Our Story

My mother is Tresa E. Speer for whom this web site is dedicated. She went in for knee replacement surgery a procedure commonly performed on people of her age (75) and with favorable results. In March of 2003, this day of surgery would become the beginning of the end for my mother. I want to share my experience with you and my numerous floods of emotions. I will start from the beginning; from the first day, we encountered the doctor who would change my and all of my family members' lives forever. I will only refer to the doctors not by name but by their specialties.

Late October of 2002, my mother went to see an orthopedic surgeon, not for the purpose of having a knee replacement, but to investigate the possibility of receiving a series of injections known as Synvisc, a substance that acts as a lubricant and shock absorber for the joints. "Healthy joints are made up of bones that are covered in a smooth cartilage and a fluid known as synovial fluid. The synovial fluid can thin out and lose its' elasticity in people with osteoarthritis. The smooth cartilage on the ends of the bones can wear away and break down. The treatment works by improving the natural viscosity of the synovial fluid. The improvements in the lubrication of the joint results in increased mobility and reduced pain. Side affects and risks tend to be minimal, while results can be good." We thought this would be worth trying. The doctor took x-rays and explained that my mother's joint was bone on bone and he felt the shots would not work. He suggested knee replacement surgery. My mother was not sure about having surgery, when she hesitated, the doctor asked her why and she stated, "She was chicken". He did a good job of selling her on the idea. He told her "your pain will be gone." With each passing day, she found it more difficult to walk and the nights of constant leg cramps, well, surgery offered her a hope for relief.

The orthopedic referred her to one of his associates, a cardiologist who would evaluate her for surgery. It was my opinion that she was not properly evaluated, but according to the medical establishment, they had a different opinion. In the end, my fears were completely justified.

The beginning of November 2002, she saw the cardiologist who ultimately cleared her for the surgery. The road of life was now beginning to change course unbeknownst to my mother or me. There were multiple attempts of scheduling the surgery. Mid November cancelled; cardiologist did not yet provide clearance, Late January 2003 cancelled; my mother was getting over a bad cold, and the cardiologist cancelled her surgery. Mid March 2003 cancelled. The day before surgery, the hospital called to cancel-no bed available. The surgery was rescheduled by the hospital for one week later. The same day the orthopedic office called back and asked if she would come four days later for surgery. This date fell on a Sunday. I was in panic mode by this time, "What is going on here"? "Who would do elective surgery on a Sunday"? As I look back, and hindsight is always 20/20, I realize the signs were already visible. My mother, however, coming from a more trusting generation did not seem concerned about all of these delays.

On that Sunday, March 16, she went to the hospital for surgery. As she was being wheeled down to pre-op, I begged her "lets go home I don't have a good feeling about this". She got a little mad at me and said, "This doctor would not do the surgery if I could not have it". She felt I was getting carried away with my emotions and told my husband in a joking manner "to keep me calm". As my mother laid on the gurney only steps away from the operating room, her chart was placed by her feet. I could not help myself from picking it up to look inside. The chart was empty except for the Medical Advance Directive, which I had just given to the nurse. I told my mother and sister "Where is all of the paperwork"? My mother told me to put the chart down before I made someone mad. When the anesthesiologist came in to talk to my mother, I showed him the empty chart and asked, "Where is all of her paperwork and blood type" he said, "They would take care of it". I was not relieved. My mother had made her decision, I could not change her mind so I would pray for the best and hope that I had over-reacted. The doctor had given me an approximate timeline as to when the surgery would be over, 2 hours and 15 minutes. He had just finished another surgery on a man, also a right knee replacement. Still that did nothing to settle my nerves. The surgery took longer than anticipated. I tried to calm myself by thinking maybe they got a late start. I could not allow myself to think about any other scenario. As the timeline approached the 3 hour mark, I was getting more anxious by the minute almost to the point I found it hard to breathe. I remember praying that this would be over and that the doctor would tell me my mom was ok. Suddenly, he was standing in front of me. He said he was sorry it took longer then anticipated, that the knee surgery was finished, But at that point I immediately started saying "oh God please no, please God, please tell me my mother is ok. The doctor said my mother had some bleeding and he thought he had nicked a vein. He had already called in a vascular surgeon to repair it. I told him just fix it. He appeared calm, collected, and very much in control. I was anything but calm. I remember thinking that maybe it was not as bad as I anticipated; I would admit I am an alarmist, at that time, I did not know how wrong I would be. It seemed like an eternity before the vascular surgeon appeared to give us his findings.

