The Arlene Berry Death Coverup: Update 2009 (Part 1)
In Memory Of
Arlene H. Berry
The implications of the findings herein are so profound that, according to a hospital insider, Health Canada has issued a "gag-order" in an effort to save face (with so many doctors and nurses involved in this unnecessary death), a blatant attempt not only to prevent the media from becoming involved, but also as a means to deny justice. In my opinion the health authorities have also insinuated themselves into a conspiracy, or party accessory (after the fact) to a medical homicide. These political and ministerial thugs, attached to the public purse, including the sinister College of Physicians and Surgeons of Ontario and their corporate counterparts seem to think that they and the physicians they seek to shield are all above the law.
Published under a wide variety of titles internationally, the Arlene Berry case stands as a testament to what can only be construed as widespread corruption in Ontario's health-care system.
In Memory of Arlene Berry
In December of 1999, Arlene Berry was sent to Timmins & District Hospital in Timmins, Ontario, where she was diagnosed, according to her physician, with "carcinoma of the left main bronchus with residual cancer of the aorta due to a complete collapse of the left lung".
Her family MD, Dr. Edward. H Jordan had been treating her assumptively for what he termed a "suspected bronchitis". It took another doctor to read her X-ray chart, and to order more appropriate testing before anything was done.
On or about January 12th of 2000, Arlene Berry was admitted to the Timmins & District Hospital in Timmins, Ontario, where she had a left lung pneumonectomyon January 13th of 2000, under the care of Dr. Claudio de la Rocha, a Cardiovascular and Thoracic Surgeon who immigrated to Canada from Mexico.
Following surgery, Arlene Berry was discharged home 5 days later. On or about March 16thof 2000, Arlene Berry returned to Timmins where she underwent follow-up study and testing at the same hospital, consisting of a CT scan, and a mediastinoscopy with mediastinotomy, as part of her post-operative evaluation.
What the family had found to be peculiar however, was a dramatic voice change at some point following the mediastinal procedures, suggesting a "partial vocal fold paralysis" thought to have been procedure related. Although she began to regain her voice in the weeks that followed, her voice remained somewhat "whispery" for the remainder of her days.
Following that testing, Arlene confided "I don't have AIDS, or brain tumors, or anything like that, but I might have a "cyst", or "infection".
A cystis a suitcase for the infectious material inside. Some of them parasites with simulation of stroke related damage in cultured human nerve cells have been reported. Trapped blood (ie. from an old hemorrhage or occipital bleed) can also lead to the growth of cysts. Patients can be asymptomatic even if the cyst is quite large.
Arlene Berry was then referred to the Northeastern Ontario Regional Cancer Centre situated at the Laurentian Site, Sudbury, Ontario for consideration of radiation therapy, under the care of Dr. Hugh Prichard, a radiation oncologist. By the end of April 2000, Arlene Berry had completed her post-operative course of radiationtherapy. In light of this treatment, her condition was seen to be stable. She had been scheduled for X-ray follow-up in Sudbury on Tuesday May 30th at 2:30 PM.
Following radiation, Arlene Berry developed "flu-like" symptoms suggestive of gastrointestinal illness within two weeks following radiation therapy, at the end of April of 2000. She died on the 24th of May of 2000. Total time lapse 24 days; mean 3 weeks plus, or just under 4 weeks.
I have given careful consideration to Guillain Barre syndrome. This disorder can develop over the course of hours or days, or it may take up to 3 to 4 weeks. Most people reach the stage of greatest weakness within the first 2 weeks after symptoms appear. 66% reach nadir in 2 weeks, 92% in 3 weeks; by definition MUST peak at 4 weeks
According to her Rx scripts, Arlene Berry had been given Amoxicillin for infection. Amoxicillan belongs to a class of penicillin-like drugs, side effects of which include severe nausea and vomiting, including abdominal pain.
According to the hospital record Arlene Berry was admitted to the Kirkland and District Hospital on May 23rd of 2000 by Dr. Spiller for "IV fluid and Gravol", evidenced at A-6. According to record, she was given more than IV and Gravol. If not Dr. Spiller, who ordered the 30 mg MS Contin on his watch? From that record it seems clear that either Dr. Spiller lied, or that he was totally oblivious to the administration of Morphine Sulfate evidenced at A-12. According to the same record, she was admitted for "vomiting".
Vomiting is not a diagnosis, but rather a symptom of many causes.
A-5 of the record documents the presenting complaint as "headaches, accompanied by severe stomach pain", and "abdominal pain ongoing for 2 weeks", for which she had been prescribed "antibiotics".
Abdominal or stomach pain concurrent with nausea and vomiting points to the abdomen as the source of the problem, which should have been a 'red flag' suggesting the possibility of intestinal obstruction. Abdominal pain can also be the result of "intestinal ischemia". The hallmark of intestinal ischemia is "abdominal pain".
OP-53 documents a history of bloody bowel movements when voiding evidenced by "bloody BM's x 4 days" (bloody, black, or tarry stools). Bloody stools may signify bleeding stomach, diverticular bleeding, or intestinal infection. The same record documents "pale-looking and lethargic". Pale skin suggests decreased blood supply to the skin. Blood vessels in the body constrict to conserve blood in the body's core, making you feel cold and your skin go pale. Lethargy and drowsiness are often associated with moderate to severe dehydration, including congestive heart failure. Lethargy may also be caused by the toxic effects of waste products on brain function.
According to the record at OP-53 she was "Here 1 week ago for UTI. Last period on 6th of May". Onset of menstrual periodis closely related to onset of migraine headaches, including illness. Case reports cited primarily in women having period in which a blood-soaked tampon may provide an excellent breeding ground for the bacteria and is a significant cause of urinary tract infections. The same record dated May 22nd documents "For 2 weeks had flu, migraines". Flu symptoms — like headache, fever, chills, stomach pain, usually appear anywhere from 1 to 4 days after a person has been exposed to the virus. Flu headache may be caused by swelling of blood vessels in the brain, due to increasing pressure. Headaches from the flu can feel a lot like migraines. Influenza is not the same as a “stomach flu,” This is most likely due to a GI (gastrointestinal) infection—not the flu. Headaches are also common in people with GI trouble. Many different types of bacteria and parasites can also cause GI infections, leading to CNS infection.
