Reference: Patient C. Jeff KXXXXXX Date of Birth: 2/13/61
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1 Reference: Patient C Jeff KXXXXXX Date f Birth: 2/13/61 43 y.. W male wh presented n Feb 16, 2004 with c/c f Adrenal Carcinma, initially diagnsed in September 2003, status pst surgical resectin in Oct 2003 with left nephrectmy, adrenalectmy and splenectmy, alng with extensive lymph nde dissectin. Pt presented with a 59 pund weight lss. Prir t diagnsis f cancer, patient had significant hx f abdminal surgery in Octber 2002 with resectin f greater than 4cm f sigmid cln with placement f a clstmy. Three mnths later, in Feb 2003, pt had clstmy takedwn. Underwent 16 treatments f radiatin, althugh advised t have 28. Pt stpped after becming very sick and was unable t tlerate further treatments. Pt tld by nclgist that chemtherapy wuld nt be an ptin and was reprtedly given less than 6 mnths t live. On Feb 3, 2004, the first pst perative cat scan shwed questinable lesin in lung (5mm), as well as a new lesin in the liver measuring 2 ½ cm. Patient presented t us with stage 4 Adrenal Cancer and was under the care f Dr. Buttar frm February 16, 2004 until June 9, 2004 and was last seen in ur clinic n June 11, Patient died n September 18, 2004 frm a pulmnary emblus, mre than three mnths after treatment had been cmpleted by Dr. Buttar Each numbered item belw is the NCMB s expert reviewer s cmments n the charts. Each bulleted item is ur respnse, with references t the medical charts shwing the facts. - Dr. Petersn: 1. NCMB Expert s (Dr. Petersn) pinin n Treatment Belw standard f practice/care Natural Killer Cell activity mre than dubled after treatment by Dr. Buttar Befre treatment: Natural Killer Cell Activity: 8.6 LU After treatment: Natural Killer Cell Activity: 20.8 LU A 150% increase in in NK Cell Activity Reference: G17,G18,G19,G27 Clearly Abve and Beynd the standard f care. If Dr. Petersn des NOT understand the relevance f increasing CD 19 and CD 56 cunt (NK Cell) activity in cancer patients, he substantiates himself that he is NOT qualified t review this case. 2. EDTA chelatin therapy has n benefit in treating cancer. First, we d NOT treat cancer with EDTA. We DO treat heavy metal txicity with EDTA. The incidence f heavy metal txicity with cancer is highly statistically significant. If the cancer patients shws heavy metal txicity, as they usually d, we REMOVE the metals.
2 Accrding t the cnventinal cancer literature, 75% t 95% f cancer patients have sme type f txicity. The etilgy f mst cancers stems frm increase in xidative stress due t sme srt f txicity. Sample References shwing crrelatin f heavy metals in cancer patients Have mre than a hundred thers. Metal Metablism Of Neplastic Cells: Alteratins That Facilitate Prliferatin? Critical Review Onclgy & Hematlgy, Vlume 42, N. 1, April 2002, pg Irn Chelatin Induced Senescence-like Grwth Arrest In Hepatcyte Cell Lines: Assciatin f TGF-beta1 Mediated p27superkip1 Expressin, Bichemistry Jurnal, April 11, 2002 Antiprliferative And Appttic Effects Of Irn Chelatrs On Human Cervical Carcinma Cells, Gyneclgical Onclgy Vlume 85, N. 1, April 2002, pg Ninety Percent Reductin In Cancer Mrtality After Chelatin Therapy With EDTA, Jurnal f Advancement in Medicine, Vlume 2, N. 1-2, Spring-Summer In additin, numerus labs drawn that are f n clinical relevance such as urine txic metals, steatcrit, Lactferrin, Lyszyme. 