The news was grim. Instead of a nicked vein, the vein was lacerated in six places, and the only working artery was torn out from behind the kneecap. Surgery would have to begin immediately to try to restore circulation to the leg. This would be the second consecutive surgery of the day and the third would follow shortly thereafter. By this time, I am in total shock and the situation was getting worse by the minute. Hours had passed and it was now in the early morning hours of the next day. The forth surgery was now underway. The surgeons were still with my mother and an update was given to me before she went to the ICU. There is a 50/50 chance they would have to amputate her foot. While the news was being given, I could not comprehend what they were saying. I began talking out loud; my mother came in for a knee replacement because her fear was that she might end up in a wheelchair and now you are telling me you might have to cut off her foot. Oh, God could this get any worse. Unfortunately, it would not take long for that question to be answered.

Before arriving at the hospital, my mom had filled out a Medical Advance Directive and Durable Power of Attorney, making my twin sister and me her proxy. It reassured me that I would have a joint decision making with her doctors. I would do what was best for her while keeping her wishes in mind.

Early morning of March 17 was the first time I was allowed to see her since 10A.M. on the 16th when she was wheeled into surgery. She was intubated,
a nasal gastric tub was in her nose and down the back of her throat. She was very pale and unresponsive. "What have they done to you", I could not stop crying. How does a woman of 75 years of age get over the trauma her body has been subjected too? I was riddled with guilt. I had checked on these doctors, the orthopedic and the cardiologist with the California State Medical Board long before the surgery took place, they told me they had clean records and no complaints. Had they missed something that I should have been able to find out? Would there be a risk factor that would have changed my mother's mind if only she had known? My head was spinning to the point I thought I was going to pass out. If only, If only, I kept repeating, God please let my mom be ok.

On March 18, the orthopedic surgeon told me he had to take her back to surgery. She had developed compartment syndrome. This would be her fifth surgery in less then 48 hours. This was supposed to be a 40-minute surgery. I asked if the vascular surgeon was going to assist and he told me no. 40-minutes turned into over 4-hours of surgery. When the orthopedic came out he said my mother had a hard time; her blood pressure had dropped low and he said" he felt her spirit leave". I thought, "What is he talking about"? In addition, he stated the vascular surgeon had come in to assist, but I never saw him. Why had he not come out with the orthopedic? From that moment on the acts of omission started. I was not told anything about her condition. I asked constantly, told them I had power of attorney, but they were tight lipped. My mother was never able to breathe on her own again without assistance from a bi-pap oxygen (Positive airflow pressure non-invasive ventilation) machine blowing breaths into her nose and mouth at the same time by a mask tightly strapped to her head, after the intubation tube was removed on March 23. The cardiologist who cleared her for surgery came in on that day. My mother took one look at him and stated "You lied to me I should never have listened to you". He seemed un-phased and left her room. On March 24, she underwent another surgery to prepare the leg for closure, the sixth surgery. By this time, she had a doctor for every part of her body, a Pulmonary, Kidney, Internist, Cardiologist, Vascular surgeon, Orthopedic, Inhalation therapist, a pain control specialist, Infection disease specialist and a Plastic surgeon all for a knee replacement. No one could help her; no one could save her. She screamed 24 hours a day for someone to help her. The doctors ignored her screams. I was told nothing, when I asked to see her leg they locked me out of ICU stating, "I would not understand". No one said she was dying. In late evening, March 31, the orthopedic called he said he will have to amputate the leg to the hip. He did not know if it would heal. I told him I needed to talk to the other doctors first to see how that would affect her overall health. I requested a meeting, only two doctors showed up, the cardiologist and the kidney doctor. They both wanted to try to stabilize her first that was on April 1.

