[Congressional Record Volume 164, Number 196 (Wednesday, December 12, 2018)]
[Extensions of Remarks]
[Pages E1659-E1662]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
INFORMATION ON THE PATIENT'S BILL OF RIGHTS
______
HON. RICHARD M. NOLAN
of minnesota
in the house of representatives
Wednesday, December 12, 2018
Mr. NOLAN. Mr. Speaker, I rise today at the request of Mike Menning
who hopes that, by sharing his story, no other family will have to go
through what he and his family have.
Dropped Off the Operating Table
Dawn Menning was Dropped off the Operating Table at Intermountain
Medical Center Hospital, Salt Lake City, UT on March 3, 2017
Dawn Menning's Narrative About Injury and Pain
Let me begin by recalling what I can about the abdominal
hernia surgery and resulting incident.
At least a year prior to March 2017 I visited Dr. Kelly
Nolan about the growth in an abdominal hernia I was
observing. She noted that it would be a repair of an earlier
surgery in 1996 and would require a more invasive approach.
In early 2017 after visiting my regular health care
physician, Dr. Nancy McLaughlin, Madsen Clinic--University of
Utah, and recognizing that the hernia had indeed grown I made
the decision to go forward with the surgery.
I visited Dr. Nolan at IHC for a pre-op appointment. I
spoke to her at length about my concern about the Homozygous
Factor V Leiden blood condition that I have--the challenge
and potential for blood clotting following surgery. She asked
if I could seek advice from my regular doctor or a hematology
specialist. Since I had never seen a specialist I contacted
Dr. McLaughlin who consulted with Dr. David Kaplan at the
University of Utah Clinic. He strongly advised against using
regular anticoagulants since the surgery was going to be in
the abdomen area and the shots, Lovenox, are administered
into the belly area. He suggested the use of a pill instead.
I contacted Dr. Nolan who called me back to say she had not
used the pill and advised to use Lovenox as she had
prescribed. I purchased the Lovenox 100 mg. on February 28. I
began using the shot one time on March 2, the day before
scheduled surgery.
I was told to NOT use the Lovenox 100 mg. on March 3, the
day of surgery, but resume using it the day after for ten
days following
[[Page E1660]]
surgery--two shots into the belly area each day.
Now onto the day of surgery as best I can remember. I
entered surgery feeling very well and was wondering how I
would feel following. I felt I was a pretty strong, healthy
70-year-old woman.
I waited for quite awhile in the hall prior to surgery and
noted that the attendant reached for a green flat toboggan
like piece of equipment that I assumed was placed under a
patient for transport. It had handles on the side as I
remember. I even thought, well, I suppose that's how I will
be transported from the gurney on which I was lying to the
operating table.
The anesthesiologist came into the hall to introduce
himself and assured me that they would monitor that I was
asleep during the surgery.
Finally I was wheeled in. They asked if I felt comfortable
moving myself onto the table and I assured them that I was
able. I do not remember what was or if there was anything
under my body.
Very soon I was off into another world.
The next thing I knew I was wheeled out of the operating
room by a female attendant and greeted by my husband who was
very alarmed. His first words were something like--I am so
glad you are alive or something close to that. I asked him
what in the world he meant. He said, ``Well, did you know
that you were dropped to the floor while being moved to the
gurney?'' I actually thought he was joking and said the same.
Marion responded with, ``No, I am not joking! They came out
and told me that while they were moving you the gurney was
not properly locked and you fell to the floor. The
anesthesiologist tried to brake the fall by extending his leg
and even hyperextended his knee.'' He said Dr. Nolan had come
to tell him and said they had examined me and found no
evidence of injury but would be sure to examine me further
before discharge.
I was wheeled back to the room and did not lose
consciousness again. Very soon I was pretty stable and the
attendant suggested that I could get dressed and leave as
soon as I wished. She recommended that Marion attend me in
dressing and take a look if there were any bruises or
evidence of injury. There was no one else of hospital
personnel who took a look at my backside or the incisions.
Dr. Nolan told me at my post-operative exam that she had come
to see me but I had already left for home. (It would seem
that in the case of the fall she would have been there soon
to see how I was doing.)