4. E1: Urine Txic Metals is a urine element analysis used fr the assessment f txic element statue, mnitring detxificatin therapy, and identifying r quantifying renal wasting cnditins. The incidence f heavy metal txicity with cancer is highly statistically significant. If the cancer patients shws heavy metal txicity, as they usually d, we REMOVE the metals. Accrding t the cnventinal cancer literature, 75% t 95% f cancer patients have sme type f txicity. The etilgy f mst cancers stems frm increase in xidative stress due t sme srt f txicity. Sample References shwing crrelatin f heavy metals in cancer patients Have mre than a hundred thers. Metal Metablism Of Neplastic Cells: Alteratins That Facilitate Prliferatin? Critical Review Onclgy & Hematlgy, Vlume 42, N. 1, April 2002, pg Irn Chelatin Induced Senescence-like Grwth Arrest In Hepatcyte Cell Lines: Assciatin f TGF-beta1 Mediated p27superkip1 Expressin, Bichemistry Jurnal, April 11, 2002 Antiprliferative And Appttic Effects Of Irn Chelatrs On Human Cervical Carcinma Cells, Gyneclgical Onclgy Vlume 85, N. 1, April 2002, pg Ninety Percent Reductin In Cancer Mrtality After Chelatin Therapy With EDTA, Jurnal f Advancement in Medicine, Vlume 2, N. 1-2, Spring-Summer 1989 F2: Steatcrit, lactferrin, lyszyme are part f the CDSA( Cmprehensive Stl Analysis/Parasitlgy x1 test which is perfrmed t assess many digestive and absrptive functins ccurring within the gastrintestinal tract as well as prviding an verview f the micrflral balance, intestinal eclgy, immunlgy and general intestinal health. D1 D51: Requirement fr mnitring renal functin, hepatic functin, electrlytes, can hemglbin cunts in a cancer patient are HIGHLY
3 relevant, especially when they are aggressively being treated fr a stage 4 cancer with multiple IV regiments daily. Labs HIGHLY necessary t mnitr patient safety Labs HIGHLY necessary t assess patient respnse Labs necessary t assist in guiding treatment intensity G1 G27: Cancer panels necessary t establish immune functin, with detailed explanatin in charts prvided G1, G9, G18 explanatin f significance f level f uncntrlled cellular prliferatin mnitring in immuncmprimised pts. Immune functin CD 19, CD 56 cunts Immune functin NKHT3 + Immuncmpetent Natural Killer Cells, NK Cell activity, NK cell activity/cell G3,G4,G11, G12, G21,G22 - Lymphcyte Subppulatin prfile CD2, CD4, CD8, CD 3, CD 26 G7, G16, G24 - Cell cycle Analysis and dsyregulatin in ncgenesis G5, G14, G23 - Apptsis and subsequent suppressin f apptsis in cancer explained in detail 5. The standard f care wuld be treatment with chemtherapy such as Mittane r enrllment in a clinical trial versus palliative care alne. C2a: Pt was tld chemtherapy was nt an ptin by nclgist. Dr. Buttar s treatment was ABOVE and BEYOND the standard f care. While under Dr. Buttar s care, pt did nt require pain cntrl. Patient lived beynd expected and predicted life span by nclgist Patient died f a dcumented pulmnary embli, NOT cancer. 6. N physician cntact dcumented. C2a: 2/16 Dr. Buttar cnducted examinatin and wrte detailed Prgress Ntes C4a,b: 3/24 Dr. Buttar cnducted examinatin and wrte detailed Prgress Ntes C5a, C5b: 4/7 Dr. Buttar cnducted examinatin and wrte detailed Prgress Ntes C6a, C6b: 4/7 Dr. Buttar cnducted examinatin and wrte detailed Prgress Ntes C9: 5/4 Dr. Buttar cnducted examinatin and wrte detailed Prgress Ntes C12a: 5/25 Dr. Buttar cnducted examinatin and wrte detailed Prgress Ntes C13: 6/9 Dr. Buttar cnducted examinatin and wrte detailed Prgress Ntes I1b: 3/15 Dr. Buttar perfrmed an IRR treatment n patient. When ever IRR s dne, Dr. Buttar always cnsults with patients and addresses any issues r questins patients have. I1a: 3/23 Dr. Buttar perfrmed an IRR treatment n patient I2b: 3/30 Dr. Buttar perfrmed an IRR treatment n patient I2a: 4/6 Dr. Buttar perfrmed an IRR treatment n patient I3: 4/14 Dr. Buttar perfrmed an IRR treatment n patient I4a: 4/20 Dr. Buttar perfrmed an IRR treatment n patient
