In heart failure, dyspnea may result from excess fluid in the lungs. Many antipsychotic medications are associated with Risk of Fatal Cardiac Effects . � A cardiac evaluation is important in virtually all patients with brain ischemia. Not only are cardiac and aortic embolism common, but many patients with cerebrovascular occlusive disease have concurrent coronary heart disease as will be deduced from the facts of this case. Compare: eMedicine - Pulmonary Edema, Neurogenic : Article by Sat Sharma, ...

42. A-5 documents Dr. Jordan's "no change in orders" at 0100 hours. Further, the same record documents that Dr. Jordan was notified of the patient's condition at 0225 hours on May 24th and he showed up at 0305 hours on May 24th, as evidenced by the record at N-4 of the nurses' notes.

43. At the time of her admission to the hospital, Arlene Berry's blood pressure was documented at 115/70, with a pulse of 79 and regular, a respiration rate of 18, with signs of mild diffuse (widespread) weakness as evidenced by the record at A-6. At the time of that assessment she was found to be "alert and oriented", with "NO Focal deficits". The bald truth is that Arlene Berry had presented with signs and symptoms of dehydration and hepatic dysfunction at the onset, signs and symptoms which Dr. Spiller in his professional capacity as the ED physician failed to recognize until it was too late.

44. According to RECORD Arlene Berry was admitted to the Kirkland and District Hospital on May 23rd of 2000 at 1845 hours whereupon she complained of being "cold". She had the chills and so the nurses provided her with extra blankets. She was not very communicative due to extreme somnolence (fatigue) and stated that she was "very tired".

45. The same record at N-6 documents family in at 1915 hours and there is also a notation with respect to "emesis of ^ 100cc yellowish fluid", what is termed as bile. When Red Blood-Cells complete their life cycle and break down naturally in the body they produce a "yellow pigment" which is then passed to the liver and excreted into bile.

46. Initially, the vomitus was yellow in color but a later episode may have been greenish as evidenced by "large greeny bloody emesis" documented at N-5 of the Nurses' Notes. This would be considered "bilious emesis" and is suggestive of a more significant back up of intestinal material.

47. Arlene Berry was still neurologically responsive when I saw here following her admission and in fact she was able to reach and use for herself the kidney basin at her bedside table as she occasioned to vomit more of the same "flu-like yellowish bile" (bilious vomitus) that she had done so many times on the days before, and in fact, she used it for herself in our presence at which time a cool cloth was provided by the nurses as evidenced by that record. It seems clear that generally a cool cloth is provided when a "mild or low grade fever" is present.

48. NOTE: The same record documents that the patient had stated that she was then "feeling a little better" whereupon she was then assisted to bed. From that record it seems clear that she was at least benefiting from Hydration. That the effects of the given medications had not yet taken effect should also be borne in mind.

49, The record at N-6 also documents telephone orders received by the hospital from Dr. Jordan at 2030 hours for the drug "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. It is also clear that the patient was in an altered state of consciousness at that time, as evidenced by extreme somnolence. Further, she stated that she was very tired. It is also clear that Dr. Jordan sought to eliminate the symptom without addressing any possible underlying cause.

50. Stemetil (prochlorperazine) is a "high-risk" antipsychotic-antiemetic drug to be used with caution, according to manufacturer's directives. Indications of this drug are primarily in the management of "psychotic disorders". Further, "unexplained, sudden deaths" have occurred in hospitalized patients treated with this type of drug. The adverse effects of phenothiazines can affect all organ systems and may be attributed either to the drug's effects on the central and autonomic nervous system, or to hypersensitivity reactions to the drug.

Symptoms of overdosage include CNS depression which may vary from simple lethargy to coma. Other possible manifestations include convulsions, autonomic reactions such as hypotension, and ileus.

Stemetil is contraindicated in the presence of circulatory collapse, altered states of consciousness or comatose states, particularly when these are due to intoxication with central depressant drugs (alcohol, hypnotics, narcotics). It is contraindicated in severely depressed patients, in the presence of blood dyscrasias, liver disease, renal insufficiency, pheochromocytoma, or in patients with severe cardiovascular disorders or a history of hypersensitivity to phenothiazine derivatives.

There are two things for certain: 1) there was "yellowish bile" vomitus at the time and shortly after the patient's admission to the Kirkland and District Hospital on May 23rd of 2000, and 2) there was bloody emesis of redish brown", and "coffee-ground vomitus" following admisistration of the drug Stemetil�.

51. According to my investigation, prochlorperazine is classed as a phenothiazine that is widely distributed into body tissues and crosses the -brain barrier. The drug is highly plasma protein bound (91-99%) and has a duration of activity from 4 to 6 hours. It is of particular interest to note that prochlorperazine "undergoes metabolism in the gastric mucosa and on the first pass through the liver". Case reports include " liver toxicity". Overdosage symptoms may vary from simple lethargy to coma.

52. A typical single dose of Stemetil for a small woman with low body weight is 5mg. Arlene Berry was given 10mg, (possibly x4) double the recommeded dosage, together with other medications. See Induced Liver Toxicity

53. From these records it is clear that Dr. Jordan elected to alienate and treat his patient unseen (at arm's length), over the telephone and without first reviewing the patient's files, akin to driving in the dark, at night with NO lights.

54. According to the Rx List data prochlorperazine (Stemetil) it is contraindicated in "altered states of consciousness" and in "comatose states. Symptoms of central nervous system depression to the point of somnolence or coma are usually associated with overdosage, and multiple drug therapy associated with toxic and metabolic causes is common in overdosage situations.

55. The antiemetic action of prochlorperazine may mask the signs and symptoms of overdosage of other and may obscure the diagnosis and treatment of other conditions such as intestinal obstruction,. Deep sleep, from which patients can be aroused, and coma have been reported, usually with overdosage.

56. The drug is also contraindicated in the presence of liver disease, renal insufficiency, or in patients with cardiovascular disorders.

57. According to my information the duty placed on a doctor is to exercise care in all that is done for the patient which includes attendance, diagnosis, referral, treatment and instruction. It is also clear that this was NOT done, as evidenced by the record at A-3, and as reflected in the record as a whole.

58. Further, there is nothing on the record which might explain the sudden absence of the severe stomach pain documented at A-5 of the nurse's triage flow sheet signed by the RN. This alone is a significant finding.

59. The record at 0020 hours seen at N-6 documents the patient's discovery by duty nurses of the patient's "head against the left side bed rail with her feet under the right side rail" and "without response" to either verbal or physical stimulation that is consistent with a Dystonic reaction to the drug Stemetil. Dystonia is defined as a movement disorder characterized by sustained muscle contractions, frequently causing twisting and repetitive movements, or abnormal postures that can result in distorted postures. Neuroleptics (antipsychotics), antiemetics, and antidepressants are the most common causes of drug-induced dystonic reactions. Predisposing factors include either a family history of dystonia, or viral infections.

The same record documents "dilated pupils" that is consistent with and suggestive of ruptured cerebral aneurysm, the most common cause for subarachnoid hemorrhages. Compare signs and symptoms of shock , or seizure.

Compare Neurological Emergencies: Coma, Seizures, Syncope, Stroke. Compare Gastrointestinal Complications. Causes of hypovolemic shock include blood loss due to trauma or gastrointestinal bleeding, and is also associated with bowel obstruction. 60. The admitting physician, Dr. Spiller, was up to assess the patient's condition at 0055 hours as evidenced at N-5. Upon examination he documented the patient's eyes as being "sluggish", and also that there was no response to "deep pain". She was simply repositioned by the nurses as evidenced by the record at N-6.

61. From that record it seems clear that the patient had suffered a near fatal reaction to the given medication at that time and that 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 documented and the ED physician, Dr. Spiller up to assess the patient between 0030 hours as evidenced at N-6 and also at 0055 hours as evidenced at N-5 of the Nurses' Notes. I assume that Dr. Jordan would have been alerted. According to the record he called in at 0100 hours but nevertheless opted not to change his orders as evidenced by his "no change in orders" also seen at N-5.

