Well, the Board did complete its investigation. Five doctors were reprimanded. The resident on duty the night of the loss is no longer allowed to practice. The ICU doctor is no longer an ICU doctor but is still practicing—three more doctors whose disciplinary hearing was held behind closed doors three weeks ago. I do not know the outcome beyond knowing one was asked for a voluntary surrender of license. I will not know the full outcome for weeks.
This past week, I met with the legal team and a third-party out-of-province Medical Examiner whose team conducted the review. And it was painful beyond imagination.
“Quite frankly, I have never seen such a confounding patient progress and decline in my 35 plus years of reviewing medical cases.
The Review of the chart in its entirety with focused questions as to the diagnostic protocols, and what appears to be presumptive treatments in the absence of confirmed diagnosis, leading to serious medical complications.
In short, the failure to follow documented guidelines led to the systematic poisoning of *****. Which cumulated in renal failure, with no supportive services offered that could have and should have resulted in a recovery. The failure of the system is an example of gross negligence bordering on willful malice.”
In the end, he agreed my Wife had NAFLD with iShack Fibrosis, which was F1/F2 . Further testing showed that it bordered on F0/F1, which was caused due to rapid weight loss associated with COVID.
The main issue was using the most potent antibiotics without following proper guidelines. Leading to systematic multi-organ involvement, which required a multidisciplinary approach to rectify.
Instead of engaging in a plan to recover. The doctor administered more at even higher dosages. When that did not work, more and higher dosages were administered.
This resulted in a cascade of issues that led to renal failure, causing fluid backup and placing pressure on the heart, which caused issues for the Lungs and Liver.
A review of the GI scopes shows no evidence of Hypertensive gastropathy but clearly shows the damage caused by Bile Reflux and potent antibiotics.
The doctor in charge should have halted all medications and provided supportive services to allow the patient's body to recover.
In the last 24 hours, an Albumin infusion should have been administered with dialysis support if the patient's blood pressure did not respond. Given that the ICU had no room, the patient should have been moved to the ER and given vasopressors to provide temporary support while the kidneys recovered.
I am paraphrasing much of what the team said in the two hours.