Actual Medical History Duke surgery records: Condition at Admission 1 Dr. Robert Isaacs records 1 2 3 4 5 Dr. Gerald Grant records 1 2 3 Pre-Op nerve study 1 Dr. Aatif Husain records 1 2 Post-Op condition 1 Anesthesia record 1 Post-Op STAT MRI Video, released two days after taken 1 Discharge report 1 Images Pre-op Post-Op 600 days latter
Of all the words, of tongue or pen, the saddest, are these: "what might have been".
Complaint filed with the Joint Commission 1
Complaint filed with North Carolina Department of Justice, District Attorney 1
North Carolina Medical Board complaints: 1 2 3 4 5 6 7
Intraoperative nerve monitoring Goggle answers
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Before Duke |
100+ days After Duke |
Danny and Shelly
We support the NCMB publishing records.
Complaint
of FRAUD filed with the department of Justice May 31st 2010
Fair balanced opinion: Left, Hospital/Doctor's defense Lawyers [including Bobby Hendricks], Right: Doctors and patients.
Miss diagnosis, / Omission/misrepresentations of IOM
during informed consent, / Intraoperative nerve
monitoring known to be "unreliable" prior to incision, / Ignoring a
HUGE post-op spinal
hematoma, / Fabricating a new medical history for the patient to fit a failed
"ELECTIVE"
surgery is all "STANDARD PRACTICE" at Duke University Hospital
Neurosurgery.Tell the patient or family nothing, and turn them over to the "closed lipped" Bobbie Hendrix Director of Risk Management.
Shelly's post-op condition 100 days after failed surgery. Home grown Physical Therapy
Still today, 650 days after the failed surgery, Director of Risk Management Bobbie Hendrix maintain, this is all Duke Hospital's "Standard of Care" in denying the 1990 shunt and the obvious HUGE cyst, HUGE post-op hematoma, and improper nerve monitoring.
Failed communication lawsuits are not rare. The most common cause of medical malpractice litigation in the United States is “failure to diagnose,” but data from medical malpractice insurance companies show that the second most common cause is failure to communicate results of radiologic examinations. 3 In fact, data disclose that communication problems are at least a causative factor in up to 80% of medical malpractice cases.
This is not surprising, considering that a survey of family medicine physicians found that errors in communication accounted for 70% of all errors in that specialty, outpacing errors in diagnosis, which accounted for 47%.4 Another study found that physicians failed to acknowledge 36% of abnormal radiologic results; 4% of these, many of which made reference to a possible cancer, were lost to follow-up
Sharing this link may just keep one other unsuspecting patient from Shelly's fate. just one would be worth everyone's effort.
919-933-4021
Thank you to the good folks who we have visited with, while we wait to see how far Duke is willing to take this amazing story while they "defend Duke Standard of care" UNC Hospital now defend Duke by refusing to see the shunt.
[update] UNC did finally agree [after two weeks of "conversations" ] with UNC Risk Management, Radiology was suddenly able "find" the 1990 shunt I showed them all 8x10 color glossies of prior to MRI's being done.
Negotiations continue with UNC Risk Management to have Radiology "finally" document the re-tethering in the 2010 MRI's caused by the huge cyst that has been there since 2006, and miss-diagnosed at [July 2008 failed surgery] Duke University Hospital as tethered cord syndrome pushing the spinal cord rearward.
I'm not making this stuff up!
Failure of radiologic communication: An increasing cause of malpractice litigation and harm to patients
Shelly's anatomy: Notice the rear portion of the vertebra are removed/missing at birth, so there is no protection from from outside forces to the spinal cord. Also notice how the spinal cord is pushed back into that area. Pushed by the HUGE cyst sitting just in front of her spinal cord [just like the 1990 surgery corrected] The cyst had once again started pushing her spinal cord rearward in 2008. [see image below]
This is the area Shelly had a surgery in 1990 to drain a fluid filled cyst that was compressing her spinal cord causing loss of sensation in her finger tips. At that time the [red] shunt/tube was installed into the cyst to keep it from re-filling and expanding against her spinal cord. [keep equal pressure in the skull and the cyst, so the cyst would not expand.]
2000 - 2006: In the following 18 years, the shunt had started to fail/plugged as is now known to be normal. Follow up MRI images were showing the cyst to be enlarging from 2000 to 2006 and the symptoms were progressing. [sensory failure in hands and feet, called a glove disturbance]
May 2008: Director of spine surgery, Dr. Robert Isaacs ordered the CT images above on the first day at Duke. That shunt was not seen in Duke University Hospital CT, images, [see Duke University Hospital diagnosis images above] even though Shelly insisted they check the shunt, what about the shunt?
June 2008: Dr. Robert Isaacs, Director of spine surgery then ordered MRI images of the area. Once again the shunt was not seen, nor was the growing, now HUGE cyst that was pressing on Shelly's spinal cord. Director of spine surgery Dr. Robert Isaacs insisted her spinal cord being displaced rearward, and her increasing symptoms were caused by "Recurrent tethered cord syndrome". This flys in the face Shelly has never had "tethered cord surgery in her life". Shelly and I were VERY uncomfortable with Dr. Isaacs diagnosis, or attitude. Shelly asked to be referred to another doctor for another opinion. Dr. Isaacs referred her to Dr. Gerald Grant Duke University Hospital Pediatrics neurosurgery Associate professor.