62. It is also clear that the patient continued to receive the prochlorperazine even after she had become comatose. There is absolutely nothing on record to suggest that the offending was ever discontinued.

63. Further, between 0200 hours and 0220 hours her BP had risen from 150/72 to 162/80, a sign of mounting hypertension such as caused or worsened in response to treatment. See High Blood Pressure: Hypertension

64. The same record documents a Heart Rate (HR) in the 160's with a rapid drop in blood pressure (BP) to 98/70 by 0235 hours. Septic shock is a potentially lethal drop in blood pressure due to the presence of bacteria in the blood.

65. From that record it seems clear that both doctors should have realized that they were faced with a critically ill young woman who was not responding to treatment and they should have been acutely aware of the danger. It is also of interest to note that NO attempt was made by either of the doctors to place the patient in the ICU at that time, between 0030 and 0055 hours.

66. By 0220 hours the patient's respiration rate was documented as "deep and soaring and without constant jaw thrust", a sign of constriction. The same record at N-5 also documents gurgly respirations. Gurgly respirations are associated with fluid ion upper airway that is consistent with obstructed airway, or dysphagia (swallowing difficulty) or depressed gag reflex and diminished respiratory drive associated with adversities of toxic neuroleptic agents. Dysphagia associated with the drug Stemetil, points to "BOWEL OBSTRUCTION", and is also associated with "RADIOTHERAPY-INDUCED ACUTE GASTROINTESTINAL TOXICITIES". Inability to swallow results in drooling (patient requires suctioning), and is associated with Parkinson-like symptoms. Drug-Induced Parkinsonism is commonly produced as an adverse effect in antipsychotic drug therapy. Abnormal sounds in the lungs is also associated with inflamatory disorders of the esophagus, gastroesophageal reflux, fluid around the lungs, fluid in lung (pulmonary edema )and/or pulmonary edema associated with congestive heart failure.

67. Further, 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. Compare

68. The same record at N-5 documents a rapid drop in BP to 98/70 at 0235 hours with 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. Central sleep apnea is particularly linked with heart failure. High blood pressure, which is associated with sleep apnea, is also a major cause of later heart failure. Stroke victims with sleep apnea tend to have higher levels of blood protein fibrinogen than stroke victims without sleep apnea. Fibrinogen is a factor in blood that causes it to clot. Higher levels of fibrinogen have been linked to both stroke and heart attack risk. High levels of fibrinogen represented a significant risk factor for both heart attack and ischemic stroke.

69. Notably, the central mechanisms that regulate breathing fail in severe hypoxia leading to irregular respirations, Cheyne-Stokes breathing, apnea, and respiratory cardiac failure in which hypoxia leads to obtundation. Lack of blood supply and/or lack of adequate oxygen delivery causes hypoxic damage to the nervous system: Apnea is due to airway obstruction caused by major decreases in pharyngeal muscle activity.

The cause of hypoxia is relatively easy to understand. It simply means that the blood is well oxygenated, there is enough oxygen carrying agent (hemoglobin) in the blood, the blood flow (CO) is good enough to carry the oxygen rich blood to the tissue, but the tissue cannot utilize the oxygen, since there is a toxin present that prevents oxygen uptake by the cells. Shock, is defined as a reduced tissue perfusion.

70. Further, there is nothing on record to suggest that the patient was oxygenated prior to intubation and from these records it is also clear that the health care providers withheld life support when the patient became critically ill. A plastic oral airway does not provide needed oxygen.

71. The same 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 "vomitus" the color and consistency of coffee-grounds composed of gastric juices and old , indicative of a slow bleeding source in the upper GI tract. Notably multiple medications, restricted diet or poor nutrition causes gastrical intestinal or GI lesions to GI bleeding.

72. Gastrointestinal bleeding is considered a potential medical emergency. From that record, it is clear that nothing was immediately done to determine a possible cause of the internal bleeding or to treat accordingly. The visible evidence is described as hematemesis, hematochezia and/or melena. In this case there is evidence of neglect with respect to both hematemesis, and melena. It is also clear that Dr. Jordan showed no concern for this patient is spite of her worsening condition.

73. According to my research, gastrointestinal bleeding should have been controlled if possible and blood purged from the gastrointestinal tract, but this was NOT done. Further, Dr. Spiller (the ED physician) did nothing to lessen or prevent the outcome, suggestive of his complicity, acquiescence, to cover-up for Dr. Jordan's stupidity, or outright incompetence or other negligence of his own.

74. The record at N-4 documents the patient's "transfer to ICU" at 0320 hours. The record at A-27 documents a BP (blood pressure) of 163/117 (high BP in response to distress or pain) at the very same time.

75. The record at A-24 documents the charting of the patients 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, that NO attempt was made by the healthcare providers to place the patient in the ICU prior to 0320 hours and further that the patient's condition remained critical throughout the night and into the small hours of the morning notwithstanding.

76. The same record documents a heart rate (HR) of 174 bpm at 0320 hours during the intubation procedure that is consistent with deep pain suggestive of "internal injury".

77. From these records alone it seems clear that the healthcare providers had done too little too late for this patient, as evidenced at N-9 N10, and N-11, and also at A-3 and A-21 of the medical record.

78.

78.1 OP-54 of the Outpatient Record documents "large blood trace leukocytes" that is consistent with staphylococcal infections suggestive of a possible hospital acquired infection.

Predisposing factors for staphylococci infections include foreign bodies, including intravascular catheters. Additional findings suggest the presence of viruses in the blood stream has been scientifically shown to induce a physiological state called "hypercoagulability." The risk of venous thrombosis is greater if patients are dehydrated.

common infectious agents in cancer patients

Hematuria�blood in urine; may indicate kidney disease

Patients rarely appear toxic or septic

Chapter VI.16. Sepsis

The Toxic Shock Syndrome and Staphylococcus

patients may appear toxic or septic

78.2 N-3 of the Nurses' Notes documents a " large amount of "dilute urine" at 0325 hours, only 20 minutes later, and again at 0450 hours as evidenced at N-1 of the record that is inconsistent with the record as a whole, and in particular with respect to A-16, marked by a complete absence of documentation as to water refill to justify urine output. Compare: Fluid overload, hypokalemia search results associated with large amount of dilute urine. A search using the terms "hypokalemic, alkalosis, low blood pressure, antipsychotic medications can be traced to anorexia nervosa, suggestive of iatrogenic anorexia in which the main causes of nausea and vomiting can be traced to morphine. Other causes include untreated Electrolyte Imbalances. Untreated, these conditions can be life-threatening. Anorexia nervosa � In Latin and Greek, �a� usually means �not�. Thus, anorexia means no appetite. The �nervosa� part asserts that the disorder is of nervous, i.e. psychological origin. It can also have iatrogenic causes. COMPARE Dangers Of Anorexia in which death is attributed to but not limited to any (combination of) the following: heart attack or heart failure; lung collapse; internal bleeding, stroke, kidney failure, liver failure; pancreatitis, gastric rupture, and perforated ulcer. These are but a tip of the iceburg consequences of eating disorders precipitated by medical treatments/procedures leading to heart arrhythmias, shock or myocardial infarction. Compare Disordered eating.

78.3 It is also of interest to note that, that there is also a complete absence of documentation with respect to the patient's elimination pattern for toileting, as evidenced at N-10 of the record that is consistent with constipation.

WHAT IS URINARY INCONTINENCE?

79. Further, there are numerous material deficiencies in the related medical records in which several pages of documentation manifest a lack of internal consistency ranging from out of sequence reports, such as the Triage Record seen at A-5, to obviously rewritten, altered and falsified nursing notes seen at N-1 N-2 and N-3, marked by error, inconsistency and contradiction, to the Ventilation Record seen at A-16 and A-17 presenting similarly with entries that are self-serving, i.e. needlessly explanation of events,i.e "without adversities", to N-4 and N-5 presenting with less than half a page suggestive of deliberate ommission,and multiple write-overs with respect to date and time that clearly suggest that the author was neither oriented to time or date, and authenticated by what appears to be the initials 'JM', what I take to be that of of the RN as evidenced at A-15 of the record signed by what appears to be the name "J. McCrank".