On April 2, once again, we were locked out of ICU while they were doing a procedure we knew nothing about and we were not going to continue playing their game. They were going to start following the Medical Directive. We finally started kicking at the ICU entrance and stated, "You better stop what you are doing until someone explains to us what is going on". We were allowed entrance only when we threaten to call the police. April 3, the 18th day in the ICU, just after midnight, my mother passed away. The next day the orthopedic sent a large vase of flowers to my mother's home with a note of condolence. Was that a way of easing his guilt? This is a question for you to answer after you hear the rest of our story.

I would learn the truth over the next three years or probably as close to the truth as one can get.

After the funeral, my sister and I went to see the orthopedic surgeon. We needed answers, the answers we had asked all of the doctors all along, what happened to my mother, when did things go so wrong and why? Since no one was willing to tell us anything, we wanted her medical records. We needed someone, anyone, to explain what had happened, and we knew those answers had to be in her records. What we were about to hear next sent cold chills down my spine. Out of the clear blue while waiting for the records the doctor made a statement I will never forget; "An attorney might tell you, you have a good lawsuit but it won't bring your mother back. Lawsuits only hurt everyone involved and it takes a long time and you should just forgive, you won't be able to heal because you will constantly be reminded". I explained we were not thinking about a lawsuit, we only were trying to understand why our mother died. I thought what a strange remark for a doctor to make. After we left his office, we looked at each other and wondered what we should be forgiving. My sister and I went to see the cardiologist on the same day as the orthopedic. When I questioned him about my mother's death he stated" your mother died as a result of having her artery cut". His statement was "my office is separate from the orthopedic surgeon" as if by separation he had nothing to do with it. I asked him why he cleared her for surgery and told him in my eyes he was as responsible for my mother's death as the orthopedic. The vascular surgeon was next on our rounds of the day. When I asked him, "should my mother have been cleared for surgery"? He answered, "In retrospect no".

Maybe it was time to get the records from the hospital and other doctors involved. It took about two weeks to receive all the records. This was going to be harder then I thought trying to understand all of this medical jargon. I was finding bits and pieces that were scaring me. Wrong blood was given, lymph nodes taken out and tested for cancer, March 18 my mother had arrested on the operating table, but we were never told about this from the doctor unless that is what "felt her spirit leave" meant not medical terminology for arrest and resuscitation. She had received no intravenous fluids vital for nutrition for over two days. Thank God, for a surgical nurse's notes, the truth of the March 18 surgery was now being revealed. The orthopedic surgeon had cut another different artery, my mother bleed out; she was given about two and a third liters of blood, the wrong blood type. She went into cardiac arrest, got a cardiac injury and pulmonary injury. The orthopedic called the vascular surgeon from the operating room. The conversation was taking place on the speakerphone; the orthopedic surgeon asked the vascular surgeon what to do and told him to get down there fast. The vascular arrived in 11-minutes to take over. I wondered why he did not feel obligated to come out to talk to us. Was he trying to hide something? Yes, they all kept the secrets for the brotherhood. I read enough; it was time to find an attorney.

Upon review of the medical records by the attorney, several more facts were discovered. Facts that even though, I was at the hospital almost ever minute of the day and night were not told to me. The doctors were making their own decisions and they enforced them. Therefore, the cover-up continued. In the most stressful time of my life, who would think the doctors would be dishonest, incompetent or negligent. Not many people have this impression of a doctor; perhaps, they have not met a bad doctor or even believe this possibility exists. Once you have been down this road trust does not come freely anymore, questions that have gone unanswered become vital, when intuition burns deep in the pit of your stomach it is a good idea to listen. Communication has two voices, the doctor and the patient. Doctors do not always know best.

In my case, the Medical Advance Directive was ignored. They had my mother signing for surgeries when she could not possibly know what she was doing. During one signing, she was intubated and not able to give informed consent. This fact was also discovered after contacting the attorney. I was completely outraged to know how far the medical establishment would over step their boundaries. What is the point of an Advance Directive if it is not upheld? In some states, this constitutes Medical Battery. I felt violated. My mother had taken the precaution to protect herself and her choice of medical decisions, how dare they violate her.