Dr. Gerald Grant: Duke University Spina Bifida clinic who at the time was shown on Duke Hospital web site as quote "Intraoperative monitoring of spinal cord and peripheral nerve function plays a key role in all cases of spinal cord tumors, tethered spinal cord, peripheral nerve cases,"...etc. [that page was removed sometime around Sept 2009, just after we filed a formal complaint with Duke University Hospital because the monitoring was do poorly, it was known, recorded in medical records to be "UNRELIABLE" prior to incision.
June 2008: Shelly and I met with Associate Professor
Dr. Gerald Grant. After thorough review of shelly condition also
failed to see the shunt, or the NOW HUGE cyst 
radically pressing Shelly's spinal
cord rearward, Dr. Grant agreed with Dr. Isaacs diagnosis of "recurrent
tethered cord syndrome", once again flying in the face of the known growing
cyst, as well as the fact Shelly never had a detethering surgery in her
life. Shelly and I were both very suspicious about the diagnosis.
Then Dr. Gerald Grant offered to use Neurodiagnostic Intraoperative Nerve
Monitoring so any potential damages to nerves during surgery could be alerted to
the surgeon as it happened, and adjustments to surgery procedure could be
altered to keep her safe.
Shelly's pre-surgery cause of deficits: Here is what SHOULD HAVE BEEN DONE as the shunt was known to have failed after 18 years. And the cyst grew, compressing Shelly's spinal cord, also probably more likely what was found once incision was made.
June 2008: Days latter, It seamed inconceivable that two Duke Neurosurgery Professors could be wrong about the syrinx/cyst now missing, or the diagnosis or tethered cord. So with the promise of nerve monitoring during elective surgery, we agreed to the surgery.
July 28th 2008: Morning of surgery, 8:29 AM Incision without reliable nerve monitoring, [ documented in surgery records] Dr. Grant did not hesitate, and disregarded the monitoring issue.
July 28th 2008: Of serious concern, once Shelly was under anesthesia, any Manulipulation, including the shaving off the hair in the surgery field, rubbing, sterilizing the area, pressing in the area to find anatomy for marking of surgery area would have started the jabbing of the shunt inside Shelly's skull, causing hemorrhaging? or any nerve damage, this may well have been why there was unreliable nerve monitoring data just prior to incision.
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| STAT POST-OP MRI [1] HUGE HEMATOMA RUNNING DOWN SPINAL CANAL IN FRONT OF SPINAL CORD INSIDE THE [2] SURGERY FIELD. [click on image] | STAT POST-OP MRI [1] HUGE HEMATOMA RUNNING DOWN SPINAL CANAL IN FRONT OF [2] SPINAL CORD WELL BELOW SURGERY FIELD. | ||
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DUKE PRE-OP IMAGE CYST |
NO ONE SAW THE CYST OR SHUNT BEFOR, DURING OR AFTER THE ELECTIVE SURGERY!!!! | ||
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IT WOULD BE TWO DAYS UNTIL STAT POST-OP IMAGES WERE RELEASED, STILL NO CYST OR SHUNT IS NOTED!!!! |
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DUKE STAT POST-OP IMAGE OF CYST |
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Above: xample of posterior cervical cyst, Left: Shelly's cervical spine cyst now almost goes all the way around her spinal cord, except for where it was pushed against the side of the spinal canal, and quickly re-tethered. UNC Neurolseurgeon states this is not a problem. And the shunt and cyst will not be mentioned in his report. |
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UNC Hospital. 600 DAYS LATTER CYST CONTINUES TO BALLOON INTO THE NEW INLARGED AREA CREATED BY DUKE UNIVERSITY HOSPITAL SURGEONS WHO DENY THE EXISTANCE OF THE CYST. UNC Hospital also do not admit the existance of the shunt, but did state "There is the suggestion of draping of the cervical cord from the C-2 to C5 levels, this raises the concern for an arachnoid cyst anterior to the cervical spine" Well at least UNC admitted there "may" be a cyst in this area. but do not mention the shunt in the middle of it. After meeting with UNC neursurgeon today, he refused to aknolage the shunt, even when we brought very clear images of 5 [five] different image stydies, as well as the actual surgery records of when it was installed. Also he told us the cyst was not a cyst, but normal CFS around the spinal cord. |
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UNC 600 DAYS POST OP IMAGE OF CYST AND SHUNT, YET SHUNT IS NOT NOTED. |
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UNC 600 + days post-op now the pre-existing syrinx/cyst has almost doubled in size. STILL DUKE UNIVERSITY HOSPITAL CONTINUE TO DENY ITS EXISTANCE, |
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After surgery Shelly was listed in good condition, sensory was documented as normal in all extremities except left arm. Motor function was listed as "weak". Physical Therapy orders were given to evaluate for rehab.
By 1:30 PM: Two hours after end of surgery, orders were given for STAT MRI, patient now ant move extremities. [limbs]
Those STAT emergency images would not be performed until 4:08 -4 1/2 hours after surgery, 2 1/2 hours after orders were given. Findings for those STAT emergency images would be held for 2 days.
The House Officer was notified of Shelly's condition, and "abnormal lab results" at 5:21 PM, 6 hours after surgery. Within moments, I was finally permitted to see Shelly, possibly for the last time. There was no one to tell me anything, everyone was gone, the white board in the room used to list who is in charge, nurse, doctor etc was all wiped clean. It was never used the whole time Shelly was in ICU., I had to ask for a marker si I could leave notes for Shelly so she knew when I would return, and how to contact me.
Shelly was very disturbing to see in this condition, especially, just hours after she walked into the hospital as normal as I did. She could only wobble her neck back and forth, begging for pain relief. As I leaned over Shelly, quivering in disbelief at her condition, trying to hold back the anger inside me at what they had done to Shelly.