80. The physicians Diagnostic Sheet at A-3 ought to have been placed on the record at the time of the patient's admission, as well as the Emergency Record seen at A-4, not filed in chronological order, both of which were dated using a "rubber stamp".

81. Further, Ambulance Call Report was filed on the record at N-7, and N-8 of the Nurses' Notes. That document ought to have been placed on the patient's file at the time of her discharge when she was sent out to Sudbury, according to the time of that event.

81.1 A-9 of the record, Dr. Jordan's Critical Care Note documents the 'Medi-Vac team were due to arrive at approximately 0435" hours, while the Ambulance Call Report at N-8 documents the time of the call event for call received at "0620" hours. 82. The record at A-6 documents the patient as having a "history of metastatic lung cancer", while the record at OP-54 documents "NO metastasis, and the Mediastinoscopy which test samples of the cells and lymph nodes for examination under a microscope are clearly documented as"NEGATIVE.".

83. Mediastinoscopy is used to stage lung cancer. Both of the aforementioned records document the results of the testing that was done at the Timmins & District Hospital on May 16th of 2000.

84. There are several late dictations, all of them questionable and I can count at least 3 two-page documents seen at A-1 through A-2, including A-6 through A-7, and also at A-8 and A-9 of the medical records, as evidenced by the times and dates upon which they were dictated and transcribed. Similar evidence may further present upon forensic examination.

85. A-1 of the record documents "she had a left lung pneumonectomy back in October of 1999", which is erroneous.

86. A-17 documents the "removal of left lung in '99", the very same error , suggestive of having been copied.

87. The same record at A-1 documents "I was called in to see her later that night because she had become "obtunded ". According to the record at N-6, it seems clear that the patient had already become obtunded (unresponsive) as early as 0030 hours, as further confirmed at 0055 hours when the ED physician was up to assess the patient condition, prior to the time Dr. Jordan phoned in regarding the patient's condition, as evidenced at N-5 of the hospital record.

88. A-1 of the record also falsely documents "she died several days later with numerous metastatic lesions to her brain". Arlene Berry died May 24th of 2000, the very same day as evidenced by her Certificate. As to the cause of death, the facts speak for themselves.

89. What I take to be the Ventilation Record at A-17 documents the arrival of the ventilatory therapist, Helene Studholme in the ICU at 0330 hours after being "called in for patient requiring ventilation."

90. N-3 of the record documents the time of the patients intubation by Dr. Jordan at 0325 hours, 5 minutes earlier, suggesting that Dr. Jordan intubated the patient unassisted. The same record documents patient "suctioned down ET tube several times for small amount of brownish mucous", while A-17 documents the patient as "being suctioned for moderate amounts of coffee-ground emesis by RN" at 0330 hours that is consistent with GI bleeding.

91. N-2 of the record documents the ET (endotrachial tube) "pulled back" at 0425 hours. The patient was intubated at 0325 hours, one hour earlier. From that record it is also clear that the Endotrachial Tube or ET had been "malpositioned" one full hour before the error was discovered by one of the nurses, as evidenced by that record. Both myself and the patients foster brother were present to witness that event.

According to my research, women have a greater chance of iatrogenic injury from endotracheal tubes, because their tracheas are smaller and thus are at higher risk for iatrogenic tracheobronchial tear. In traumatized tissue, bacterium produces many toxins. Further, prolonged suction can result in infection if the mucous membranes are traumatized. 92. According to my research when an endotrachial tube is misplaced in the esophagus and misplacement is detected late, the compromise of the patients safety can be significant. Perforation of a viscous into the peritoneal cavity, i.e. the intra-abdominal esophagus, or other trauma related causes in which ascites may become infected secondary resulting in spontaneous bacterial peritonitis cannot be ruled out. Ascites is an excess of fluid in the membrane lining of the abdomen (the peritoneal cavity). Most cases of bacterial peritonitis occur as a result of ascites due to chronic liver disease, or in kidney failure

Clinical signs and symptoms of biliary peritonitis include abdominal pain, nausea, and vomiting. Compare:eMedicine - Ventilation, Mechanical : Article by Ryland P Byrd, ...

Traumatic injury to the central nervous system (CNS) initiates an autodestructive cascade of biochemical and pathophysiological changes that ultimately results in irreversible tissue damage.
Esophageal Perforation, Rupture and Tears. CompareMechanical Ventillation.

93. A-26 of the record documents a BP of 78/70 at 0235 hours, while N-5 of the Nurses' Notes documents a BP of 98/70 at the very same time that is consistent with copious error. Low blood pressure is a sign of shock and can also contribute to further decreasing perfusion. Hypotension = systolic pressure <90 mm Hg). Hypotension itself is a late sign of hypovolemia or hypovolemic shock.

94. A-16 documents a BP of 163/117 at 0330 hours, while N-3 documents a BP of 136/85 at the very same time. (Suggests Hypertension Stage 2: *Compelling indications are high-risk situations such as CHF, MI, CHD, diabetes, kidney disease, stroke. Patients with chronic kidney disease or diabetes are treated to BP goal of less than 130/80 mm Hg. Drug therapy indicated. Compelling indications have specific medications). Blood pressure is usually considered normal if it's above 90/60 mm Hg, but can vary from person to person.

95. Further, N-3 documents a "large amount of dilute urine" at 0330 hours, and also at 0425 hours as evidenced by the record at N-2, and again at 0450 hours as evidenced at N-1, suggestive of overly rapid "fluid overload" due to overzealous and negligent IV infusion, and may be associated with hyponatremia caused by impaired water excretion in the presence of continued water intake. Hyponatremia is a condition known as "water intoxication." It is the opposite of dehydration. Compare Electrolyte Physiology. Excessive output of very dilute urine can also result in large free water losses and severe hypernatremic dehydration. Compare: Fluid and Electrolytes. In contrast, an acute adrenal crisis can present with vomiting, abdominal pain, and hypovolemic shock.

Various edematous disorders, including heart failure and hepatic cirrhosis, are associated with hypervolemic hyponatremia.

96. NOTE: There is nothing on record to suggest close monitoring of serum sodium (serum Na) levels. Irreparable harm can befall a patient when abnormal serum sodium levels are administered or corrected too quickly or too slowly.

97. Hyponatremia is the most common electrolyte disorder and is associated with brainstem herniation due to cerebral edema. Compare:
1.Electrolyte Disorders.
2. Traumatic Disorders.

98. Interestingly, hyponatremia is also associated with dehydration , and patients with clinically significant hyponatremia present with non-specific symptoms attributed to cerebral edema, ie. anorexia,nausea and vomiting, lethargy, headache, obtundation, and signs of brainstem herniation , including coma; they have fixed unilateral or dilated pupils, abnormal posturing, and respiratory arrest.

99. A-16 of the record also documents a blood pressure of 121/81 at 0400 hours, while N-2 of the Nurses' Notes documents a BP pressure of 112/57 at the very same time.

100. At 0352 hours the patient's blood pressure was documented at 85/52, some 17 minutes later, as evidenced at N-2 (in which BP is inadequate for normal perfusion and oxygenation. According to my research, at the point of loss of BP the resulting end organ injury is often irreversible ie., endothelium, lung, kidney liver, etc. Compare azotemia, in which renal underperfusion cannot be rulled out.

101. A-24 of the record documents a heart rate (HR) of 154 at 0330 hours while the Ventilation Record at A-16 documents at HR of 126 at the very same time, a significant difference.

102. From these records it is clear that nothing was done to bring the patients blood pressure under control in a timely manner and would have resulted in "permanent brain damage" at that point. According to my research, there would have been a loss of perfusion and autoregulation with rapid drop in BP and it is also clear that when it did happen, nothing was immediately done to correct it. Within seconds to minutes of the loss of perfusion to a portion of the brain, an ischemic cascade is unleashed that, if left unchecked, causes a central area of irreversible infarction = Ischemic Stroke. Thrombotic strokes are a major cause of brain attacks. Researchers have determined the cause to be associated with thrombotic thrombocytopenic purpura that can lead to kidney failure or stroke. A stroke has the same relationship to the brain as a heart attack does to the heart; both result from a blockage in a blood vessel that interrupts the supply of oxygen to cells, thus killing them. Compare Hemorrhagic Stroke.

