Wednesday Sept 6: Simon Grennan smoked some fish he had caught and next day served it for lunch to himself, his 16-year old daughter Mary, and her boyfriend George Miller. All three fell ill early Friday morning. Simon was struck first, vomiting until he felt he ought to seek medical attention at Whitehorse General Hospital. Intending to enlist his daughter to drive him, he discovered she too had nausea. Both were driven to hospital and were seen by Dr. Kanachowski who diagnosed gastroenteritis. This can result from eating spoiled food.
After returning home, Simon improved slightly but Mary did not. At midnight Friday she returned to hospital where she told the duty physician, Dr. Galloway, that she had been vomiting all day, was feeling quite weak and had abdominal cramps. The diagnosis continued to be gastroenteritis. She was given IV fluids and sent home Saturday.
Dr. Reddoch – Stolen files, death of a key witness, political pressure from the Yukon Medical Association, and conflict of interest among the judges of Yukon Court.
The mother did the driving because Simon and George were still unwell. Mum also contacted their GP Dr. Reddoch and explained that three people were ill from food poisoning. At the mother's insistence, Reddoch phoned the hospital and arranged to have Mary admitted.
The health status of George Miller is unclear as he died before trial in an accident and could not give evidence.
But the hospital chart did become evidence. Nurse McDonald set the tone with this entry: “Sunday night Mary Grennan stated she was too weak to open her mouth or too weak to hold a water glass. Breathes normally when asleep but seems to hyperventilate and dramatize her illness when awake and has an audience.” Nurse McDonald later explained that she ascribed some events as dramatizing because they would not otherwise fit the diagnosis of gastroenteritis.
Mary in fact had vomiting, stomach cramps, and was dehydrated – signs of food poisoning. She also had progressive weakness, difficulty swallowing, and labored breathing – signs that a primary neurological illness was afoot.
On Monday morning Dr. Reddoch saw his patient. He did not then (nor at any time) take a history and he shirked the physical examination. Reddoch opted for talk, discussing the recent death of Mary's grandmother. This conversation must have been one-sided, in view of the nurses' ongoing notes that Mary “spoke in uncomprehensible whispers and displayed total dependency on others.” Reddoch then charted his opinion: “Globus hystericus. Throat clear. Chest clear. Discuss anxiety, etc.” The term globus hystericus means a sensation of something in the throat, but without any organic cause.
Globus Hystericus: this diagnosis given to 16-year-old Mary Grennan was defamatory, patronizing, and wrong. Her real condition? Botulism from a clear case of food poisoning. Two other people visited the ER with identical symptoms from the same spoiled fish.
Later on Monday, Nurse McDonald wrote in the hospital chart: “Ativan given for throat spasms re anxiety. Mother still at bedside and aware of Doctor Reddoch's diagnosis of throat spasms. To keep patient calm and breathing at a normal rate, it is important that she not hyperventilate and get uptight. Patient remains weak and will not assist with any movement like a rag doll.”
However another nurse, Alan Macklon, “did not see Mary act in an overtly anxious way. She did not seem emotionally distraught.” Ativan is a tranquilizer used to treat anxiety; a side effect is that it decreases respiratory function.
And Mary worsened. Nurse McDonald continued to ridicule. On Monday night, McDonald wrote in the chart at 10.10 pm: “Patient assisted back to bed by two staff, buckled at the knees and slid to floor stating she was too weak to walk. Very dramatic.”
The same night at 10.30 pm a different nurse – Nurse White – instructed her Aide to test the blood oxygenation level. Checking blood oxygen was not routine, nor did Dr. Reddoch or any other physician suggest it, but was something the nurses were doing of their own volition. The Aide reported that the oxygenation level began at 84% then stabilized at 88%. This startled Nurse White who decided to recheck the reading. She did so after having Grennan breathe deeply; it now read 90%.
Nurse White decided to make another blood oxygen check before alerting Dr. Reddoch. She returned to Grennan's room at 10:45 pm but found her sleeping and decided against disturbing her. At 11:07 pm she sent her Aide to redo the blood oxygenation test. The Aide returned immediately to report that Grennan was not breathing, and had no pulse.
Emergency resuscitation! Grennan was intubated and her heart function was restored, but without spontaneous respiration. On Tuesday she was transferred by air ambulance to St. Paul's Hospital in Vancouver. There a neurology specialist explained that botulism would cause pulmonary arrest, after which the heart will function briefly until the lack of blood oxygen arrests it. Emergency measures had restored Mary's heart function, and treatment later restored spontaneous breathing, but by then the brain was so damaged by prolonged absence of oxygen that she never regained consciousness.