We arrived at the hospital in the morning and less than
five hours I was back home.
I had been prescribed pain medication (Norco 5 mg 1 to 2
tablets every four to six hours as needed) and used it as
prescribed.
I resumed the use of the Lovenox 100 mg two times a day for
five days. Since I would not have enough 10 more doses on
March 8.
The weekend was rough--I experienced much pain and
discomfort. I was not able to get up off the couch and was
thankful for a bar next to out toilet. Getting into bed
required the help of Marion, lifting my legs into bed and
even helping me to get up off the bed and turning.
By Monday morning the pain was increasing--rising into my
right side rib cage area. By then bruising in the abdominal
area had grown far beyond the incision area.
We called Dr. Nolan's office and were invited to come to
the office for examination. She checked my incision noting
that it was no oozing and agreed to order x-rays. She checked
the x-ray and said there was no evidence of cracked ribs and
said I should try to cut back on the pain medication as I was
able, perhaps using some Ibuprofen in between doses of Norco
since it has a high risk of addiction and dependence and a
side effect is constipation which is always a challenge for
me. Dr. Nolan also explained that she had not seen exactly
what had happened since she was doing charting off to the
side and didn't see anything until she heard a commotion and
saw I was on the floor. She did not offer details of number
of people but did retell us that the anesthesiologist had
hyperextended his knee.
I resumed my recovery at home. My husband made a visit to
the hospital to inquire about the fall. He did not receive
too much information but invited the Risk Management Staff to
at least offer an apology and visit me at home.
The rest of the week went pretty much the same although in
addition to the bruising my abdomen area was swelling and
tender. The bruising had spread out, down and up.
On March 8 by recommendation of the Dr. Nolan I purchased a
pain medication that would assist the transition from
narcotic medications to less strong medications--Triamino 20
mg. I tried using this but was longing for the Norco since
the pain was so intense.
During the night on Thursday, March 9 I had so much pain
and the pain medication was not helping. We went to the ER at
IMC. They noted intense pain, tender to the touch on my
abdomen. They started me on an IV for fluids. I begged for a
stronger pain medication but did not receive if for several
hours.
They did chest x-rays. An ultrasound and I don't remember
what else--but the ultrasound clearly showed that I had a
large hematoma in the abdomen area! This was obviously the
cause of the increased pain--the pressure on the incision and
the mesh that was used was causing intense pain.
Twelve hours after arriving I was admitted to a room. They
finally started me on an IV pain medication. After just a few
hours they said I could be discharged and they would give me
a stronger pain medication to take home. I declined insisting
that I wanted to be sure I was ahead of the pain before going
home. They also discontinued the use of the Lovenox shots.
The explanation was that since I had developed a hematoma the
blood thinner could interfere with my body's ability to
absorb the blood in that area. They explained that since
blood in a hematoma is very sticky it wasn't possible to
drain the collection but it would be a long process for my
body to deal with this. I was told to NOT use Ibuprofen since
that is a mild anticoagulant.
I returned home on March 11. I was given Norco 7.5 mg--a
stronger dose--one tablet every 4-6 hours. I was eager after
four hours!
The next week is kind of a blur--time passed with a perch
on the couch, in our bed (continued needing help to lift my
legs) and a few visitors.
On Monday, March 13 we had a visit from IHC. They brought a
lovely bouquet of flowers and were very sympatric but oh, so
careful about what had actually happened. They were evasive
about how many people were present.
That week I tried to resume some sort of ``normalcy'' to my
life. I went out for short periods of time. I was able to
move a little easier and didn't need assistance for getting
in and out of bed. However, the pain never left me.
Now onto March 23--I went to visit my primary doctor, Nancy
McLaughlin, to report what had happened. She was very alarmed
and concerned about the resulting blood problem. I reported a
very poor urinary stream and she assured me that this could
all be the result of weakened muscle tone and should improve
in time.
Time moved on and I even tried unsuccessfully to resume
water aerobics that I enjoy. The pain was too much.
