Sunday, February 17, 2019

When a Vegetative-State Patient Returns to Tell the Tale

One patient's recovery from a vegetative state sheds new light on consciousness.


On July 19, 2013, John spent the evening with friends, returning home around midnight. He made himself a snack, said goodnight to his parents, and turned in. Everything seemed normal. But at 6:30 a.m. the following morning, things were far from normal. Margaret awoke to the sound of her 19-year-old son choking to death in his bedroom, just a few yards away. She rushed into his room and found him unresponsive, lying face down in his own vomit.

John was rushed to his local emergency room. A CT scan showed extensive damage to the white matter in his brain, including the frontal and parietal lobes, regions critical for working memory, attention and other high-level cognitive functions. This kind of brain damage, widespread and diffuse with no clear borders between healthy and damaged tissue, is common when the brain has been starved of oxygen. When the oxygen dries up, the brain starts shutting down little by little, piece by piece, until there isn’t even enough functional tissue left to keep our most primitive bodily functions, like breathing, going. John wasn’t quite there, but he was close. On admission, he had a Glasgow Coma Score of three out of a possible fifteen. You can’t score lower than a three, not without being dead.

Several months later, John was declared to be in a vegetative state. Vegetative state patients open their eyes, grunt and groan, and occasionally utter isolated words, although they remain unresponsive to any form of external stimulation. Like zombies, they appear to live entirely in their own world, devoid of thoughts or feelings. The condition differs from a coma; comatose patients are also unresponsive, but their eyes remain closed and they do not exhibit any sleeping and waking cycles.

Arriving in hospital after a serious brain injury there will be some period, usually days or a few weeks, when the prognosis – the likelihood of making a reasonable recovery – is completely uncertain. Yet paradoxically, as time passes, the possibility of recovery diminishes rapidly. With a brain injury like John’s, the chances of recovering after three months are very low and patients are usually reclassified as "permanently vegetative." We tested John using every tool we had at our disposal, looking for some sign of inner life, but we found nothing. A state-of-the-art fMRI scan revealed a moribund, unresponsive brain. High-density electroencephalography (EEG) also yielded null results. Everything we tried failed to kick start John’s severely damaged brain.

Seven months later, we called Margaret to see whether John’s condition had changed. “Why don’t you ask him?” Margaret said. Against all the odds, John was now talking, brushing his teeth, eating, and walking. When I heard the news, I couldn’t believe it. I checked his medical records. The circumstances of his case were clearly described by several neurologists who had examined him over the course of his illness. Everyone agreed that John had sustained very severe brain damage that had left him in a vegetative state. And the CT scan revealed just how extensive that damage had been. Yet, now he had recovered. And we had no idea how.

I arranged to examine John again to see if he remembered anything of his time in a vegetative state. As he sat opposite me in his wheelchair, he remained quiet and detached. Perhaps it was all part of his recovery. Perhaps only some parts of John had come back – maybe, some part of his personality had been left behind. “Do you remember anything of your previous visit to my lab?” I asked him. “I remember Steve, your student. He put electrodes on my head and he had a deep voice." Steve does have a deep voice and “he put electrodes on my head” is as good a lay description of EEG as I have ever heard. But that was only the beginning. John went on to tell us everything about that first visit, down to the tiniest detail. His account was extraordinary. Despite appearing to be completely vegetative for many months, John had been entirely aware all the time, silently watching, listening, and waiting.

A little over a year later, I drove to John’s home to see how he was doing. As the front door opened, my astonishment – and curiosity – deepened. I was immediately struck by John’s personality, which now broke through in a way that had been entirely absent when I’d seen him a year earlier. I started to wonder whether he had returned from the abyss in parts, bit by bit. The last time I’d seen John, some parts of him were definitely there—his body, his memory, his physical being. But some parts were definitely missing, and it was only clear now, a year later, what they were. Now John the person had returned; John the personality. The essence of John was finally back, perhaps not completely, but enough to know that he was going to make it eventually. All of him.