4 I4b: 4/27 Dr. Buttar perfrmed an IRR treatment n patient I5a: 4/28 Dr. Buttar perfrmed an IRR treatment n patient I5b: 5/4 Dr. Buttar perfrmed an IRR treatment n patient I6b: 5/11 Dr. Buttar perfrmed an IRR treatment n patient I6a: 5/18 Dr. Buttar perfrmed an IRR treatment n patient I7b: 5/25 Dr. Buttar perfrmed an IRR treatment n patient I7a: 6/1 Dr. Buttar perfrmed an IRR treatment n patient I8a: 6/9 Dr. Buttar perfrmed an IRR treatment n patient - Dr. Mann: 1. The pint f the chelatin therapy is nt stated in the recrd. Failure f the reviewer, the NCMB r designated expert witness t be up t date n the medical literature is nt Dr. Buttar s respnsibility. 2. Recrds: This is the weakest part f the care. There are n recrds f justificatin f the treatments given except fr what appear t be pre-packaged paragraphs describing the ratinale fr testing fr heavy metal txicity and immune functin. This infrmatin is nt described in terms specific tests and prcedures fr this patient. This is crrect. Since the ratinale is always the same, it is prepackaged t save time and effrt. Metals increase xidative stress. Oxidative stress leads t DNA mutatin and Immunsuppressin. DNA mutatin leads t ncgenesis. Immunsuppressin leads t suppressin f apptsis. All this leads t cancer. C4b: Immune functin, results heavy metal testing C7b: Immune functin(cancer Panel) C12A: Immune functin (Cancer Panel) E1-E7b: Urine txic Metals G1-G27: Immune functin (Cancer Panel) 3. There is n written assessment f the patient s respnse t the infusins and chelatin therapy. C4a, C4b: Dr. Buttar dcumented patient s respnse t all treatments under the Subjective prtin f the Sap nte C5a: Dcumentatin f patient s respnse t all treatments under the Subjective prtin f the SOAP nte C6a: Dcumentatin f patient s respnse t all treatments under the Subjective prtin f the SOAP nte. C7a:Jane Garcia, NP dcumented patient s respnse t all treatment under the Subjective prtin f the SOAP nte. C9: Dr. Buttar dcumented patient s respnse t all treatments under the Subjective prtin f the SOAP nte. C10a:Jane Garcia, NP dcumented patient s respnse t all treatments under the Subjective prtin f the SOAP nte. C11a: Jane Garcia,NP dcumented patient s respnse under the Subjective prtin f the SOAP nte. C12a: Dr. Buttar dcumented patient s respnse under the Subjective prtin f the SOAP nte.
5 C12b: Jane Garcia,NP dcumented patient s respnse under the Subjective Prtin f the SOAP nte. C13: Dr. Buttar dcumented the patient s respnse under the Subjective prtin f the SOAP nte. 4. Mst f the ntes are written by Jane Garcia, ANP, are ften ut f rder, are ccasinally cuntersigned by Dr. Buttar and d nt reflect nging examinatin f the patient r bserved changes in his clinical status, linked t his therapy r therwise. When medical recrds given t NCMB, recrds and prgress ntes were in rder.,c12b: Dr. Buttar either wrte r c-signed ALL but ne Prgress Nte ) C2a: Signed Prgress Nte C4a: Signed Prgress Nte C5b: Signed Prgress Nte