On May 3 I visited Dr. McLaughlin again. She noted
abdominal pain and pain in my right buttock. She spoke to me
again about the H/O hypercoagulable state. She was also
pleased that I was scheduled to visit a hematology
specialist.
On May 4 I visited Dr. David Kaplin, Hematology. He noted
the evidence of a rectus sheath hematoma, sequel and
Homozygous Factor V mutation. He was careful how to cast
blame but said he certainly would not have recommended the
Lovenox shots since they thin the blood and area administered
right into the area close to the incisions. He said there are
articles speaking of the ill effects of using this
anticoagulant for abdominal surgeries. When I asked him--
could this have been caused by the fall he answered--caused,
yes perhaps but surely exasperated by the presence of blood
thinners. He said in a court of law would he be willing to
say one or the other was the cause? No, but surely both
played a part. I went home with more information than I had
come with.
Life went on--the pain was not gone. The swelling had
reduced but the muscle tone in my abdomen was very poor. I
tried resuming some exercise but experienced pain if I pushed
a bit to hard.
The pain in my right buttock improved through
recommendations from a physical therapist friend to do a set
of exercises in our home.
I can honestly say that I had pain, a kind of pulling
muscle pain, well into July 2017. I was cautious with lifting
and reaching. Sudden twisting caused a jolt. My stomach area
remained sensitive.
Today--I do have occasional pain in my abdomen area but I
have no way of determining if that is from the surgery and
invasion of four incision point and the one small incision
where the mesh was inserted OR the residual effects of the
hematoma.
In looking back it appears to me as if there were a
succession of errors that caused my pain and suffering.
____
The Story
As told by Mike Menning, Husband/Power of Attorney
On Friday, March 3, 2017 my wife, Dawn Menning, a 70-year-
old woman, was dropped from the operating table onto the
floor as she was being transferred from the operating table
to the gurney at the Intermountain Medical Center. Dawn had
what was supposed to be a routine surgical procedure to
repair an abdominal hernia. After the procedure Surgeon Dr.
Kelly Nolan came to report to me how things went. She
explained that the surgery went well, however at the end she
said, ``there is one other thing that you should know. Your
wife was dropped from the operating table onto the floor.''
Dr. Nolan went on to say that she didn't think Dawn received
any major injury. She did add that I should ask the nurse in
charge to check Dawn over for any major bruises before she
was released from the hospital. Although I asked the nurse in
charge to do so, she did not.
A little background--not much consideration was given
before surgery in regard to the fact that Dawn has a blood
clotting condition, Factor 5 Leiden. Consequently extra
precautions needed to be taken to respect the potential of
blood clots following surgery. Advice from her primary
physician was to use an oral medication to deter clotting.
However, the decision from Dr. Nolan was that she would begin
shots of Lovenox given into the belly three days prior to
surgery and ten days following. This medical condition should
have been emphasized to the surgical staff so that precaution
and extra concern should have been a high priority during and
[[Page E1661]]
following surgery. Extreme caution and tender handling should
have been taken in the move to prevent possible bruising or
even a hematoma in the area of the surgery--right near the
point of entry of the blood thinner.
I stayed in the waiting room bewildered by this news until
I received the call from recovery to meet Dawn. It took a
very long time before I received the call that she was on her
way. I met an attendant coming out of the elevator pushing
Dawn on the gurney. I expressed my joy in seeing her and
asked her if she knew what had happened. I told her that she
had been dropped off the operating table onto the floor. She
didn't believe me at first, she thought I was joking. The
nurse said, ``Yes, she was dropped, but it was a controlled
fall.'' This is the first I heard the words, ``controlled
fall.'' I thought, now what does that mean? It was very
obvious that the reason it took so long to get her out of
recovery may have been because the medical staff had to have
time to get their story together and make sure they were all
on the same page.
That afternoon, even before Dawn was discharged, I went to
see the IMC administrator Joe Mott. He called in Ms. White,
Patient Relations. I explained what had happened. Mr. Mott
said to me, ``What do you want me to do about it?'' I said
your surgical staff violated my wife's unconscious body and
personhood. The least you could do is apologize. He said they
would stay in touch.