The Coroner's expert documents "decreased attenuation throughout both cerebral hemispheres suggesting no cerebral perfusion", which supports 1) a loss of cerebral perfusion associated with an untimely response to a rapid drop in BP, and 2) inadequate oxygenation, despite the fact that oxygem levels were returned to normal by compensatory mechanisms, marked by a clinically evident inability to adequately ventilate and/or oxygenate. Compare: SHOCK - A clinical syndrome defined by a state of profound and widespread reduction in tissue perfusion. ? Shock/ Hemorrhage/ Thrombosis Shock - A low-perfusion circulatory ... main organs affected: brain, heart, lungs, kidney.

103. It is also of significance to note that adequate cerebral perfusion must be restored within 3-5 minutes for complete neurological recovery. It is also clear that this was NOT done.

104. The physicians Critical Care Note, a late dictation which purports to have been dictated at 0420 hours on May 24th of 2000 seen at A-8 of the record documents "later that evening she rapidly deteriorated and became unconscious without responding to verbal stimuli or painful stimuli", while the record at N-2 of the Nurses' Notes documents "attempts to pull away to painful stimuli" at 0400 hours only 20 minutes earlier, suggesting that she was indeed responsive. I was present at the time and had asked the patient in the presence of her foster brother if she could hear me to wiggle her toes, and she did, not once but twice. In my opinion, she appeared to be more "paralyzed" from the given meds than anything, suggestive of the "locked-in-state", for example, a condition in which a person is conscious and able to think but is severely paralyzed due to nerve paralysis or spinal cord compression, a condition mimiced by high cervical cord lesions and severe drug-induced dystonias eg. prochlorperazine.

According to my research, multiple blood clots in the CSF are the initial cause of post-hemorrhagic ventricular dilatation and lysis of clots.

105. A-16 of the record was initialled by Helene Studholme and Janice Chamaillard, jointly. The latter is the author of N-1, N-2, and N-3 of the Nurses' Notes and the co-author of A-16 of the Ventilation Record, while 75% of that record was authored by Helene Studholme, the Ventilatory Therapist.

106. The two versions of the patients vital signs is proof of deception and fabrication to downplay what really happened on the part of the healthcare providers named herein.

107. What I take to be the Physician's Lab Record at A-24 and A-25 documents the patients vital signs at 5 minute intervals, beginning at 3:15 hours. There is a complete absence of record in several distinct columns, primarily relating to the patients vital signs at the time of the intubation procedure, suggestive of "edited lab notes" by the physician after the fact to conceal iatrogenic (doctor caused) injury. As can be seen after comparison of the records the credibility of the doctors and nurses,the physician's records, the Nurses'Notes and the record as a whole are severely impaired.

108. What I take to form a part of a continuous 2 page record at A-24 and at A-25 appears to have been printed on two separate printers. Ironically, both pages are marked Page 1 of 1 (in lieu of Page 1 of 2, and 2 of 2), to rule out conformity or consistency. Further, when both pages are superimposed one over the other and held over light, the printed headings are misaligned. Further, the print sizes are slightly different.

109. The Cardiac Index at A-18 documents the patient's Vent Rate at 129 bpm at 0417 hours with heart and breath rate "increased", as confirmed by the Sinus Tachycardia that is consistent with systemic inflammatory response to clinical insult, (arrhythmias secondary to medications, and electrolyte imbalances) such as caused or worsened by medications suggestive of Neuroleptic Malignant Syndrome (NMS). Shock, and blood loss, are also common causes asn are associated with an Abnormal Ventricular Electrocardiogram. Compare: Evidence of Neuroleptic Drug-Induced Brain Damage in Patients: A partial, Annotated Bibliography (CIRCARE). CIRCARE. (CITIZENS FOR RESPONSIBLE CARE & RESEARCH). Also Airway Management. Abnormal Rhythms. Electrocardiogram (ECG) SEE Heart Failure - Introduction

The same record documents an unconfirmed ECG that is consistent with possible heart failure, according to an MD. All aspects of that document are now currently being investigated.

110. Sinus Tachycardia results from increased automaticity of the SA node, for instance, due to increased sympathetic stimulation of the heart, fever or cardiac toxicity. That the patient's Heart Rate had soared to 174 bpm at the point of intubation should also be born in mind.

111. Pathologic Tachycardia (abnormally rapid heartbeat -over 100 beats per minute) accompanies anoxia (lack of oxygen to tissues) as caused by anemia, congestive heart failure, hemorrhage or shock, which can be responsible for a drop in the patient�fs blood pressure and decreased perfusion to the patient�fs coronary arteries. An abnormally fast heart rate could be due to injury, heart disorders, low blood oxygen (hypoxia), drugs , hypoxemia, hypovolemia, or to a panic attack. It is also a normal response to pain, and is associated with heart failure Compare the Laboratory Findings. Compare:Arrhythmia Recognition. Arrhythmias. Approach to Common Problems - Sinus Tachycardia - Differential. Arrhythmia Recognition The EKG Measures the Body's Electrical Activity. Manifestations of Congestive Heart Failure range from laboratory abnormalities over a presentation undistinguishable from acute hepatitis to fulminant failure.

The same report documents an "inferior ischemia", a sign of decreased oxygen supply to vital organs suggestive of arterial occlusion, for example, resulting in reduced or poor blood flow which can induce cerebral tissue ischemic injury by producing "mid-line shift " and " herniation" .Thus "Ischemia" is an insufficient supply of to an organ, usually due to a blocked artery. Reduction in blood flow (relative ischemia) impairs O2 delivery and causes cerebral hypoxia.

112. The same record documents an abnormal ST&T wave segment on ECG that is consistent with adverse effects of the given medication, as reported in the Compedium of Pharmaceuticals and Specialties (CPS) 2003.

113. Interestingly, the patient's age was falsely documented at "55 years" when in fact she was only 41 years of age suggesting that this Chart may have been fraudulently replaced with that of another more elderly patient. Alternatively, it goes to the credibility of the remainder of that Chart, and the credibility of the remainder of the physician's records. Findings suggest that with older patients, the incidence of adverse reactions may be greater in patients over 55 years of age, since the half-lives of antipsychotic are often prolonged. The fact that age 55 showed up on the chart of a 41 year old patient is seen to be significant suggestive of a possible secret and fraudulent reporting of adverse events associated with the Stemetil.

114. The physician's Lab Work Summary at A-19 documents the charting of a course of HEMATOLOGY and Coagulation. It documents a FIBRINOGEN level of 4.67 H (the normal range is 2.00-4.00), increased in response to injury, hypertension, and trauma. Fibrinogen decreases with liver disease, due to decreased hepatic synthesis. However, fibrinogen may be normal or even elevated until late stages of hepatic disease. There is a significant correlation in the white blood cells and plasma fibrinogen in thrombotic stroke. Fibrinogen allows blood to clot more easily. Compare: Hypertension and Risk in Ischemic Heart Disease

115. The same record at A-19 documents a D-dimer test level of 1000 H (<500), including hematological findings in the High (H) and Low (L) ranges suggestive of pathology associated with "blood disorders ".

116. According to my research, high levels of fibrinogen can cause abnormal arterial "clotting". Serum fibrinogen levels in a safe range is <300 mg/dL.

117. Fibrinogen acts to promote platelet aggregation (clumping together of platelets at the site of injury) resulting in diminished flow and delivery of oxygen to the body, i.e. arteries, heart, and brain, kidneys i which thrombosis and organ damage occur because of excess platelet aggregation. Thus excess fibrin clots capture the platelets and produce thrombosis with impaired organ perfusion.

118. D-dimer suggests "thrombosis" (blood clotting) and is the confirmatory test in Disseminated Intravascular Coagulation (DIC) . Thrombosis= Formation of a clots within vessels of the brain or neck. "Over two thirds of all strokes are due to thrombosis." Ref: D-dimer.htm Trauma, particularly brain injury, is associated with DIC (Levi & Ten Cate, 1999).

