Yes, it keeps getting closer and closer to completion, but that old, dreaded tendency to rewrite rather than complete keeps getting in the way.
I can't expect you to read another version, so I won't post another until the final draft. What I *will* do, however, is post the exchange of emails between Dr. Amen, director of the clinic, and myself. Pretty-much *everything* I sent to Dr. Amen I'm sending the medical board -- so what you see here will be repetitious. Sorry.
I find the emails hilarious.
Dr. Amen is my psychiatrist's (pdoc's) friend, colleague and boss. He also has a financial (and reputation) stake in my not filing (and, more importantly, *winning*) a medical malpractice lawsuit against the pdoc and the clinic.
Even knowing all that about his motivation, one has to sniff delicately around the smell of the bullshit.
I had contacted his personal assistant, who suggested she would pass along to him email I sent to her. [BTW, If you look at his bio on his web site (http://www.amenclinics.com/meet-dr-amen/), you will see he is an avid table tennis (ping pong) player.]
-------------------------------------------------
[Here's my first email to him:]
Subject: Preliminary Story
Date: Friday, 3/26/2010
Hello Dr. Amen -
I'd like to express my admiration for you and my respect for Dr. [pdoc] of your Fairfield office. I could (and should) thank you for allowing Dr. [pdoc] to treat me _pro bono_ last year when my finances became nonexistent. If I may, allow me to defer those conversations for another time.
I've been looking for ways to make this story shorter yet at the same time clear and accurate.
This first telling will be a sort of an outline. Few dates. Some details omitted. I'll supply those the next time I tell the story. I'm going to start where the most recent events began and leave what preceded and followed them for later. I can supply those details and history, provide supporting documentation, and add other meaningful elements later. Please understand that this is by no means intended to convey the complete picture, but just a general overview of a relatively brief period of time (less than 6 months). Also, I'm a patient, not a doctor, so please forgive me if I get some of the terminology wrong.
The topic is the care Dr. [pdoc] provided me.
I like Dr. [pdoc] and (transference notwithstanding) I think he likes me. I wish I didn't have to say the following. And I say it not for dramatic effect, nor as an exercise in hyperbole. Dr. [pdoc]'s negligence nearly resulted in my death. It *did* result in the loss of several days of my life (and my wife's life), out-of-pocket expenses, pain and suffering, emotional distress, and whatever else a lawyer would add, but I *don't* want to get lawyers involved. I don't like lawyers very much. I am neither litigious nor avaricious (as, certainly, lawyers are). I don't want revenge or retribution. All I want is appropriate recompense. I want us to arrive at what is *appropriate* in an amicable way, not a contentious or adversarial one. I hope we can do that.
I should say before I begin that Dr. [pdoc]'s Progress Notes and the emails he and I exchanged support everything I say. To save me some work, you might ask for copies of those things from the Fairfield office (also note they haven't been able to find his Progress Notes sheet from 15 Oct 09, but he should be back in the office on Monday).
The abbreviated story:
1. I was suicidal. Dr. [pdoc] knew it. He put calls into my local sheriff's department and local hospital Emergency Psych services to explore using a 5150.
2. To the Lamictal he had put me on 3 years before, he added Abilify.
3. It drove my blood sugar sky high (I'm a diabetic), so he switched me to Lithium, to be (as his Progress Notes say) "a prophylactic against impulsive suicide." (20 Nov 09)
4. He intended to get me to 900mg QD, but (quite prudently) started me at 300mg BID.
5. After a while he ordered a Lithium blood level. The result was .9
6. He sent an email (and a copy of the lab results) saying there was no reason to increase the dosage; the level was fine on 300mg BID. .
7. I developed a suicidal ideation so strong that following a telephone interview one morning a month later he called in the 5150.
8. I was taken to a local county emergency psychiatric facility, where I stayed through the day and overnight.
Should I feel grateful that he was "looking out" for me and that he called in the 5150? Should I feel angry that I had put my life in his hands and he mismanaged my medication to the extent that I was having the strong suicidal feelings that led him to call in the 5150?
9. The psychiatrist with whom I met in the hospital the next day scoffed at the suggestion a 265-pound man could have a Lithium blood level of .9 on 300mg BID. [In fact, no other psychiatric professional with whom I've met (psychiatrists, psych nurses, or even psych techs), before or since talking with that psychiatrist in the county emergency facility, has had any other reaction than incredulity at the notion my ".9" blood level was possible at that dose. I said "scoff" earlier. It isn't a word I've found reason to use in as long as I can remember, but it describes their responses accurately.] It was at that point he explained the meaning of a "trough level" blood test.
10. +++Surprise interruption+++ The reason I hadn't heard about "trough level" tests, by that or any other name or description, is that Dr. [pdoc] never told me to get one. Never told me what it was. Never provided instructions about how to get one. So far as I know, until I told him what it was after my stay in the emergency psych hospital, he had never heard of it. One might infer that from his emails of 22 Jan 10. That seems unlikely, surely, but whether he knew or not, by his not telling me, the results were the same.
11. A different doctor, a few weeks later, told me to just increase to 900mg -- "You probably could take 1200, but start with 900 and get another test. A *trough* level this time."
12. So I increased to 300mg 2QD pm + 300 1QD am, a total of 900mg QD. (I only recently changed to it one dose/day, 300mg 3QD pm)
13. I took a trough level test (having the draw done BEFORE the morning dose). It was .5. The third psychiatrist with whom I met said that while .5 is lower than the usual .6(or sometimes .8) to 1.2 efficacious range quoted in the literature, based on my improvement, it may be that combining it with the Lamicatal made it effective. It was not recommended that I increase the dose, but rather that I seek CBT or (preferably) DBT.
14. Now I am neither a doctor nor a chemist nor a mathematician, but wouldn't you guess .5 on 900mg/day would be roughly 3.3 at 600mg/day?
15. I've been learning about Lithium. It's what I call a "Goldilocks and the 3 Bears" medication -- not a technical term, I know. Dose just a little too high, big problems -- maybe death of patient. Dose too low, it does nothing at all. Dose just right, prophylaxis against impulsive suicide.
16. I'm not certain of my medical terminology here, but I believe Dr. [pdoc] was prescribing to a patient with known suicidal ideation the equivalent of a placebo.
17. I'm lucky to be alive.
I haven't given extraneous details (at least, I hope, not many) and I have many more things to say. But here's the truth: If Dr. [pdoc] didn't know how to monitor and manage Lithium (i.e. ordering a trough level blood test), he shouldn't have been prescribing it. Whether he had no experience doing so or hadn't sufficient *recent* experience and had forgotten, prescribing it without knowing how was negligent. If he *did* know how to monitor and manage it, he needed to tell me (or write it down) to ensure the results were meaningful. In that case, not doing so was negligent. I'm sorry to have to say this, but in *any* event the negligence is real. The results are bad. The potential results were tragic.
I understand you have requested copies of the Progress Notes. I will send the emails, as well as a more detailed narrative, once you express an interest in reading them. Please, let's work this out.
I can tell you 3 of the 4 things I want now, I haven't yet figured out the details of the fourth, but can sketch them out in general.
A. I want you to pay my out-of pocket expenses associated with the 5150. Invoices from the County for their emergency psychiatric services, the ambulance company and the psychiatrist who saw me there total just slightly more than $3,000. (Available on request)
B. I want you to promise to discuss this matter with Dr. [pdoc] and take steps to prevent it happening again. I'm not asking you to fire him or demand he give up his license to practice medicine. I'm asking that you not allow him to prescribe medications with which he either isn't familiar or might choose not to educate his patients. What I'm saying is: I want you to look out for your patients' well-being.