John is not the first person to have made a seemingly miraculous recovery from a coma or vegetative state. Jan Grzebski, a 65-five-year-old Polish Railway worker, woke up in 2007 after 19 years in a coma, which he had entered as the result of a brain tumor. Grzebski credited his wife Gertruda with his awakening. She would not give up on him, although doctors said he would never recover and gave him only two or three years to live. She moved him every hour for 19 years to keep him from getting bedsores.

Could anyone achieve the same miraculous result with enough willpower, love, and family support? I don’t think so. Every brain is different and every brain injury is different. We have learned a tremendous amount about the brain over the past 20 years, and about the tenuous, fragile nature of consciousness, yet we still know so little about how and why some people recover from brain injury and some don’t.

What we do know is that any sort of brain injury will likely have long-lasting pervasive effects. It’s not the same for any other organ of the body. We can replace kidneys, lungs, hearts, and livers and essentially we are still ourselves—a little wobbly for a while perhaps, but the same person. Many of us manage to return to live full and complete lives—perhaps the same lives we would have lived had we not fallen ill, notwithstanding the emotional scars we inevitably carry when our lives have been threatened.

But serious brain injury is fundamentally different. It changes us, it alters our ability to move, react, interact, and respond. And recovery is far harder, if it occurs at all. Of course, we can’t transplant brains (at least not yet) but even if we could it wouldn’t help us to recover in the way that transplanting a heart or a kidney helps us to recover. Because after a brain transplant, “we” would not recover; “we” would be someone else. We might look the same, but with someone else’s brain in our heads we would be an entirely different person. Conversely, transplant your brain into another body and you would still be you—not that other person. Of course, you’d look different. It’s tantalizing to think that you might even feel different in ways both subtle and apparent. But you would be essentially the same person living in another body. The same thoughts, the same memories, the same personality. Your sense of being, the cascade of thoughts, feelings, and emotions that comprise our conscious experience of the world would be largely identical. Like a perfect disguise, the appearance is different, but underneath the person is unchanged.

There’s no escaping it: We are our brains.

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When a Vegetative-State Patient Returns to Tell the Tale

Spring Valley Mayor Alan Simon disbarred for bad behavior as a judge

SPRING VALLEY - Mayor Alan Simon has been disbarred as an attorney after 50 years for the ranting, threatening behavior that got him stripped of his robes as a judge.

A state Supreme Court Appellate Division released its decision on Wednesday disbarring Simon immediately. Simon had been admitted as an attorney on Dec. 18, 1968, according to the decision.

The court's decision stated: "Ordered that the respondent, Alan Michael Simon, is disbarred, effective immediately, and his name is stricken from the roll of attorneys and counselors-at-law."

Simon didn't return a request for comment on Wednesday. The disbarment doesn't affect the 75-year-old Simon's job as mayor

Until being booted from the bench, Simon had served as a Spring Valley judge since 2005 and Ramapo Justice Court since 2011. He was appointed acting Hillburn village justice in 2016.

His indiscretions occurred in Spring Valley, a government known for its dysfunction during the past decade.

The disbarment decision cited the findings of the New York State Commission on Judicial Conduct and a state Court of Appeals upholding the commission's recommendation removing Simon as a judge in Spring Valley and Ramapo in 2016.

The courts upheld professional misconduct charges claiming Simon’s "actions reflect a pattern of calculated misconduct that mitigates against [his] assertion that the misbehavior complained of will not be repeated if he is allowed to remain on the bench."

Based on charges filed against Simon, the Judicial Commission had recommended Simon be removed from the bench.

The commission found the facts showed Simon guilty of ranting in court, and bullying, harassing and threatening his staff, fellow judges and village officials with arrest or contempt of court. The commission also found Simon gave false testimony at his hearing.

Simon repeatedly threatened to hold various employees and officials in contempt, the courts said, and "willfully interjected himself into the political process involving the election of an office other than his own."

The Court of Appeals upheld the judicial removal.

The state's highest court found Simon, "among other things ... used a sanction — a tool meant to shield from frivolous conduct — as a sword to punish a legal services organization for a perceived slight in an inexcusable and patently improper way."

While Simon in his appeal acknowledged being rude and abrasive at times, his lawyers argued the penalty of removal from the bench was too harsh and a sanction was more appropriate.