According to the record at A-6, she returned to the ED (emergency department) the following day, on May 23rd of 2000 "with the very same complaints".
Rapid evolution of illness and patient return within 24-48 hours suggests a severe illness.
The RN who saw her noted that she had been "taking morphine" for pain management, and also that she had recently "stopped" taking the morphine, noting her recent medical history that for "2 weeks" she had the "flu". The same record also documents a question mark (?) with respect to possible morphine allergies, seen at A-5.
OP-53 documents a history of Tylenol and Aspirin, including a documented "daughter states takes a lot", suggests a history of drugs that can break the gastric barrier, and damage the gastric mucosa, ie., NSAID's (non-steroidal anti-inflammatory drugs). Aspirin is the drug classically associated with Reye syndrome.
According one of her Rx scripts, Arlene Berry had been prescribed sodium phosphate (usually used to treat constipation) while under the care of her oncologist, and sodium dosucate prescribed by her family MD, and to the best of my knowledge kept taking them following her discharge home, until her prescription ran out. She had found the prescribed laxitives to be ineffective and so turned to over the counter laxitive and tap water enemas for what appeared be drug opiate induced dysmotility.
Enema is contraindicated in patients with fulminant disease, because of the danger of precipitating toxic megacolon or perforation of the colon. Unfortunately, the health care providers who attended to this patient failed miserably to educate or instruct her in helpful ways.
What appears to be a referral at A-6 of the medical record, a chart-copy from the admitting physician (Dr. Spiller), directed to the attention of the family physician, Dr. Jordan, documents what I take to be a provisional diagnosis of "vomiting", while the record at N-11 documents "vomiting, lung CA".
According to Dr. Jordan, "she had presented to the ED several days before with vomiting and it was thought that she had a UTI", to rule out delay in seeking treatment. According to the hospital record at A-8 "she was given antibiotics and sent home".
According to the outpatient record at OP-54, the patient's recent head CT scan showed "NO METASTASIS", and her mediastinoscopy, a surgical procedure to examine the mediastinum inside of the upper chest between and in front of the lungs, were found to be "NEGATIVE". From that record it seems clear that NO clinically detectable metastasis were found.
The Health Management Record at A-21 of the record documents the patient's sensory cognitive perceptual pattern as "sedated". Increased sedation is also a serious side effect of many pharma agents, including electrolyte derangements which can mimic sedative intoxication.
The record at A-23 documents a "slurred speech" as evidenced by a checkmark in the upper left corner. Speech that is unintelligible, slurred, or whispery, suggests that the various muscles required to form speech are weakened.
The record at OP-54 dated May 22nd of 2000 documents a "haggard appearance", including "large blood trace leukocytes", what I take to mean leukocyte estrace, marked by an unusually high number of white blood cells (WBC's).
Weakness of facial muscles produces a characteristic haggard appearance, or a deceptively disinterested facial expression. The characteristic appearance of a "haggard" or "mournful" face and drooping eyelids is caused by facial muscle paralysis. A sagging mouth or a crooked smile is a part of the same problem.
The Outpatient Record from the hospital dated May 22nd of 2000, seen at OP-54 documents a recent history of "hematuria" (blood in urine) for "three days". The healthcare provider who saw her made a diagnosis of UTI. The same record documents a prescription for Cipro, for treatment of "urinary-tract infection". The belated test result however, what I assume to have been a urology test, or a bacterial culture test, evidenced at OP-55 of the record, later returned a finding of "NO Growth". A negative urine test can also suggest the presence of unusual bacteria or viruses causing symptoms of UTI.
The record at OP-54 documents "SEPTRA DS GIVEN BEFORE & CIPRO GIVEN AFTER". The same healthcare provider (whose signature is illegible) also made a notation with respect to the "flu", which was then directed to the attention of the patient's "family MD", namely, Dr. Jordan.
Cipro is a broad-spectrum antibiotic indicated in the treatment of a variety of infections, including the flu. Bactrim/Septra is also the antibiotic most frequently associated with drug-induced aseptic meningitis. Certain combinations of medications, such as penicillin and sulfa-based antibiotics can cause the body's immune system to react by over-stimulation, sending white blood cells (called T cells) rampaging through the body destroying its own tissues. This is known as an autoimmune disease and can be triggered following a surgical infection, or by a flu-like illness or a stomach infection. As the immune system fights off the infection, it mistakenly attacks the peripheral nerves.
N-9 of the nurses' notes documents a precaution for a "resistant bacteria" ,as evidenced by a check mark in the upper right hand corner of that document, under the subheading for "INFECTION CONTROL PRECAUTIONS". The same precaution is also noted in the upper right hand corner of the record at A-21. There are no further details.
At the time of her admission to the hospital, Arlene Berry's blood pressure was documented at "115/70 bpm, with a pulse of 79 and regular", with signs of "mild diffuse weakness" and "difficulty ambulating", evidenced at A-6. The same record documents a respiratory rate of 18, on admission. The normal adult respiration rate is 12 to 18 breaths per minute. At the time of this assessment, Arlene Berry was found to be "alert and oriented", with "NO Focal deficits".
The emergency department record at A-6, what I take to be Dr. Spiller's physical examination, documents a "soft, non-tender" abdomen, and "no masses", suggestive of a typical admitting physical note to express an overall, normal, negative abdomen. A negative finding can also suggest hypotonia, a disorder that causes low muscle tone that results in muscle weakness. Constipation is more common due to hypotonic gut musculature. Hypotonia is often the presenting sign for many systemic diseases and diseases of the nervous system. The abdominal muscles feel 'soft and doughy'; also a sign of gastropareses in clinical diabetes, which can rapidly progress to intestinal obstruction.