119. The aPTT (activated Partial Thromboplastin Time) a test used to determine the efficacy of various clotting factors used in the diagnosis of coagulation disorders documents the therapeutic range for Heparin therapy at 60-100 seconds (23-35 is the normal, >60 seconds=Panic) and is elevated in 90% of those with coagulopathy, an increased bleeding tendency due to decreased hepatic synthesis of clotting factor, i.e. with prothrombin ( a protein involved in clotting, most commonly prolonged by vitamin K deficiency and liver disease) time increased. The time of that assessment was documented at 0400 hours.

Notably, coagulopathy in severe sepsis is commonly associated with multiple organ dysfunction. Sepsis as the host response to infection, involves a series of clinical, hematological, inflammatory and metabolic responses that can ultimately lead to organ failure. Severe sepsis is typically associated with activation of the coagulation system, leading to deposition of thrombin in the microvasculature = Interaction of coagulation and inflammation. Coagulation system and platelets are fully activated in uncomplicated sepsis.
Keywords: Activated Protein C, antithrombotic, coagulation, endothelial cells, fibrinolysis, inflammation, organ dysfunction, sepsis

120. The same record documents the patients Blood Cell Count beginning with the WBC's or White Blood Cells (the normal is 4.0-11.0), also known as the Leukocytes with a count of 22.4 #PH, increased to more than double the normal range, and is associated with allergic response, presenting in this case with what I take to be an abnormally high alkaline blood pH (alkalosis). A pH above 7.0 is alkaline; the higher the number, the stronger the alkali. Blood Gasses.

Alkalosis is a condition of excess base (alkali) in the body fluids. 6.2 CHEMICAL CLASSIFICATION OF CAUSES OF CHANGES IN BLOOD pH Compare: Arterial blood gas analysis. Metabolic Alkalosis.

121. The White Blood Cells (leukocytes) are also elevated with dehydration, hyperviscosity secondary to dehydration, and infection causes. It is the most common form of leukocytosis. Leucocytosis is an increase in the number of white blood cells in the blood. It is a common feature of inflammatory reactions, particularly those caused by bacteria. The type of leucocyte increasing in number is dependent on the stimulus type and chronicity; subtypes include:

neutrophilia
basophilia
eosinophilia
lymphocytosis
monocytosis

Blood MEDLINEplus Medical Encyclopedia: WBC count

122. The record at A-19 documents a Lymphocyte Count of 2.0 L (low) suggestive of "Lymphocytopenia" in which LYMPHOCYTES are reduced with nutritional deficiency, infection or an exhausted immune system. Compare: 1)Autoimmune Hepatitis, also 2) Autoimmune Hepatitis. A person with autoimmune hepatitis has autoantibodies circulating in the bloodstream that cause the immune system to attack the liver. This disease is associated with other autoimmune diseases, including Hemolytic anemia. Lymphocyte.net: Information about lymphocytes Immune System Lymphocytes

123. Lymphocytopenia causes may also arise from accelerated destruction of T cells or other syndromes associated with depletion of lymphocytes . Low numbers of lymphocytes may be seen in different diseases such as hepatitis, lymphoma, or AIDS. Compare: Hepatitis Central, Lymphocytes. Further, signs of toxic shock syndrome when T cells are absent: S. aureus shock in immunodeficient adults.

124. Interestingly, iatrogenic lymphocytopenia is caused by cytotoxic chemotherapy and radiation therapy, marked by a reduction in the absolute number of T cells. Lymphocytes are the most sensitive to whole body radiation and their count is the first to fall in radiation sickness. The number of lymphocytes declines within the first 12 to 48 hours after exposure. This is followed over several weeks by a decline in the number of other blood cells. The decline in lymphocytes is one of the best early signs of the severity of the radiation injury. The Immune System and Radiation - Hanford Health Information ... THE MERCK MANUAL, Sec. 20, Ch. 278, Radiation Reactions And ... THE MERCK MANUAL, Sec. 20, Ch. 278, Radiation Reactions And ... THE MERCK MANUAL, Sec. 11, Ch. 135, Leukopenia And ...

125. The same record documents an Absolute Lymphs (Lymphocyte) Count of 0.4L (low), suggestive of "ascites", a sign of chronic liver disease, or evidence of cardiac failure, due to fluid build-up in the abdomen in which liver disease is the most common cause. Among conditions that contribute to ascites development include hepatitis and heart or kidney failure. The main pathogenic factor is sodium retention. Compare: Ascites, Symptoms, Signs, and Diagnosis. Clinical review Underlying condition causes of Ascites: heart, lung, and liver disorders. What are the signs and symptoms of the condition?. As can be seen, abdominal pain is at the top of the list with causes of the condition traceable to radiation therapy, side effects of which include bowel obstruction, and http://atoz.iqhealth.com/HealthAnswers/encyclopedia/HTMLfiles/3163.html>heart disease, or congestive heart failure. Congestive heart failure, also known as CHF, is a condition in which a weakened heart cannot pump enough blood to body organs. Since the pumping action of the heart is reduced, blood backs up into certain body tissues.

Corticosteroids, such as prednisone, can reduce damage to healthy organs. None was prescribed nor given by the patient's oncologist, Dr. Prichard, nor any other doctor who attended to this patient while she was under their care.

126. If the ascites is due to liver disease the fluid may be clear to "yellowish", uninfected and have a low cell count. If bacterial infection is present in ascites this may suggest spontaneous bacterial peritonitis in which abdominal pain is a prominent finding. If peritonitis is not treated promptly and effectively multisystem organ failure occurs rapidly. Liver function tests, including clotting profiles were NOT done in a timely manner.

127. Further, the same report documents the Neutrophils (also known as granulocytes) with a count of 92.0 H (normal 47.0-77.0), also shows Absolute Neuts of 20.0 H (normal 1.3-6.7), and is increased in response to acute infections (bacterial or viral), drug toxicity and hemorrhage.

Leukocytosis (especially neutrophilia) indicates systemic infection.

Endotoxins and other bacterial products appear to cause direct cellular injury while eliciting cytokines that attract neutrophils, which enhance (hypersensitization, brain edema, and hypercoagulability with vascular inflammation from endotoxin) the inflammatory effect.

Leakage of oxidative metabolites from the neutrophils into the tissue can potentiate the inflammatory process.

128. The HCT (hematocrit) shows a count of 0.361 L (low). A low hematocrit is referred to as being anemic. There are many reasons for anemia. Some of the more common reasons are loss of (traumatic injury, surgery, bleeding colon cancer), nutritional deficiency (iron, vitamin B12, folate), bone marrow problems (replacement of bone marrow by cancer, suppression by chemotherapy , kidney failure). An abnormal hematocrit = sickle cell anemia. Signs of blood loss, such as shock, hypotension, and a falling hematocrit level are associated with liver trauma.

129. HCT - Hematocrit is thus the measurement of the percentage of red blood cells in whole blood with a reduction suggestive of anemia. Normal Female Range is 37-47%. Anemia is present when hematocrit is <37% in women.
Ref: HCT Fact Sheet

130. The RDW (Red Cell Distribution Width) shows a count of 18.4 H (normal 11.50-16.8) increases before MCV (Mean Corpuscular Volume) becomes abnormal suggestive of anemic hemoglobinopathy.

A-30 of the record documents an Arterial pO2 of 129.0 H (normal 75-100).

Increased arterial pCO2 (hypercapnea) causes cerebral dilation

CO2 diffuses through blood-brain barrier into the CSF to form H+ (via carbonic acid) which then causes the vasodilation

Deficient oxygenation of the blood (<90 mm Hg arterial pO2). Decreased arterial pCO2 as occurs during hyperventilation causes cerebral vasoconstriction, decreased blood flow, and cerebral hypoxia.