Dawn was discharged and did not see the surgeon again that
day. The medical staff completed no further examinations. The
nurse suggested that when it was time for my wife to get
dressed, I should assist her and I check for any evidence of
bruising.
On Monday, March 6 Dawn and I went back to visit with the
surgeon, Dr. Kelly Nolan. Dawn was experiencing very sharp
pain in her right abdomen and wondered if she could have
broken ribs. Dr. Nolan ordered x-rays. She said although she
was in the operating room at the time of the fall she did not
see what was happened until she saw her patient on the floor.
She also explained to us what was meant by the ``controlled
fall.'' Apparently the anesthesiologist stuck out his leg
under her head and supported her as she fell as best he
could. We were not told what appliances or means were being
used to transfer. They claim the gurney was not locked and
slid away. Who, why and how many were involved--we did not
know. The unanswered questions did not help to answer the
question, ``why did she have so much pain in a large area of
her abdomen?
NOTE: Years ago I served on an volunteer ambulance team in
our hometown in Minnesota. I was a trained in Advanced First
Aid for ambulance personnel--today's equivalent of an EMT I
know from personal experience if the transfer is properly
done, it is almost impossible to drop a patient.
Three days later the pain was increasing--not getting
better at all. During the night of Thursday, March 9 Dawn was
experiencing uncontrollable pain, even using the strongest
pain medication she had been prescribed. I took her back to
the hospital to the emergency. They kept her there for a LONG
time, in fact, twelve hours, attempting to get her pain under
control--not successfully. They did recommend the Lovenox be
stopped--only after further tests--CAT and ultrasound--which
clearly showed a large hematoma. Her abdomen was filled with
blood!
Pain continued for months, including a bout with extreme
pain far below the site of the incision as well as pain down
the right side of her backside and leg.
About ten days after the ``incident'' two people from IMC
came to our home, one from the Risk Management Department and
one from Patient Relations. They apologized for what happened
and gave Dawn a bouquet of flowers. I asked if we could see a
copy of the ``incident report.'' We were told that was not
possible because under the law it is sealed. Risk management
controls IMC's risk WOW--not comforting when my wife
continued to experience severe pain. Risk Management repeated
the report about ``controlled fall.''
My wife did go to the Department of Records to obtain the
medical records from the hospital. They made reference to the
fall, but did not explain how it happened or what really
happened. IMC did not release the incident report, because
under law the incident report is sealed, property of the
hospital.
My Response in the Weeks Following the Incident
I consulted attorneys from four well-known law firms. Each
one told me that they would NOT take the case because under
Utah law it is impossible to win in the courts. They further
informed me that under Utah law, when an unconscious person
is dropped from the operating table during or after the
surgery that the patient and her legal representative are not
allowed access to the incident report. Under present Utah law
patients taking a case like this to court and winning is out
of the question because incident reports are sealed,
therefore the medical personnel and the hospital are immune
from prosecution. So, the result is; it is impossible to know
what has happened or how it happened. Therefore, there is a
great need for The National Unconscious Patient's Bill of
Rights.
Interesting Thought for Consideration
``Assume that you purchased your first car 50 years ago, a
1947 Cadillac convertible. You took immaculate care of the
cherished automobile; own the car today, and then took it in
for repairs. Also assume that you entrusted your beloved car
to one of the most modem and reputable repair centers in the
city, leaving it in the hands of highly qualified,
professional mechanics. You were invited to wait in the
service garage waiting area because garage and insurance
concerns do not permit you to watch the repairs being made. A
couple hours later the head mechanic meets you in the waiting
area to tell you that your car was dropped off the hoist onto
the concrete floor. No more information is given and all you
can do is take your broken car home. Later, you go back to
the repair center seeking answers and help for your car. You
see the repair center's manager and tell him what the car
meant to you. His response is, ``Well, what do you want me to
do?'' You say, ``Maybe you could start by apologizing.''
About ten days later he and a couple of people from the
repair center come to your home to apologize and deliver a
bouquet of flowers. He says, ``You will be charged for the
original repairs and you need to know that under special
legislation for 'repair shop and mechanic protection', you
cannot get the report of how it happened or a report of the
damage to your car.''