On examination, the physician who saw her documented positive bowel sounds, evidenced at A-6. Hyperactive bowel sounds provide the most immediate indication of persistent upper GI bleeding/GI hemorrhage. Gastrointestinal bleeding ALWAYS requires prompt physician evaluation. An increased white blood cell count may indicate an infection. Crampy abdominal pain can suggest accute bleeding. Fatigue, shortness of breath, lethargy and pallor may also be noted. Other findings may include hematemesis, coffee-ground vomitus, bloody stools, Black or tarry stool, rectal passage of bright red clots and jellylike material or melena. Decreased urine output (urinary incontenence), tachycardia, and hypotension accompany blood loss; can also suggest shock from excessive blood loss.
Arlene Berry was still neurologically responsive when I saw her following her admission. She was able to reach and use for herself the kidney basin at her bedside table, as she occasioned to vomitmore of the same flu-like "yellowish liquid" that she had done so many times on the days before, and in fact used it for herself in our presence, at which time a cool cloth was provided by the nurses, as evidenced by the record at N-6.
The same record documents upwards of "100cc yellowish fluid", what is frank bile, or 'bilious vomit'. The time of that assessment was documented at 1915 hours on May 23, 2000, following Arlene Berry's admission to the Kirkland and District Hospital. The same record documents that the patient had stated she was "very tired", whereupon she was then assisted to bed, as evidenced at N-6.
Vomiting is a symptom of many causes. The clinical difference between bilious and non-bilious vomiting (ie, vomiting yellow or green) is critical in distinguishing life threatening abnormalities.
The word "bilious" comes from the word cholera. The word cholera is Latin for bilious disease and has come to indicate a severe intestinal infection. People with bowel obstructions may repeatedly vomit yellow, or green colored bile and a history of frequent bilious vomiting in the presence of abdominal pain should have been a 'red flag' suggesting intestinal obstruction, which should have been treated emergently.
Arlene Berry also complained of being "cold" and so the nurses provided her with extra blankets, evidenced at N-6. Her very last words were that she was "feeling a little better", also evidenced by that record.
A-26 documents a body temperature >37.0 . According to the record at the documented temperature is slightly above 37ºC at approximately 37.8 suggesting a low-grade fever. Pathogenic bacteria grow best at human body temperatures in the 37ºC range.
According to the medical record at N-6 Arlene Berry was admitted at 18:45 hours and had spent 75 minutes in the ER, as evidenced at A-3. In all that time, the ED physician, Dr. Spiller, did very little. NO simple blood tests were done or even ordered at that time. It is also clear that no course of action was charted, marked by a clinically evident inability on the part of the ED physician to adequately make a proper evaluation or even make a provisional diagnosis. In fact, Dr. Spiller had no idea what to look for, electing to play the "wait-and-see" game in the face of life threatening indicators. Not only did the patient's family physician fail to attend, NO diagnosis or differential diagnosis was made following the patient's admission at that time, or at all. NO protocols were followed.
A-3 of the record, what I take to be the physician's diagnostic chart is a total blank. Again, from that record it seems clear that nothing was entered because nothing was done. The same record was filed out-of-sequence. The emergency record at A-4 was also filed out-of-sequence. Interestingly both of these records were dated using a rubber stamp that is consistent with backdating techniques.
The record at A-12, what I take to be physician orders documents a concomitant or concurrent administration of Senokot (laxative), MS Contin (narcotic analgesic), Statex (morphine family), and Gravol (an anticholingeric agent), including IV solution and additives, the most dangerous of which is the MS Contin, a brand name for "Morphine Sulfate".
Coadministration of narcotic analgesics such as MS Contin with laxitives, ie. Senokot may have additive central nervous system (CNS) and gastrointestinal (GI) system effects which can increase the risk of severe constipation or paralytic ileus, including CNS depression.
"Contin", is a pharmaceutical industry buzzword for "time-release" or "continuous" release. Additionally, Arlene Berry had been given Statex (a narcotic: opioid agonist analgesic, also used to relieve pain) which also belongs to a class of the morphine family. Notably, morphine is contraindicated to sedation, brain tumours, or increased pressure in the head or spinal cord, possible abdominal problems requiring emergency surgery, in patients having a substantially decreased respiratory reserve,
"MS" (morphine sulphate) is often confused with 'Magnesium Sulphate'. Magnesium Sulfate is used to treat severe constipation. Overuse of laxitives, or in combination with bisphosphonates or Magnesium Sulfate, or an overdose of magnesium sulphate used to treat severe constipation can lead to hypermagnesemic pseudo-coma, which mimics a central brainstem herniation syndrome.
According to the record at A-13, Arlene Berry was given 30 mg (po bid) morphine by nurse McCrank at 2000 hours on May 23rd, the eve of her death in the face of an undiagnosed and undifferentiated condition(s) associated with "abdominal pain". Nurses do not dispense medications to patients without a doctor's order. A judicious dose of morphine on standing order to patients with non-traumatic abdominal pain is usually in the range of 05. mg/kg.
The record at N-6 also documents telephone orders received by the hospital from Dr. Jordan at 2030 hours for Stemetil 10mg by IV, 4 times daily for "control of nausea", given by the RN, as further evidenced by the physician's orders seen at A-11. Stemetil suppresses activity in the trigger zones of the vomiting center by "paralyzing the gastrointestinal tract" which governs the vomiting reflex, which can also exacerbate dismotility. A typical single dose of Stemetil for a small woman with low body weight is 5mg.
The antiemetic action of Stemetil (prochlorperazine) may "mask the signs and symptoms of drug overdosage from other drugs and may obscure the diagnosis and treatment of other conditions". Increased sedation is a serious side effect of this type of agent. Oversedation results in obtundation, characterized primarily by reduced alertness and hypersomnia.
Hypersomnia is defined as a state of sleep in excess of 25% of the expected normal. Further, phenothiazines have even been reported to trigger diabetes in patients with no previous history of diabetes.
Morphine and prochlorperazine have a profound impact on bowel motility, often resulting in fecal impaction.
The co-administration of a narcotic analgesic and a neuroleptic agent will result in neuroleptanalgesia with drug-induced reduction of oxygen intake, resulting in respiratory depression. Respiratory depression represents the principal negative variable introduced with "conscious sedation" and left unrecognized and untreated, is the cause of panic, including most serious complications.