1) Reduction in blood flow (relative ischemia) impairs O2 delivery and causes cerebral hypoxia. 2) Unconsciousness results after only a few seconds of oxygen deprivation. Compare: Cerebral Blood Flow
View HTML

See: Metabolic effects of increased Arterial pO2

131. Further, RDW is a standard part of the complete count. (The Mean Corpuscular Volume (MCV ) test is usually used to determine what type of anemia a person may have. If elevated, it may indicate anemia from vitamin deficiency such as Vitamin B12 or folic acid. If it is below normal, it usually indicates anemia from iron deficiency.)

132. Mean Corpuscular Volume (MCV) Increased
1. Vitamin B12 Deficiency
2. Folate Deficiency
3. Immune Hemolytic Anemia
4. Liver disease

133. The same report documents a Platelet Count of 544 H, increased with coagulopathy (platelet coagulant activities) or platelet aggregation (cohesion of platelets to each other forming clumps). Platelets are thus cells that form the primary mechanism in blood-clots.

134. Platelets (also known as thrombocytes) coagulate the . Platelets plug bleeding capillaries and vessels. With infection, or when the body is cut or otherwise injured, white blood cells (WBC's) rush to the site as the first line of defense. Platelet aggregation contributes to the coagulation cascade with activation, i.e. esophageal perforation or other trauma/procedures and can lead to DIC and hemorrhage. Platelets are also elevated with drug-reactions, including dehydration. Dehydration from any cause increases blood viscosity and raises the risk for thrombus formation.

A diminished number of platelets (below the lower limit of normal) is called thrombocytopenia and an elevated number (above the upper limit of normal) is called thrombocytosis. WBC . Increased
. See Thrombocytosis

135. Platelet Count May Predict HCV Liver Disease Progression

136. Larger platelet volume also indicates younger and more active platelets of recent onset volume (equivalent of MCV for Red Cells) in the Complete Blood Count. See Tests: Complete Blood Count Blood Tests: Complete Blood Count

137. The same record documents Absolute Monos (monocytes) with a count of 0.60 (normal 1.0-5.5) with a reduction indicative of a anemia. The normal range for the monocyte count is 200 - 950 /�L. See Monocyte Count -

Decreased = Lymphopenia

1. Aplastic Anemia (a disorder in which the bone marrow)

2. Lymphocytic Anemia

3 - anemia, or a low red cell count

4 - bleeding problems due to poorly working clotting cells, called platelets

5 - loss of normal white cell function, which

increases the risk of infection 6 - a need for red blood cell transfusions

138. A decrease in the number of circulating monocytes may be seen with:

Innunodeficiency syndrome, including congenital (DiGeorge syndrome, etc) and acquired (AIDS) conditions

Neoplasia, including Hodgkin's disease, non-Hodgkin's lymphomas

Radiation therapy

Chemotherapy/Antineoplastic Drugs

139. Monocytes are considered the bodys second line of defense against infection. In cancer, leukemia or neop[lasms the moncytes become "elevated or what is called Monocytosis. An abnormal increase in the number of monocytes in the circulating blood.", to rule out Metastasis. Toxic substances can also injure monocytes.

140. Hemoglobin is the protein inside red blood cells that carries and provides the main transport of oxygen and carbon in the blood. It is composed of "globin", a group of amino acids that form a protein and "heme", which contains iron. It is an important determinant of anemia (decreased hemoglobin) or poor diet/nutrition or malabsorption. Liver disease can lead to a shortage of hemoglobin. The hemoglobin test is used to check if there is enough hemoglobin in the blood.

140.1 The record documents a Glucose Random of 13.2 H (normal 4.1 - 7.8), a condition in which the amount of blood glucose (sugar) in the blood is higher than normal suggestive of hyperglycemia, a metabolic disorder, and is associated with renal physiology, such as clinical diabetes, for example, and may be associated with functional renal failure, ie. hepatorenal syndrome. If levels of serum Glucose Randon are too high, the person is hyperglycemic, and may need insulin.

What do abnormal results mean? Additional conditions under which this test is performed include Acute adrenal crisis. Adrenal crisis occurs if adrenal insufficiency is not adequately treated. Acute adrenal crisis is a medical emergency caused by a lack of cortisol. Patients may experience lightheadedness or dizziness, weakness, sweating, abdominal pain, nausea and vomiting, or even loss of consciousness. Risk factors for adrenal crisis include physical stress such as infection, trauma or surgery, adrenal gland or pituitary gland injury. Glucose Test.

141. A-20 of the Laboratory Discharge Summary documents a Serum Potassium level of 3.4 L (low) suggestive of hypokalemia (a decrease in the serum potassium concentration below 3.5 mEq/L caused by a deficit in total body potassium stores or abnormal movement of potassium into cells) which leads to an electrolyte imbalance as caused by ongoing or severe fluid losses form the GI Tract , i.e., such as from vomiting and malnutrition which can lead to weakness, fatigue and cardiac problems. Anything below 3.5 creates a serious risk of cardiac arrhythmias leading to cardiac arrest. Potassium plays a crucial role in the body, regulating heart beat and other critical functions. Low levels of potassium--known medically as hypokalemia (HI-poh-kah-LEE-me-uh) can be dangerous and potentially FATAL. Thus hypokalemia can commonly result from the loss of potassium through dehydration, vomiting, and gastric suction, and is also associated with hyponatremia. See: Potassium Metabolism.Compare: Iatrogenic Hypokalemia. Search: Metabolic Toxic Electrolyte Imbalance

141.1 Hypokalemia: Abnormally low potassium concentration in the blood; it may result from excessive potassium loss by the renal or the gastrointestinal route, from decreased intake, or from transcellular shifts. It may be manifested clinically by neuromuscular disorders ranging from weakness to paralysis, by electrocardiographic abnormalities (depression of the T wave and elevation of the U wave) by renal disease, and by gastrointestinal disorders.

142. The most common problems associated with reduced potassium levels are hypertension, congestive heart failure, cardiac arrhythmias, depression, and fatigue. A variety of conditions can cause the loss of potassium from the body. The most common of these conditions are vomiting, diarrhea, and other gastrointestinal problems, such as Constipation. See: THE MERCK MANUAL, Sec. 3, Gastrointestinal Disorders . Medications can also cause depletion of potassium. Hypokalaemia is commonly caused by medication.

143. Compare: Electolyte Imbalance -Hypokalemia and hyperkalemia. Low potassium - Hypokalemia increases the resting membrane potential of cells, resulting in muscle weakness, impaired urine concentrating ability, polydipsia and arrythmias. It is usually due to gastrointestinal or renal losses of potassium. Hypercalcemia

144. No serum Potassium replacement was ordered or administered. It is not known what the patient's potassium level was at the time of her admission. No lab tests were performed soon enough to verify or treat accordingly.

Signs and Symptoms of potassium deficiency include cardiac arrhythmia, muscle pain, general discomfort or irritability, weakness, and paralysis. In my opinion the ED physician, Dr. Spiller should have ordered monitoring by electrocardiogram and done appropriate testing at the onset, but failed in his duty of care to do so.

145. That the patient was seen by family to be propped up in the arms of two nurses hyperventilating or "gasping for air" with only a plastic oral airway in her mouth should be borne in mind.

146. The ambulance call report seen at N-7 of the Nurses' Notes documents that the patient was intubated and vented and that she was seen to be stable but that she appeared to be "pale, dry and cool," clinical manifestations of adrenal insufficiency, or SHOCK: fairly reliable signs of compromised perfusion Pale � Whitish color indicates hypo perfusion (shock), is a medical emergency. Compare:EM guidemap - Upper GI bleed.

147. Hypovolemic shock occurs when there is insufficient or inadequate circulating throughout the body. The most common causes of hypovolemic shock include hemorrhage from any source, or volume depletion related to dehydration. Hemorrhage is defined as a loss of from any cause. Common causes of hemorrhage include traumatic injury, surgery and gastrointestinal bleeding. Compare: Understanding Shock Syndrome

148. There is an X mark in the box pertaining to allergies NKA suggestive of NO KNOWN ALLERGIES, and a further notation claiming "Dr. now suspects that cancer has gone to the brain". The same report documents "intracranial bleed" that is inconsistent with the "coffee-ground emesis" (bloody emesis) documented in the Nursing Notes and on the Ventilation Record on or about the time that the patient was intubated.

