Gurgly respirations are associated with fluid (air/fluid) in upper airway that is consistent with obstructed airway, or dysphagia (swallowing difficulty) or depressed gag reflex and diminished respiratory drive associated with adversities associated with antipsychotic medication, and in particular   toxic neuroleptic agents, or opiod poisoning.  The quality of breath sounds may help in determining the level of obstruction.  Oropharyngeal obstructions tend to be "gurgly;"  while laryngeal or upper tracheal obstructions are usually "raspy" or stridorous. See:  Stridor   Direct tracheal suctioning should have immediately been  performed to remove meconium from the airway.  Compare  rales on pulmonary exam which  can suggest  left ventricular (LV) dysfunction or mitral regurgitation -  (pulmonary rales suggests systolic heart failure) Cached

MedlinePlus Medical Encyclopedia: Breathing sounds - abnormal ...

Dysphagia associated with the drug Stemetil,  points to  "bowel obstruction",  and is also associated with "RADIOTHERAPY-INDUCED ACUTE GASTROINTESTINAL TOXICITIES". Compare Profiles and Time Course of Acute Radiation Toxicity Symptoms ...

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  herapy.  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.  See:  Antiparkinson drugs

Tardive dyskinesia  are involuntary movements, especially of the lower face, that develop after exposure to a group of medications known as neuroleptics. The drug Stemetil is such a medication.  Short spasmodic contractions of the right leg were observed by family  following intubation of this patient.  The abnormal movements include tongue thrusting (Protrusion of tongue), which explains the nurse's use of the plastic oral airway,  and the "without continuous jaw thrust" documented at N-3 of the Nurses' Notes.

Tardive Dyskinesia is a serious, irreversible neurological disorder. The same record at N-3 documents a Blood Pressure  of 163/70 at  0320 hours that by 0352 hours had dropped to 85/52. Compare neuroplegia, nerve paralysis as caused by neuroleptic drugs. Neuroplegia was born from a physiopathological study of states of shock.    Prochlorperazine has neuromuscular blocking effects. The combination of peripheral alpha-blockade and dehydration may result in severe hypotension during  overdose. 


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".

The same record at N-5 documents a rapid drop in Blood Pressure 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". Obstructive sleep apnea may cause a stroke. Central sleep apnea is particularly linked with heart failure.

High blood-pressure, actually hypertension, 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. Reference: The Fibrinogen Test.
Related Information. Fibrinogen Links .
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. Cheyne-Stokes breathing is a respiratory pattern that oscillates between hypoventilation and hyperventilation.

 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.  Shock, in this case is therefore confirmed.


Hypoxic comes from the Greek word "hypo" meaning "under", the word "oxygen," and the Greek word "ikos" meaning "pertaining to".   ischemic comes from the Greek word "ischein" meaning "to hold back"  from the Greek word  "haima" meaning "blood" and the Greek word "ikos" meaning pertaining to". The word "encephalopathy"  comes from the Greek word "enkephalos" meaning "brain," and the Greek word "pathos" meaning "suffering." Put the two words together and you get "brain suffering".


Further, there is nothing on record to suggest that the patient was adequately oxygenated prior to intubation and from these records it is also clear that the health care providers withheld  life support for the purpose of accelerating death following iatrogenic injury when the patient became critically ill.  A plastic oral airway does NOT provide needed oxygen.

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 blood, old blood which can grow coagulase negative staphylococci  indicative of a slow bleeding source in the upper GI tract. The presence of blood in the gastrointestinal tract results in increased ammonia and nitrogen absorption from the gut, and may also predispose to kidney hypo-perfusion. Dark or brownish blood usually indicates that blood is coming from a kidney or ureter. Vomit that contains blood may have a red or brown appearance. Other findings suggest that brown vomitus contains feces - indicating that it has come from large intestines. Obstruction below the middle of the small bowel also gives rise to brown vomit. Blood-containing methemoglobin is chocolate-brown color. Clinical signs: dyspnea, sudden death, “muddy?mucous membranes, “brownish?appearance to blood. Methemoglobin can be a sign of Tylenol poisoning. Acute formation of methemoglobin is a life-threatening condition caused by multiple medications. Ammonia has multiple brain and neuro-toxic effects,  including altering the transit of amino acids, water, and electrolytes across the neuronal membrane. Ammonia has been considered the major compound responsible for hepatic encephalopathy. Compare acute neuro-toxicity of ammonia in Portal-Systemic Encephalopathy.