Neurolept-analgesia, also called "conscious sedation" refers to the use of major tranquilisers, ie stemetil/prochlorperazine in conjunction with narcotics such as morphine. Neurolept-analgesia is defined as a state of CNS depression.
Notably, my wife had also been given penicillin based medicines and sulfonamides such as Bactrim (Septra DS) and CIPRO (cyproflaxin) on the days before her admission; penicillin and sulfa-based antibiotics can cause the body's immune system to react by overstimulation.
Septra DS is an antibacterial agent with a wide spectrum of adversities (difficulty breathing; closing of the throat; swelling of the lips; and unusual bleeding).
Cross-reactions between penicillins and sulfa-drugs including sulfonamides are common triggers of drug-induced serum sickness and fixed drug eruptions. Signs and symptoms of overdosage reported with sulfonamides include anorexia, colic, nausea, vomiting, dizziness, headache, fatigue, drowsiness, decreased appetite. Hematuria may also be noted.
N-5 of the Nurses' Notes documents "Sudden large queery bloody emesis,reddish brown liquid" at 0255 hours, on May 24th of 2000. Submit, when everything in the intestine slows down, everything in it backs up.
N-3 documents an "Suctioned orally thick brownish secretions"at 0320 hours (in the small hours of the morning), suggestive of a more significant backup of intestinal material, i.e., vomiting of fecal matter due to obstruction of the bowel, evidenced by family present as "a large chocolate coloured (gross appearance), odorless, pasty material, looking pretty much like feces". If you are unable to open your bowels due to an obstruction somewhere, then your feces cannot exit your body via the normal route and you can get nauseated and start to vomit fecal matter. This condition requires urgent medical attention and probably surgery.
The same record documents "suctioned down ET tube several times for small amount of brownish mucous" (a reddish brown liquid, suggestive of old blood or admixture of blood and gastric content) at 0330 hours, while A-17 documents "being suctioned for moderate amounts of coffee-ground emesis by RN" at 0330 hours on May 24th. Suctioning infers that the patient's airway has become obstructed with secretions or debris. Any negligence of the patient's throat secretions may lead to hypoxia, brain edema and further deterioration in a patient's condition leading to a vicious circle, which if not broken will lead to death.
The record at A-5 documents a blood pressure of 115/75 at 17:05 hours on May 23rd that by 18:45 hours had dropped to 100/50 bpm. Marked blood pressure lability with alterations between hypertension and hypotension following paresis suggests an atypical course of GBS.
A-20 of the record documents a Glucose of 13.2 H mmol/L (the normal range is 4.1 - 7.8). High blood sugar usually comes on slowly. To convert mmol/l of glucose to mg/dl, multiply by 18. (13.2 x 18) = 237.6 mg/dl.
Random Blood Sugar Test (RBS) measures the level of glucose in the body at any point of time. If the level of sugar is between 140 mg/dL and 200 mg/dL, the patient is diagnosed with prediabetes. If the level of sugar exceeds 200 mg/dL, then the patient is diagnosed with diabetes. Glucose levels of 11.1 mmol/l (200 mg/dl) at 2 hours confirms a diagnosis of diabetes. Symptoms of severe high blood sugar include drowsiness and difficulty waking up.
A-19 of the record documents an elevated WBC Count of 22.4 H. WBC = Leukocytes. The presence of an elevated WBC count is called Leukocytosis. White cell count is actually 22,400. A normal WBC is 5,000 to 10,000. Normal Adult Range: 3.8-10.8 thous/mcl Optimal Adult Reading: 7.3 WBC leukocytes are the body's primary defense against bacterial infection and also reflect the degree of physiologic stress. WBC's are also elevated with dehydration, and hyperviscosity secondary to dehydration. If the total WBC is high due to a rise in neutrophils and eosinophils, then an allergic, or parasitic process is most likely. An increase in the WBC count (leukocytosis) is also a typical response to noxious stimuli.
The record at A-19 documents a Neutrophil count of 92.0 H with an absolute neuts of 20.0 H.
Neutrophils, are also known as "segs","PMNs"or "polys"(polymorphonuclears). CSF in bacterial meningitis is typically dominated by the presence of PMNs. PMN’s generally predominate in bacterial infections. Patients with subdural hematoma, metabolic abnormalities, or meningitis may seem to be encephalopathic.
"The presence of polymorphonuclear granulocytes does not rule out the diagnosis of Guillain-Barré syndrome". Eur J Neurol 10(5): 479-86.
Neutrophilia (or neutrophil leukocytosis) is a condition where a person has a high number of neutrophil granulocytesin their blood. Neutrophilia may be due to a number of acute and chronic causes such as infection, inflammation, emotional stimuli, drugs, metabolic hormonal, and endocrine disturbances, including hematologic abnormalities.
Wegener's granulomatosis, granulomatous cerebral amebiasis, vasculitis, and heart attack are high on the order of Neutrophilia.
Leukocytosis, especially neutrophilia, indicates systemic infection and is rare in the absence of bacterial "superinfection", also called "superbugs" are bacteria, viruses or mixed infection which are resistant to antibiotics.
The record at A-19 documents a Lymphocyte count of 2.0 L(low) suggestive of lymphocytopenia in which lymphocytes (T-cells) are reduced with nutritional deficiency, infection, and ascites due to "fluid build-up in the abdomen", and/or an exhausted immune system. If bacterialinfection is present in ascites this may suggest spontaneousbacterial peritonitisin which abdominal pain is a prominent finding. If peritonitis is not treated promptly and effectively multisystem organ failure occurs rapidly.
A-19 documents a Red Blood Cell (RBC) Count of 4.30(3.80 - 5.80 is normal), but the HCT (Hematocrit) is very low, with a reduction suggestive of anemia. Anemia is also a prominent cause of dyspnea when the hemoglobin concentration falls below 8-10 g/dl.
The same record seen at A-19 documents an HCT count of only 0.361 L (low): HCT is the measurement of the percentage of red blood cells (RBC's) in whole blood. The hematocrit (HCT) is another way of measuring the amount of hemoglobin (Hb), and in this case it is very low. Thus anemia is present when HCT is <>1.0 x 109/L.