149. The same report also documents " pulses x 4 good", including "head/neckOK"; "chest OK;" "abdomen OK"; pelvis OK; and "extremities OK." Further, there is nothing on the Ambulance Call Report with respect to the "bloody vomitus" documented in the Nurses' Notes.

150. The very same report documents a "Nature Code 0" (No Code = No Care) a "withdrawal of life support" from a critically ill patient or DNR "do not resuscitate order" issued against family wishes. The time of that report was documented at 0620 hours on May 24th of 2000, only hours before the patient's death. Do not resuscitate (DNR) means no chest compressions, no defibrillation, no assisted ventilation, no endotracheal intubation, and no cardiotonic medications. The same record documents a Code 3.3 "Withholding Treatment".There was NO "Do Not Resuscitate" order on the client�s health record nor had there ever been a designated agent who declined continued resuscitation on behalf of the patient. The decision to terminate Arlene Berry was made solely by Dr. Edward Henry Jordan and his accomplices.

151. According to the Nurses' Notes at N-1 of the record the patient was given Gravol 50 mg x 10 by paramedics at 0620 hours, while the record at N-7 with respect to medications documents "See Nsg Notes".

152. Notably, Dimenhydrinate (Gravol) is contraindicated in chronic lung disease and has also been reported to "mask the toxic effects of other ".

153. DRUG-Induced liver disease can "mimic viral hepatitis" or biliary tract obstruction as well as any other type of liver disease. Compare: Portal-systemic encephalopathy in non-cirrhotic patients.

154. The complications of acute liver failure are numerous and include: sepsis, gastro-intestinal bleeding, cerebral edema, renal and cardiac failure. Varices may also result from portal vein thrombosis. Compare: Vascular Disorders of the Liver / L.J. Worobetz.

155. Disseminated Intravascular Coagulation is associated with sepsis, especially with "gram-negative" bacteria or fungal infection. DIC leads to both bleeding and thrombosis.

156. Respiratory failure results when the physiological capacity of the respiratory system is less than the body's physiological requirement and can be defined when the arterial PO2 (PaO2) is less than 60 mm Hg or the arterial PCO2 (PaCO2) is greater than 45 to 46 mm Hg. Clinical Features of Respiratory Failure: Pulse oximetry estimates the O2 saturation of the hemoglobin, which in this case is inconsistent with much the blood-work. A high CO2 level is always associated with hypoxia.

157. Gastrointestinal bleeding should be controlled if possible and purged from the gastrointestinal tract.

158. Given the known effects of penicillin and penicillin-like drugs the possible effects of concomitant administration of toxic neuroleptic agents such as prochlorperazine in the circumstances, Arlene Berry may have gone into shock, or cardiac arrest.

Her eyes were sunken in appearance, with swelling and distortion of the face eyes, and mouth (lips), as was the case, marked by elongated facial furrows with redness and swelling to the face in the area of the right eye suggestive of massive edema, as evidenced by all who attended Arlene Berry's funeral) the swelling of the larynx would have blocked the airway to the right lung, preventing breathing, followed by unconsciousness.

159. Artificial ventilation and oxygen should have been prioritized and promptly administered to include withdrawal of the offending , but were NOT. Instead the patient was seen to be propped up in the arms of two errant nurses (not a recovery position) gasping for air, with only a plastic oral airway in her mouth for quite some time. There was consternation among the nurses - the horrific look on their faces said it all.

160. When Dr. Jordan finally showed up in the small hours of May 24, 2000, precious moments that followed were not taken up with measures to save his patient's life, but rather ways to accelerate her demise. He even proposed a "DNR" (do not resuscitate order) and asked us bluntly if we would prefer to let "nature take its course". The family was not impressed and so insisted that she be placed on "life support".

161. Obviously, Dr. Jordan did not support the use of aggressive interventionist treatment to keep alive someone he had already injured, for to give treatment to remedy a wrong would expose the fact that mistakes were made.

162. Arlene Berry was seen to be the victim of a botched intubation procedure which could have saved her life but instead resulted in possible internal injury and internal bleeding (e.g. esophageal or lethal gastrointestinal perforation associated with careless instrumentation), due to "malpositioning" of the endotracheal tube which triggered a quick deterioration of her condition; one full hour went by before the error was discovered and the endotrachial tube pulled back. 1) eMedicine - Esophageal Perforation, Rupture, and Tears 2) eMedicine - Esophageal Perforation, Rupture and Tears : Article Excerpt by: Martin J Carey, MD, MPH, BCh 3) Esophageal Perforation, Rupture and Tears from Emergency Medicine / Gastrointestinal

163. According to the medical record the intubation procedure was performed by Dr. Jordan, assisted by Helene Studholme, a Respiratory Therapist at the Kirkland and District Hospital.

164. Following the bungled intubation, rather than confine clotting of the to the site of the injury, or perhaps due to his mindless and promiscuous use of inappropriate lab settings or other negligence it seems clear that Dr. Jordan triggered a "Coagulation Cascade" of spontaneous slugging of the blood sending numerous "blood-clots" to her brain, resulting in herniation or intracerebral hemorrhage. The levels of Fibrinogen, and the D-dimer charted in the medical record for May 24, 2000, together with "evidence based medicine" criterion confirms the Disseminated Intravascular Coagulation. MEDLINEplus Medical Encyclopedia: DIC (disseminated intravascular ... Visit our medical library for information on Disseminated ... Postgraduate Medicine: Disseminated intravascular coagulation Disseminated Intravascular Coagulation (DIC) Profile, ... Acquired Disorders of Coagulation MEDSTUDENTS-GASTROENTEROLOGY THE MERCK MANUAL, Sec. 13, Ch. 156, Bacteremia And Septic Shock Adrenal Pathology Section 1: First Principles of Gastroenterology
Chapter 14 - Section 13: First Principles of Gastroenterology

165. At the first meeting with the coroner held at the OPP Detachment in Kirkland Lake, Ontario in July of 2001, Dr. McLellan, the Regional Coroner admitted to family that there was "no evidence on record of metastatic cancer".

166. At a subsequent meeting between family and the Regional Coroner, Dr. McLellan provided us with a view of Arlene's prior CT scan that was done in Timmins, Ontario on or about the 16th of March of 2000. I had accompanied Arlene to the Timmins and District Hospital on that date. A special contrast dye was injected into a vein before the CT scan was done. "NO clinically detectable metastasis was found".

167. A mediastinoscopy with biopsy (tissue sample) had also been done on that date. The result of that testing also proved "NEGATIVE". Mediastinoscopy is used to stage lung cancer, especially when enlarged nodes are seen on chest x-ray or CT scan.

168, There was a marked change in her voice as a result of this testing. She was told her voice would return to normal in time. At the time of her dearth, Arlene had started to regain her normal voice.

169. With respect to the initial CT scan hereinbefore mentioned, according to the Coroner's expert, "in the right occipital region there is a spot that measures less than 1 cm that is consistent in appearance with either a small hemorrhage or perhaps a small metastatic tumor". He could only speculate. According to my research it can also suggest either an amyloid deposit which is the hallmark of Alzheimer's disease, including recent onset Alzheimer's) or an "old occipital bleed" such as from an old injury. Further findings suggest that abscess can mimic tumors in presentation and radiologic studies. Lung is primary site of infection, but brain is second most commonly involved organ and may be caused by staph if there are hemorrhagic multiple abscesses.

170. Further submit that the occipital lobes interpret vision. Had it been a recent tumor, there would have been onset visual misperception with visual impairment and subsequent loss of vision with evolution. Arlene Berry had NO visual deficits, indeed she had "No focal deficits", apart from the signs and symptoms of hepatic dysfunction which the ED physician failed to in his duty of care to recognize. The patient had even been oriented to date, place and time at the time of her admission to the Kirkland and District Hospital on May 23rd of 2000.