C. I want you to have Dr. [pdoc] write me a letter of apology. Nothing elaborate of [note: this was a typo in the original email. It should say "OR humiliating"] humiliating; perhaps merely a note saying he's sorry he never (for whatever reason) told me to get a trough level Lithium blood test and he's sorry for the resulting consequences. He needn't elaborate on the specifics of those consequences. I will, of course, sign a release and a nondisclosure (or whatever is appropriate) when we conclude this matter.
D. The complex one. I want recompense for the days I lost in an emergency county psychiatric facility, as well as all the time I spent in follow-up meetings and sessions. I want something for my wife's time, as well. I want something for the pain and suffering and the long-term impact on my self-image and esteem. I want something for having to check the "Yes" box when asked about Psychiatric hospital treatment on future New Patient forms.
Part of that suffering is the weeks I spent where the last thought before I fell asleep, the first thought when I woke in the morning, and my thought every minute my mind wasn't occupied with something else during the day was of killing myself. Not so oddly enough, I haven't had those thoughts since my medication level became efficacious. Not once since February 10th. Even in the midst of my depression, when I was undermedicated, both before and after the 5150, I was able to write down a few of my ideas in support of suicide -- although I wasn't able to focus long enough to complete a treatise of any length. If you want to read them, I can send them to you. I have no interest in the subject; no interest in my writings any more. I literally cannot now imagine having those thoughts.
Nobody should have those feelings. Once Dr. [pdoc] began prescribing Lithium *specifically* to prevent them, I shouldn't have had them either.
Please get back to me.
Be well,
Rich Orwell
p.s. In the years before diabetes caused adhesive capsulitis, I used to be one heck of a table tennis player. Did you know when Tom Hanks was shown playing in the movie "Forest Gump" it was all "cgi" (computer generated)? A pity.
-------------------------------------------------
[his first reply]
Subject: RE: response
Date: Saturday, 3/27/2010
Dear Rich:
I am pleased you are doing better.
I feel sad that you are turning your anger against someone who sincerely tried to help you, without cost, because he cared about your well-being.
I have looked at Dr. [pdoc]'s notes, communicated with him on numerous occasions about your care, and feel that he did what he felt was appropriate for you. Dr. [pdoc] is an esteem [sic] psychiatrist and does not feel that any apologies are necessary or that you should receive any money from us. I concur with him, and will forward any more correspondence you send to my staff to our attorneys if you persist in asking for us to pay for your expenses of the 5150.
I hope you are receiving further care from professionals you trust.
I use a shake hands paddle grip, the pen holder grip never quite did it for me.
Warmest regards,
Daniel G. Amen, MD
-------------------------------------------------
Hmmmmmmmmm. "Pdoc did a good job. We will sic the attorneys on you."
Right.
-------------------------------------------------
[my 2nd email to him]
Subject: RE: response
Date: Saturday, 3/27/2010
Dear Dr. Amen -
First, it's an honor to "talk" with you (although I *hate* communicating via email).
Please look at this and send one more reply with a response to the question below.
How much spin may the server apply to the ping pong ball when dropping it?
OK, OK, that wasn't the question :)
I agree with everything you said about Dr. [pdoc] as s man and as a professional. I, too, hold him in high regard. He's an very intelligent man with eclectic tastes, as are you and (to a lesser extent) am I.
I am not "angry" at him.
I agree he did everything he reasonably could have done for me, and more, with one exception.
I can sum it up in one sentence: By relying on the meaningless results of the random Lithium level blood test he ordered instead of getting a TROUGH LEVEL test, he left in place a worsening suicidal ideation that he treated with the equivalent of a placebo.
So, here's my question. It concerns prescribing Lithium: To paraphrase what every other psychiatrist with whom I've spoken says, "Trough level blood tests are meaningful. Basing the dose you prescribe on any OTHER kind of blood test (random or peak level) is simply wrong." Please tell me, do you agree or disagree with those other doctors? I respect you and trust you will tell me the truth.
If you disagree, please say so and point me to somewhere I can read and learn to think along the lines you do.
If, despite what you believe is true about Lithium, your attorneys tell you not to make an admission that might hurt you, let me suggest an alternative. Instead of answering the question directly, why not ask me another question that sustains a dialog? If you've talked about me with Dr. [pdoc], he's probably told you I'm not a weasel. I'd like to put all this behind me.
Thank you for your good wishes. I, too, wish you well.
Rich
-------------------------------------------------
[his 2nd reply]
Subject: RE: response
Date: Saturday, 3/27/2010
No spin when you throw the ball. I don't drop it.
The lithium level is meaningful, trough or not, if you know what you are doing and depends on many different clinical factors. Your situation was complicated, as you likely remember and you were not being seen as you needed to be. He was trying to save your life.
Daniel
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[my 3rd email to him]
Subject: RE: response
Date: Saturday, 3/27/2010
Hello, Dr. Amen -
Thank you for your time.
I used to hit the ball out of my hand, but got busted for it. Apparently, one should toss or drop the ball a certain distance to demonstrate there's no initial spin on it. I also learned to play using sandpaper paddles. Kids today play with mattresses on their hands. Luckily, I stopped playing :)
Please understand that I *absolutely* believe Dr. [pdoc] was trying to save my life. A good man, a kind man, a caring man, a better man in many respects than I. I'm sorry to say, however, none of that is germane.
My understanding of the standard of care for Lithium is that one does not order a peak or random blood level to decide the appropriate dose. (I say this gently) I would rather he had found another psychotropic solution than use one improperly. I don't know how often I should have been seen. I know I was lucky to have been seen *at all* -- that was generous on your part and his. But when he initiated a protocol that requires monitoring, he took on an obligation to do it right. Isn't that so?
The problem is that in not monitoring the Lithium level correctly, while he may not have exacerbated my suicidal depression, he didn't help at all. That is demonstrated by the simple fact that a 300mg QD increase in Lithium after the 5150 completely eliminated the suicidal ideation.
Had he ordered a trough level test, it would have shown a reading of .3 -- the .9 he got 1 or 2 hours after my morning dose led him to the erroneous conclusion I had an efficacious level in my body. Seeing the .3, he surely would have increased the dosage and ordered another follow-up test.
The test was on 12/16/09. On 12/18/09 he sent this via email: "Your lithium levels are fine with the 600 mg. per day so there is no need to raise it at this time."
That simply wasn't true. The test he ordered by mistake was meaningless.
Whether he didn't *know* to order a trough level test or he just forgot to tell me doesn't matter. When you say, "The lithium level is meaningful, trough or not, ..." are you saying you would routinely order *other* than a trough level? If so, may I ask how often? Based on my (limited) conversations with psychiatrists and (rather extensive) research of the literature online, I can't believe you would (except in extraordinary situations, about which I haven't heard) do other than get trough level readings.
I hope you don't for a moment think I *like* to be saying these things. I do, however, think what I suffered shouldn't have happened. I think it was very preventable. Don't go running to the lawyers, but I think my seeking reasonable compensation for it is entirely appropriate.
Thank you,
Rich Orwell
p.s. If you want, you can put my name into YouTube to see a dozen or so short videos of me doing stand-up comedy on stage. I already have much longer videos of you on PBS.
Original psychology/psychiatry-oriented humor. I think I've only told the first one on stage:
Being bipolar is like buying a Peter Paul candy bar. Sometimes you feel like a nut; sometimes you just wanna f---ing kill yourself.