Simon's lawyers —  Joseph Maria of White Plains and Lawrence Mandelker of Manhattan — had maintained he would tame his behavior if reinstated to the bench.

His lawyers called Simon's behavior "a misguided attempt to either improve the physical conditions of the court, improve the performance of court personnel or improve the integrity and independence of the court from a corrupt mayor," a reference to then-Spring Valley Mayor Noramie Jasmin, who later went to prison on federal charges.

Simon won election as Spring Valley mayor in November 2017 after winning a September Democratic Party primary in the village where Democrats hold a heavy majority among registered voters.

He also has lost his temper as mayor, firing employees and, at one time, cursing at a trustee and employee.

Simon has had a long career in government, serving as a Bronx prosecutor and public defender in Rockland County before working for more than a decade as Ramapo's town attorney.


He also served a controversial stint as the town building and zoning administrator, leaving under a cloud of allegations that he overstepped his authority by signing and overriding engineering reports.

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Spring Valley Mayor Alan Simon disbarred for bad behavior as a judge

Wisconsin nursing homes face funding shortfalls, few workers

MADISON, Wis. — Advocates say Wisconsin’s nearly 400 nursing facilities are in crisis due to a shortage of workers and the state’s low Medicaid reimbursement rate.

Health groups Wisconsin Health Care Association and LeadingAge Wisconsin have requested that lawmakers allocate about $83 million in the next two-year budget to help the state’s nursing facilities cover costs and avoid closure.

The association’s CEO, John Vander Meer, tells Wisconsin Public Radio that 27 skilled nursing facilities have closed since 2016. He says eight facilities have announced closures this year alone.

A report last year also identified about 16,500 vacancies at nursing facilities across Wisconsin.

Vander Meer says state data show Wisconsin’s skilled nursing facilities lose over $70 a day for every Medicaid patient they serve.

He says the challenges won’t be addressed in one budget.

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Wisconsin nursing homes face funding shortfalls, few workers

Saturday, February 16, 2019

Ohio AG: Nursing home patient ‘rotted to death'

Current and former employees of an Ohio nursing facility are accused of mistreating two patients in their care, including one who died as a result of the nurses' actions, Attorney General Dave Yost said Thursday.

A Franklin County grand jury indicted seven people who worked as nurses in 2017 at Whetstone Gardens and Care Center in Columbus, Yost said in a news conference.

The defendants face 34 charges, including involuntary manslaughter and patient neglect, Yost's office said.

One patient "literally rotted to death" as a direct result of the nurses' neglect, Yost said, adding that another suffered physical harm because nurses falsified her medical records and forged signatures.

"This is gut-wrenching for anyone who has entrusted a care facility with the well-being and safety of a loved one," Yost said.

The accused include six current and former employees and a contracted certified nurse. According to online court records, they have not entered pleas and no attorneys were listed for them.

A spokesman for Whetstone said it has been cooperating with law enforcement since concerns arose two years ago.

Four employees were immediately fired for falsifying the second patient's records, spokesman Ryan Stubenrauch told CNN.

But Whetstone "strongly" disagrees with accusations that its employees were responsible for the other patient's death, Stubenrauch said.

Two employees accused of manslaughter were suspended pending the outcome of the investigation, he said. The contracted certified nurse is no longer at the facility, he said.

"It's truly a tragedy any time one of our residents dies," he said. "We're confident that this man's tragic death was not the result of neglect at our facility."

A timeline of the allegations


The first patient developed wounds on his body in February 2017 that progressed to gangrenous and necrotic tissue, Yost said. Nurses delayed bringing him to a hospital, where he died on March 5, 2017, from septic shock as a result of the wounds.

Three defendants were indicted on charges of involuntary manslaughter, gross patient neglect and patient neglect, Yost said. They are accused of failing to take medically appropriate steps that could have saved his life.

Whetstone disagrees that the treatment provided by employees caused his death, Stubenrauch said.

"There are a lot of circumstances around that gentleman and his untimely passing," Stubenrauch said. "We are confident that once those things come out it will be clear that the care he was provided at Whetstone did not contribute to his death."