Further findings suggest  that  multiple medications,  restricted diet or  poor nutrition causes gastrical  intestinal or GI lesions to GI bleeding. Drugs that are orally administered are generally absorbed from the gastrointestinal (GI) tract into the systemic circulation. See:  GI bleeding studies  Compare:  Irritable Bowel Syndrome   See:   Overview of Drug Interactions.    GI Bleeding  

Reference: Pathology of Gastrointestinal Bleeding, and flu-like symptoms associated with Hepatitis C. Compare also Ischemic Hepatitis - Shock Liver Hepatic ischemia is a deficiency of blood or oxygen supply to the liver that causes injury to liver cells. Low blood-pressure resulting from any condition,  including heart failure, abnormal heart rhythms, dehydration, severe bleeding, and infection  can lead to hepatic ischemia.                         

Gastrointestinal Bleeding  is considered a potential medical emergency.   From the 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 suggesting iatrogenic  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.  Further findings suggest that blood turns brownish  from lack of oxygen.  Decreased amount of oxygen. = Hypoxia. CompareNINDS Cerebral Hypoxia Information Page.  GI bleeding studies      Gastro Resource Centre
.

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 resulting in further iatrogenic injury.

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

A-16 documents a Blood Pressure  of 121/81 at 0400 hours,   while N-2 documents a Blood Pressure  of 112/57   at the very same time.

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.

The same record documents a heart rate (HR) of 174 bpm at 0320 hours during the intubation procedure that is consistent with  "clinical insult",  such as associated with  deep pain.

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,    N-10,  and  N-11,  and also at A-3  and  A-21 of the medical record.

78. The record at N-4 of the Nurses' Notes documents "incontinent blood tinged urine" at 0305 hours that is consistent with impaired water excretion marked by  incontinent urine output suggestive of possible hyponatraemia.

OP-54  of the Outpatient Record documents  "large blood trace leukocytes"  that is consistent with Staphylococcal infections  suggestive of a possible hospital acquired infection.          [PDF] Staphylococcal and Streptococcal Infections

Staph Infections: What Causes Them?


Incontinence is loss of bladder control and is a very serious side effect of antipsychotic medications such as Stemetil.

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.
=======================================================================
Compare: Common infectious agents in cancer patients

Hematuria: blood in urine; may also  indicate kidney disease

Patients rarely but may  appear toxic or septic  Compare:  Sepsis

Chapter VI.16. Sepsis   One infection Staph is responsible for is sepsis, a blood-poisoning disease   Dartmouth Medical School - Publications

The Toxic Shock Syndrome and Staphylococcus  Compare:  Kawasaki syndrome

   
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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.

See: 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  Iatrogenic Electrolyte Imbalances.  Untreated, these conditions can be life-threatening. Compare:  Overhydration

Anorexia Nervosa (Latin term meaning "nervous want of appetite") is a potentially fatal eating disorder. 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 iceberg consequences of eating disorders precipitated by medical treatments/procedures  leading to heart arrhythmias, shock or myocardial infarction.  Compare Disordered eating.

 It is also of interest to note  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. The failure to document that information  is further proof of negligence on the part of the health care providers.

   

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 seen in the Triage Record  at A-5,  to obviously rewritten, altered and  falsified  nursing notes seen at N-1,  N-2,  and N-3 of the record,  marked by error, inconsistency, omission  and contradiction, to the Ventilation Record seen at   A-16,  and A-17  presenting similarly with  self-serving entries, i.e. needless explanation of events, such as  "without adversities", to  N-4 and N-5 presenting  with less than half a page suggestive of deliberate omission, 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,,  neither records  filed in chronological order, both of which were dated using a "rubber stamp", suggestive of  backdating.


81. Further, the 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.

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.

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 being  "NEGATIVE.".  Mediastinoscopy is also 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.

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.

Further, A-4 of the record, what I take to be a Trauma Legend barely visible in the Physician's Notes situated at the lower right hand side of that page there is an obliterated area suggesting perhaps a "white-out", or erasure. There may be others but due to the fact that these are photocopies and not the original records they are not well opacified, however further and other evidence may present similarly upon forensic examination. Trauma is defined as any insult to the body. Obviously the variety of clinical insults is tremendous.

A-1 of the record documents "she had a left lung pneumonectomy back in October of 1999", which is erroneous. A-17 also documents the "removal of left lung in '99",   the very same error ,  suggestive of having been copied.

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.

A-1  of the record also falsely documents "she died several days later with numerous metastatic lesions to her brain".  According to the Death Certificate,  Arlene Berry died May 24th of 2000,  the very same day, unless the death cetiificate was falsified.

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."

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",  suggestive of old blood and/or gastric juices ,  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.

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 patient's 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. Further, the coagulation cascade starts when tissue factor is exposed to the bloodstream due to a cut or other injury.