I prefer to pronounce it BIP-uhlar (sort of like Tripoli), because buy-PO-lar sounds too cold and clinical. BIP-uhlar sounds more, I don't know, *perky*, doncha think?
You can gauge a bipolar's mood by having him spit in a glass of water. If it sinks, he's depressed. If it floats, he's phlegm-buoyant."
Good advice: "Don't focus on the minutiae. Take it with a grain of gestalt."
Be well,
R.
-------------------------------------------------
It was at that point that he stopped sending replies.
-------------------------------------------------
[my 4th email (after the 3rd got no response)]
Subject: RE: response
Date: Monday, 3/29/2010
Good morning, Dr. Amen -
[It is difficult to build a friendship on the foundation of one man seeking money from the other. That's not a proverb; merely an observation. I wish we had met under different circumstances (although we probably did so briefly at some A.D.D. function 10 or 15 years ago).]
I've been thinking about what you wrote about Lithium levels.
May I ask you one more hypothetical question? "If you were presented a Lithium level reading, told the patient's current dose, and asked what dosage you'd recommend, would you ask how long before the test it had been since the patient's last dose?"
We all know the serum level varies dramatically over time. The standard of care in prescribing Lithium is the use of trough level tests.
You said, "The lithium level is meaningful, trough or not, if you know what you are doing and depends on many different clinical factors." If you don't know if you're looking at a trough, random or peak reading, just how meaningful is it? No matter what your levels of education, experience and expertise, I would contend you can't "know what you are doing" in that case.
Further, by not telling the patient specifically to get a trough test and not inquiring as to the timing of the patient's last dose relative to the test time, do you not run the risk of keeping the patient on a dose so low as to be essentially a placebo? That's exactly what happened to me. My test result was THREE TIMES what a trough level would have shown.
I have some good news. I've worked out a way you can pay me without admitting liability. You can buy my jokes to use in your books, speaking engagements, PBS appearances, etc. Here are some sample attributions you can use:
o Rich Orwell, A.D.D. Patient
o Rich Orwell, Comedian
o Rich Orwell, Friend
Or, you may use them without attribution. Simply pay what I will ask. This is not about extortion; this is about making me whole for out-of-pocket expenses, the cost of my time and my liberty, and the pain and suffering I experienced as a result of negligence.
You may be tempted to get lawyers involved (although not about the quality of the joke below). I hope you don't. While I am not a "tough guy" negotiator, I know my story would resonate with a jury.
Dr. [pdoc] is a very good man who wanted to save my life. He made a mistake that nearly ended it instead. I have no wish to see that aired in open court. I know in an adversarial court action you would risk far greater financial exposure than what I'll be asking. Let's skip it.
You may say, "What the heck, that's why we have malpractice insurance." Instead, why not ask what I want?
I look forward to hearing from you.
Be well,
Rich Orwell
-------------------------------------------------
[my 5th email (after the 3rd & 4th got no response)]
Subject: Goodbye for now, I suppose
Date: Monday, 3/29/2010
Hi, Dr. Amen -
I don't want to bother you any more than I have already, so this will be my last email unless you send a reply.
While I hoped to continue a dialog concerning the standard of care for prescribing Lithium, I understand if you consider it against your best interests to do so.
I rather had expected, though, some response to (the longer versions of) "Eskalith for bipolar bears", "A manic's spit floats because he's phlegm-buoyant" and "Take it with a grain of gestalt." Either rants or raves would have been welcome; it's rare for me to find an somebody who understands certain parts of my material. I do better in the Mensa humor groups.
Be well,
Rich
-------------------------------------------------
I want to comment on what he said in his 2nd reply on 3/27: "The lithium level is meaningful, trough or not, if you know what you are doing and depends on many different clinical factors."
I defy you to find another doctor who prescribes Lithium who will agree.
If I haven't talked about it already, let me make a simple statement: The Standard of Care (or "Standard of Practice") for prescribing Lithium is called Therapeutic Drug Monitoring (sometimes "Therapeutic Drug Management") -- TDM. It relies on the "trough level" blood test -- standardized as "12 hours after last dose" around the world. Every guideline specifies certain ranges of Lithium in blood to help determine therapeutic (efficacious) doses.
While it is true a doctor will take into account other aspects of a patient's health (such as age and kidney function) in determining how much Lithium to prescribe (and whether to prescribe it *at all*), I'm more than "pretty certain," after researching the subject for nearly 3 months, you won't find anybody who says anything but get "trough level tests."
I have to add one more thing, something I said in one of the 4th email I sent:
If you don't know if you're looking at a trough, random or peak reading, just how meaningful is it? No matter what your levels of education, experience and expertise, I would contend you can't "know what you are doing" in that case.
-------------------------------------------------
To call Dr. Amen, a man I honor and respect in almost any situation, a lying sack of s#$% would be rude, perhaps inappropriate. But Dr. Amen's pdoc is also his friend and Dr. Amen doesn't want to get sued. So, I'm sorry to say, in this case I believe "lying sack of s#$%" is appropriate, indeed.
And, by ignoring my request for a small amount of compensation, Dr. Amen has brought on himself a complaint to the state medical board and a big, fluffy malpractice suit. And I'll win.
Tuesday, May 25, 2010
Monday, May 17, 2010
Progress
It's taken a long time, but I'm finally getting close to filing a complaint with the California state medical board. After they censure my pdoc, I'll use their having taken action to support my malpractice lawsuit.
The bad news, of course, is if they don't finish their investigation in time, I'll need to file the malpractice suit without them.
The good news is that the preparation for the complaint will serve as perfect documentation for the malpractice attorney.
Hooray!
The bad news, of course, is if they don't finish their investigation in time, I'll need to file the malpractice suit without them.
The good news is that the preparation for the complaint will serve as perfect documentation for the malpractice attorney.
Hooray!
Wednesday, May 5, 2010
What do you get? Boney fingers.
There's a song out there someplace that says "What do you get if you work your fingers to the bone? Boney fingers."
And so I sit here, after working my fingers, etc. for several hours. I'm working on a complaint to my state medical board concerning the actions/inactions of my pdoc (my psychiatrist). I decided to post it here for two reasons: (1) I have nothing to hide and (2) I want an archive of my work available on the 'net in case my computer goes down.
Remember, this is a letter to the Medical Board of California.
---------------------------
You have a great deal more medical education, experience and expertise than I, but I don't know if you are a psychiatrist who has prescribed Lithium before. If so, please skip down to "My Story." If not, please don't be offended if I begin with an analogy, a children's story I hope you know called "Goldilocks and the Three Bears."
I have spent many hours in the last few months learning how psychiatrists prescribe Lithium. I know the story will be relevant.
In the story, Goldilocks first finds three bowls of porridge. She tries them, saying of each, "That's too hot," "That's too cold, “and "Just right." And then she finds three beds and when she tries them says, "That's too hard," "That's too soft," and "Just right." I actually don't remember how the rest of the story goes but I *do* know how it relates to prescribing Lithium.
You see, Lithium has a very narrow therapeutic range. If you prescribe a dose just a little too high, it's toxic -- perhaps fatally so. Most complaints and malpractice claims about Lithium involve giving patients overdoses of the drug. I'll discuss the Standard of Care to prevent overdosing below.
Prescribing too low a dose of Lithium, on the other hand, is like leaving a light switch in the "Off" position. Until you reach the threshold at which Lithium becomes therapeutic, and the switch changes to "On," it literally does nothing at all. Let me add the words "nada" and "zilch" for emphasis. Unlike some medications, there is no benefit at all if the patient takes a dose even a little bit too low.