The second patient suffered physical harm as a result of inadequate care because nurses falsified her medical records, Yost said.

The patient's medical records contained false information and forged signatures of nursing staff. An investigation found that the patient's medical file listed care at times when the patient was not physically present at the facility.

"As soon as it happened we did an immediate review and fired the people who broke our rules and our trust," Stubenrauch said.

Five nurses were indicted on charges including forgery and gross patient neglect. The patient later died, but no one faces charges related to the death.

"These victims were completely dependent on others for day-to-day care, which their families trusted Whetstone Gardens to provide. Instead of providing that care, evidence shows these nurses forced the victims to endure awful mistreatment and then lied about it," Yost said.

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Ohio AG: Nursing home patient ‘rotted to death'

Nebraska attorney in medical school killings case disbarred

OMAHA, Neb. (AP) — The Nebraska Supreme Court has disbarred an already-suspended attorney who played a key defense role for a former doctor convicted of killing four people with ties to an Omaha medical school.

The high court said in a ruling Friday that Jeremy Jorgenson violated state law and attorney rules of conduct by continuing to make filings and practice law after his 2017 suspension, failing to inform clients of his suspension and failing to return clients' money.

Jorgenson's disbarment is the latest in a string of troubles he's faced since agreeing in 2016 to help represent Anthony Garcia in the former doctor's first-degree murder case.

Garcia was convicted later in 2016 of killing the 11-year-old son and a housekeeper of Creighton University faculty member William Hunter in 2008, and killing pathology doctor Roger Brumback and his wife in 2013. Prosecutors said Garcia blamed Hunter and Brumback for his 2001 firing from Creighton's pathology residency program. Garcia was sentence last year to death.

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Nebraska attorney in medical school killings case disbarred

News Florida News Jury selection starts in $1 billion Florida Medicare fraud case

Chicago Tribune reporter David Jackson explains how wealthy nursing home operator Philip Esformes allegedly became the orchestrator of a $1 billion Medicaid and Medicare bribery and kickback scheme. Oct. 4, 2016.
Jury selection is set to begin in the trial of a health care executive accused of defrauding Medicare of $1 billion, one of the nation's biggest such cases.

Jurors chosen beginning Monday will decide the fate of 50-year-old Philip Esformes, who operated a network of 30 nursing homes and assisted living facilities in Florida. Prosecutors say Esformes and other conspirators referred thousands of Medicare patients to their facilities even if they didn't qualify for services.

He has a history of running nursing homes in Florida, Missouri and Illinois.

Esformes is also accused of accepting kickbacks for steering Medicare patients to other health care providers, which then billed the government program for unnecessary services.

Esformes has pleaded not guilty and has been jailed since his 2016 arrest. Two others involved in the scheme have pleaded guilty.

Esformes faces a lengthy prison sentence if convicted.

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News Florida News Jury selection starts in $1 billion Florida Medicare fraud case

Friday, February 15, 2019

Left on patio in wheelchair, ex-Marine died of heat stroke at care facility, Calif. lawsuit says


Gene Rogers lived a large life before dementia began to chip away at it.

A former Marine who signed up at 17 and fought in Korea, Rogers went on to become a stock car racer, earned an electronics degree and spent more than three decades working for AT&T as he and his wife, Kathryn, raised three boys during their 60-year marriage.

He spent his retirement in Carlsbad, Calif., living near Camp Pendleton where he started in the Marine Corps and where his passion for golf took him to a course nearly every day.

Then, he got sick.

Faced with the reality that 81-year-old Kathryn couldn’t care for him alone, the family sold the Carlsbad home, banked the proceeds and found a pleasant, $5,540-a-month assisted living facility where Rogers could receive around-the-clock care in a secure environment.

On Dec. 30, 2017, Rogers went to live at Meadow Oaks of Roseville, a tan stucco facility along Linda Creek in California that touts itself as offering “well-being and a positive, active lifestyle.”

Six months later, the 83-year-old Rogers was dead from heat stroke after allegedly being left alone on a patio in his wheelchair, then forgotten about for hours outside as the summer heat built. State licensing officials investigated the death and in October, announced their fine: $1,000.