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 cause  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.
ASCITES - Fluid accumulation around the liver and other abdominal organs resulting from portal hypertension.
The rapid development of ascites, especially if observed in a patient with FHF accompanied by abdominal pain, suggests the possibility of hepatic vein thrombosis (Budd-Chiari syndrome).

Clinical signs and symptoms of biliary peritonitis include abdominal pain, nausea, and vomiting. Spontaneous bacterial peritonitis is common in patients with late onset hepatic failure. 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. Compare: Esophageal Perforation, Rupture and Tears. See ESOPHAGUS ILLUSTRATION. CompareMechanical Ventillation.

A-26  of the record documents a Blood Pressure  of "78/70"  at 0235 hours, while N-5 of the Nurses' Notes documents a Blood Pressure of  "98/70"  at the very same time  that is consistent with copious error. The same record documents a body temperature above >37.0癈.  Fever has been defined as a body temperature elevated to at least 1癋 above 98.6癋 (37.0癈).  According to the record the documented temperature is just under <38.0癈.

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. As shock progresses, the body temperature falls, respirations become rapid and shallow. Urine output is reduced. Interventions: Blood volume must be restored quickly to ensure a rapid return of oxygenated blood to the perfusion of deprived tissues. It is also clear that this was NOT done.

A-16  documents a Blood Pressure  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.  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 urine-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.

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.

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

Note:   During bacterial meningitis, brain edema can lead to increased intracranial pressure ... Brain herniation may also occur with untreated bacterial meningitis.,  hematoma is associated with a midline shift

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  dilated pupils, abnormal posturing,  and respiratory arrest.
 
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 of 112/57 at the very same time.

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 Blood Pressure the resulting end organ injury is often irreversible ie., endothelium, lung, kidney liver, etc. Any condition that compromises the host defense system increases the likehood of infection and sepsis. Compare azotemia, in which renal underperfusion cannot be rulled out. See also Endothelial Injury.

A-24  of the record documents a Heart Rate of 154 brm at 0330 hours while the Ventilation Record at A-16 documents a  HR of 126 at the very same time, a significant difference.

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.

 

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.


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"   than anything from the given meds  (with the exception of twitching or short spasmodic contractions of the right leg),  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.  Paralysis as such can also be induced by chemical restraint. Chemical restraint using phenothiazines  may impair heat dissipation, as well as lower seizure thresholds and potentially increase cardiotoxicity.  Due to the lowered threshold,  abnormal firing results in a "domino effect" of one neuron exciting another which can exert significant influence on many organ systems at once.

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

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.


 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, such as  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. As with discrepancies throughout the related medical records it also seems clear that liver function abnormalities may have been  omitted altogether, or falsified by Dr. Jordan and his accomplices and the fabrication  of these records is just one aspect of the Kirkland and District Hospital's corporate criminal conspiracy to cover up the truth.

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 appear to be  slightly different.  Similarly,   A-14  shows a misaligned margin suggesting a split or cut in the page,  with  A-13, and  A-27  presenting similarly.

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, or adverse event with arrhythmias secondary to medications, including electrolyte imbalances such as caused or worsened by medications, suggestive of the Neuroleptic Malignant Syndrome (NMS).  Shock, and blood-loss, are also common causes and  are associated with an  Abnormal Ventricular Electrocardiogram. See: Basis of ECG Diagnosis... Compare: Evidence of Neuroleptic Drug-Induced Brain Damage in Patients:  A partial, Annotated Bibliography  (CIRCARE).= CIRCARE. (CITIZENS FOR RESPONSIBLE CARE & RESEARCH).  Ref:    The Cardiac Exam: Auscultation    Compare:   MVS Cardiac Auscultation     Auscultation of the Heart  THE MERCK MANUAL, Sec. 16, Ch. 197, Approach To The Cardiac ...    (A Practical Guide to Clinical Medicine)   Echocardiography

Compare: Myocarditis = inflammation of the heart in which sinus tachycardia is the most frequent finding. Sinus Tachycardia is also associated with cardiac toxicity, which can be traced to the drug Stemetil. See also literature on Airway Management. Abnormal Rhythms. Electrocardiogram (ECG)

REFERENCE: [1] [2] [3] [4] [5] [6]
Compare the the ECG at A-18.
Each drug tends to have a signature, meaning a typical pattern of injury. In the case of phenothiazine type drugs, this pattern of injury closely mimics acute viral hepatitis, clinically, biochemically and histologically.

Identifying Drug-Induced Changes in Electrocardiogram - features individuals whose ECG's have been altered due to multiple pharmacologic agents.