Lithium is strange that way. Only the therapeutic dose is "Just right." Deciding the dose on the basis of body mass isn't a good idea. While "So many milligrams per kilo" is an effective guideline with many medications, how the body metabolizes Lithium varies among patients. When writing the first prescription for Lithium, psychiatrists don't start by aiming for a therapeutic dose; they start lower and use a protocol to build to it over a period of time.
I promised to tell you how a psychiatrist avoids overdosing a patient. It's the same way a psychiatrist avoids *under*dosing. It’s the method the psychiatrist uses to titrate the patient to a therapeutic dose: start low, test the level in the blood, increase if indicated, and repeat. This is called "Therapeutic Drug Monitoring" (TDM) -- sometimes called "Therapeutic Drug Management" -- and is the absolute standard in prescribing Lithium. I will explain a good deal more about TDM below but the key elements of the procedure are (1) the frequency of tests and (2) the nature of the tests the psychiatrist orders.
My Story
------------
My Story will consist of the following 5 elements: (1) my recollection of events, (2) emails my psychiatrist and I exchanged, (3) "Progress Notes" he wrote during and after each session, (4) the paraphrased statements of other psychiatric professionals I have seen (and contact information for them), and (5) miscellaneous other things to complete the picture (such as Medication Information Sheets on Lithium, lab slips and lab results). Everything I'll be saying is absolutely true.
I'm sorry if I will sometimes use the wrong medical terminology or syntax, but this is not my area of expertise. I hope you will bear with me and understand the points I'm trying to make. I apologize, as well, for the length of the narrative. I wanted to be thorough.
Along the way, I will state what my research has shown to be universally accepted medical facts, practices and standards. While I will provide a few supporting citations, the number of citations will by no means be exhaustive, merely definitive. If you need more verification, please ask a psychiatrist, read peer-reviewed journals (of psychiatry, pharmacology, therapeutics) from this country or anywhere abroad, consult the NIH, or take whatever steps you like to confirm what I say is, in fact, accepted both in the USA and around the world.
What you will find below is that my psychiatrist, Dr. XXX of the Amen Clinic in Fairfield, California, completely violated the Standard of Care with regard to prescribing Lithium. He attempted to intervene in my suicidal depression by prescribing Lithium, but botched the "TDM" protocol I will describe in two significant ways that allowed me to be undermedicated. I took the equivalent of a placebo for nearly two months. I hope I needn't point out that prescribing a placebo as medication to treat a suicidal patient is *not* indicated.
The results were devastating. I am lucky to be alive.
I say this neither to be dramatic nor to employ hyperbole. You will see an easily demonstrable and incontrovertible fact; Dr. XXX's actions and inactions nearly cost me my life. Such negligence should neither be sanctioned nor condoned. It should not, in fact, be allowed. Under similar circumstances, another patient might die.
=====================
In the scheme of things, this seems like a small point, but I'm angry about it.
I brought my wife with me to Fairfield on DATE. She sat in the waiting area for the first ### minutes while I met with Dr. XXX, then he and I asked her to join us. Almost the first words he said concerned my desire to commit suicide. My wife knew I had been severely depressed but I had never told her I was considering suicide. In my mind, telling her would have been overly dramatic, or cruel, or impolite. It had never crossed my mind to discuss the subject with her. Sharing that information, when she could do nothing to help, to my way of thinking, was just *wrong.* Those thoughts and feelings were reserved for my psychiatrist, who would hold them in confidence. It took Dr. XXX about 5 seconds to violate that confidence.
Although she did her best to hide her reaction, in our car driving home she told me she had been unpleasantly surprised and saddened to hear the news. And I will admit to being surprised, as well. While I *may* have signed a consent form authorizing Dr. XXX to violate my confidentiality, I certainly don't remember having done so.
Isn't some large, mostly herbivorous, semi-aquatic mammal supposed to protect a patient's privacy? (The Hippo or something?)
Unless Dr. XXX can produce something I signed to the effect that he could share with my spouse things I had said to him within the bounds of doctor-patient privilege and with the expectation of confidentiality, I think his having violated my privacy warrants censure, at least. I'll leave that up to you.
=====================
Therapeutic Drug Monitoring [or "Therapeutic Drug Management"] (TDM) of Lithium
----------------------------------------------------------
As we've heard, a dosage of Lithium only slightly above the therapeutic level is toxic, perhaps deadly. So TDM is the standard method of insuring safety and efficacy. Here are the steps:
1. Start with a low dose.
2. A few days later, when the patient's body has had time to stabilize to that dose, test the serum blood level of Lithium.
3. If the level is less than therapeutic (according to widely published standards, but adjusted by the doctor's clinical observation of the patient and the patient's feedback), increase it.
4. Repeat steps 2 and 3 until a therapeutic level is reached.
5. Keep patient on that dose, monitoring every few months.
The key points are:
A. Don't wait too long after beginning at any given dose before testing. This is especially true if your intention is to prevent suicide. Obviously, the soonest practicable timeframe to reach efficacy is desirable. A suicidal patient ought not wait for whatever benefit Lithium at a therapeutic level provides. You needn't be hasty, but be prudent about it.
A steady-state level is widely accepted to be achieved within a period of 4-5 days. That’s when to test.
B. The level upon which any change of dosage is determined is universally known to be a "trough level" reading. What does that mean and why is it so? Because you don't want a random number and you *certainly* don't want a peak number (reflecting the spike in that follows the patient ingesting the medication). The *only* level you should consider is the trough level, which is obtained by having the patient take his/her evening dose, wait 12 hours after the evening dose, then get the blood work done *before* his/her morning dose.
After reading vast amounts of information available on the Internet (not on the blog of some bipolar patient, mind you, but articles from universities, medical journals, professional associations, textbooks, clinical guidelines and the like), let me sum it up this way: I can provide you with hundreds, perhaps thousands, of citations that attest to trough level blood testing being the standard for TDM and TDM being the standard for prescribing Lithium.
=============================
I've been considering possible reasons why Dr. XXX didn't tell me to get a "trough level" test. Try as I might, I can think of only three.
Reason #1. He had never prescribed Lithium before. In that admittedly unlikely event, he would have to gather prescribing information from various sources. The epocrates information sheets he gave me were intended for patients, not doctors, but they never mentioned "trough level" blood tests. I think, at the very least, he would have consulted journals of psychiatry and/or pharmacology before writing a prescription. Certainly the protocol for TDM would be mentioned in those publications. If, of course, he wrote a prescription without knowing the protocol for establishing an efficacious dosage, he was seriously negligent, but I find this difficult to believe.
Reason #2. The same is true if he *had* prescribed Lithium before, but it had so long ago that he forgot the correct procedure. Again, if he didn't knowing how, he shouldn't have been prescribing. Doing so would have been negligent. But, again, I find this possibility hard to believe.
I am obliged, however, to mention that you will see emails he and I exchanged following my 5150 stay, from which a reasonable man might infer he *didn't* know about the trough level TDM protocol. There are a few ways to interpret them, but some interpretations are disturbing.
Reasons #1 and #2, above, seem particularly unlikely because Bipolar Disorders and Depressive Disorders are common comorbidities of ADHD. Dr. XXX works at a clinic specifically known for treating patients who go there because they have ADHD. While I haven't asked, I should think Lithium is a medication that would be prescribed frequently at his clinic. In fact, the customized lab slip he sent to me following my 5150 experience of January 19-20 had a pre-printed box just for Lithium Level, so one would think it is a test they would order regularly.