The monocytes are a type of phagocyte which mature into "macrophages"; they are important germ eating cells. The majority of patients with Guillain-Barré syndrome will have 10 or fewer monocytes.
Patients with a low monocyte count have a higher risk of getting sick from an infection, particularly those caused by bacteria. In cancer, or leukemia, the monocytes become elevated. In this case the monocyte count is well below the normal range.
A-20 documents an O2SAT (oxygen saturation)- arterial oxygen saturation (SaO2) of 98.9 H, with with a NORMAL reference and an evident run time of 1720 hours, notably several hours after the patient's alleged time of death, following her transfer out to Sudbury on May 24th of 2000.
The same record documents an Arterial Ph of 7.437, in the normal range. The time of that assessment is documented at 0400 hours. Hydrogen ion concentration expressed as pH "Power of Hydrogen". A Normal pH is 7.35 - 7.45. Neutral pH is 7. For example, the pH of blood is normally 7.4 and that of muscle is 7.0. pH under 7 is acid; pH over 7 is basic or alkaline. The metabolic pathways of the body require a slightly alkaline environment. Anything below 7.20 is generally considered critical. At 7.0 the heart will stop beating.
A-18 of the medical record documents an "inferior ischemia", a sign of reduced oxygen supply to vital organs due to reduced or poor blood flow to the heart. An "inferior ischemia" is the hallmark of "impaired organ perfusion", as it implies that, unless corrected, there may not be enough oxygen in the blood to sustain vital organs.
The same record at A-18 documents "Sinus Tachycardia". Sinus tachycardia occurs when the sinus rhythm is faster than 100 beats per minute. The rhythm is similar to normal sinus rhythm with the exception that the RR interval is shorter, less than 0.6 seconds. P waves are present and regular and each P-wave is followed by a QRS complex in a ratio of 1:1. At very rapid rates, the P-waves might become superimposed on the preceding T waves such that the P waves are obscured by T waves. Sinus tachycardia, (>90/min), is seen in over 35% of patients with Guillain-Barré Syndrome, and over 30% suffer from hypertension (Parry, 1993).
A-20 documents a Sodium level of 144 (137 - 145) mmo1/L. Sodium is an electrolyte that helps with nerve and muscle function, and also helps to maintain blood pressure. Sodium circulates in the body fluids outside the cells. It is very important for maintaining blood pressure. Sodium is also needed for nerves and muscles to work properly.
CAVEAT: Hyperglycemia can lower the serum sodium concentration by 1.6 mEq/L for each 100 mg/dl, also giving rise to a false test.
A-20 also documents a serum potassium level of 3.4 L at 0400 hours on May 24th of 2000. Low potassium is defined as a potassium level below 3.5 mEq/L.
A-20 of the hospital record documents a CK (Creatine Kinase) level of only 40 units per liter (U/L) at 0400 hours. CK is the most sensitive enzyme and in the presence of most diseases, levels can be elevated as much as 50 to 100 times the reference level. In females, total CK should typically be 10 to 79 units per liter (U/L).
Metastatic malignant neoplasms cause severe body wasting-cachexia. The hallmark of muscle damage or muscle wasting is elevation of CK concentration.The wasting away of fat and muscle (cachexia) is the most visible hallmark of metastatic cancer. Persons with cancer typically have high CK levels.
Notably, Guillain-Barré syndrome does not produce evidence of muscle inflammation such as elevation of the CK. Further, a normal CK (CREATINE KINASE) at the time of the patient's admission would argue favorably against a diagnosis of metastatic CA, at that time.
EVIDENCE OF SUBSTANDARD CARE
N-10 of the Nurses' Notes document the patient's level of care as "routine", which showed little or NO concern for patient safety. Further, NO close patient monitoring or toxicological screening was done, marked by a complete absence of nursing care plan, as evidenced at A-21 of the medical record. In fact, NO inherent bloodwork was done in a timely manner. NO protocals were ever followed or implemented, in this case.
Stemetil is widely distributed into body tissues and fluids. Stemetil undergoes metabolism in the gastric mucosa and on first pass through the liver where it enters the enterohepatic circulation and is excreted chiefly in the feces.
Stemetil can also lead to changes in the blood-brain barrier (BBB), allowing an infectious agent to gain entry to the brain and produce lethal central nervous system (CNS = brain and spinal cord) infection. The scientific literature describe two bacterial factors specific to the meningitis pathogen that thwart the normal protective role of the blood-brain barrier, leading to serious infection.
Further, sugar solution in IV creates gaps in the blood-brain barrier allowing chemicals to enter. Infected material can block the blood vessels to the brain, and Stemetil can help shuttle it directly into the brain and CNS. Once across the blood-brain barrier, the infection enters neural cells, with resultant disruption in cell functioning, perivascular congestion, hemorrhage, and inflammatory response diffusely affecting gray matter disproportionately to white matter.
Blood borne infection in the blood lyse easily. It seems logical to assume that Stemetil would be contraindicated to serious infection for this reason.
Stemetil poisoning is marked by oversedation, respiratory depression and hypotension. Stemetil (prochlorperazine) intoxication or poisoning can also cause deep physiologic depression that resembles and can mimic brain death
It is also clear that Dr. Jordan sought to eliminate the symptom "nausea", without his attendance, as evidenced by the phone order"for control of nausea" and without any appropriate blood testing, or addressing any possible underlying causes.
Further, Dr. Jordan neglected to consider the etiology of the nausea and vomiting as a condition requiring prompt medical intervention. Instead, he elected to give the patient a brain damaging neuroleptic antipsychotic-antiemetic drug without any review of her medical record, and without the benefit of toxicological screening or close monitoring, evidenced at A-21. Clearly, the etiology of the nausea and vomiting had never been determined, as evidenced at A-3.
The record at 0020 hours seen at N-6 documents the discovery by duty nurses of the patient's "head against the left side bed rail with her feet under the right side rail". Sensory loss in GBS, if present, takes the form of proprioception (loss of sence of one's own perception of the relative position of neighbouring parts of the body to each other), which is occasionally impaired spontaneously, especially with extreme fatigue.