Mary Grennan remained comatose from that day in 1995 until she died in April 1996 – on her seventeenth birthday.
The Yukon Medical Council took action. Dr. Allon Reddoch was told: The Inquiry Committee will investigate your conduct or capability, or fitness to practise medicine in the Yukon with regard to the following charge, namely, that you from September 10 to September 11, 1995 failed to take appropriate steps in the management, treatment and care of Mary Grennan at Whitehorse General Hospital, in that you did not:
The Yukon Medical Council reached a unanimous conclusion that Dr. Reddoch was guilty of unprofessional conduct for these reasons:
Penalty: Dr. Allon Reddoch was fined $5000, was required to attend a clinical competency program, and faced a published reprimand.
The spoiled fish harbored Clostridium botulinum which causes botulism, a rare form of food poisoning. This bacteria produces a neurotoxin directed at the neuromuscular junction. Symptoms are the gastric upset of any food poisoning plus double vision (diplopia), drooping eyelids (ptosis) and other neurologic signs. Reddoch's guilt lay not in his failure to diagnose botulism specifically. His negligence lay in his rigid, lethal denial that the symptoms were real. Reddoch preferred instead to defame the patient's character – and this sealed his fate.
In plain terms: You don't give a psychogenic diagnosis to a patient with severe nausea and vomiting when two other people who ate the same fish had the same gastric symptoms. Mary ate more fish than anyone and developed difficulty breathing and swallowing, red flags for organic neurologic disease. You don't label primary neurologic symptoms as ‘anxiety,’ then prescribe a tranquilizer which further erodes respiratory function.
Dr. Reddoch showed a blatant and cavalier disregard for this patient's health and well-being. What were those insults again? — whining, dramatizing, anxiety, uptight, hyperventilating to impress an audience, and globus hystericus. When an MD uses such defamatory language it points to an underlying hatred of the patients that he treats.
In all the legal venues, Dr. Allon Reddoch tried to block the expert witness Dr. Paul Assad, who testified to the standard of care expected in the Whitehorse region of Yukon Territory. Assad described “the protocols of dealing with a patient that are established when you're in second year medicine. Any family physician has to do these things every day. The practice in noting down a patient's history and examination, and observations on reassessment, should be the same in a small, medium or large hospital.”
The Court accepted Dr. Assad's testimony because it focused on the standards for a GP, not a specialist, and because it applied equally to populous and remote geographic regions. The evidence was damning: Dr. Reddoch did not even meet the standard of care taught in second year medical school.
In Grennan v Reddoch et al 2000 YKSC 25 the judge ruled: ”It was reasonable for the Inquiry Committee (of the Yukon Medical Council) to accept Dr. Assad's evidence. I am not persuaded that Dr. Assad should be barred from giving opinion evidence to this Court.”
Mary Grennan ate tainted fish, developed botulism, was admitted to Whitehorse General Hospital under the care of Dr. Reddoch, and within two days went into a coma.
Mary Grennan never emerged from her coma. She died on her seventeenth birthday.
The Yukon Medical Council investigated Dr. Reddoch and found him guilty of unprofessional conduct.
Just when the Yukon Medical Council found him guilty, Reddoch applied for the presidency of the Canadian Medical Association. On his application form, Reddoch lied and said there were no disciplinary judgments against him. The lie was uncovered; Reddoch was elected president of the CMA anyway.
Dr. Reddoch appealed his disciplinary decision to the Yukon Supreme Court, but lost. The Court upheld the verdict of unprofessional conduct. Reddoch then resigned as president of the Canadian Medical Association.
The Grennan family filed a malpractice suit against Dr. Reddoch. A year later, following a nine-day trial in Yukon Supreme Court, Ed Grennan won $143,850 in damages for the death of his daughter Mary. A judge from Alberta presided at trial because all of the Yukon Supreme Court justices were forced to withdraw due to conflict of interest when the media learned that each knew one or more of the parties involved.
To prepare for his Court appeals, Reddoch requested his disciplinary file from the Yukon Medical Council. In reply, the YM Council disclosed everything except 4 internal letters sent from their legal counsel to the Discipline Committee which investigated Reddoch. The letters were protected by attorney-client privilege. Heedless, Reddoch pursued them anyway. The wrangle was resolved by the Yukon Court of Appeal which denied access, saying: “Reddoch was on a fishing expedition, and had no evidentiary basis to demand the final records.”