[One *might* interpret the emails he and I exchanged immediately following the 5150 to mean he had no clue how to prescribe Lithium. That interpretation, however, is only one of many that are possible. When we get there, I’ll let you decide.]
Which leaves us with only Reason #3.
Reason #3. He simply forgot to tell me what a trough level test is and that I should get one. I suppose I'd be more concerned if #1 or #2 were true. A prescribing physician not knowing what he's doing would be an alarming state of affairs. The possibility of simply forgetting to tell me, however, is also very disturbing. He knew I was seriously suicidal. This was, very much, a "life or death" situation. We discussed Lithium (in his office???),(via XXX emails), he sent me a lab slip that said nothing about trough level testing. In short, there were many, many times he could simply have said, "Take your evening dose, then wait 12 hours before the test, but before your morning dose."
If establishing the correct dose was critical to my staying alive, why wasn't he concerned about getting the blood work right? And why wasn't he concerned about getting it right *right away*?
And so I sit here, after working my fingers, etc. for several hours. I'm working on a complaint to my state medical board concerning the actions/inactions of my pdoc (my psychiatrist). I decided to post it here for two reasons: (1) I have nothing to hide and (2) I want an archive of my work available on the 'net in case my computer goes down.
Remember, this is a letter to the Medical Board of California.
---------------------------
You have a great deal more medical education, experience and expertise than I, but I don't know if you are a psychiatrist who has prescribed Lithium before. If so, please skip down to "My Story." If not, please don't be offended if I begin with an analogy, a children's story I hope you know called "Goldilocks and the Three Bears."
I have spent many hours in the last few months learning how psychiatrists prescribe Lithium. I know the story will be relevant.
In the story, Goldilocks first finds three bowls of porridge. She tries them, saying of each, "That's too hot," "That's too cold, “and "Just right." And then she finds three beds and when she tries them says, "That's too hard," "That's too soft," and "Just right." I actually don't remember how the rest of the story goes but I *do* know how it relates to prescribing Lithium.
You see, Lithium has a very narrow therapeutic range. If you prescribe a dose just a little too high, it's toxic -- perhaps fatally so. Most complaints and malpractice claims about Lithium involve giving patients overdoses of the drug. I'll discuss the Standard of Care to prevent overdosing below.
Prescribing too low a dose of Lithium, on the other hand, is like leaving a light switch in the "Off" position. Until you reach the threshold at which Lithium becomes therapeutic, and the switch changes to "On," it literally does nothing at all. Let me add the words "nada" and "zilch" for emphasis. Unlike some medications, there is no benefit at all if the patient takes a dose even a little bit too low.
Lithium is strange that way. Only the therapeutic dose is "Just right." Deciding the dose on the basis of body mass isn't a good idea. While "So many milligrams per kilo" is an effective guideline with many medications, how the body metabolizes Lithium varies among patients. When writing the first prescription for Lithium, psychiatrists don't start by aiming for a therapeutic dose; they start lower and use a protocol to build to it over a period of time.
I promised to tell you how a psychiatrist avoids overdosing a patient. It's the same way a psychiatrist avoids *under*dosing. It’s the method the psychiatrist uses to titrate the patient to a therapeutic dose: start low, test the level in the blood, increase if indicated, and repeat. This is called "Therapeutic Drug Monitoring" (TDM) -- sometimes called "Therapeutic Drug Management" -- and is the absolute standard in prescribing Lithium. I will explain a good deal more about TDM below but the key elements of the procedure are (1) the frequency of tests and (2) the nature of the tests the psychiatrist orders.
My Story
------------
My Story will consist of the following 5 elements: (1) my recollection of events, (2) emails my psychiatrist and I exchanged, (3) "Progress Notes" he wrote during and after each session, (4) the paraphrased statements of other psychiatric professionals I have seen (and contact information for them), and (5) miscellaneous other things to complete the picture (such as Medication Information Sheets on Lithium, lab slips and lab results). Everything I'll be saying is absolutely true.
I'm sorry if I will sometimes use the wrong medical terminology or syntax, but this is not my area of expertise. I hope you will bear with me and understand the points I'm trying to make. I apologize, as well, for the length of the narrative. I wanted to be thorough.
Along the way, I will state what my research has shown to be universally accepted medical facts, practices and standards. While I will provide a few supporting citations, the number of citations will by no means be exhaustive, merely definitive. If you need more verification, please ask a psychiatrist, read peer-reviewed journals (of psychiatry, pharmacology, therapeutics) from this country or anywhere abroad, consult the NIH, or take whatever steps you like to confirm what I say is, in fact, accepted both in the USA and around the world.
What you will find below is that my psychiatrist, Dr. XXX of the Amen Clinic in Fairfield, California, completely violated the Standard of Care with regard to prescribing Lithium. He attempted to intervene in my suicidal depression by prescribing Lithium, but botched the "TDM" protocol I will describe in two significant ways that allowed me to be undermedicated. I took the equivalent of a placebo for nearly two months. I hope I needn't point out that prescribing a placebo as medication to treat a suicidal patient is *not* indicated.
The results were devastating. I am lucky to be alive.
I say this neither to be dramatic nor to employ hyperbole. You will see an easily demonstrable and incontrovertible fact; Dr. XXX's actions and inactions nearly cost me my life. Such negligence should neither be sanctioned nor condoned. It should not, in fact, be allowed. Under similar circumstances, another patient might die.
=====================
In the scheme of things, this seems like a small point, but I'm angry about it.
I brought my wife with me to Fairfield on DATE. She sat in the waiting area for the first ### minutes while I met with Dr. XXX, then he and I asked her to join us. Almost the first words he said concerned my desire to commit suicide. My wife knew I had been severely depressed but I had never told her I was considering suicide. In my mind, telling her would have been overly dramatic, or cruel, or impolite. It had never crossed my mind to discuss the subject with her. Sharing that information, when she could do nothing to help, to my way of thinking, was just *wrong.* Those thoughts and feelings were reserved for my psychiatrist, who would hold them in confidence. It took Dr. XXX about 5 seconds to violate that confidence.
Although she did her best to hide her reaction, in our car driving home she told me she had been unpleasantly surprised and saddened to hear the news. And I will admit to being surprised, as well. While I *may* have signed a consent form authorizing Dr. XXX to violate my confidentiality, I certainly don't remember having done so.
Isn't some large, mostly herbivorous, semi-aquatic mammal supposed to protect a patient's privacy? (The Hippo or something?)
Unless Dr. XXX can produce something I signed to the effect that he could share with my spouse things I had said to him within the bounds of doctor-patient privilege and with the expectation of confidentiality, I think his having violated my privacy warrants censure, at least. I'll leave that up to you.
=====================
Therapeutic Drug Monitoring [or "Therapeutic Drug Management"] (TDM) of Lithium
----------------------------------------------------------
As we've heard, a dosage of Lithium only slightly above the therapeutic level is toxic, perhaps deadly. So TDM is the standard method of insuring safety and efficacy. Here are the steps:
1. Start with a low dose.
2. A few days later, when the patient's body has had time to stabilize to that dose, test the serum blood level of Lithium.
3. If the level is less than therapeutic (according to widely published standards, but adjusted by the doctor's clinical observation of the patient and the patient's feedback), increase it.