The ED physician, Dr. Mark Spiller was up to assess the patient's condition. Upon examination her eyes were documented as being "sluggish". She was simply repositioned by the nurses, as evidenced by the record at N-6. Her"pupils were dilated at approx. 5 mm" with "very little reaction to light", and far from getting better she was becoming progressively worse, as evidenced by a sense of urgency seen on the record to the attendance of the patient with increased activity evidenced at N-6 between 0030 and 0055 hours, also noted at N-5. Clearly, from that record and apart from running around the room looking busy and repositioning the patient, nothing was done. It seems clear that the ED physician failed to properly assess the patient's condition, which fell far below an acceptable standard of care. Further, to add insult to injury, NO blood-work had yet been done.
While the clinical feature of 'fixed dilated pupils' is a valuable clinical sign it does not necessarily mean that the patient has severe brain injury.
I assume that Dr. Jordan would have been alerted by phone. He claims to have called in at 0100 hours but nevertheless opted not to change his orders, as evidenced by the "no change in orders" seen at N-5. From that record it is clear that Dr. Jordan elected to alienate and treat the patient over the telephone, unseen, in the face of life threatening indicators, all of them ignored and without ever having reviewed the patient record.
Further, between 0200 hours and 0220 hours the patient's blood pressure had risen slightly from 150/72to 162/80, a sign of mounting hypertension such as caused or worsened in response to treatment. The record at A-26documents the time of that assessment as 0220 hours, while N-5 documents the time of the same assessment at 0230 hours, a 10 minute difference. The same record documents a HR (heart rate) in the 160's, what is termed "sinus tachycardia".
A-26 documents a blood pressure of 162/80 with an SaO2 of 80% at 0220 hours, followed by a lethal drop in blood pressure to 78/70 by 0235 hours, in which blood pressure rises or falls significantly, a hallmark feature of alternating hypotension and hypertension.
CAVEAT: Systolic blood pressure <80 mm HG is a hallmark of haemodynamic instability. The term "hemodynamic instability" is most commonly associated with an abnormal or unstable blood pressure, especially hypotension, or trauma due to clinical insult.
The record at A-17 documents a complete cessation of the use of abdominal and accessory muscles, evidenced by a "0 use of acc muscles"; and a "0 use of abd muscles"; the muscles of respiration, accessory muscles and diaphragm are affected, suggestive of respiratory and accessory muscle paralysis (crisis) requiring intubation and mechanical ventilation. Functional abdominal muscles also play a role of in conjunction with the accessory expiratory muscles. The time of that assessement is documented at 0330 hours.
Accessory muscle paralysis will result in apprehension and anxiety.
EVIDENCE OF ALTERED RECORDS
There are numerous material deficiencies in the related medical record of Arlene Berry which manifest a complete lack of internal consistency, ranging from out of sequence records, from the physician's Discharge note seen at A-1 and A-2, which is mared by error, inconsistency, omission, and contradiction, to the nurses Triage, to obviously rewritten, altered, and falsified medical records, tailored to obfuscate the truth, seen between N-1and N-3 of the nurses notes, with A-16 and A-17 presenting similarly, including as follows:
A-26 of the record documents a BP (blood pressure) of 78/70 at 0235 hours, while N-5 documents a BP of 98/70 at the very same time, suggestive of copious error.
A-24 documents a heart rate of 174 bpm at 0330 that is consistent with "trauma", while the Ventilation Record documents a heart rate of only 126 at the very same time, a significant difference.
A-4 of the record, what I take to be a Trauma Legend, barely visible in the physician’s notes situated in the lower right hand side of that record, there is an "obliterated" area suggesting a white-out, or perhaps an erasure. From that record it seems clear that relevant information was deliberately withheld, or removed to conceal an event.
TRAUMA is defined as any insult to the body, clinical or otherwise.
The record at A-6 documents a "history of metastatic lung cancer", while the outpatient record at OP-54 clearly documents "no metastasis"and "mediastinoscopy negative".
N-4 and N-5 present with less than half a page of documentation consistent with deliberate omission, such as having rewritten that record for the express purpose of withholding incriminating information.
A-16 documents a blood pressure of 163/117 at 0330 hourswhile N-3 documents a blood pressure of 136/85 at the very same time. The same record documents a blood pressure of 121/81 at 0400 hours, while N-2 documents a blood pressure of 112/57 at the very same time. More copious error.
N-4 of the record documents that Dr. Jordan was called in at 0225 hours. A-1 of the record documents "I was called in later that night because the patient had become obtunded", while the record at N-2 documents "attempts to pull away to painful stimuli" as late as 0400 hours on May 24th, being one hour and thirty-five minutes later, according to the record.
Was it the doctor's belief that Arlene Berry ceased to be a human being after becoming unresponsive following undiagnosed, untreated and/or inappropriately treated conditions? So much so that he decided to write her off?
N-10 of the record which documents the patient's bowel routine and urinary elimination pattern for toileting is a complete blank, with the very same information that ought to have been recorded, also omitted at OP-53 of the record.
The record at N-5 documents a physician "assessments unchanged" despite the fact that the patient had already gone into respiratory distress, as evidenced by "Cheyne-Stokes" respirations with periods of"apnea"lasting"5-8 seconds".
Sleep Apnea means"cessation of breath".It is characterized by repetitive episodes of upper airway obstructionthat occur during sleep, usually associated with a reduction in blood oxygen saturation. Other causes include panic attacks.
Low oxygen saturation may be present with advanced respiratory muscle involvement. If proper balance is not restored or corrected, the heart and lungs may fail and the brain will literally begin to suffocate.
The record at N-5 documents the respirations as "deep and soaring without constant jaw lift"as early as 0220 hours. A-26 of the record documents "gurgling",and "snoring" and is evidenced in the lower left corner of that record.
N-5 of the record documents "family in" at 0250 hours. On seeing the patient, we found her to be propped up in the arms of two nurses, gasping for air, with only a plastic oral airway in her mouth. A reason for this , according to the duty nurse was "to keep the patient from swallowing her tongue". It is also of interest to note that NO attempt was made by either of the doctors to place the patient in the ICU in a timely manner.
