and even after the Tuesday September 21, 2010, office visit in my Duke orthopedic surgeon Dr. Michael Bolognesi's clinic, where PA Diane Covington effectively shrugged her shoulders at my open wound
I knew I had an ally at Duke in my cardiologist, Dr. Michael Blazing and he set up a second opinion for me at UNC Orthopedics with Laurence Dahners, MD.
From my perspective (and by the stated purpose of even UNC Orthopedics "Final Report"), the second opinion was because I had an open wound and absolutely no physician at Duke would acknowledge (much less treat) my open wound.
Oh, was I in for a "special treat" at UNC Orthopedics.
You see, the good Dr. Bolognesi faxed a copy of the "Elopement Report" to UNC Orthopedics' Dr. Laurence Dahners. Funny. I don't recall signing a medical authorization release. But it would not really matter - if Dr. Bolognesi is determined to sabotage my ability to receive medical care, he can frame the lies/distortions as "necessary for continuing care" or Dr. Bolognesi could just engage in good ole "gossip" between boys. HIPAA is a joke.
I did manage to get a copy of the Report from UNC. It's fun to read because the boy doctor (David McNabb, MD) was charged with the responsibility of "reconciling the discrepancies between Duke's version of events and the patient's version of events." Specifically, boy doctor (David McNabb, MD) charted that he told me (as I was scared, in pain and in tears with a gaping wound) "I was just trying to resolve the discrepancies between her reported history and documented history from Duke University Medical records that had been faxed to us prior to her visit."
And despite the ridiculous UNC Orthopedic Report by the boy doctor (David McNabb, MD), he does in fact chart the actual discrepancy -- and in my favor -- check out the "assessment" - "left tibial open wound."
Ahh, finally a physician (perhaps not board certified but a physician none the less) acknowledges my open wound. The boy doctor was still focused on the "elopement report" that never mentioned the wound.
UNIVERSITY OF NORTH CAROLINA HOSPITALS
Chapel Hill, NC 27599
Patient Name HANDY, CHERYL
Medical Record Number 173-xx-xx
Date of Service 09/23/2010
Teaching Physician Laurence Dahners, MD
Dictated by David C McNabb M.D.
REFERRING PHYSICIAN: Michael Blazing, M.D.
REASON FOR VISIT: Ms. Handy is a female, who comes to clinic today for evaluation of her left tibial wound.
HISTORY OF PRESENT ILLNESS: Ms. Handy ie a female, who underwent left high tibial osteotomy at Duke University Medical Center in 12/2004 for varus alignment of her leg. The patient reports that she attempted rehabilitation starting in O8/2005 and developed symptomatic hardware. The patient reports that she had her hardware out in 07/2005 at Rush Medical Center in Chicago and returned to North Carolina. The patient reports that she was going to go back to Rush Medical Center due to feelings of pain and warmth in her left tibia where the prior hardware removal had taken place.
The patient was scheduled an MRI through her cardiologist at Duke University on O9/10/2O10 and the results of the MRI prompted her cardiologist to send her to the emergency room under consultation with her Orthopaedist at Rush, however, it seems from a clinic note at Duke University that the patient left the emergency room ama due to a long wait. The patient then returned to clinic and Dr. Blazing told the patient to present to the emergency room and Dr. Blazing spoke with the orthopaedic department and that she would be seen by them soon in the Emergency Department this did occur and the patient was taken to the operating room on 09/13/2010 for a washout of her left proximal tibial osteomyelitis.
The patient remained in-house postoperatively for a therapy and follow up for her cultures. Cultures showed according to the patient that she had coac-negative staph. From discharge paperwork at Duke the patient "had been set up for home IV antibiotic therapy with nafcillin.
Again according to medical documentation the patient was dubious of the IV antibiotic therapy and cancelled the home infusion therapy. On the cay of discharge, the patient could not be found in her room and had left AMA with elopement. The treating team had planned to have her PICC line removed as she had refused home IV antibiotic therapy; however, this did not occur and the patient was not given any discharge instructions as she left without anyone knowing. The patient was referred to our clinic by Dr. Blazing for a second opinion. In discussion with the patient today was told that if she did have a coag-negative Staph that the treatment and treatment plan she had had thus far seemed appropraiate.
Then the patient was asked if she would like any further explanation of this and the patient became disgruntled, picked up her clothing and belongings and left the room only to return a few seconds later- To explain that she was a patient and "just wanted to be treated." Upon further questioning, I mentioned that the patient that I was trying to resolve two conflicting sets of information one that she was telling me that her caregivers at Duke did not want to treat her properly or explain her-therapy - and the — information -ie
On the way, I told the patient that I was sorry for her feelings that she was not being cared for properly and I was just trying to resolve the discrepancies between her reported history and documented history from Duke University Medical records that had been faxed to us prior to her visit. The patient left the clinic against medical advice and without belng thoroughly evaluated or seen by the attending physician Dr. Dahners.
ASSESSMENT: Left open tibial wound.
PLAN: The patient left AMA; therefore, examination was not able to be undertaker, and a plan of care was not able to be developed for the patient.
DAVID C MCNABB M.D. dd 09/23/201010:48 dt: 09/23/10 23:41
Electronically signed on 09/26/2010 by DAVID MCKABB
Pt. left in the middle of being seen by the resident Dr. McNabb so I never saw the patient.
Electronically signed on 09/26/2010 by LAURENCE DAHNERS
I hope that medical school graduates are better at charting than boy doctor David McNabb, MD. Lets have some fun on New Years Eve and count Dr. David McNabb's errors.
- There is no evidence (because it is untrue) that I left the Duke ED AMA because of a long wait, returned to Dr. Blazing's Clinic and then returned to the ED. That would be silly. I arrived at the ED via ambulance at 5:00 pm on a Friday. How would I get to my cardiologist's office (not walking distance) and then return back to the ED?
- The "reason for the visit" says to evaluate the wound. But Dr. McNabb charts "[t]he patient was referred to our clinic by Dr. Blazing for a second opinion. In discussion with the patient today was told that if she did have a coag-negative Staph that the treatment and treatment plan she had had thus far seemed appropriate."
- By his own charting, the reason for my visit was to evaluate the wound, not discuss the antibiotic plan. My concern was "why did the surgical wound for a bone infection open"?"Is there still an infection in there" I specifically asked Duke Infectious Disease Expert (and my assigned physician) Dr. Robert Wolfe and he said "I do not know."
- Contrary to Dr. McNabb's charting, I did not "pick up my clothing" because my clothing was not off. That would have been weird since I had shorts on and the wound is on my upper tibia. I did pick up the bandages that were on the floor. Dr. McNabb did not even attempt to help me.
- I am not sure how Dr. McNabb made the assessment despite the fact the wound is obvious. Dr. McNabb went out of his way to avoid looking at the oozing wound.
- As I left the exam room in tears, I passed directly by Dr. Laurence Dahners. I could have reached out and touched him (or vice versa). In fact, there was a group of orthopedic surgeons in a common area that I passed as I limped in tears. My wound was completely open to the elements. UNC Hospitals did not care about my well-being.
Again, no medical care professional cared that I hurt or was scared or crying.
UNC Orthopedics got their $45 co-pay. Dr. David McNabb flat out told me that he could not treat me until he "resolved the discrepancies between what Duke said happened and what I said happened."
Doesn't the tie go to the side with the open surgical wound?