Never-ending impact

Sometimes locked in silence: the 

other victims of medical errors

By David Baker
Posted June 8, 2023

   The three nurses who clocked in for their shifts on the fourth floor of Samaritan Hospital in Troy, N. Y. one evening back in November 2003 could not have imagined that the collapse of one of their patients that night would set off a series of events that is still going on 20 years later.

   The patient, who had try 1 diabetes, was Lisa Baker.  Just after 2 a.m. on November 11 she was found not breathing and - according to an entry in her medical chart - with a blood/glucose level of 2 mg/dL.

   Any reading below 60 mg/dL requires immediate treatment. 

   Lisa lapsed into a coma, her brain and other organs damaged by the lack of glucose and oxygen. She died three weeks later.

   The medical chart shows no indication that a check of her was done for the four hours after a first episode of hypoglycemia earlier in the evening - even though checking to ensure that a patient’s glucose has stabilize at a safe level is required by the hospital’s “hypoglycemia protocol”, a written instruction the attending physician had that evening ordered in a written entry in the chart to be used if Lisa’a glucose level dropped.

   That collapse, and the hospital’s refusal to acknowledge what its own records show, led to two lawsuits, one against the hospital and two doctors, the other, naming four individual staff members that was filed after the hospital refused to allow the first complaint to be amended.

   The claims were dismissed after Samaritan Hospital’s lawyers paid Mathew Leinung, an endocrinologist at Albany Medical Center, to provide an affidavit saying that the nurses who ignored the attending physician’s written order did not fall below the standard of care. This despite the medical chart showing that what happened - hypoglycemia that starts while a patient is a healthcare facility - was what Medicare later termed one of 28 ’never events’ events so egregious that they should never happen, and for which it would deny payment for treatment resulting from the event, and that Lisa’s death certificate listed as a cause of death “profound hypoglycemia,”

   But that rule was not in effect in 2003; Samaritan Hospital was paid $73,000 for treating Lisa in its ICU for the three weeks she was in a coma prior to her death. 

   The dismissal of the lawsuit prompted this blog, with its details of dozens of lawsuits against Capital District hospitals alleging deaths and serious injuries, lawsuits that the area’s media had ignored, while running endless ads for the hospitals.

   A related web page brought a lawsuit in 2012 from the hospital; an obvious attempt to suppress information about the lawsuits. The lawsuit was resolved after two years with a change of its web address. It is still up, with the new address, capitaldistrictheslthclaims.com.

  And now a book about Lisa’s case is coming, creating a near permanent record of the events surrounding Lisa’s totally preventable death.

—

   Four people are listed in the hospital records -  and were named in the second lawsuit - as being on duty in the hospital’s fourth-floor Progressive Care Unit that night. Of those, it was Mary Ann Salvana Lee, then 33 years old, who signed the chart entries relating to Lisa.

   Lee had been issued a New York nursing license just nine months earlier, on February 21, 2003, according to the state’s online listing of professional licenses. It is still current, expiring on January 31, 2026.  Lee, now 51 years old, is still living in the Albany area.

   Of the other three, Mary Kay Keller and Mary Martin have either retired or left the profession; their licenses have expired. There is no indication that the fourth person listed in the hospital’s records, Elza Villajuan, has ever held a nursing license; either her name was misspelled or she may have been a patient aide.

—

There are many ways people can unintentionally cause serious  injury or death: Leaving a child to die in a hot car;  Not securing a gun that is then found by a child who unintentionally shoots someone. 

   Or giving a patient an IV shot into her spine instead of a vein, as two doctors at Albany Medical Center Hospital did in 1985, taking the life of 21-year-old Lillian Cedeno and her unborn child. 

   And most people who make such a mistake will live with it for the rest of their life, reliving over and over the details of the event.

   Some seek relief from the guilt with alcohol.  Marriages will be destroyed.  Some people take their own lives.

   Others go into denial, refusing to admit even to themselves that they are responsible for the tragedy. 

   The first victim is the patient harmed or killed by a medical error.

   The others are first the patient’s family - and then the people who made the error, and might want to acknowledge the mistake but are left to suffer in silence by management’s routine aggressive defense of every claim that it was responsible for an injury or death in its facilities.

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Link

How a terrible mistake by two Albany Med doctors took two lives: https://bit.ly/3NkpgzS

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ER staff sued

 Alleged spinal injury brings lawsuit

 against Samaritan Hospital

By David Baker

Posted June 5, 2023  

   A Rensselaer County man who went to the emergency room at Samaritan Hospital in Troy, N.Y. with stomach pain and vomiting has filed a lawsuit alleging that he was damaged when a tube that was passed through his nose into his stomach allegedly causing spinal fluid and air to enter his brain.