The Reddoch disciplinary file vanished and was never found. It happened in March 2000 when the Registrar of the Yukon Medical Council traveled to Vancouver to discuss the case with their YMC lawyer. During the trip, the Registrar stored the Reddoch file in her suitcase, locked in the trunk of her car. Between March 17 and 19, the Reddoch file was stolen from that vehicle. The entire suitcase was lost and never recovered. Afterward, Reddoch broadcast defamatory accusations: he said “the Council had something to hide,” and he implied the suitcase was lost “to prevent a review of the file.”
However, it is unlikely the Registrar – who owned the suitcase – would sacrifice her clothing and other property to get rid of a file folder. If ruse it was, there are simpler ways.
And the Yukon Medical Council, as an organization, would not purloin their own file. This file had been read into evidence at two venues – the YMC Disciplinary Inquiry, and the Yukon lower court. Both times, the file served to convict Reddoch of unprofessional conduct, which was the Council's goal. The file vanished on the eve of the final round in Yukon Appeal Court (the upper court). Reddoch was the only person with a motive to get rid of the file.
A parallel case offers insight: In New Brunswick, a lady doctor whose license was suspended by the College of Physicians and Surgeons (for arson) was later found not guilty in criminal court when prosecutors learned that documents vital to the case had been destroyed. That MD benefited (she escaped conviction) due to lost evidence.
Reddoch had a similar destiny. After his disciplinary file was stolen, the legal process turned abruptly 180°, and judicial decisions now came down in this Yukon doctor's favor.
Reddoch closed his family practice and became a medical advisor with the Yukon Worker's Compensation Board.
The Medical Profession Act confers authority on the Yukon Medical Council (YMC) to govern and investigate MDs. The YMC is similar to the College of Physicians and Surgeons in other regions. Up to 2001, the YMC was run by the Justice Department of the Yukon Government.
A separate organization, the Yukon Medical Association, is a push-back organization run by doctors which aggressively promotes doctors' interests. In November 2001 this Association passed a non-confidence vote in the Yukon Government, and made 7 recommendations for reforming the YMC. Main points: The Association wanted the YMC Registrar to be a doctor (instead of a Justice employee) and wanted the YMC run at arm's length from government. The Association “strongly supported the notion of self-regulation of MDs because protecting the reputation of doctors was paramount.”
The Yukon Appeal Court overturned the finding of unprofessional conduct made by the Yukon Medical Dr. Reddoch. Yet the disciplinary decision had been upheld by the Yukon Supreme Court based on a consistent, solid body of evidence.
The Yukon Appeal Court canceled the $143,850 damage award to the Grennans.
Tuum Est - It Is Up To You
Touches of barbarism in his contours.
Thomas Hardy (1891)
In law the duty to diagnose was established long ago. The precedent Wade v. Nayernouri 1978 ONHC established that:
An erroneous diagnosis does not alone determine a physician's liability. But if the doctor, as an aid to diagnosis, does not avail himself of the scientific means and facilities open to him for the collection of the best factual data upon which to arrive at his diagnosis, does not accurately obtain the patient's history, does not avail himself of referrals to specialists – then the net result is not an error in judgment but constitutes negligence.
A thorough history, physical examination, tests, and consultation with colleagues and specialists, are basic to a proper diagnosis. A reasonable doctor should also heed a patient's complaints during treatment for they may be harbingers of change in condition.
This phrase is used to teach medical students to anticipate common diseases rather than very rare ones.
But rare diseases do exist. When the clinical picture is puzzling, a competent MD must think of zebras before resorting to blaming patients for causing their own symptoms. The disease is difficult, not the patient or the person.
Cavalier dismissal of neurological symptoms is particularly risky: Weakness, dizziness, labored breathing, difficulty swallowing, aphasic speech, lack of coordination – these are serious signs and should not be labeled ‘psycho-social stress’ unless it is a diagnosis of exclusion — and probably not even then.
A ‘diagnosis of exclusion’ means a diagnosis to be used only if no organic disorder is suggested by the symptoms. But this presumes an MD is familiar with the symptoms of every disease, whether common or rare, whether known or yet unknown to medical science. In decades past, such arrogance did prevail among doctors trained never to admit ‘I don't know.’
But today via the web, most patients absorb medical knowledge to a level of sophistication never before seen in human history. Patients also acquire a copy of their own clinical chart: the MD's opinion no longer circulates only among his colleagues.
Today, if a doctor unsuited to science decides to label perplexing symptoms ‘psychogenic’ accompanied by a scatter-gun list of terms that reads like the index of a psychiatry textbook — then that MD may not only get sued for civil negligence, but also face criminal charges for libel, slander, or defamation.
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