The same record documents an unconfirmed  ECG that is consistent with heart failure,  according to one MD who sent me an eMedicine Case Diagnisis on Exertional Fatigue,  by Michael E. Zevitz, MD  who is Clinical Assistant Professor, Department of Medicine, Chicago Medical School.  All aspects of that document are now currently being studied  for comparative analysis.  Earlier on, another MD from South Africa had  also sent me an e-mail  suggesting Azotemia.  Preliminary  findings suggest that  both of these doctors are right of course.

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.  Additionally, a  wound or injury caused suddenly = Acute Trauma.

Pathologic Tachycardia (abnormally rapid heartbeat  over 100 beats per minute) accompanies anoxia  (lack of oxygen to tissues) such as caused by anemia, congestive heart failure, hemorrhage or shock,  which can be responsible for a drop in the patient's blood pressure and decreased perfusion to the patient's coronary arteries.  An abnormally fast heart rate could be due to injury,  heart disorders,  low blood-oxygen  (hypoxia), hypokalemia,  hypoxemia,  hypovolemia, or to a panic attack, ie.  the panic factor from clinical situations or iatrogenic insult. Compare:  Panic disorder   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.   See:  Anemias
 
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 blood to an organ, usually due to a blocked artery.

 Decrease or blockage of blood flow to an organ or tissue = Ischemia. Ischemia leads to clinical event called "stroke". Compare The Pathophysiology of Hemorrhagic Shock - A clinical syndrome resulting from decreased blood and oxygen perfusion of vital organs resulting from a loss of volume.
Reduction in blood  flow (relative ischemia) impairs O2 delivery and causes cerebral hypoxia.

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

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 medications  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 drug Stemetil.

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 is a  protein which is synthesized by the liver. 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

FIBRINOGEN LEVEL CARE GUIDE INFORMATION FIBRINOGEN LEVEL -
 

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 ".

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

Fibrinogen  acts to promote platelet aggregation - clumping together of platelets or cells in the presence of fibrinogen at the site of injury resulting in diminished blood flow and delivery of oxygen to the body,  i.e. arteries, heart, brain, and  kidneys in 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. Abnormal platelet aggregation is often the trigger for a heart attack. See: Platelet aggregation test

D-dimer suggests  "thrombosis" (blood clotting) and is the confirmatory test in Disseminated Intravascular Coagulation (DIC) . Disseminated intravascular coagulation (DIC), previously considered a specific disease, is now considered part of a pathophysiologic process involving excess coagulation such as seen in sepsis and related disorders, e.g. systemic inflammatory response syndrome (SIRS), or multi-organ dysfunction syndrome. Thrombosis= Formation of a clot(s) within vessels of the brain or neck.

PATHOLOGY EL: Hemostasis and Thrombosis, Pathology

[PDF] THROMBOSIS CURRICULUM
Format de fichier: PDF/Adobe Acrobat - Version HTML

 "Over two thirds of all strokes are due to thrombosis."

Trauma, particularly brain injury, is associated with DIC (Levi & Ten Cate, 1999).

Compare BRAIN DAMAGING NEUROLEPTIC DRUG in which poisoning or drug intoxication can cause deep physiologic depression that resembles and can mimic brain death.

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.  See: Bleeding time

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. Compare:  Idiopathic thrombocytopenic purpura
Keywords: Activated Protein C, antithrombotic, coagulation, endothelial cells, fibrinolysis, inflammation, organ dysfunction, sepsis.

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 pH (alkalosis). A pH above 7.0 is alkaline;  the higher the number, the stronger the alkali.   See: Blood gas analysis         Compare  Alkaline phosphatase test

Compare:Blood/Gas Profiles

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. Compare: Respiratory alkalosis

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.


Leukocytosis also can occur in Intestinal obstruction, strangulated hernia, and leukemoid reactions (a reaction resembling leukemia, but is actually due to other conditions such as infections).

Reference:MEDLINEplus Medical Encyclopedia: WBC count. Compare LABORATORY FINDINGS - Shock

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 - a state of immunodeficiency characterized by a reduction of the number of T-lymphocytes, unlike absolute lymphocytosis in peripheral smears w/ seen in malignant disease. Further, a decreased percentage of lymphocytes may indicate Sepsis.

Compare: Autoimmune Hepatitis, a disease in which the body's immune system attacks liver cells. This causes the liver to become inflamed (hepatitis). A person with autoimmune hepatitis has autoantibodies circulating in the blood-stream that cause the immune system to attack the liver. This disease is associated with other autoimmune diseases, including hemolytic anemia. Compare: Non-immune hemolytic anemia caused by chemical or physical agents: non-immune adverse reactions. Autoimmune disorders develop when the immune system destroys normal body tissues. This is caused by a hypersensitivity reaction. hemolytic due to toxic agents, ie. infection, bacterial lysins. Compare Drug-induced immune hemolytic anemia.