4. Repeat steps 2 and 3 until a therapeutic level is reached.
5. Keep patient on that dose, monitoring every few months.
The key points are:
A. Don't wait too long after beginning at any given dose before testing. This is especially true if your intention is to prevent suicide. Obviously, the soonest practicable timeframe to reach efficacy is desirable. A suicidal patient ought not wait for whatever benefit Lithium at a therapeutic level provides. You needn't be hasty, but be prudent about it.
A steady-state level is widely accepted to be achieved within a period of 4-5 days. That’s when to test.
B. The level upon which any change of dosage is determined is universally known to be a "trough level" reading. What does that mean and why is it so? Because you don't want a random number and you *certainly* don't want a peak number (reflecting the spike in that follows the patient ingesting the medication). The *only* level you should consider is the trough level, which is obtained by having the patient take his/her evening dose, wait 12 hours after the evening dose, then get the blood work done *before* his/her morning dose.
After reading vast amounts of information available on the Internet (not on the blog of some bipolar patient, mind you, but articles from universities, medical journals, professional associations, textbooks, clinical guidelines and the like), let me sum it up this way: I can provide you with hundreds, perhaps thousands, of citations that attest to trough level blood testing being the standard for TDM and TDM being the standard for prescribing Lithium.
=============================
I've been considering possible reasons why Dr. XXX didn't tell me to get a "trough level" test. Try as I might, I can think of only three.
Reason #1. He had never prescribed Lithium before. In that admittedly unlikely event, he would have to gather prescribing information from various sources. The epocrates information sheets he gave me were intended for patients, not doctors, but they never mentioned "trough level" blood tests. I think, at the very least, he would have consulted journals of psychiatry and/or pharmacology before writing a prescription. Certainly the protocol for TDM would be mentioned in those publications. If, of course, he wrote a prescription without knowing the protocol for establishing an efficacious dosage, he was seriously negligent, but I find this difficult to believe.
Reason #2. The same is true if he *had* prescribed Lithium before, but it had so long ago that he forgot the correct procedure. Again, if he didn't knowing how, he shouldn't have been prescribing. Doing so would have been negligent. But, again, I find this possibility hard to believe.
I am obliged, however, to mention that you will see emails he and I exchanged following my 5150 stay, from which a reasonable man might infer he *didn't* know about the trough level TDM protocol. There are a few ways to interpret them, but some interpretations are disturbing.
Reasons #1 and #2, above, seem particularly unlikely because Bipolar Disorders and Depressive Disorders are common comorbidities of ADHD. Dr. XXX works at a clinic specifically known for treating patients who go there because they have ADHD. While I haven't asked, I should think Lithium is a medication that would be prescribed frequently at his clinic. In fact, the customized lab slip he sent to me following my 5150 experience of January 19-20 had a pre-printed box just for Lithium Level, so one would think it is a test they would order regularly.
[One *might* interpret the emails he and I exchanged immediately following the 5150 to mean he had no clue how to prescribe Lithium. That interpretation, however, is only one of many that are possible. When we get there, I’ll let you decide.]
Which leaves us with only Reason #3.
Reason #3. He simply forgot to tell me what a trough level test is and that I should get one. I suppose I'd be more concerned if #1 or #2 were true. A prescribing physician not knowing what he's doing would be an alarming state of affairs. The possibility of simply forgetting to tell me, however, is also very disturbing. He knew I was seriously suicidal. This was, very much, a "life or death" situation. We discussed Lithium (in his office???),(via XXX emails), he sent me a lab slip that said nothing about trough level testing. In short, there were many, many times he could simply have said, "Take your evening dose, then wait 12 hours before the test, but before your morning dose."
If establishing the correct dose was critical to my staying alive, why wasn't he concerned about getting the blood work right? And why wasn't he concerned about getting it right *right away*?
Friday, April 23, 2010
Details, I promise
I promise to provide all the details to support my allegations. As I said, I have the emails my pdoc (psychiatrist) and I exchanged, the emails between me and Dr. Amen, my pdoc's Progress Notes (from each time I spoke with him), lab slips and lab results. Everything to prove, in no uncertain terms, that the care I received nearly caused my death.
It continues, however, to stick in my craw that Dr. Amen would make so specious an argument to explain away the harm that was done me as "[Your psychiatrist] was trying to save your life." I will continue to explain what happened until nobody can be unclear on the chain of events and where the blame squarely rests. Here is the abbreviated, yet entirely accurate, version.
1. I told my pdoc I was feeling suicidal. He listened and agrees.
2. He put me on Lithium, telling me nothing about it other than it's been around a long time and is coming back into favor among pdocs.
3. While he *should* have had my serum blood level of Lithium tested within a few days of starting to take the medication, he waits more than 2 weeks.
4. He neglected to tell me to get a "trough level" test -- a test 12 hours after the evening dose but before the morning dose. That would be a "low" test during the day. Knowing no better, I had the test one or two hours after the morning dose, a "peak level" reading that (as it turns out) was THREE TIMES what the trough level result would have been.
5. Unaware he had botched the ordering of the test (and that is the *generous* interpretation -- it's possible he simply didn't *know* he should be getting and evaluating trough level readings), he sent me an email and a copy of those meaningless lab results and said, "No need to increase the dose. Everything's fine." (Again, I'll provide the exact words later.)
6. Roughly a month went by, during which I was miserable and contemplating my death every waking moment of every day. If I had access to a little money and a car, so I could exit this life with dignity, the way I wanted, I'd be dead now.
7. My pdoc and I had a regularly scheduled phone talk. He recognized my situation was dire and called the cops. They took me away to a County emergency psychiatric facility on a 72 hour involuntary hold (suicide evaluation).
8. A psychiatrist in the facility told me the lab result I quoted to him (because I had memorized it when my own pdoc sent it to me), had to be wrong. The reading was inconsistent with the low dose I was taking. It was he who explained "trough level" and "peak level" blood tests.
9. I proceeded to go (with my long-suffering wife) to several more mandatory meetings with county psychiatrists, one of whom said, "Don't wait to increase your dose. Get a new blood test LATER. Increase it!"
And so I did. And here I am. No thanks to the psychiatrist Dr. Amen employed.
I need to provide a small piece of technical information, so you'll understand the story above.
- Lithium at too high a dose is toxic, perhaps lethal.
- Lithium at loo low a dose does NOTHING AT ALL. It's as though you aren't even taking it.
- Lithium at a "therapeutic dose" is like throwing a switch. It goes from having NO effect to having efficacious effects.
The "standard of care" -- the accepted medical practice -- the protocol for prescbribing Lithium involves "therapeutic drug monitoring." Start the patient on a low dose, wait a few days for it to stabilize in the patient's system, take a trough level blood test, increase the dose if indicated. There is certainly more to it, such as evaluating the patient's other medical conditions and *asking* how the patient is doing, essentially all the other things we want doctors to do for us.
What we *don't* want is for a doctor to base his decision about whether or not to increase the dose of medication on a test he ordered wrong and the results of which are so *completely* wrong as to leave the patient absolutely without any benefit from the medication prescribed.
- If he didn't know the protocol for prescribing Lithium, he should not have done it. Negligence.
- If he had once known the protocol for prescribing Lithium but had forgotten it, he should not have done prescribed it. Negligence.
- If he simply forgot to tell me to get a trough level test -- and let me interrupt to say that he and I had mutual respect and he had always kept me fully informed about my treatment -- then that verges on criminal negligence. He didn't invest the time I took to explain to you what a "trough level" test is. What was that, 10 seconds typing slowly?
I've said I only want money damages from Dr. Amen for my pain and suffering.
Fuck that. I'm going after my pdoc's license.
It continues, however, to stick in my craw that Dr. Amen would make so specious an argument to explain away the harm that was done me as "[Your psychiatrist] was trying to save your life." I will continue to explain what happened until nobody can be unclear on the chain of events and where the blame squarely rests. Here is the abbreviated, yet entirely accurate, version.
1. I told my pdoc I was feeling suicidal. He listened and agrees.
2. He put me on Lithium, telling me nothing about it other than it's been around a long time and is coming back into favor among pdocs.
3. While he *should* have had my serum blood level of Lithium tested within a few days of starting to take the medication, he waits more than 2 weeks.
4. He neglected to tell me to get a "trough level" test -- a test 12 hours after the evening dose but before the morning dose. That would be a "low" test during the day. Knowing no better, I had the test one or two hours after the morning dose, a "peak level" reading that (as it turns out) was THREE TIMES what the trough level result would have been.
5. Unaware he had botched the ordering of the test (and that is the *generous* interpretation -- it's possible he simply didn't *know* he should be getting and evaluating trough level readings), he sent me an email and a copy of those meaningless lab results and said, "No need to increase the dose. Everything's fine." (Again, I'll provide the exact words later.)
6. Roughly a month went by, during which I was miserable and contemplating my death every waking moment of every day. If I had access to a little money and a car, so I could exit this life with dignity, the way I wanted, I'd be dead now.
7. My pdoc and I had a regularly scheduled phone talk. He recognized my situation was dire and called the cops. They took me away to a County emergency psychiatric facility on a 72 hour involuntary hold (suicide evaluation).
8. A psychiatrist in the facility told me the lab result I quoted to him (because I had memorized it when my own pdoc sent it to me), had to be wrong. The reading was inconsistent with the low dose I was taking. It was he who explained "trough level" and "peak level" blood tests.
9. I proceeded to go (with my long-suffering wife) to several more mandatory meetings with county psychiatrists, one of whom said, "Don't wait to increase your dose. Get a new blood test LATER. Increase it!"
And so I did. And here I am. No thanks to the psychiatrist Dr. Amen employed.
I need to provide a small piece of technical information, so you'll understand the story above.
- Lithium at too high a dose is toxic, perhaps lethal.
- Lithium at loo low a dose does NOTHING AT ALL. It's as though you aren't even taking it.
- Lithium at a "therapeutic dose" is like throwing a switch. It goes from having NO effect to having efficacious effects.
The "standard of care" -- the accepted medical practice -- the protocol for prescbribing Lithium involves "therapeutic drug monitoring." Start the patient on a low dose, wait a few days for it to stabilize in the patient's system, take a trough level blood test, increase the dose if indicated. There is certainly more to it, such as evaluating the patient's other medical conditions and *asking* how the patient is doing, essentially all the other things we want doctors to do for us.
What we *don't* want is for a doctor to base his decision about whether or not to increase the dose of medication on a test he ordered wrong and the results of which are so *completely* wrong as to leave the patient absolutely without any benefit from the medication prescribed.
- If he didn't know the protocol for prescribing Lithium, he should not have done it. Negligence.
- If he had once known the protocol for prescribing Lithium but had forgotten it, he should not have done prescribed it. Negligence.
- If he simply forgot to tell me to get a trough level test -- and let me interrupt to say that he and I had mutual respect and he had always kept me fully informed about my treatment -- then that verges on criminal negligence. He didn't invest the time I took to explain to you what a "trough level" test is. What was that, 10 seconds typing slowly?
I've said I only want money damages from Dr. Amen for my pain and suffering.
Fuck that. I'm going after my pdoc's license.
Thursday, April 22, 2010
Here's what I wanted
As I said, Dr. Amen sent me 2 emails in response to those I sent to him. After (briefly) explaining what had happened, I asked him to do 4 things: (1) have a talk with my pdoc (psychiatrist), explaining the standard of care and therapeutic drug monitoring of Lithium -- so no more patients would be put at risk, (2) have the pdoc write a letter of apology to me for putting me through a life-threatening situation, (3) pay my out-of-pocket expenses (slightly more than $3,000) for the ambulance and county emergency psychiatric hospital stay I had to endure as a result of my pdoc's grossly ineffective and negligent treatment of my depression, and (4) make me an offer for what value he would place on the days out of my life I spent involuntarily confined, the days I spent subsequently going through the county's follow-on psych treatment, and (most importantly) the weeks of constant torment I experienced before and after the hospital stay until I found a new pdoc who said, 'Sure, increase your Lithium dose from 600mg to 900mg each day."
That, gentle reader, was all it took to climb out of the depths of despair and re-enter the realm of the living.
Now it wasn't as though ANY psychiatric professional (nurses, technicians) I met thought it possible that I had the blood level I told them I'd seen on 600mg. They all SCOFFED at the possibility. They assumed there must have been an error because they assumed, of course, the result I was reporting was from a trough level test -- remember, NOBODY orders anything but a trough level test. And then I met with an actual pdoc in the county facility. After he finished scoffing, he asked about the time of day I had the test. It was at that moment I learned about "trough level" and the Lithium protocol.
I had hoped Dr. Amen would have made an appropriate settlement offer. I had, after all, promised to sign a confidentiality agreement in exchange. And I appreciate that he has financial exposure here. He certainly doesn't want any admissions of culpability running around.
Perhaps it wasn't fair of me to say, "Make me an offer." Maybe I should have proposed an amount. There's an old saying in negotiation, "He who speaks first, loses." Had he been prepared to offer more than I wanted, I would have been reducing what I received. I think, as well, I wanted to see what value he placed on my life and my happiness. I haven't added up all the days, but I know it was more than TWO MONTHS of constant misery that I suffered as a direct result of his doctor mishandling my medication.
If it comes to a medical malpractice trial, I will march pdocs onto the stand until the judge and jury shout, "Enough!"
And so, what did Dr. Amen offer? He stopped communicating with me.
And now I must do 2 things: (1) look for a malpractice attorney who sees a large enough potential judgment to justify taking the case, and (2) via this blog make sure the world knows what the Amen Clinics did, such that I nearly died.
Much more to follow.
That, gentle reader, was all it took to climb out of the depths of despair and re-enter the realm of the living.
Now it wasn't as though ANY psychiatric professional (nurses, technicians) I met thought it possible that I had the blood level I told them I'd seen on 600mg. They all SCOFFED at the possibility. They assumed there must have been an error because they assumed, of course, the result I was reporting was from a trough level test -- remember, NOBODY orders anything but a trough level test. And then I met with an actual pdoc in the county facility. After he finished scoffing, he asked about the time of day I had the test. It was at that moment I learned about "trough level" and the Lithium protocol.
I had hoped Dr. Amen would have made an appropriate settlement offer. I had, after all, promised to sign a confidentiality agreement in exchange. And I appreciate that he has financial exposure here. He certainly doesn't want any admissions of culpability running around.
Perhaps it wasn't fair of me to say, "Make me an offer." Maybe I should have proposed an amount. There's an old saying in negotiation, "He who speaks first, loses." Had he been prepared to offer more than I wanted, I would have been reducing what I received. I think, as well, I wanted to see what value he placed on my life and my happiness. I haven't added up all the days, but I know it was more than TWO MONTHS of constant misery that I suffered as a direct result of his doctor mishandling my medication.
If it comes to a medical malpractice trial, I will march pdocs onto the stand until the judge and jury shout, "Enough!"
And so, what did Dr. Amen offer? He stopped communicating with me.