171. Dr. Mclellan also provided us with a view of a CT scan which he purports that was done at the time of Arlene's death. It shows numerous blood clots and traumatized tissue abscess (blood and pus isolates) and massive edema of the right cerebral hemisphere, including a 1 cm midline shift that is consistent with Ischemic Stroke, or perhaps Hemorrhagic Stroke, and herniation.

(Compare: Coagulase: > Compare coagulase-negative staphylococci), and Radiation Necrosis - Further submit that a CT scan measures density and cannot by itself differentiate between blood clots and tumors. All cerebral hematomas, whatever the cause, have a similar resolution pattern on CT. Plain radiographic findings are nonspecific, but they may be useful in showing the extent of associated skeletal trauma. Vascular malformations and brain tumors are better visualized on MRI HEMATOMA - Definition
Blood Clot Center - HeartCenterOnline Strokes & Blood Clots eMedicine: Blood Clots

172. NO Magnetic Resonance (MRI) Testing was done. NO biopsy was done. NO autopsy was done. Among causes of Hemorrhagic Stroke include untreated hypertension, coagulopathies, and ICP (Increased Intracranial Pressure).

173. With the decreased attenuation throughout the cerebral hemispheres due to rapid or spontaneous development of blood clots there would have been little or no perfusion.

174. Had Arlene Berry been started on corticosteroids (cortocosteroids: a type of steroid usually given to reduce inflammation) to reduce brain swelling, and had she been treated responsibly, she could have enjoyed respite from her condition and may have recovered without further complications. But without timely response due to medical mismanagement and criminal negligence on the part of the doctors and nurses involved herein, Arlene Berry died unnecessarily.

175. Further findings suggest that patients with a diagnosis of a primary or metastatic brain tumor associated with a CNS event should have a meticulous review of their history for possible "iatrogenic" causes. As can be seen from this case, little or no attention was paid to the patient.

176. ADDENDUM The College of Physicians and Surgeons of Ontario conducted an investigation into the of Arlene Berry which consisted primarily of downplaying all complaints by "omission" and in fact failing to address the key concerns put forth. The bald truth is that they "tailored" the investigation to suit themselves. The investigator, C. Michelle Mann was either uninformed, ignorant, or outright criminal in her investigation.

177. To downplay by omission is to "obfuscate the truth". In my opinion she violated the provisions of the Criminal Code. All of the doctors and hospitals named in the Arlene Berry coverup were "partners" in the NORTH Network, a telehealth network experiment undertaken by the Harris government from a 1995 OMA study to compensate for hospital funding cutbacks and doctor shortages. They all had and still have a vested interest in protecting each other against the legal s of treating patients unseen at arm's length, over the telephone . They are now, by their own doings the key players in the Arlene Berry coverup conspiracy for which I will hold all of them criminally liable.

178. Dr. Barry McLellan was one of the original proponents of the NORTH project, leaving his position as medical director of the North network to become Regional Coroner for Northeastern Ontario. In fact, he was affiliated and closely tied to all of the doctors and hospitals named in the Arlene Bearry "coverup", all of whom were partners in the North telehealth network. As such, Dr. McLellan had a personal and vested interest in the Arlene Berry case as to affect his personal judgment. He allowed his professional duty to come into conflict with his personal interests as to constitute a conflict of interest, ahead of public duty, which he misused for personal ends. Conflict of interest is a precondition for biased or corrupt behaviour. He had a duty to disclose such interest(s) and by failing to do so he acted illegally, and in my opinion, contrary to the provisions of the Criminal Code of Canada, via provisions related to corruption in public office, and the Conflict of Interest Code.

Case in Point:

179. SERIOUS breach of standard which goes to impeach the credibility of the Coroner's investigation into the unnecessary death of Arlene Berry. Further, Dr McLellan was Vice-President of Medical Trauma and Clinical Services at Sunnybrook Health Science Centre in Toronto Ontario for 5 years. He was medical director of the NORTH Network and had recently assumed the position of Regional Coroner.

The Coroner's response to a family request for a formal inquest into Arlene Berry's death elecited the following response notwithstanding "evidence of altered and falsified medical records" in which liver function tests are suspected of fabrication, including a preponderance of evidence of medical wrongdoing.

180. A family request for a formal inquest into Arlene Berry's elicited to following response from Dr.McLellan: "I want to stress that an inquest is not intended to be the vehicle by which someone is found to be responsible or accountable for a "death "As a result of my investigation and having carefully reviewed all information available I do not feel.. that a jury might make useful recommendations directed to the avoidance of similar circumstances". . "The venue to determine accountablity is either the criminal or civil courts". . "After careful consideration of all information available to me I have therefore made a decision to not hold an inquest into Ms. Berry;s death".

181. Further, Dr. McLellan had told the deceased's family that he had no dealings through his office with the College of Physicians & Surgeons. He "lied", in fact he conducted what Dr. Jordan's legal counsel described as a "parallel investigation" with "multiple communication" between the Coroners' office and the College.

182. "CROWNERS" elected as Keepers of the Pleas of the Crown featuring Dr. Barry A. McLellan

Malcolm W. Everett,
Investigative Correspondent

[email protected]

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The Medical Record of Arlene Berry for May 23rd and 24th of 2000

MEDICAL Terms Dictionary

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The O2 Saturation is the total amount of oxygen bound to hemoglobin in the red blood cells in comparison to the total amount possible. For instance, if your O2 Saturation is 50%, your hemoglobin is carrying only half of what it is capable of carrying.

Alterations of Renal and Urinary Tract Function

GLOSSARY OF TERMS AND ACRONYM EXPANSIONS FOR PERFUSION TECHNOLOGY ... (PDF)

http://www.myasthenia.org/drugs/reference.htm

Hypokalemia is implicated as a potential factor in a variety of immune-mediated complications exposure to a variety of medications. Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

Evidence-Based Medicine Internet Resources

mens rea

Radiation Toxicity

Esophageal Varices

Occult blood, stool (fecal occult blood test)

EM guidemap - Coma

DISTURBANCES IN ACID-BASE METABOLISM

* taken from "CLINICAL DIABETES" Patients with a history of retinopathy, nephropathy, or neuropathy should be presumed to have GI abnormalities until proven otherwise.

Clearly, the adulterated medical record was delivered to the recipient under false pretences. It was intended that it be acted upon as genuine and to the detriment of and with intent to defraud the recipient of any rightful claim. It is also clear that the omissions constitute concealment and that which is seen as contradictory constitutes a fabrication.

See: Gastroenterology Chapter 14 - The Liver in which: Primary sclerosing cholangitis is the most common cause of secondary biliary cirrhosis in adults. It affects about 10% of patients with ulcerative colitis or Crohn's colitis, although 30% of patients with PSC have no background of inflammatory bowel disease at the time of presentation. Patients are commonly asymptomatic. Just as with PBC, PSC causes presinusoidal portal hypertension, so variceal bleeding may present early - i.e., prior to the onset of jaundice (Table 13).

Thrombi in contact with flowing blood tend to propagate, as more clot forms on their surface. Propagation is in the direction of blood flow, and may ultimately obstruct the blood flow.

*****Thrombi and emboli can firmly attach to a blood vessel and partially or completely block the flow of blood in that vessel. This blockage deprives the tissues in that location of normal blood flow and oxygen. This is called ischemia and if not treated promptly can result in damage or even death of the tissues (infarction and necrosis) in that area.

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Swelling of the abdomen is also a sign of heart failure

hospital acquired injuries such as deep venous thrombosis (DVT), line sepsis,

Dehydration from any cause increases blood viscosity and raises the risk for thrombus formation.

Because significant trauma can cause both significant cerebral and systemic injuries, those with lower initial GCS scores are more likely to have hypotensive events.

iatrogenic injury to the lungs with over-aggressive fluid resuscitation

The Stated Case: 1, 2, 3.

Dehydration can be exacerbated by severe or prolonged vomiting resulting in loss of fluid volume and is associated with electrolyte imbalances, including hypokalemia, hyponatremia, hypomagnesemia, and hypochloremia (Bender et al., 2002). The combination of inadequate intake and excessive output from vomiting in patients who already are compromised by cancer or its treatment puts patients at an even higher risk for life-threatening complications.