C6b: Signed Prgress Nte C8: Signed Prgress Nte C9: Signed Prgress Nte C10b: Signed Prgress Nte C11b: Signed Prgress Nte C12a: Signed Prgress Nte C13: Signed Prgress Nte C5a: Under (O) Objective f SOAP nte, exam, findings dcumented C6a: Under (O) Objective f SOAP nte, exam, findings dcumented C7b : Under (O) Objective f SOAP nte, exam, findings dcumented C9: Under (O) Objective f SOAP nte, exam, findings dcumented. C10b: Under (O) Objective f SOAP nte, exam, findings dcumented C11b: Under (O) Objective f SOAP nte, exam, findings nted C12a: Under (O) Objective f SOAP nte, exam, findings dcumented C12b: Under (O) Objective f SOAP nte, exam, findings dcumented C13: Under (O) Objective f SOAP nte, exam, findings dcumented C4a: Under the Subjective prtin f each SOAP nte, specific C5a: Under the Subjective prtin f each SOAP nte, specific C6a: Under the Subjective prtin f each SOAP nte, specific C7a: Under the Subjective prtin f each SOAP nte, specific C9: Under the Subjective prtin f each SOAP nte, specific C10a: Under the Subjective prtin f each SOAP nte, specific C11a: Under the Subjective prtin f each SOAP nte, specific C12a: Under the Subjective prtin f each SOAP nte, specific C12b: Under the Subjective prtin f each SOAP nte, specific
6 C13: Under the Subjective prtin f each SOAP nte, specific 5. The recrd des nt use SOAP. C2a: 2/16/04 - SOAP nte is CLEARLY used C2b: 2/23/04 - SOAP nte is CLEARLY used C4a C4b: 3/24/04 - SOAP nte is CLEARLY used C5a C5b: 4/6/04 - SOAP nte is CLEARLY used C6a-6b : 4/20/04 - SOAP nte is CLEARLY used C7a,C7b,C8: 4/28/04 - SOAP nte is CLEARLY used C9: 5/4/04 - SOAP nte is CLEARLY used C10a C10b: 5/13/04 - SOAP nte is CLEARLY used C11a C11b: 5/18/04 - SOAP nte is CLEARLY used C12a: 5/25/04 - SOAP nte is CLEARLY used C12b: 6/2/04 - SOAP nte is CLEARLY C13: 6/9/04 - SOAP nte is CLEARLY used 6. Overall: belw standard f practice/care, particularly in terms f dcumentatin f the attending awareness f patient status, justificatin fr therapies chsen, and awareness f effects f such therapies. C13: Dr. Buttar Signed all his prgress ntes and c-signed all f the Mid Level Prvider s ntes. C2a: Signed Prgress Nte C3a: Signed Prgress Nte C3b: Signed Prgress Nte C4b: Signed Prgress Nte C5b: Signed Prgress Nte C7: Signed Prgress Nte C8: Signed Prgress Nte C9b: Signed Prgress Nte C11b: Signed Prgress Nte C12a: Signed Prgress Nte C13: Signed Prgress Nte C4b: Under (O) Objective f SOAP nte, exam, findings dcumented C5a: Under (O) Objective f SOAP nte, exam, findings dcumented C6a: Under (O) Objective f SOAP nte, exam, findings dcumented C7b :Under (O) Objective f SOAP nte, exam, findings dcumented C9: Under (O) Objective f SOAP nte, exam, findings dcumented C10a: Under (O) Objective f SOAP nte, exam, findings dcumented C10b: Under (O) Objective f SOAP nte, exam, findings dcumented C11b: Under (O) Objective f SOAP nte, exam, findings dcumented C12a: Under (O) Objective f SOAP nte, exam, findings dcumented C12b: Under (O) Objective f SOAP nte, exam, findings dcumented C13: Under (O) Objective f SOAP nte, exam, findings dcumented 9. In additin t the abve issues, there are several examples f repetitive bld sampling with questinable utility. D1 D51: Requirement fr mnitring renal functin, hepatic functin, electrlytes, can hemglbin cunts in a cancer patient are HIGHLY relevant, especially when they are aggressively being treated fr a stage 4 cancer with multiple IV regiments n a daily basis.
