- What if you have a bit of cognitive dysfunction?
- What if you’re older (most people who are reported as having tetanus are older)
- What if you aren’t as clear as you once were?
- What if you are so overwhelmed by the pain and the feeling that your back muscles will bend you backwards that you don’t say things quite right, or calmly?
- What if you don’t say you were worried about some food you ate?
- What if you don’t ask if cold could cause muscle contractions?
- What if the first sounds the ER doctors heard from you were screams?
- What if the doctors didn’t see the muscle contractions in your back? or didn’t see the contractions at all and thought you had stomach cramps?
- What if you told the doctor you have a bit of brain damage and it’s hard for you to explain and the doctor began asking you about brain operations?
- What if you became exasperated and shouted that didn’t matter that the problem was the tetanus, that you’d jammed a needle into your toe?
What if you added, without undue emphasis, that you’d stepped on a darning needle two months ago after you’d been gardening, but you doubted that could have anything to do with this.
|TBI (Traumatic Brain Injury) affected my health
care on October 7, 2004.
I was unable to be clear because of extreme pain
and fear caused by the muscle contractions.
When I asked for accommodation of my disability
it was denied by hospital staff.
In the absence of accommodation my symptoms
were inaccurately reported.
Alex Valdez, CEO
St. Vincent Hospital
465 St. Michael’s Drive
Santa Fe, New Mexico 87505
I am writing to you because St. Vincent Hospital, which is “classified as a sole community provider by Medicare” has failed in its legal duty under the ADA, title II.
I am qualified under the ADA, Title II. Tests administered through the Department of Vocational Rehabilitation show that I’ve lost about half of my working memory and my processing speed. These losses are a disability.
On October 7, 2004, because I was in extreme pain from muscle contractions in my back, I had difficulty explaining what was wrong. I asked a nurse and Dr. Raboff to call Corrine Romero, my TBI case manager, and tell her I was in the ER, and ask her to come to help me explain. Corrine Romero had observed the first contraction I had, a week earlier.
Corrine did not came. After I was released, I asked Corrine about it and she said that no one had called her.
Because I was refused accommodation for my disability: TBI, I am suffering from the same thing that caused me to be taken to the ER on October 7, 2004, and this is causing me serious damage.
As a point of law, this is an ADA case and not a medical malpractice case. This means I do not need an expert medical witness to go to trial on my complaint that the hospital failed to provide guidelines and oversight to ensure that my disability was accommodated.
The reason the failure to accommodate is so serious, is that the medical records that were created in the absence of clear input from me (absent because I was denied accommodation of my disability) are dangerously inaccurate; “Dangerous” because those inaccurate records have been relied upon by other ER doctors and Whole Life Clinic to deny me not only treatment, but medical examination since October 7, 2004.
Some of the inaccuracies created by the failure to accommodate my disability are shown on the Abdominal Pain sheet:
1. Under “Historian: patient HX Exam Limited By:” it says “will not allow MD to move pt”
- a. fails to note that movement caused painful contractions
- b. fails to note guarding against extreme pain
- c. fails to note TBI which I stated I have
- d. fails to note that I asked for my case manager to be called to help me explain
2. “Pt. uncooperative” I can’t read the next bit, then “Hostile & Threat”
- a. the contraction pain was dictating my behavior to a large extent
- i. the contraction pain made me very irritable
- ii. Several times I screamed, “If you want to see pain like this continue, Vote for Bush;” that is not a “threat.”
3. Under “HPI”
- a. “generalized myalgias”
- i. there was nothing general about the extreme pain from the contractions of my back muscles on the right hand side.
- b. “muscle cramps” –
- i. what I was feeling and what caused Whole Life Clinic to call an ambulance was not cramps; it was muscle contractions that pulled me backwards in the most painful way that made me scream the same way I did when I was giving birth to my son.
4. Under “started”
- a. “accidental needle” … but what is the next word?
- b. “4 weeks ago” is wrong, it happened on August 14, 2004
- c. “removed 2 ½ weeks” is wrong, I removed the quarter inch of needle two days after it went into my toe and broke off
- d. “sa” what is that????
- e. I can’t read the next two lines, but if they say that the first problem was “Tweek” it would be wrong because I had some red lines under my toe nail right after I took the needle out. Because of the lines I soaked my foot for about 4 hours a day for about a week in Epsom salts, and I took 2 sm. Bottles of Vitamin C. The red lines got really faint after that so I stopped worrying about them.
- f. “Pt concerned about tetanus Tricore had tetanus” I can’t read the next word.
