Tuesday, September 29, 2009

More incomplete charting and more lies

Here is the preoperative report. Note that it says that I have no history of problems with anesthetic. This is a lie. I went into great detail about my paradoxical reactions to anesthesia, my previous 4 open reductions of my femur 2 without general anesthetic (none with sedation), the reasons why they did it that way, right down to the hair loss. This is completely missing from my chart. They only list my tonsillectomy (my bad paradoxical reactions not even mentioned although I told them all about it!) and my c-section, for which I was NOT knocked out! I explained in graphic detail all the problems that I had with the first 2 femur surgeries when they used general anesthetic, along with the fact that I had an epidural and stayed awake and chatting with the operating team the whole time the last 2 times. I told them that the anesthesiologist for the femur surgeries said that I fought them the whole time under g/a. He was more than happy to have me awake. Why do you suppose that entire conversation and any allusions to it or a broken Femur are missing? HMMM?
I don't have ALLERGIES to anesthesia. I guess paradoxical reactions, waking up in restraints, depression, hair loss etc. are the patients private problems, not a problem for health care providers! They could care less. If you do not die, then it's just ducky with them.
Look what Aaron put at the bottom. "Alert pt. prior to GA if necessary." I didn't say to ALERT me. I said we would have a discussion about how best to proceed if THEY thought it would be necessary. I informed him that an additional local anesthetic such as procaine or pain medication would have to suffice. AT NO TIME DID I GIVE PERMISSION IN ANY WAY SHAPE OF FORM FOR SEDATION OR G/A! I TOLD him that general anesthetic was NOT going to be necessary, that we would just have to figure it out if the block didn't work. What I didn't say precisely (not that it would have worked) the magic words "under no circumstances." I thought that a simple "no," along with not signing an informed consent (or any consent) for this kind of anesthesia would suffice. I would have signed out AMA before I risked death etc. for a stupid broken arm. The Versed prevented this...
It also states at the bottom that the "Plan and Risk of Anesthesia explained to the patient/guardian; understood and accepted. This is a false statement. Yes they explained that they desperately wanted to give me general anesthetic, but I vigorously declined this! How dare they simply state this as a fact! Where is my signature stating that I accepted this? What risks were explained? I don't see any risks outlined! The hospital was cited for this. What about the risk of DEATH just to fix a broken arm? What about the risk of brain hypoxia and PTSD from their sedation. See anything at all about SEDATION?
Also on this page is an "Evaluator Signature" Who the hell is this now? Nobody knows. This is in violation of patient right laws which state that the signature must be legible. It also violates the law in that this person was never explained to me, he and his job are not listed as one of the people involved in my care. Course there is no list at all about anybody... The hospital was cited for this one. I have a right to know who is performing any tasks.
I also want to point out that nobody offered me a Bier block. See the boxes in the corner. This is the block I had to remove the hardware before I became a cripple. The Bier block worked PERFECTLY! There was no need for the dangerous and inconsistent Axillary block! No "need" for general anesthetic and positively, absolutely, no need for Versed. It is as a direct result of being poisoned with Versed that I had this horrible, unnecessary and controversial surgery at all.
Also note that the DATE is wrong. Could this be a replacement chart? It is dated the day AFTER surgery. I wasn't anywhere near this place on that date. My age is also erroneously listed as 55. I won't be 55 until next year and this was 3 years ago. I am also NOT 15'6" tall. My goodness that would be some kind of trick wouldn't it? My records are replete with false, manufactured, erroneous, incomplete and incorrect data.

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