These events occurred at a prominent tertiary care, university teaching hospital (AMC). For the purpose of this story, it will be identified only as “AMC.” For Part One of the story, click here.
- A document titled “pre-anesthesia evaluation” is in the record. The doctor did not talk to me nor did he need to. I did not even need to have been alive. He had copied facts word for word from the new patient pages I had completed the day before at my surgeon’s clinic. His signature time of 11:02AM needed to have been before 7:59AM. His documentation is not valid. The charge to Medicare is fraudulent.
- There is no recorded anesthesia plan.
- For 2.5 hours intra-operative medications included the simultaneous administration of not 1, but 2 anesthetics resulting in so much hypotension (low blood pressure) that there was also continuous administration 2 medications (phenylephrine and ephedrine) intended to prevent or correct low blood pressure. The corrective medications caused my awful nausea.
The explanation column of the anesthesiologist’s record is blank. Only a beginner would mash on the accelerator and on the brake at the same time.
- The consent on which I had placed my cursive signature had been replaced by a pre-printed 2 page document which I first saw in August 2015; my signature is typed on the second page and it is not witnessed. Moreover, the time of day on the signature page is earlier than that on the document. I found in the legal record no valid consent for surgery or anesthesia.
The consent for surgery on which I wrote my cursive signature did not include the usual disclaimers; I realized in January 2015 that its length of well less than half a page was most peculiar.
- Missing from the “legal record” are both the consent I actually signed which did not mention anesthesia and the many page new patient form I completed the day before. The pre-anesthesia evaluation looks more real than it was. The privacy office was asked for the missing pages February 2016. They have not been sent. Individual pages, but not the process, can be shredded.
In addition to that in surgery, at AMC there appears to be instruction in subterfuge or deceit. An AMC administrator said in July 2015, “Your story hasn’t changed.”
Truth usually does not. Although my chart has amendments, this doctor’s promotion up the AMC academic ladder in May 2016 suggests the institution has not disciplined him.