- i. This line is important because I was “concerned” about tetanus,
- ii. whereas Dr. Raboff and Paolo G. were describing me as saying, “I have tetanus.”
- 1. the Behavior Health report describes me as “paranoid”
- 2. false reports of this nature are damaging
- g. “Pt claims chronic B12 deficiency resulted instability fell
5. Under “time course”
- a. “still present” and “constant” do not reflect the fact that the contractions stopped when I remained still
- b. “persistent since Tweek” doesn’t describe that the contractions started at Whole Life Clinic. I had one contraction a week earlier, but that one sudden contraction was not in itself ongoing. It was observed by Corrine Romero.
6. Under “quality”
- a. “cramping” would have been more clear if sharp had been added to indicate the extremely painful nature of the contractions
7. Under “location”
- a. only the front of the diagram is marked and it wrongly shows my arms and shoulders as being affected by the pain
- b. the back of the diagram should have been marked: The major pain had been in my back when the muscles there, on my right side, contracted.
8. Under “severity” “relieved by”
- a. “nothing” is incorrectly circled. Holding myself totally still kept the contractions from happening.
9. Under “similar symptoms previously”
- a. this is crossed out, whereas there was a contraction a week earlier
10. Under “ROS”
- a. “trouble breathing” seems half heartedly circled, whereas the tightening of my diaphragm muscles was making breathing tough.
- b. “joint pains diffuse” is totally inaccurate. My joints weren’t painful at all.
- c. “back pain” is circled here, which appears to substantiate that the back side of the diagram should have been marked.
- d. “diffuse” is inaccurate since the contractions had been in precisely one set of muscles on the right side of my back
- i. additionally, my abdominal muscles were tight
- ii. my diaphragm muscles were tight
- iii. my muscles on my sides were tight
- iv. leg, arm muscles were not affected
11. Under “prior work up”
- a. “head trauma” noted by not fact I asked for Corrine Romero to help
- b. “cognitive difficulties since” but still they did not call Corrine Romero as I asked
- c. “has difficulty” can’t read the rest… but still they did not call Corrine Romero as I asked to help me clearly explain
12. I can’t comment on “Medications” … “see nurses notes” because I haven’t got time to find the notes because of how long it takes me to do things because of the loss of a significant part of my processing speed.
13. Under “Social HX” it fails to record that I said I do not use drugs.
- a. this failure is apparently related to the fact extensive drug testing was done on me
- b. while extensive drug testing was done, the doctor refused to look at my toe or touch it
Because of the enormous amount of time this take me, I don’t have time to do the second page.
This page shows, however, that several extremely important facts were ignored or recording in a conflicting manner (no pain in back vs. diffuse pain in back, as an example).
What concerns me now, as it did then, is that the continuing muscle tightness that I am experiencing is tetanus.
The tightness was so extreme that to walk across one single square foot of saltillo tile, it took me three steps. It was so extreme that I could not bend even an inch without making my back muscles feel like they might contract again. The tightness was so extreme I couldn’t lift my Brita pitcher when it had more than an inch of water because of the extreme pressure and strain that put on my tight muscles.
In the beginning, the tightness turned to pain very rapidly; Being up more than a minute caused pain, and that pain increased by the second.
I want to make it clear that when I talked about my muscles feeling like they had after I had my appendix out, this was in my letter to Dr. Bardwell, I was describing not a level of pain, but of constriction… after I had my appendix out I couldn’t stand up straight. I got right up and walked around, but I couldn’t stand up straight.
The day I came home from the ER I had incontinence, and I had it again yesterday. Yesterday and several days last week I relapsed.
It is very hard to sit up and soak my foot. If I had been heard, allowed to communicate my history with the help of
my case manager, then the hospital and doctors would have had a clear picture of what was wrong, Failing that,
they did not and I remain inadequately treated as a result of discrimination.
I am complaining because unless I complain you will continue to ignore the points I have previously raised, and I
will never be able to feel secure that ER or hospital care is available to me as a person with a disability.
I am extremely distressed that when I went to the ER a second time, on October 31, 2004, the inaccuracies of October 7, 2004 appeared to affect my visit. That is, when I was asking the doctor about my toe, he interrupted saying that he knew what I was going to say, and I didn’t have an infection. He did not look at my toe to make that determination. He did not look at my toe at all. So, he must have made that determination on the basis of the discriminatory notes from October 7. He appeared to take nothing I said seriously and when I asked him what was wrong with me he said I should research fibromyalgia. If I had not been discriminated against, I would not have a medical record from October 7, 2004 saying I’m paranoid. I really object to this kind of discrimination and its impact on my health.
I have a web page with some pictures of my toe on it: