Concerned and angry!

What is the name of your state? Arizona

My husband went to primary care doctor back in 2001 with neck/shoulder pain. Was given muscle relaxers/anti inflammatory and a xray. The x ray came back questionable so he was referred to orthapedic doctor wich ordered a MRI of neck. It came out normal. My husbands pain continued. Orthopedic doctor gave him some anti inflammatory and physical therapy. But other than possibly there being a little inflamation going on there was nothing the orthopedic could see. My husband finished physical therapy, it helped some. The inflammatory medications made his stomach upset so he quit taking them. Since nothing major was found he stopped going to this doctor. About 1 year later he went in to primary care and complained of increased pain in neck/shoulder/arm area with some burning in thighs also. Primary care doctor took some blood work and ANA was borderline positive. He was then referred to a Rheumatoligist. They did extensive testing, everything came back negative and my husband was told he had "fibromyalgia" by one rhuematoligist. They passed my husband off to a physicians assistance because the rheumatoligist that diagnosed him with this did not accept patients with "fibromyalgia". He was given various drugs, Neurontin, Zanaflex, Darvocet. Nothing seemed to work. He still went in and complained about neck/shoulder/arm pain. He asked for xrays on several occasions and was ignored. Finally he insisted on seeing the doctor..not the physician assistant. The doctor they set him up with (DR. X) kept telling him he had fibromyalgia and to continue medication. My husband told him he couldnt handle the pain all the way to his arms, so Dr. X ordered a nerve test to determine if any nerve damage present. My husband walked out of the test during the middle of it because of the pain it caused. So the only test that was done was to his right arm for carpal tunnel and it was negative. He would not let them complete the rest. He returned to Dr X and told him what happened. Dr Gluck seemed to ignore him, told him to continue meds and come back in a couple months. The same thing he always told him. The pain worsened and he was unable to sleep and was barely making it through a work day. On his next appointment i told him to demand a x-ray. Again he was turned down. Dr. said nothing would show up on a plain x-ray. He gave my husband Plaxil and a referral to a Physiciatrist. When my husband came home, I became very angry at the results and told him to call in and demand a MRI if the doctor felt that a plain x-ray would not show anything. Dr. X'S nurse called back and left message that Doctor felt this would not do any good and would not show anything. My husband called our primary care and informed them of the situation and asked them to order an x ray. It did show damage. So they went on and ordered an MRI also. Mean while we went back to Dr. X and showed him the X-ray report. He took a rude attitude and said everyone at age 40 had a neck that looked like that, and that a MRI wouldnt show anything because this "pain" was all in my husbands head, that is why he referred him to a Physiciatrist. We had a few words and left. The MRI showed "left paracentral subligamentous disc protrusion" at c5-6 level, disc desiccation at same levels, straightened cervical lordosis as well as upper cervical torticollis with convexity to the left. Even when we returned to Dr. X office to demand that he remove the diagnosis of "fibromyalgia" from his medical record, this doctor still had the attitude that most of this was in my husbands head, even after seeing the MRI report, at my insistance, he dictated that my husband was no longer a candidate for "fibromyalgia". My husband is now a candidate for spinal surgery. My question is this, my husband works as a laborer and lifts, pulls, pushes much weight. By this doctor misdiagnosing him for all these years and just sending him right back to work to do more damage, can we sue? I am sure these 2-3 years of working like this caused more damage. Thank you for your advice, Rachel.

Your post raises several questions, because this could be malpractice, it could be worker's compensation, or could be normal aging.

I suggest that you begin compiling a complete copies of all your husband's resords, including everything in his files not just what they send to other doctors and attorneys. Copy both sides when needed. This means going to the doctor's office and doing an inhouse review of your husband's records, requesting a copy of everything in the file, labs, reports, a copy of telephone or computer printouts for messages or appointments. Referals. Go to each other doctor or healthcare provider and request to look at theirs and then get copies, that way you will know what is in the file and that they sent or copied for you is everything. You will actually have more than they will send when requested by subponea. Your husband has a right to see all his records although there may be some limits to psychological records, they still can be obtained.

Go to the hospital, do the same thing, do an in house review and request copies of everything including ambulance reports. Also check on police and or fire department reports if there was an amulance called.

Go to the diagnostic imaging providers, request copies of their records including copies of all the films/images, orders and reports, same for the emg etc, ask for full disclosure reports. It is important to have the orders because how the image is ordered will determine what they look for and how the report is written, many things within normal limits will not be mentioned unless they are asking for it or an gross abnormality is present. Even most doctors don't know what radiologists really look at. Ask a radiologist to explain what they found as normal limits for brain images when doing the beta testing on medical school students.

Go to the pharmacy and request records of Rx and make a list of OTC's begin keeping records of these if you haven't already, keep containers of samples and inserts etc.

Write out a complete medical history including family members.
Write out a chronology of the events, doctor's appointments, referals.
These can be amended as needed.

This will cost you for these copies, just keep track of your written requests and receipts. Make copies of all the paper records.

Your doctor cannot "remove" anything from your record, he can "amend" the record, you don't really want him to remove anything from the record, you want to have as accurate record of what happened as possible and let the facts speak for themselves and let the attorneys and experts do their job.

Then go find a good personal injury attorney, they can determine where to go from there but you will have given them the best information to advise on your case. For example, they may need an IME or compare the images from 2001 and 2004, that may be key to how your case goes. Most likely there will be some worker's compensaiton aspect to it since there may be some counter claims and it may be more complex than malpractice. Doctors are allowed some range within their scope of practice and standard of care.

Call your state medical board and ask for complaint forms.

Consider the referral to the psychiatrist because some psychotorpic Rx are very effective in the treatment of chronic pain and it is natural and expected to be depressed after such an experience and your husband will need the support along the way.

Also, now is the time to try to be as healthy as possible, limit alcohol, no smoking, healthy diet and exercise as tolerated and perscribed. Doing positive things will improve your and your husband's quality of life. Look for support groups for chronic pain, back or mobility problems, arthritus and or FM, these groups will offer common sense guidance he doesn't have to have a particular Dx to join.

spidyeyes

Your husband may have a claim of worker's comp, if he has followed procedure for notifying his employer and filing a claim. Most likely, he does not have a claim of medical malpractice as he suffered no damage that he would not have otherwise suffered.

It is important to remember that in the second year of his complaints, when the more serious neurological symptoms were reported, all of the tests performed showed no physical process to be the cause.

He received proper diagnostic exams in the early stages and the proper treatment, anti-inflamatory meds. Your husband stopped taking the medication without consulting with his physician for remedies that would allow him to continue on the right medication while avoiding the harsh side-effects.

The diagnosis of fibromyalgia was probably correct at the time. It is not a permanent diagnosis. To demand that the diagnosis be removed was inappropriate as the MD is duty-bound to record and maintain a record of his 'impression' of the condition at the time.

Your husband walked out on a test designed to evaluate muscle response to electrical stimuli (simulating normal electrical activity). Pain is one of the possible responses and is important in making a diagnosis. The physician can not be held responsible for the actions of your husband.

Conservative treatment/management is the treatment of choice and it has been upheld in the court of appeals that failure to provide conservative treatment (for disc injury) before surgical intervention is an act of professional negligence due to the risks of surgery and the risk of infection.

Many of the findings on the x-ray showing disc protrusion are muscle spasms and will subside with conservative treatment and medication. In many cases, disc protrusion can be managed without surgery.

Obviously, your husband and the physician did not have a therapeutic relationship and your husband should have changed physicians as was in his right unless he was bound to certain providers (PPO, HMO, etc.). Even if his insurance limited providers, he could have sought a physician outside of the network and paid the difference.

Save your money and your time in obtaining copies of medical records. Your husband needs to make an appointment with a medmal attorney in your area and discuss these issues with the attorney. Your husband probably needs to make an appointment with a worker's comp attorney, also.

Best wishes,
EC

spidyeyes
Please edit your post and remove the name of the physician. The forum prefers that names of individuals not be posted.

Thanks!
EC

spidyeyes, I am a former worker's compensation claims adjuster. It has been about 10 years since I have been in the field but I still feel qualified to comment.
I agree with ellencee that you should not go all over town acquiring your husband's medical records. You certainly have a right to all of them but you should seek counsel and he or she would request the records. It is inadvisable to try to "play attorney".

When your husband first experienced the pain and went to physicians what reason did he give for making the appointment? (On all medical forms it generally asks, "is this an injury? is the injury due to a car accident or an industrial accident"?) How your husband answered those initial questions is key. Not to say that shifting his focus to Worker's Compensation (if indeed he is having trouble doing his job) is impossible, but back in my day if the condition was "pre-existing" it was then deemed an "aggravated condition" and based on further facts a claim would either be accepted or denied. It is the further facts that would be instrumental in making a claim now. For example, if your husband had an "episode" at work when he lifted something and could not continue, then there would be a distinct "date of injury". Sounds like what your husband has experienced is what we used to call "gradual onset", a much shakier claim than a clear injury with a clear date. But, still not impossible to submit. Much rests on what he wrote on the forms when it all began.

Go to see an attorney. Good luck!!
Patti
P.S. I also concur with ellencee about surgery. That should be considered a very last ditch resort. Your husband could improve tenfold with physical therapy (and it sounds like he has not had any).

I wasn't suggesting you play attorney, only make that job easier for them. It has been my experience as a patient and as a forensic expert who's job was evaluating medical records that much of what you need is not submitted under subponea and the evidnece speaks for it's self.

For example walking out in the middle of an EMG could by it's self be seen many ways, but if there is no informed consent on file and the pain was unbearable then it is seen differently, I personally had hemmorages left by an emg, they are not always painless. Or if the mri is ordered wrong, this actually hapened to me following a skull fracture, they did no CT or MRI in the ER. 3 days later I came back worse and vomiting and CSF coming out my nose from the Fraxture, they did a CT it should have been a MRI because blood becomes hypodense at 72 hours and images are better on MRI and it would have caught the Fracture because the slice had to be thin enough to find it. Instead a screening CT was done. I asked to see it, which took an act of God and I could see with my blerry eyes that the CT was abnormal, something you don't want to see when it is yours! This is a part of my training.

The report came out NORMAL because it was the wrong test, the doctor forgot to inform the radiologist I had a head injury! My notes to the doctor were not copied when the records were requested, my disability claim was denied and I was forced back to work with csf still running out my nose! lost pay for 3 weeks and lost a promotion. 6 months later I contacted the radiologist, there were orders in the chart which I had copies, so I was able to speak to him. I explained my training and what I saw, he and his colleagues looked at them again, oops! ABNORMAL!!!! but too late for the disability claim. I say this because there may be a requirement for you to get appropriate care, so if your doctor failed to provide you with what they consider appropriate care, they may hold it against you. They did amend the report and then all my MRI's and CT's were compared to look for changes over time because I had an earlier MRI that was NORMAL, OOPS again all of them were abnormal!

So without the copies from the file which they would not send because they go in the part of the file of other things and not their work product, I was denied my claim, this is what would have been sent. Another time I looked at my file in another facility, the pages sent under subponea were stamped, and many pages were not copied and sent, they had the information needed. If you get the records, you get no suprises later on and time to follow up on things such as getting proper care.

I was receiving treatment for an industrail injury, a aprt of that was Motrin, I was sitting there and the pt asked, had I been out in the sun because I looked sunburned. No, turns out, I was allergic to Motrin and a lot of other things and ended up with a adverse drug reaction called Stevens Johnson Syndrome which can be life threatening. They didn't diagnose it for 6 months, so when the skin was sliding off my hands and feet they thought I was using my hands, working, when I wasn't supposed to use them, so it made me look like I wasn't folowing doctor's orders, a far cry from having an adverse drug reaction! So your husband's intolerance of NSAIDS could have saved his life, does his record show if he was given alternative pain relief like ice? Is he allergic to Sulfa or other antibiotics or any medication, that could be a factor. Often times the records hold the answers it just takes someone looking at it from a broad perspective, sometime a diagnosis takes years to reach or make definative.

You need a good attorney to sort through it to see what your options are and I agree, surgery is not always the best option. If your husband has limitations then look into Americans with Disabilities Act ADA, there may be work modifications available to modify his work or even make it safer for everyone.