Weakness of tongue and retropharyngeal muscles causes positional airway obstruction; difficulty with protruding tongue and difficulty swallowing indicate that bulbar involvement is significant, which requires that these patients be placed on ventilators in order to breathe. Snoring, sleep apnea and gasping for breath are part of the same problem. Failure to manage the airway with endotracheal intubation when necessary or in a timely manner is clear evidence of negligence.
I had asked the patient twice, in the presence of her foster brother, if she could hear me to wiggle her toes, and indeed she did, not once but twice, to be absolutely certain. An observation made by her foster brother as he gently stroked her right cheek was the seeming appearance of the patient attempting to pull her face forward as though trying to lift her head off the pillow. The inability to lift the head off the pillow by flexing the neck is another danger sign associated with GBS; it frequently develops simultaneously with phrenic nerve (diaphram) weakness.
In my opinion, Arlene Berry appeared to be more paralyzed or blunted than anything, with the exception of lower limb joint contractions which rapidly diminished and became hyporeflexic.
Her condition was cataleptic-like, characterized by a profound hypnotic state, or psychomotor condition of morbid sleep, such as seen in cataplexy, neurolepsis, sleep paralysis, or narcolepsy. Underlying causes of catalepsy include severe emotional trauma, and emotional shock. Compare: neuroleptanalgesia(conscious sedation)in combination with a severely paralyzed motor function.
Although patients with GBS in the setting of preserved consciousness may appear to be completely obtunded, they are technically awake and fully lucid. But he/she may literally not be able to move a muscle in response. The GBS patient only appears to be unresponsive due to a severely paralysed motor function. It has been shown that more than half of the time it is the family and not the physician who first realized that the patient was aware.
Stuporand coma are characterized by impairment of the arousal system. In stupor, a person arouses only in response to strong verbalor tactile stimuli, awakens briefly, and then lapses back into a sleeplike state after the stimulation stops. In coma, a person cannot be roused to consciousness.
With GBS the patient is conscious but unable to respond due to a severely paralysed motor function.
N-3 of the record documents "resp noisy","shallow","Cheyne-stoke"at 0320 hours. Cheyne-stokes breathing is a respiratory pattern that oscillates between hypoventilation and hyperventilation, usually the result of diencephalic insult. It is also seen during sleep in some normal individuals.
Noise heard during any part of the respiratory cycle may indicate airway obstruction or alteration in airway patency. Patients with neuromuscular disorders have rapid, shallow breathing secondary to severe muscle weakness, which requires that these patients be placed on ventilators in order to breathe.
The record at 0255 hours documents a"sudden large bloody-emesis of reddish brown"or what is known in medical circles as "coffee-ground emesis" ie. dark brown tinged vomit the color and consistency of coffee-grounds, composed of gastric juices and old blood, which can rapidly grow bacteria.
Vomit that contains blood may have a red or brownish appearance and is called coffee ground vomiting indicating that it has come from large intestines, suggestive of a slow bleeding source in the upper GI tract. Obstruction below the middle of the small bowel also gives rise to brownish vomit.
Gastrointestinal (GI) bleeding due to stress ulceration in GBS is reported in the literature.
GI bleeding is considered a potential medical emergency. It involves assessing hemodynamic stability, resuscitating the patient as needed, locating the source of the bleed, and treating the underlying cause.
From the record it seems clean that NO emergency measures were taken with respect to GI bleeding and that this medical EMERGENCY event was met by the doctors with complete indifference.
The record at N-4 documents "incontinent blood tinged urine"at 0305 hours. Incontinent "tinged urine" is consistent with severe dehydration, often mistaken for hematuria (blood in urine). Incontinence can be the result of hypotonia, or neurogenic bladder.
Notably, N-3 of the record documents a "large amount of dilute urine" (polyuria) at 0325 hours, only 20 minutes later. This finding would be inconsistent with hematuria.
The record at N-2 documents "Foley draining lge amt dilute urine" at 0425 hours, while N-1 of the record documents "Foley catheter emptied for 1200cc dilute urine" at 0450 hours that is consistent with conditions featuring osmotic diuresis and by diabetes insipidus ("water diabetes") It occurs in association with Na+ Disorders, primarily related to Na negligence due to iatrogenic fluid overload.
Na is lowered 1.6meq/L for every 100mg/dl glucose. The central causative mechanism in this case, involves a hyperglycemia-induced osmotic diuresis and resultant dehydration. Polyuria due to excess fluid intake and glucose-induced osmotic diuresis is common in patients with transient hyperglycemia. The hyperglycemia emanates from a commonly identified diabetogenic stressor, such as infection, which precipitates the onset of the syndrome, which in turn produces pseudohyponatremia commonly associated with hyperglycemia.
A-15 documents the 24 hour IV fluid balance record, that between 1745 hours and 0200 hours was administered as follows:
A-14 documents an " IV gid prn", meaning that fluid and medication rate of administration to be is given by IV as follows: "2/3 and 1/3", being a 3.3 % dextrose and 0.3 % sodium chloride @ the rate of 100 cc/hr, as evidenced at A-15.
The same record documents a total Na of 1000 cc TBA, (to be absorbed), documented by nurse Bates at 1745 hours; with a 150 ABS (absorbed) by 1900 hours, documented by nurse Ferguson, shows 150 cc absorbed over a period of 75 minutes; far exceeds the rate of 100 cc/hr. Anything above 100 cc/hr points to "overly rapid infusion".
Na 850 cc TBA remaining at 1900 hours documented as ABS (absorbed) by 0200 hours, over a period of 7 hours, resulting in a "surplus" of 150 cc fluid, with an additional 1000 cc TBA, and no further documentation with respect to Na monitoring. The ventillation record at A-16shows a complete absence of information with respect to "Water Refill".
Hyponatremia results from a "surplus of water" due to Na negligence.Other evidence of fluid overload as indicated by "ascites" due to fluid build-up in the abdomen.