7 Labs HIGHLY necessary t mnitr patient safety Labs HIGHLY necessary t assess patient respnse Labs necessary t assist in guiding treatment intensity 10. -weekly assessment f immune functin frm 2/25 5/10 withut written cmment r interpretatin f the results r adjustment f therapy. Assessment f immune functin was cmpleted 3 times in this patient G1 G8: Once prir t initiatin f treatment n Feb 25, 2004 G9 G17: Once during the treatment n Apr 20, 2004 G18 G25: Once twards the end f the first phase f tx, n May 10, 2004 Clinical interpretatin and cmments are discussed in the Assessment and Plan f the OV when tests became available fr review. G27 is a running cmparisn that was given each time t the patient and reviewed in detail with the patient. Cpy f G27 given t patient at time f review intravenus infusins 03/03/2004 t 06/11/2004 withut cmment n change in clinical status r side effects r justificatin fr further infusins. IV tx are administered via a prtcl established t change the underlying physilgy f the patient frm an acid t alkaline state with an emphasis in increasing aerbic metablism frm the predminant anaerbic metablism characteristic in ncgenesis. IV infusin given based n prtcl, as per the AMESPA Curse, which is an ACCME apprved, AMA Categry 1 CME curse. Pt s respnse t IV treatment is dcumented in nursing ntes n a daily basis t assess any adverse clinical status r side effects f tx and per prtcl, is brught t the prvider immediately There was n such adverse effect r clinical status change in this patient, and therefre, there is NOTHING dcumented. Yu can t dcument smething if it did NOT ccur. J4 J16 dcuments - All nrmal evaluatins dcumented, with vital signs, including befre and after bld pressures, weight, and pulse and respiratry rates were dcumented, as per ur clinic prtcl multiple bld draws fr labs frm 3/18/ t at least 6/11/2004 fr electrlytes, liver and kidney functins, irn studies and lipid levels which changed very little, were nt justified in the ntes, were ften ut f rder, and were rdered abut nce per week, again withut dcumentatin r justificatin. D1 D51: Requirement fr mnitring renal functin, hepatic functin, electrlytes, can hemglbin cunts in a cancer patient are HIGHLY relevant, especially when they are aggressively being treated fr a stage 4 cancer with multiple IV regiments n a daily basis. Labs HIGHLY necessary t mnitr patient safety Labs HIGHLY necessary t assess patient respnse Labs necessary t assist in guiding treatment intensity Frtunately, this patient was ding well, but ften, this is nt the case. We mnitr all patients clsely.
8 If we had NOT mnitred, an adverse event culd have ccurred and the NCMB wuld be investigating the LACK f prper mnitring. All labs are kept in rder and were in rder when charts were given t the NCMB. C3: Nte Dcumentatin f Labs perfrmed n 2/24/04, 3/17/04, 3/25/04, 4/5/04, and 4/8/04 fr cmparative analysis f renal, hepatic functin, electrlytes, irn levels, hemglbin/ hematcrit levels. As stated abve labs are dne t mnitr patient safety, assess patient respnse, and assist prviders in guiding treatment f patient. C4b: Under (O) Objective f SOAP nte findings dcumented C5a: Under (O) Objective f SOAP nte findings dcumented C6a: Under (O) Objective f SOAP nte findings dcumented C6b: Dcumentatin f Labs perfrmed n 4/01/04, 4/13/04, 4/15/04, and 4/19/04 fr cmparative analysis C7a: Under (O) Objective f SOAP nte findings dcumented C7b: Under (O) Objective f SOAP nte findings dcumented C9: Under (O) Objective f SOAP nte findings dcumented C10a: Under (O) Objective f SOAP nte findings dcumented Of labs perfrmed n 5/3/04, 5/7/04, and 5/11/04 fr cmparative analysis C10b: Under (O) Objective f SOAP nte findings dcumented C11a: Under (O) Objective f SOAP nte findings dcumented C11b: Cntinuatin f dcumented findings C12b: Under (O) Objective f SOAP nte findings are dcumented 13. The main deficiencies are in the areas f dcumentatin f justificatin fr treatments, repetitive serum tests, and lack f a sense f management f this patient using assessment linked with ratinale fr treatment. The standard f care is belw average in this case. C2a: There is a definite plan f treatment as listed under the A/P prtin f the SOAP nte. This was the patient s initial visit. Plan f treatment cntinued at each subsequent ffice visit as dcumented under the A/P f each SOAP nte. This is definitely within the standard f care. C2b: Dcumentatin under (A/P) Assessment / Plan f Sap nte C4a - C4b: Dcumentatin under (A/P) Assessment / Plan f Sap nte C5b: Dcumentatin under (A/P) Assessment/Plan f Sap nte C6b: Dcumentatin under (A/P) Assessment/Plan f Sap nte C7b,C8: Dcumentatin under (A/P) Assessment/Plan f Sap nte C9: Dcumentatin under (A/P) Assessment/Plan f Sap nte C10b: Dcumentatin under (A/P) Assessment/Plan f Sap nte C11b: Dcumentatin under (A/P) Assessment/Plan f Sap nte C12a,C12b: Dcumentatin under (A/P) Assessment/Plan f Sap nte C13: Dcumentatin under (A/P) Assessment/Plan f Sap nte
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