   The patient, William Kramek, was then transferred by ambulance to Albany Medical Center Hospital, where a patch was placed to stop the leak of spinal fluid.

   The complaint says that “..as a result of defendants’ negligence, Plaintiff was cause direct trauma from insertion of the nasogastric tube resulting in him becoming diaphoretic [sweating excessively], eyelids dropping, seizure activity and leaking cerebral spinal fluid through his nose.”

   The complaint names Samaritan Hospital, St. Peter’s Health Partners - and 10 entities that provide physicians under contract to work in emergency rooms, some of the entities apparently owned by the hospital operator itself.

   The lawsuit was filed on May 31, 2022 but is now on hold  after one of the contracted entities, Envision Healthcare Corporation, filed for Chapter 11 bankruptcy protection in May, reportedly owing $7.7 billion to dozens of other organizations. 

   The filling comes five years after Envision was taken private by the private equity group KKR in a deal valued at $10 billion.

   In addition to Envision Healthcare Corporation the complaint lists as defendants two other entities that appear to be associated with and perhaps owned by Envision Healthcare and share the same Florida address: Envision Physician Services, LLC; and Emergency Medical Association of New York P.C. 

   Another two entities under contract with the hospital, Emergency Medical Associates and Emergency Medical Associations PLLC, share an address in Parsippany, N.J. One of them appears to have been set up by a doctor, Stanley W. Docyk of Ballston Spa, N.Y., which then contracted to provide Docyk’s, services to the hospital.

  Four of the 10 corporations are apparently owned and operated by St. Peter’s Health Partners: St. Peter’s Health Partners Medical Associates; St. Peter’s Health Partners Emergency Associates; and Manning Emergency Medical Associates all list 315 S. Manning Boulevard in Albany - the address of St. Peter’s Hospital - as their address. Another defendant, Emergency Medicine Physicians of Samaritan, PLLC, lists 2215 Burdett Ave. in Troy - Samaritan Hospital’s location - as its address.

   Press reports on Envision’s bankruptcy filing suggest passage in 2020 of the federal No Surprises Act impacted Envisions’s revenues. The act restricts how doctors who work in a hospital but are employed by an agency can bill patients whose insurance was not accepted by the outside physicians. Before the passage of the act patients who often had no idea that the doctor treating them was not an employee of the hospital and did not accept their insurance were getting billed for thousands of dollars - and getting sued when they were unable or unwilling to pay the surprise bill.

   The lawsuit, which also name Kramek’s wife Anne as a plaintiff,  was filed by the Troy law firm E. Stewart Jones Hacker Murphy. 

  Representing Samaritan Hospital, St. Peter’s Health Partners and St. Peters’ Health Partners Medical Associates is  the Albany firm Thorn, Gershon Tymann & Bonanni. 

   Manning Emergency Medical Associates PLLC, Envision Healthcare Corporation , Envision Physician Services LLC, and Emergency Medial Association of New York are represented by O’Connor, O’Connor, Breese & First of Albany.

   A check of the Albany Timers Union archives produced no story about the Kramer lawsuit. As has been reported on this page, TU publisher George Randolph Hearst III has a seat on the St. Peter’s Health Partners’s board and has raised millions of dollars for the company. 

   Over past 26 years the paper has ignored dozens of lawsuits alleging wrongful death and serious injury filed against hospitals and other facilities now operated by St. Peters Health Partners.

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George Randolph Hearst: Opinion: A duty abandoned. 

Physicians' hidden employers

 In this ER, the doctors don't work for the hospital

   For years, hospitals and nursing homes have filled open nursing shifts with people from staffing agencies. A nurse might work a singe shift or cover it for a week. But the rest of the nurses would be employees of the facility.
   But, as the complaint described in the story above reveals, at Samaritan Hospital in Troy, most, if not all the physicians in its emergency room are employees not of the hospital but of a separate legal entity.
   And not just one agency. In the lawsuit filed by William and Anne Kramek, there are 10 legal entries listed as defendants. Five of them appeared to be wholly owned by one company, Envision Healthcare Corporation.
   And more puzzling is that another four are evidently creations of St. Peter’s Health Partners - which owns and operates another of the defendants, Samaritan Hospital, where William Kramek alleges his injury occurred. 
    In May, citing debts of almost seven billion dollars, and after missed an interest payment, Envision Healthcare Corporation filed for protection under the bankruptcy laws. The company says it will continue to operate during the bankruptcy proceeding. 
   Not clear is why a hospital a would have some, maybe all its emergency room physicians employed by a separate legal entity. And if, every unwell person who arrived St. Peter’s Health Partner ERs prior the implementation of the No Surprises Act was told and clearly understood that their health insurance might not be accepted by the entity paying the physician, and that they, the patient, would be responsible for physicians’ bills.

—David Baker