The word "auto" is the Greek word for self. The immune system is a complicated network of cells and cell components (called molecules) that normally work to defend the body and eliminate infections caused by bacteria, viruses, and other invading microbes.

In toxic shock, profound but transient lymphocytopenia associated with marked leukocytosis was the most striking laboratory finding and one not previously emphasized in the literature. S. aureus was isolated from sites of soft-tissue infection, the or the endocervix in all except one case.

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 patient's.

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 ... Sec. 11, Ch. 135, Leukopenia And ...

The same record documents an Absolute Lymphs (Lymphocyte) Count of 124. 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.

 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.

 Further, the same report documents the Neutrophils (also known as granulocytes) with a count of 92.0 H (normal 47.0-77.0). Neutrophils are a mature white blood cell that fights bacterial infections. Neutrophil accumulation in tissue is another  hallmark of inflammation and is associated with a variety of pathological conditions. The same record also shows Absolute Neuts of 20.0 H (normal 1.3-6.7), and is increased in response to acute infections (bacterial or viral), blood-toxicity and hemorrhage. In fact all of the relevant literature suggests that neutrophilia typically occurs because of inflammation and infection, especially pyogenic bacterial infection, as is the case here. Leakage of oxidative metabolites from the neutrophils into the tissue can potentiate the inflammatory process.

Toxic change in neutrophils is not necessarily associated with "toxemia". The term derives from the fact that these abnormalities were first noticed in human patients with gram negative sepsis and endotoxemia. Toxic change in neutrophils can be associated with inflammation of any cause if severe enough to intensely accelerate neutrophil production.

Leukocytosis (especially neutrophilia) indicates systemic infection.

Study of Information : Endotoxins and other bacterial products appear to cause direct cellular injury while eliciting cytokines that attract neutrophils, which enhance (hypersensitization, brain edema (during bacterial meningitis, brain edema can lead to increased intracranial pressure), and hypercoagulability with vascular inflammation from endotoxin) the inflammatory effect >>endotoxin shock. It has been well-described in the scientific litererature that the presence of endotoxin is common in rapidly dividing bacteria at sites of localized infection and abscesses in the gut.


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. One caveat: bleeding may be severe even when the hematocrit is normal since it can take 24 to 72 hours to reflect the volume loss.

129. HCT - Hematocrit is thus the measurement of the percentage of red blood cells in whole bloodwith 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 Blood-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
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See: Metabolic effects of increased Arterial pO2

131. Further, RDW is a standard part of the complete blood 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 with
1. Vitamin B12 Deficiency
2. Folate Deficiency
3. Immune Hemolytic Anemia
4. Liver disease


The same report documents a Platelet count of 544 H, what is Thrombocytosis , increased with coagulopathy (platelet coagulant activities) or platelet aggregation (cohesion of platelets to each other forming clumps), may also indicate a benign reaction to an infection, surgery, blood vessel injury, or certain medications. Further, thrombocytosis can cause bleeding or thrombosis. Platelet count (marked thrombocytosis common in second week of toxic shock-like syndrome illness). High platelet count (over 500,000) may predispose to either clotting or hemorrhage. Platelets are thus cells that form the primary mechanism in blood-clots.

See: Table 1: Causes of thrombocytosis.

Increased numbers of platelets in the peripheral blood = Thrombocytosis.            In Toxic Shock, thrombocytosis (rather than thrombocytopenia) is common.  Compare  Thrombocytopenia

Platelets (also known as thrombocytes) coagulate the blood. 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 iatrogenic trauma/procedures and can lead to DIC and hemorrhage. Platelets are also elevated with drug-reactions (toxicity & brain damage by disrupting the balance of body & brain metabolism), 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

Platelet Count May Predict HCV Liver Disease Progression

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 Blood Tests: Complete Blood Count Tests: Complete Count

A-19  documents a Monocyte Count of 3.0 with a marked decrease as evidenced by ABSOLUTE MONOs (monocytes) with a count of 0.60 (normal 1.0-5.5) with a reduction [<0.60] indicative of a anemia. MONOCYTE: A variety of blood cells (white). The normal range for the monocyte count is 200 - 950 /礚. A decreased lymphocyte count = lymphopenia may be caused by chronic infections, severe stress (Hyperadrenocorticism), and kidney failure. An increase in monocytes is typically observed during the phase of recovery following many infections, including hematologic neoplasms. Compare: DRUG INDUCED LYMPHOPENIA associated with -


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

2. Lymphocytic Anemia

3 - anemia, or a low red cell blood count

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

5 - loss of normal white blood cell function, which

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


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.

Monocytes are considered the bodys second line of defense against infection. In cancer, leukemia or neoplasms 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.

Hemoglobin is the protein inside red blood cells that carries and provides the main transport of oxygen and carbon in the . 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 oxygen in the body tissues. See  Hemoglobin test

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 pathophysiology, 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.  See  Creatinine test

Three separate types of acute kidney failure have been identified: pre-renal, intrinsic, and postrenal. Pre-renal ARF occurs when low blood circulation leads to significantly low blood flow, and is often caused by dehydration, shock or low cardiac output (as seen in heart failure). Glucose Test.

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, a prominant finding in Distributive (septic, anaphylactic, neurogenic, and adrenal insufficiency mediated) Shock. Acute adrenal crisis is a medical emergency caused by a lack of cortisol (a steroid hormone secreted by the outer portion, or cortex, of the adrenal glands) - it has marked effects on carbohydrate metabolism and is an immunosuppressant.

Risk factors for adrenal crisis include physical stress such as infection, trauma or surgery, adrenal gland or pituitary gland injury. Patients may experience lightheadedness or dizziness, weakness, sweating, abdominal pain, nausea and vomiting, or even loss of consciousness.

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. In addition, loss of potassium and volume contraction from vomiting potentiate metabolic alkalosis.

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

 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.

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.

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

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.

The same record at A-20 documents a Creatine Kinase (CK): 40 - normal range is 22 to 198 U/L (units per liter). CK tests are used to evaluate neuromuscular diseases, but CK levels don't always reflect the level of functional impact on the individual. CK is an enzyme normally found in the brain, heart and skeletal muscleElevation of CK-I may be seen in stroke, extreme shock, or brain tumor. In females, total CK should be 10-79 units per liter (U/L). If elevation of CK may be seen in stroke, extreme shock , or brain tumor, why would the CK show normal???

Symptoms of an acute toxic reaction include agitation, tachycardia, hypertension, dilated pupils, trismus, and sweating, whereas the more severe cases may be characterized by hyperthermia, disseminated intravascular coagulation (DIC), rhabdomyolysis, and acute renal failure. In more severe cases, elevated creatine kinase levels are often present, with levels as high as 122,341-555,000 IU/L being reported. Creatine is also decreased with renal perfusion (hypotension, dehydration, CHF), and urinary tract infection.
CAVEAT:
The Coroner alleges "multiple metastatic brain tumors", and no drug reaction. Why then is there a normal CK and so much evidence to the contrary?

 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 HYPOVOLEMIC SHOCK: fairly reliable signs of compromised perfusion. Compare TSS     Pale ?Whitish color indicates hypo perfusion (shock), is a medical emergency. Compare:EM guidemap - Upper GI bleed, including ANS and Shock.  See:  Upper GI examination

Compare Shock Syndromes in which vasoconstriction, pallor, cold peripheries all point to circulatory failure.

 Hypovolemic shock occurs when there is insufficient or inadequate blood circulating throughout the body. The most common causes of hypovolemic shock include hemorrhage from any source, or blood 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

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.

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" or "COFFEE-GROUND EMESIS" documented in the Nurses' Notes. Compare: Castrointestinal Bleeding     See    MedlinePlus Medical Encyclopedia: Vomiting blood

The very same report documents a "Nature Code 0" (No Code = No Care) or hospital shorthand for "bed shortage", Code Zero, including a "withdrawal of life support" from a critically ill patient or DNR "do not resuscitate order" issued against family wishes, and without lawful consent. 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 patient抯 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.

In Dr. Jordan抯 FPC letter to the College of Physicians and Surgeons of Ontario dated November 28, 2000 he writes 揑 discussed the situation with family members and a decision was made to intubate Ms. Berry? It seems absolutely clear, that the doctor (as in this case) knew of the need for emergency care and after ordering it, canceled it and "waited" for her death after withdrawing life support from this critically ill patient. This is further reflected in A-1 of the medical where where Dr. Jordan writes "She died several days later with numerous metastatic lesions to her brain". It would have taken the patient several days to die without life support. Notably also, the body of the deceased was not immediately returned to Kirkland Lake. They had withheld it for several days. Arlene Berry was made to suffer a death by dehydration - .

With dehydration, dehydrated blood becomes thicker and sluggish, and therefore, more prone to clotting. Dehydration interrupts blood flow which causes clots, cutting off the supply of oxygen to various parts of the body such as kidney resulting in kidney clots.