Rapid correction of hyponatremia, even mild hyponatremia, risks neurologic complications (see Fluid and Electrolyte Metabolism:Osmotic demyelination syndrome). Generally, Na should be corrected no faster than 0.5 mEq/L/h. Increase should not exceed 10 mEq/L over the first 24 h. Any identified cause of hyponatremia is treated concurrently.
The record at N-6 documents "IV infusing well".There are no further IV related entries on that record, or any other record, either to indicate when or if the IV was discontinued, or to show that the rate of administration was being monitored, suggestive of patient dumping, or abandonment, with deliberate omission by reason of Na negligence.
The same record documents the use of a No. 20 "Quick Catheter"; signed by nurses Bates, Ferguson, and McCrank (may or may not be relevant). RN is ultimately responsible for monitoring rate of infusion.
The same record documents a "hard" IV site in the "R" (right) hand; clot formation due to irritation, of the vein from solution or medications is the most common cause of a hard IV site. The back of the hand has weaker veins, and is not commonly used for IV antibiotics. Seriously ill patients require accurate fluid balance monitoring because IV fluid also contains the medication(s). Rapid infusion may also lead to overdosage.
Circulatory overload can occur if IV is not regulated properly and IV fluids infuse too rapidly for the patient's body to handle. Signs of fluid overload include tachycardia, elevated blood pressure, dyspnea and other signs of respiratory distress. Neuromuscular disease is another well-known cause of dyspnea.
Notably, Stemetil 10mg was added to the IV at 2030 hours. The drug is sedating and a potent vasodilator, which also crosses the blood-brain barrier. Patients are usually "volume expanded" prior to its use, often due to negligence, resulting in neurologic derangement.
Hyponatremia is diagnosed by measuring serum electrolytes. However, serum Na may be artifactually low when severe hyperglycemia increases osmolality. Water moves out of cells into the ECF. Serum Na concentration falls about 1.6 mEq/L for every 100-mg/dL (5.55-mmol/L) rise in the plasma glucose level above normal. This condition is called translational hyponatremia because no net change in the amount of Na has occurred.
The record at N-4 documents the patient's "transfer to ICU in respiratory distress" (sudden breathlessness) at 0320 hours, while record at N-3 documents a "congested oral airway" at the very same time, meaning congestion of the breathing passages. Obstruction of the air passages of the nose, mouth, or throat may also lead to difficulty breathing.
Certainly the inability to breathe properly can be alarming, and many persons will immediately react with anxiety, fear, or panic.
The record at A-24 documents the mechanical charting of the patient's vital signs that commenced recording at 0315 hours. It is interesting to note that the patient's transfer to the ICU had not yet taken place, and that no prior attempt was made by any of the healthcare providers to place the patient in the ICU prior to that time. It seems clear that the healthcare provider had done too little too late as evidenced by the records at N-9, N-10, N-11, including A-3, and A-21.
From the record as a whole, it is also clear that both doctors should have realized at the onset, from the severety of the patient's signs and symptoms that they were faced with a critically ill young woman who was not responding to their questionable treatment. They should ALSO have been acutely aware of the danger.
Critically ill patients frequently have multiple physiologic derangements that come from a range of possible sources and occur simultaneously.
N-5 of the medical record documents a gurgly respirations as evidenced by a "gurgly resps" at 0220 hours, a sign of constriction suggestive of thoracic trauma (patients are often in shock). The same record documents "deep and soaring and without constant jaw thrust", such as associated with the airway and swollowing difficulty in respiratory compromise. Gurgling is a bubling sound. It usually indicates upper airway obstruction from secretions, emesis, or blood. Gurgling respirations indicate the presence of fluid in the airway, usually blood or vomit, or both.
The record at N-4 of the Nurses' Notes documents "incontinent blood tinged urine"at 0305 hours that is consistent with urinary incontinence (leakage of urine) or blood tinged urine if bladder infection is also present. Urinary dysfunction such as incontinence (leaking) of urine is a prominant finding in GBS patients due to autonomic abnormalities. Incontinence is loss of bladder control, and is also a very serious side effect of antipsychotic medications. Further, during episodes of hypokalemic periodic paralyses urinary output is decreased during the attack because water accumulates intracellularly in muscles.
Dark, concentrated urine in decreasing amounts (incontinent tinged urine)is also a prominant finding in patients with high blood sugar, including dehydration.
A-8 of the related record documents "patient was unconscious with respirations of approximately 30 and laboured", that is consistent with dyspnea- difficult or labored breathing. Dyspnea is breathlessness due to high filling pressures and pulmonary congestion/edema, i.e. shortness of breath, a smothering feeling, inability to get enough air, and suffocation. Breathing may become laboured and difficult; laboured breathing is the hallmark of respiratory distress and respiratory failure due to paralysis of the diaphragm. Dyspnea should always be taken seriously.
A-1 documents "plantars upgoing bilaterally". Submit that the plantar reflex is a hallmark of the Babinski sign, a test for signs of disease process in the `motor neurons` of the pyramidal tract. Initial drowsiness, bilateral plantar responses, and quadriparesis, is strong clinical evidence of central involvement consistent with drugs or toxins that affect the basal ganglia, thalmus or brain stem. Babinski's sign is also a prominent finding in Bickerstaff's brainstem encephalitis (BBE), a variant of the Guillain Barre syndrome. Further, "limb weakness in GBS is nearly always bilateral" - (Parry, 1993).
The lower limb is often ischemic in diabetes. Fecal impaction as a cause of acute lower limb ischemiais also reported in PubMed.
The patient became apparently unresponsive, as evidenced at N-5, and went into respiratory distress, requiring ventilation for which she was transferred into ICU at 0320 hours, according to the record at N-3. The same record documents the time of the patient's intubation by Dr. Jordan at 0325 hours, 5 minutes later. What I take to be the Ventilation Record at A-17 documents the arrival in the ICU of the hospital's ventilatory therapist, Helene Studholme at 0330 hours, after being "called in for patient requiring ventilation". From these records, it is clear that either the ventilatory therapist was not present at the time of the intubation procedure because she did not show up until 5 minutes later, or that the intubation did in fact take place at an earlier time, such as 0320.
CONTINUED: See Part 2