eupnea, air entry decreased,
July 13
820 short of breath on exertion, occasional cough
1130 eupnea, air entry decreased, short of breath on exertion
0415 not tolerating current diet, shortness of breath on exertion
1615 eupnea, decreased air entry – lower lobes
1730 not tolerating current diet, nauseated
July 14
0500 eupnea, decreased air entry – lower lobes, shortness of breath on exertion
815 eupnea, decreased air entry – lower lobes, occasional cough
1200 eupnea, decreased air entry – lower lobes, cough in am
1338 ate about half of what was served
1856 eupnea, decreased lower lobe
2000 not able to clear airway of secretion, eupnea, decreased air entry – lower lobes, oxygen delivered nasal
July 15
0530 eupnea, decreased air entry – lower lobes, oxygen delivered nasal,
0910 air entry decreased – lower lobes, not able to clear airway of secretion,
1300 air entry decreased – lower lobes, not able to clear airway of secretion
July 16
0530 oxygen delivery – room air
0830 not tolerating current diet, nausea, save tray to try and eat later
0835 eupnea, decreased air entry – lower lobes
1310 eupnea, decreased air entry – lower lobes
2000 unable to clear airway of secretion, oxygen delivery – room air
July 17
0700 oxygen delivery – room air
0800 not able to clear airway of secretion, eupnea, decreased air entry – lower lobes,
0900 not tolerating current diet, does not normally eat in morning, save tray to try and eat later
1400 eupnea, decreased air entry – lower lobes
According to the records from 2200, July 17 through to Terra’s release, it appears there was no difficulty with her breathing and eating her liquid diet
Definition of eupnea --normal, good, unlaboured ventilation, sometimes known as quiet breathing or resting respiration
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Letter dated Nov 14/07 to Dr Klein from the College
“Upon review of the above file, I note that some of your records are not legible and do not meet the College’s expectation that records can be interpreted by the average health care professional.”
“Would you please provide a typed transcription of the enclosed records?Additionally, would you please comment on the legibility of your records?”
Let us look at the copious notetaking by this surgeon:
Dr. Klein’s writing was horrendous. How on earth could a nurse or anyone read and understand? The chances of misinterpreting his orders/notes are quite high!
Look closely at the transcribe notes. Compare his rather inept notetaking compared to the nursing records. The CPSO considers this acceptable for a surgeon caring for his patient post operatively?
Surgeon’s Daily Notes Upon visitation
July 11, 2006
OR Note:
Proc: Lap - open Right hemicolectomy and excision of large mesenreric cyst
Surg: Klein, Esser, Shedletsky
GA: Zadic No comp.
July 12, 2006
VSS afeb No gas Abdo soft Comfortable
July 13, 2006
HR: 100, Temp 38.1 Feels better today No gas Wound: ok Abdo soft Hungry
July 14, 2006
Temp: 36.0 (Max 38.1) HR:80 + gas (passing gas) abdo still tender incision okay
WBC: N (normal) Con't clears (fluids)
July 15, 2006
VSS, afeb Wound infection -> opened + gasCon't as is
July 16, 2006(This note was written by the clinical fellow)
AVSS (afcbrile, vital signs stable) c/o nausea, no vomiting wound packed incisional pain
I/P (impression plan): stable, blood work
July 17, 2006
Some diarrhea, otherwise well Plan: home 1-2 days
July 18, 2006
Afeb Well, eating well Plan: home 2 days
July 19, 2006
VSS, afeb Well
Decreased pain, decreased diarrhea, C. diff. Negative
Plan: home in am
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I think his notetaking substantiates my assertions that Dr. Klein did not look at the nursing notes regarding the abdomen, incision and all the records. If he did, I am sure he would have commented on the size of the abdomen and the oozing, purulent, foul discharge from the abdominal incision.
Note: July 18, at 1248 is not Dr. Klein’s handwriting—who wrote it for him?
July 19, 06 at 1730
1 – Home tomorrow with H/C
[Please be advised that this was not either Doctor’s handwriting or mentioned that the order was documented on behalf of attending physician. The discharge order was actually written by a nurse] I have no idea if the written scribble matches the typed version. Inadequate and meaningless physician progress notes.