Death by dehydration is accompanied by fever, convulsions, retraction of the eyes into their orbits, drying out of the mouth and skin, among other things. before death results several days later in a cruel and violent death. The element of duty is now satisfied because once the physician undertook care for the patient the physician had a clear duty to exercise reasonable care toward the patient. According to Dr. Jordan "On May 23, 2000, Ms. Berry was seen in the E.R. and admitted by Dr. Spiller with symptoms suggestive of metastatic CA of the brain." The same record documents that the patient 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".

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 bilious vomit. Who the hell do these asshole doctors think they are?


 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".

Notably, Dimenhydrinate (Gravol) is contraindicated in chronic lung disease and has also been reported to "mask the presence of underlying organic abnormalities or the toxic effects of other DRUGS."

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

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

. 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.  A low hemoglobin usually indicates the person has anemia.  
Gastrointestinal bleeding should be controlled if possible and purged from the gastrointestinal tract.

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 or both.

Following her transfer to Sudbury on May 24th of 2000 Arlene Berry was was returned to Kirkland Lake several days after family had been notified of her . 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 (deep wrinkles in the skin) with a rashlike redness (resembling a sunburn) and swelling to the face in the area just below the right eye suggestive of massive edema (swelling from excessive accumulation of serous fluid in tissue) that was evidenced by all who attended Arlene Berry's wake and funeral. Compare fixed drug eruption, a circumscribed skin lesion as caused by continuing or repeated exposure to a sensitizing drug. Drug eruptions are common iatrogenic diseases. Compare: angioedema.
Artificial ventilation and oxygen should have been prioritized and promptly administered to include withdrawal of the offending drug, 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.

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".

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.

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.

REFERENCE:

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 blood 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 sending numerous % blood-clots" to her brain, resulting in herniation or intracerebral hemorrhage. The levels of Fibrinogen, and D-dimer charted in the medical record for May 24, 2000, together with "evidence based medicine" criterion confirms not only the the Disseminated Intravascular Coagulation, but also activation of the coagulation cascades, an essential component in the development of multi-organ failure and is associated with Sepsis.   Sepsis results from a generalised inflammatory and procoagulant response to an infection. Inflammation has long been known to be part of the body抯 response to infection. Evidence is accumulating that coagulation is part of that response. See: Fibrinogen test

MEDLINEplus Medical Encyclopedia: DIC (disseminated intravascular ... 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  See: Septic shock


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

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 medium (dye) was injected into a vein before the CT scan was done. "NO clinically detectable metastasis was found". A mediastinoscopy to directly see the organs inside the mediastinum, with mediastinotomy to collect tissue sample had been done on that date. The result of that testing proved "NEGATIVE". Mediastinoscopy is also used to stage lung cancer, especially when enlarged nodes are seen on chest x-ray or CT scan. Further, contrast medium-induced nephrotoxicity (CMN) is a common form of iatrogenic acute renal failure. The mechanism for CMN is not understood, but renal insufficiency, dehydration, and congestive heart failure are risk factors. See:  Computed tomography scans

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.    It is also consistant with  Occipital Neuralgia, such as associated with headache that can mimic migraine headache (brain tumors, lesions, etc.). , which is often misdiagnosed. The bald truth is that localizing signs of brain tumor include a loss of vision on the side of an occipital neoplasm. Compare occipital abscess,   a pyogenic brain abscess, usually of bacterial origin.  Thrombus is hyperdense  on CT : compare hyperdense temporo-occipital hematoma. NONTRAUMATIC NEUROEMERGENCIES    Types of Wrong Diagnosis - CureResearch.com   Related Condition Misdiagnosis - CureResearch.com   Systemic infection is a common complication of stroke. However, brain abscess as a complication of stroke has never been reported.

Central Nervous System

www-medlib.med.utah.edu/kw/sol/sss/ subj2.html - 65k - Cached

(Further, tumors of the occipital lobe specifically may produce homonymous hemianopia or partial visual field deficits.) According to my research it can also suggest 1) a neurotoxic amyloid-like  protein deposit or plaque which is the hallmark of Alzheimer's disease,   including recent onset Alzheimer's),  2 ) an "old occipital bleed" such as from an old injury, 3) or a occipital dermoid cyst, or abscess secondary to occipital dermoid cyst which is the hallmark of a brain abscess, or perhaps even a Subdural hematoma.   A subdural hematoma is a collection of mostly "clotted blood"  that accumulates between the brain  and the skull.