But the Rogers family is far from satisfied with the results of the state’s investigation, which they said has left them with numerous questions about what happened to Gene Rogers.

“It was June the 30th, the hottest day of the year so far,” his son Jeff said in an interview with The Sacramento Bee. “We got a call late in the day and they said, ‘Hey, your father’s being taken to the hospital to get checked out.’ They weren’t specific about what happened. They just said, ‘We’re hoping to have him checked out. Seems like he’s OK.’ There was no panic in their voice.

“Then I got a call from the hospital and they said he came in in critical condition, and I was like, ‘What are you talking about?’ He was completely unresponsive to anything but pain stimuli, his skin temperature was like 104, they had to bag him in what they refer to as a cooling bag to get his skin temperature down.”

An investigation by the state Department of Social Services’ community care licensing division found that “staff failed to provide adequate care and supervision” and levied the fine, which was doubled from $500 because “you have been cited for repeating the same violation within 12 months.”

State records show that 24 days after Rogers was left on the patio, another resident living at Meadow Oaks with her husband “was able to leave the facility unattended” at 7 p.m. on July 24, 2018. That resident “fell outside on the street while walking and 911 was called,” a state facility evaluation report dated Aug. 6, 2018, states.

Westmont Living, the La Jolla-based company that operates Meadow Oaks, did not respond to telephone and email requests for comment.

Rogers’ death has spawned a wrongful death lawsuit filed on behalf of his family by Sacramento attorney Sean Laird, as well as an enhanced review of whether the facility should face a fine of up to $15,000, the most allowed under state law, according to elder care advocate Carole Herman.

The case also has raised questions about the events that led to Rogers’ death, with the family and the lawsuit alleging that staff members gave conflicting stories about what happened that day.

High hopes


Rogers’ family said they had high hopes when he was placed at Meadow Oaks, a location they preferred after looking at other options and deciding he was better off near Sacramento rather than the San Diego area, where monthly residential fees could easily top $10,000.

SAC_VeteranDeath_018_190206
Hector Amezcua hamezcua@sacbee.com 
 
They also said things appeared to be going well for Rogers at the facility, where he enjoyed watching “The Big Bang Theory” on television and playing chess and checkers with a young staffer who had taken a liking to him. Family members visited on Sundays, once bringing along four generations of relatives.

But problems began to emerge, according to Jeff Rogers and his mother, who said they began to notice his hygiene was beginning to suffer and that they found him alone on the patio several times.

“This complete neglect led to a variety of harm to (Rogers) at Meadow Oaks, where he was unkept (unkempt), unmonitored and recklessly neglected,” according to the family’s elder abuse and wrongful death suit, which was filed in Sacramento Superior Court in November. “On multiple occasions family members found (Rogers) unattended in his wheelchair on the patio where he was left for long periods of time, without assistance, and would become groggy and difficult to understand.”

The suit says Rogers “could not push himself in his wheelchair, and certainly could not push himself and open the door either to exit or enter the facility by himself.”

“Family members, on multiple occasions, instructed the facility not to leave him outside unattended,” the suit reads.

Despite that, Rogers ended up on the memory care patio of the facility after breakfast about 9:45 a.m. June 30, the state’s report on the incident states.

The report was compiled after a complaint was filed by Herman, president of the Foundation Aiding the Elderly, or FATE, in Sacramento, on behalf of the family.

“On 6/30/18, during a heat storm with temperatures hovering around 103 degrees, Mr. Rogers was left unattended on the patio of this facility for an estimated 3-4 hours and suffered from extreme heat exposure which caused him to suffer a heat stroke,” Herman’s complaint states.

SAC_VeteranDeath_015_190206
Hector Amezcua hamezcua@sacbee.com 
 
The high temperature that day in downtown Sacramento was 103, according to the National Weather Service, and Rogers remained on the patio until at least 11:30 a.m., according to the state’s investigation.

Who was watching?


Logs kept at the facility show Rogers was checked on hourly, and the facility’s executive director told investigators Rogers was given water at 10:30 a.m. One staffer told investigators she gave Rogers “water to avoid dehydration several times,” according to the state’s report.