During those 18 days, my mother was tortured and we as a family were all terrorized. When the orthopedic surgeon wanted to take her leg, she was already in the final stage of her life. She had multiple organ failure, sepsis throughout her entire body and her leg was already dead. It had been poisoning her body from March 16 the first day of surgery. I believe with all of my heart and soul the purpose of taking her leg with to get rid of the evidence. There was no way of reversing the damage they had done to her.
The orthopedic stated, "He would have her up again and out of the hospital in a few days". She would have died on the operating table-I have no doubt. It appeared that he was desperate and determined that some secret not be revealed. I eventually found out what I felt his motive could be. He seemed to know all about medical malpractice lawsuits. Much to my painful discovery, he was not a novice to the justice system. There were multiple complaints (suits) filed in 1996, 1997, 1998, (2) in 2001, (2) in 2002, our case in 2003, and it did not stop after my mother's death, 2004, and two more filings in 2006. The orthopedic was not alone in his knowledge of lawsuits, as I found out later every doctor involved in my mother's care had multiple lawsuits some as current as December of 2002. This finding almost sent me over the edge to the point of no return. Why could I not find out this information when I researched this doctor? If only we had known, my mother would not have taken the risk by letting him do surgery and would still be alive today.

I was not able to see her leg until at the mortuary even though I had asked more then once at the hospital. They stated, "I would not understand". Were they so confident in believing that I would not look at her leg when I had a chance? They had gotten away with their non-sense for 18 days. Did they think I would understand when I saw her leg by myself? You can see it for yourself if you are brave enough to look. I believe everyone that contemplates knee surgery should see what he or she could be up against if the surgery goes wrong.

In summary, the orthopedic surgeon saw my mother for the initial consultation only once in October 2002, performed surgery five months later in March 2003, cut two arteries, failed to manager her care while in ICU, failed to keep her family informed, ignored the Medical Advance Directive. In the 18 days, I saw the orthopedic surgeon on these days only, March 16, 17, 18, and at 8:00 p.m. on April 2, just hours before my mother's death. He said he was sorry and commented, "Your mother was a fighter". He then left her room.

The State of California Licensing Bureau for the hospital investigated the hospital. One of the investigators telephoned me to say, "I should have my attorney report the orthopedic surgeon to the California State Medical Board or I should make a complaint myself" when I asked why she told me "they found his actions to be disastrously dangerous". I was not surprised by their findings; I had already made that determination myself.

My mother's fight was over mine was just beginning. It is difficult to relive the events of those final weeks of my mother's life, but oh so necessary. Life's lessons are cruel. Perhaps, it is what we do with the knowledge we have learned that will make a difference for those who may follow in our footsteps. I am determined that my mother's death will not be in vane. I would find the strength to continue my quest for justice and try to make a difference in someone else's life.

This malpractice suit, for me, is not about retribution or revenge. I pray everyday that justice will be served and that all involved in this tortuous and untimely death will be held accountable for what they did in the name of medicine. I also pray that the doctors have learned a few lessons themselves, causing them to re-access their priorities and values.

My mother would become part of another valuable lesson, one I call a miracle, and am so grateful for experiencing. On April 2, before she went into a coma, she made several attempts to speak. Her voice was weak and barely audible. The oxygen machine was extremely loud and was doing most of the breathing for her. I struggled to listen. She said, "Grandma is here". I looked at my mom's sister, my aunt, "Did she know her Grandma"? She told me "no". I was puzzled. My mom's ICU room was glass front with a clear view to the nurse's station. She wanted to know "Who all those people were". I told her it was the just the nurse's station. She replied, "No, never mind you can't see them". I was frightened; I had no idea what she was talking about or why. I still did not know she was dying. Her final attempt to speak she said "Annie is that you"? Finally, it had become crystal clear to me. Annie was my Grandma, my dad's mother. She died from a heart attack when I was 8 years old. All 8-year-old children know that people go to heaven. I now understood, my mother was telling me good-bye and it would not be long. I held her hand until she took her final breath and knew without a doubt when she left my world she would be home in heaven.

I had received my miracle, not the one I had been desperately praying for, that my mother's life would be spared, but I would now know she would still be loved, taken care of and not alone. Thank you, Jesus for your Blessing.