Letter 8: If Only
In reviewing the clinical notes from the endocrinologist’s office, it looked as if her
focus was on your diagnosis from 15 years earlier of Polycystic ovary syndrome
(PCOS). And yet, your autopsy found no evidence of PCOS. Why hadn’t the
endocrinologist tested you to see if you actually had PCOS? After suggesting you
were androgynous and hirsute, why didn’t they do any testing for either? Why did
they recommend that you stay on Yaz when the reason for your consultation was
elevated liver function, which is a known side effect of Yaz?
Where was their compassion? Where was there scientific curiosity? Where was their desire to prevent harm to their patients? The endocrinologist’s website bragged about their ability to treat PCOS – but given how popular Yaz was as birth control, why didn’t they know that the symptoms of PCOS and Yaz are similar (all they had to do was look those symptoms up online)? Why didn’t this endocrinologist know that and consider an alternative diagnosis? They did no tests to support the PCOS diagnosis and got most of the clinical observations (such as hirsutism) wrong. The M.E. found positive proof that the diagnosis was incorrect.
Sadly, what we know now about your treatment and the way the medical profession works was a major contributor to Yaz killing you.
Annie, it broke our hearts again when we realized how easily you could have been saved. If only anyone had considered that something prescribed for you caused your symptoms and the outcome! Medicines are intended to change how your body functions. Doctors feel reassured when medicine causes changes that successfully deal with our symptoms, but reluctant to even consider that the medication they prescribed could cause symptoms that are known side effects.
When we looked at your phone records and the OB/GYN appointment sheet we realized that about an hour after you picked up your last Yaz prescription (two weeks before your death) you had called your OB/GYN to make an appointment. You must have noticed the listed side effects of Yaz and suspected Yaz as a cause of your numerous medical problems! The receptionist did not tell you to discontinue Yaz or even refer you to a health professional for a phone consult. Apparently, they thought your call only warranted a routine response of making an appointment.
Your appointment was made for early on a Sunday morning. Late in the week, you realized that a Sunday appointment must be a mistake; after all, the doctor’s office had not called to remind you of the appointment. You rescheduled but died before physically seeing the NP. Our investigation has revealed that this doctor regularly made appointments at weird times and sometimes he or his staff did not show up! Even if you had gone to the office, would they have been there? We’ll never know.
Our investigation also revealed that after stopping hormones like Yaz for just two weeks the risk of blood clots decreases dramatically - it washes out of your system. You were not sexually active so had no risk of pregnancy. All it would have taken was for the doctor to tell you to stop Yaz until you came in.
Your OB/GYN could have stopped the Yaz…
The primary care doctor (or nurse practioner) could have told you to stop taking it…
The endocrinologist could have told you to stop taking it…
If only…if only…if only. Too many wasted opportunities that resulted in wasting your beautiful, promising life!!
Two years later, the Maryland Medical Board would exonerate both the OB/GYN and the endocrinologist of any wrong doing.