And now I must do 2 things: (1) look for a malpractice attorney who sees a large enough potential judgment to justify taking the case, and (2) via this blog make sure the world knows what the Amen Clinics did, such that I nearly died.
Much more to follow.
Wednesday, April 21, 2010
No good deed, etc.
They say "No good deed goes unpunished."
I've received two email responses from the esteemed Doctor Amen concerning this situation. He said (to paraphrase) "an experienced doctor can interpret results" -- which is, as I've said, complete bullshit -- because if that same experienced doctor doesn't know he's looking at peak level results instead of trough level results, he has no *clue* what he's seeing. He also said (paraphrasing again), "Your pdoc (psychiatrist) was trying to save your life."
And so he was. A kind, caring, generous man who was seeing me (with Dr. Amen's agreement) "pro bono" -- for free. A significant part of my depression was a downturn in my wife's and my finances. I won't get into that now. But I had sent emails to my pdoc saying I could no longer afford to see him. He called me out of the blue one day to tell me he'd gotten approval from Dr. Amen to see me at no charge. There's more to that part of the story, but it begs the question: Am I entitled to feel as though I was violated when the doctor was providing services for free and was seriously trying to help?
I have an unequivocal answer, "Hell yes."
Should his good intentions excuse his life-threatening negligence? I say, "Hell no."
He's a good man. A experienced, talented and caring man. A better man than I in many ways. Despite all that, he made a simple mistake. His negligent act violated the standard of care in prescribing Lithium. When I say, "I'm lucky to be alive", I'm completely serious. And any objective pdoc (psychiatrist) reviewing the history of my case would agree.
He intervened in a life and death situation and began treatment. A good thing. Unfortunately he didn't follow through with the protocol for establishing a therapeutic dose. He ended up doing no good at all (and, some would argue, made it worse).
I like him. He tried to do a good thing. He fucked up. I could be dead right now. What more can I say? In my place, how would YOU feel?
I've received two email responses from the esteemed Doctor Amen concerning this situation. He said (to paraphrase) "an experienced doctor can interpret results" -- which is, as I've said, complete bullshit -- because if that same experienced doctor doesn't know he's looking at peak level results instead of trough level results, he has no *clue* what he's seeing. He also said (paraphrasing again), "Your pdoc (psychiatrist) was trying to save your life."
And so he was. A kind, caring, generous man who was seeing me (with Dr. Amen's agreement) "pro bono" -- for free. A significant part of my depression was a downturn in my wife's and my finances. I won't get into that now. But I had sent emails to my pdoc saying I could no longer afford to see him. He called me out of the blue one day to tell me he'd gotten approval from Dr. Amen to see me at no charge. There's more to that part of the story, but it begs the question: Am I entitled to feel as though I was violated when the doctor was providing services for free and was seriously trying to help?
I have an unequivocal answer, "Hell yes."
Should his good intentions excuse his life-threatening negligence? I say, "Hell no."
He's a good man. A experienced, talented and caring man. A better man than I in many ways. Despite all that, he made a simple mistake. His negligent act violated the standard of care in prescribing Lithium. When I say, "I'm lucky to be alive", I'm completely serious. And any objective pdoc (psychiatrist) reviewing the history of my case would agree.
He intervened in a life and death situation and began treatment. A good thing. Unfortunately he didn't follow through with the protocol for establishing a therapeutic dose. He ended up doing no good at all (and, some would argue, made it worse).
I like him. He tried to do a good thing. He fucked up. I could be dead right now. What more can I say? In my place, how would YOU feel?
Take wrong test results and add water ...
OK. OK. Water wasn't involved. But wrong test results certainly were.
When my pdoc (psychiatrist) didn't specifically order a "trough level" blood test (a test done 12 hours after my evening dose of medication but before my morning dose). he could have gotten *any* blood level. The "12 hour" thing allows the body to get to its lowest level of Lithium in the system. On th other hand is what he actually got. A test run 1 to 2 hours after my morning dose. A so-called "peak level" test. The highest possible test result I woulkd ever have during the day.
Now, what I've said before is that there is no value at all to "random level" or "peak level" test results. The ONLY test results used by doctors to determine if a therapeutic level of Lithium has been reached is the "trough level" test. This isn't my *opinion*. It is accepted scientific fact. A doctor who tells you in this context that "any lithium level is significant" is a lying sack of shit. And I mean that in the nicest possible way.
What's far worse than knowingly attempting to interpret peak level test results in providing patient care is what my pdoc did. He *didn't know* he was looking at peak level readings, because he hadn't specifically ordered trough level readings. He actually thought the ".9" result the test result showed was a trough level reading -- which would have meant the dose I was taking was the correct one. As I later learned from having the correct troough level test taken on a higher dose, a trough level test WOULD have shown a result of ".3" -- a result indicating I was getting no benefit whatsoever from the dose he had prescribed.
By not ordering the right test, yet interpreting the results as though he HAD, my doctor left me dangerously undermedicated at a time when I was suicidally depressed. What he did was the equivalent of nothing. Worse than nothing, in fact, because he told me the dose I was taking was fine when every day I was walking closer and closer to death.
To sum up. While there may be more instances of medical malpractice, the two that stand out are (1) waiting too many days after beginning Lithium therapy to order the first blood test and (2) ordering it in such a way that the results were not trough level results (and, in fact, turned out to be peak level results). His misinterpretation of the results might be excused. If he truly believed he had ordered the test correctly, than his interpretation of the results would have been appropriate. Of course, he *didn't* order the test correctly, so his interpretation of the results put my life at risk.
Am I being ungrateful? Read the next post.
When my pdoc (psychiatrist) didn't specifically order a "trough level" blood test (a test done 12 hours after my evening dose of medication but before my morning dose). he could have gotten *any* blood level. The "12 hour" thing allows the body to get to its lowest level of Lithium in the system. On th other hand is what he actually got. A test run 1 to 2 hours after my morning dose. A so-called "peak level" test. The highest possible test result I woulkd ever have during the day.
Now, what I've said before is that there is no value at all to "random level" or "peak level" test results. The ONLY test results used by doctors to determine if a therapeutic level of Lithium has been reached is the "trough level" test. This isn't my *opinion*. It is accepted scientific fact. A doctor who tells you in this context that "any lithium level is significant" is a lying sack of shit. And I mean that in the nicest possible way.
What's far worse than knowingly attempting to interpret peak level test results in providing patient care is what my pdoc did. He *didn't know* he was looking at peak level readings, because he hadn't specifically ordered trough level readings. He actually thought the ".9" result the test result showed was a trough level reading -- which would have meant the dose I was taking was the correct one. As I later learned from having the correct troough level test taken on a higher dose, a trough level test WOULD have shown a result of ".3" -- a result indicating I was getting no benefit whatsoever from the dose he had prescribed.
By not ordering the right test, yet interpreting the results as though he HAD, my doctor left me dangerously undermedicated at a time when I was suicidally depressed. What he did was the equivalent of nothing. Worse than nothing, in fact, because he told me the dose I was taking was fine when every day I was walking closer and closer to death.
To sum up. While there may be more instances of medical malpractice, the two that stand out are (1) waiting too many days after beginning Lithium therapy to order the first blood test and (2) ordering it in such a way that the results were not trough level results (and, in fact, turned out to be peak level results). His misinterpretation of the results might be excused. If he truly believed he had ordered the test correctly, than his interpretation of the results would have been appropriate. Of course, he *didn't* order the test correctly, so his interpretation of the results put my life at risk.
Am I being ungrateful? Read the next post.
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