Further findings suggest that abscesses can mimic OTHER CONDITIONS,  including tumors in presentation and radiologic studies. Lung is the primary site of infection, but the brain is the second most commonly involved organ and may be caused by staph if there are hemorrhagic multiple abscesses. A bacterial  brain abscess may mimic brain tumors, and may cause death due to herniation.  Next: Misdiagnosis of Underlying Causes of Death

Pseudotumor Cerebri can easily be confused with a brain tumor because its symptoms closely mimic those of brain tumors, possibly because of abnormal buildup of cerebrospinal fluid placing pressure on the brain.   Pseudotumor cerebri  is diagnosed by ruling out all other possible causes for symptoms and confirming that the cerebrospinal fluid pressure is increased.  Tumor Types: Other Brain Related Conditions

See: Pseudotumor Cerebri, literally means "false brain tumor".  It is caused by increased pressure within the brain and is most common in women between the ages of 20 and 50. Compare:  Demyelinating Pseudotumor  -  because it can mimic a variety of other diseases (such as brain tumors, meningitis, systemic lupus erythematosis, etc.), PTC is generally a diagnosis of exclusion. Pseudotumor Cerebri: Differential Diagnosis

Further findings suggest the CT scan appearance of cerebritis is that of an ill-defined hypodense contrast enhancing area, or a CT scan that shows decreased density and loss of definition = NOT WELL OPACIFIED -->Blood Clots (hematomas), microabscesses or bacterial infection of the CNS. Symptoms are those of a flu-like illness, with evidence of brain involvement indicated by lethargy, confusion, irritability, tremors, or seizures. Compare  Mimics of Brain Tumor on Neuroimaging: Part II. These include subdural hematomas, brain abscesses, hydrocephalus, benign intracranial hypertension, etc... hepatic abscess appears as a single or multiloculated mass with low attenuation, suggestive of "decreased attenuation". Brain abscess is caused by intracranial inflammation with subsequent abscess formation, and may occur within the cerebral hemispheres.

Compare:CT Scanning..


Clinical presentation of brain abscess is usually similar to other intracranial space-occupying lesions. Systemic symptoms are usually mild and fever may not be obvious. However, the symptoms of an abscess tend to be more rapidly progressing than those associated with a neoplasm.  Compare Neuroradiology Imaging Teaching Files showing a Cerebral Abscess with midline shift.

Further, spontaneous haemorrhage associated with a brain abscess including spontanuous brain absesses as a complication of stroke is reported in the literature.

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.

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 reveals numerous blood clots and traumatized tissue with brain abscesses (blood and pus isolates), including visceral microabscesses and/or blood clots with massive edema of the right cerebral hemisphere, including a 1 cm midline shift that is consistent with  Bacterial (pyogenic)     infections of the CNS: and herniation.
CAVEAT:
Purulent exudates, clotted blood, radiation necrosis, and fibrinous deposits are usually the result of trauma (including clinical insult), and infection, or both.
Disseminated abscesses can occur in multiple organs,including the brain, eyes, kidney, heart, liver and spleen.

Staphylococcus aureus  abscesses often occur following  haematogenous (blood borne) infections.

Further findings suggest WBC elevated with abscesses. Compare CNS Infection
hepatic abscesses. Brain abscess is caused by Iintracranial  inflammation with subsequent abscess formation. See Intracranial abscesses in adults: an analysis of 54 consecutive ... in which Staphylococcus aureus was the most commonly found causative agent.

Central nervous system infections


 Compare -MeSH definition:MeSH Hierarchy

The radiographic appearance of brain metastases is nonspecific and may mimic other processes, such as infection. Therefore, the CT or MR scan must always be interpreted within the context of the clinical picture of the individual patient,  particularly since cancer patients are vulnerable to opportunistic CNS infections.  Primary and Metastatic Brain Tumors

Further submit that a Computed Tomography,  or CT scan measures density (images represent 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. Magnetic resonance imaging (MRI) of the head is done to: 1)Evaluate blood flow to the brain, 2)MRI can diagnose bleeding in or around the brain, 3)Diagnose tumors, infections, or inflammatory conditions (such as encephalitis or meningitis) of the brain or brain stem; hence with  MRI, it is easier  to detect tumors, chemical reactions, blood clots, and so on. MRI scan of the brain is becoming the imaging modality of choice for brain tumors

Diagnosis of primary brain tumors in the elderly is more difficult and often delayed due to nonspecific symptoms that mimic the physical and cognitive changes seen in the normal aging process  Monofocal acute inflammatory Demyelination (MAID): lesions present as large masses that mimic brain tumors.  Headaches and motor deficits were the most common presenting symptoms. Language problems and motor deficits were the most common findings on physical examination

ALTERED LEVEL OF CONSCIOUSNESS AND COMA

Drug intoxication is a reversible cause of coma that might mimic brain death.