Personal Hospital Records

I recently received my personal hospital records in the mail.  (I had ordered them back in mid-December, and it took them this long to get them to me!)

The records date back to 1988 so there was some interesting reading.  (It seems my tinnitus dates at least that far back.  Fascinating!)

But the bulk of the record concerns my most recent stay in hospital (January 2012) for my total hip replacement.  Even that record contained some interesting enlightenment.

Did you know that the attending nurses listen to the patients when they are on the phone?  Yes, they do and they record the gist of those phone calls on the patients' files.  (Note to self:  Next time you are hospitalized, be careful.  Be very, very careful!)

As well, there are occasions when the wrong information is recorded against a patient's file.  In those cases, a line is drawn through the entry and the word "error" is written over top.

There were several such entries against my file for some reason.  I'm guessing it was because there was so little to record about me (and so much to record about the numbnuts patient in the bed beside me), that the nurse felt compelled to write something on my file.  (I know that's not likely but it sounds good, doesn't it?)

In one instance, an entry that I know is an error was not scored out.  So the record stands that on the morning of February 3rd (the day before I was released), I "reported blood on my underwear" after a visit to the washroom and an examination of my vagina revealed no tear.  That never happened!  The next day, my file contains an entry that was subsequently scored out as an error.  "No vaginal discharge noted."  Seems evident that the entry for the previous day did not apply to me since the entry for the next day didn't apply.

This leaves me to think that on release from hospital, patients should be given the right to review the file that will form a permanent record of their stay.  That way, the record can be corrected in a timely fashion.

While it distresses me that my file contains that error, what I find even more disturbing is the fact that the record of the surgery itself does not include a reference to the fact that I woke up during the surgery and spoke to the anaesthesiologist, that immediately upon waking in recovery I reported having wakened during the surgery, that the anaesthesiologist was called to come to talk to me about what happened, and that I retained the memory of having wakened up.  

Although the descriptive record of the surgery does not indicate that I woke, the Anesthesia Record contains the following entries:  

• 8:38  Surgery Start time
• 8:45  (Upper airway obstruction secondary to additional fentanyl IV re:  c/o pain intermittently)  (Note:  this is when I woke up -- a mere seven minutes into the surgery!)
• 8:55  (Convert to GA; bolus PPF and LMA insertion with transient drop in Sp02; promptly recovered with establishment of PSV back-up mode)  (Note:  GA is general anaesthesia; Bolus PPF refers to the IV insertion of Propofol, the anaesthetic that killed Michael Jackson; LMA insertion is a Laryngeal Mask Anaesthesia which enables the anaesthetist to channel oxygen or anaesthesia gas to a patient's lungs during surgery; Sp02 is Oxygen Saturation; and PSV is Pressure Support Ventilation -- a method of assisting spontaneous breathing in a ventilated patient). 
• 9:42  Surgery End time

So, it would seem that with the delivery of intravenous fentanyl, I experienced an upper airway obstruction (I started choking).  Then, when they gave me general anaesthesia to knock me out (I kept telling the anaesthetist that I was awake and she had to tell them to stop what they were doing until I was asleep again), I had serious breathing problems and they scrambled to "recover" me.

Nice going docs!  You were warned ahead of time that I had breathing issues with anaesthesia.  Perhaps you should have listened to me.

My problem with the foregoing is that never once while I was in the hospital did anyone approach me to discuss what happened. Well, the anaesthesiologist was called in to see me in recovery to tell me that I had awakened and was "quite agitated" so she had to give me general anaesthesia "for a short time" during the surgery.  (If you look at the timing above, I was given GA for almost the complete surgery -- close to an hour!)

The first near-miss for me occurred back in 1982 when I had my bunions removed.  But that time, the surgeon was good enough to tell me that they had "almost lost" me on the table.  He is the one who explained my difficulty with anaesthesia and how it should be handled in future. Thirty years later, it only took seven minutes into the surgery before they ran into problems, and serious issues arose immediately upon administration of the general anaesthesia.

I strongly believe that I should have been told about the challenges that occurred on January 30, 2012, so that I would be fully informed and could share the information when preparing for any future surgeries.

Now I have it in writing.  You can be sure I'll be taking a copy of the Anaesthesia Record with me when arranging any surgeries from here on out.

What should you take away from this?

If you have had surgery, or if you have a surgery in future, ask for a copy of your complete hospital medical report.  I think everyone should have complete information about their own health.  Obviously, the doctors aren't going to tell you!