That staffer, who is identified as “S2” but not named, went to lunch from 10:35 a.m. to 11:10 a.m., and investigators who interviewed three other staffers who were on duty that day “could not confirm that S2 found a replacement caregiver to cover her lunch break,” the state’s report states.

During the lunch break, there was only one other staffer on duty, and that worker told investigators she did not cover for the woman during lunch, according to the report.

At 11:30 a.m., two workers went outside to bring Rogers back inside for lunch and “found him unresponsive,” the report says.

“Ambulance records, however, revealed that 911 was called at 12:04 p.m.,” the state’s report says. “(Rogers) had been sitting outside for 1 hours, 45 minutes or longer when temperatures were increasing and reached 93 degrees by 12 PM when emergency services were called.

“The temperatures were verified by a local city weather graph. When (Rogers) arrived at the hospital, his body temperature was 103.4 (F), he was dehydrated, and had multiple areas of sunburn (basic blister burns)/redness on body.”

Rogers was admitted to intensive care, but family members said doctors told them there was little hope for him, and that at one point he became unable to swallow. He was moved to hospice care and died July 14. The cause of death was listed as “heat stroke due to prolonged exposure to sun and heat,” the state report found.

The report initially was classified as “confidential.” But after inquiries by The Bee, social services officials released the report and filed a new copy of it, noting that the original “was inadvertently marked ‘confidential’ instead of ‘public.’ ”

Placer County coroner’s officials listed Rogers’ death as “accidental.”

The Rogers family alleged in their lawsuit that Meadow Oaks frequently did not have enough staff on hand to supervise residents. Jeff Rogers said he was present when one resident managed to slip out the front door of the facility unnoticed, and said he had to alert staffers.

“In fact this facility had been cited by the state of California for inadequate staffing based on multiple events in 2017 and 2018,” the Rogers lawsuit states.

The Rogers family said they believe Gene Rogers died simply because staffers forgot he was on the patio and left him there.

“I went down there and I said, ‘What happened...?’ ” Jeff Rogers said. “The only person that gave me their story was the director. It was like she was reading from a script: Dad got himself outside like he often did, he was checked on and given water at regular intervals and that’s when he got himself back inside.

“Well, someone’s handing me a boatload there,” Rogers said, insisting that his father could not have wheeled himself out the door and certainly could not have gotten back inside through a door that he said was kept locked. “It seemed like something was being covered up.”
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Left on patio in wheelchair, ex-Marine died of heat stroke at care facility, Calif. lawsuit says

Ex-wife of fugitive former attorney speaks as manhunt continues

SANDY SPRINGS, Ga. (WGCL) - The ex-wife of a fugitive former attorney suspected of killing his mother says she and her children are terrified he'll show up.

On the day he was supposed to begin serving a prison sentence for fraud, police say disbarred Georgia attorney Richard Merritt killed his own mother.

A nationwide manhunt has been underway ever since.

Merritt’s ex-wife and children are in protective custody.

"We are scared, we've been hiding, we have protection from the US Marshals office,” Dr. Merritt said.

She says her ex led a double life, was a verbally abusive drunk and allegedly snapped on Feb. 2, when he allegedly killed his own mother.

That was the same day he was set to turn himself over to authorities for a 15-year prison sentence for defrauding clients.

"I think he was drunk and I think he told her he wasn't going,” Dr. Merritt said.

She says she believes others are helping Merritt evade capture. Dr. Merritt added that she's fearful of how a confrontation with police will end.

"I think suicide is a possibility,” she said. “He destroyed us with what he did."

The US Marshals service is offering a $5,000 reward for information that leads to Merritt's capture.

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Ex-wife of fugitive former attorney speaks as manhunt continues

See Also:
Disbarred Georgia attorney Richard Merritt on the run after allegedly killing his mother

Disbarred Cobb attorney gets prison for defrauding clients 
 
Disbarred Lawyer Jailed on Theft, Elder Abuse Charges
 

Minnesota Senate panel approves cameras to watch nursing home residents


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Minnesota Senate panel approves cameras to watch nursing home residents