You may say, this is really a terrible comparison, and it
is. You see this happened to my wife, Dawn, whom I have loved
and cherished for more than 50 years. And now I compare her
to an old car--not even close--even an insult, but I think
you get the point.
____
Dawn Menning Seeks Resolution by Promoting the National Unconscious
Patient's Bill of Rights
I will work to introduce and seek the passage of ``The
National Unconscious Person's Bill of Rights.'' This
legislation will include language requiring all medical
surgical procedures to be recorded by audio and video.
In my search and input from a University of Utah doctor, we
can only find four times in recent U.S. medical history that
unconscious patients have been dropped off hospital's
operating tables.
In the early 90's a lady from Denver area was dropped off
the operating table and was paralyzed from the neck down
In the late 90's a 28 year old lady was dropped from the
operating table at the Clarion Hospital in Pennsylvania,
resulting permanent injuries
In 2012 a 75 year old patient was dropped off the operating
table at Duke University Health System Hospital, he died of
complications a short time later
In 2010 a patient was dropped off an operating table at St.
Joseph Hospital, Minneapolis MN, he died a short time later
of complications.
We praise God that Dawn did not die from injury
complications or was paralyzed in the process.
Now Intermountain Medical Center is recorded in these
statistics.
____
The National Unconscious Patient's Bill of Rights
The National Unconscious Patient's Bill of Rights shall be
placed in Federal Law; such shall include, but not be limited
to:
1. All surgical procedures must be recorded by mounted
video camera and be kept in the patient's permanent record
for a period of two years.
2. In the event of an incident or accident concerning an
unconscious patient, the hospital or medical clinic shall
maintain the recording as part of the patient's permanent
record.
3. The incident reports and video shall be made available
to the patient and the patient's legal representative and can
be presented as evidence in a court of law.
4. A patient shall have the right to know the names and
roles of the members of such person's health care team (taken
from the Virginia Commonwealth University Health System).
____
Recent Historical Grounds for the National Unconscious Patient's Bill
of Rights
Legislators and others can lay the foundation for the
passage of legislation making video cameras mandatory in
medical clinics and hospitals where surgical procedures are
performed using the following examples. With today's modern
technology video recording of surgical procedures can be
provided at minimal cost.
Consider previous precedents--
1. In the State of Utah and other states the Departments of
Motor Vehicles mandate that all motor vehicle and emission
inspection technicians are videoed by camera as they do the
inspections. Any MV (motor vehicle) inspection facilities
shutting off the state-mandated video camera shall be fined
and/or have their license revoked. Surely if the State of
Utah requires the Motor Vehicle inspection to be videoed
doing their work, the legislature can pass legislation
requiring hospital to video patients under anesthesia the
same privilege.
2. In the case of Andrea Constand vs. William Cosby Jr, one
of the issues was that Ms. Constand was abused while she was
in an unconscious state. Similarly, should a Utah law remain
on the books giving medical professionals and the
Intermountain Medical Center immunity from the law when a 70-
year-old woman, my wife, was clearly abused while in an
unconscious state? The question is--was it an accident? Or
was it an incident? Whatever happened, we will not know
because there is no video and there are no means to obtain
the information legally. This is the heart of the matter.
[[Page E1662]]
3. Most state and local officials, as well as the public,
encourage and support body and car cams for law enforcement.
These video cameras have been proven to be very helpful for
protection of policeman and the public.
4. Consider the most recent case of Nurse Alexandra Wubbels
barring police from drawing blood from an unconscious
patient. Her position was that the unconscious patient has a
right to know what is happening to their body. She stood her
ground. The police thought they had a right under the law, it
didn't play well in the media. The end result, Salt Lake City
and the University Hospital settled for $500,000 payment to
Ms. Wubbels.
Today's society will not longer accept gross mistreatment
of unconscious patients presently shrouded in secrecy. The
National Unconscious Patient's Bill of Rights will promote
the use of modem technology, cameras mounted and in use
during surgical procedures. Upon request from the patient
such recordings must be available to patient or assigned
legal representative. Doctors and medical staff will be held
responsible for their actions.
____________________