HPARB created to defend doctors/surgeons --- Created to present a false impression that citizens have a recourse to appeal OCPS inept decisions

ONTARIO CITIZENS BEWARE! 

 THE HEALTH PROFESSION APPEAL AND REVIEW BOARD MERELY PRETENDS TO BE AN AVENUE FOR A CITIZEN TO QUESTION A DECISION FROM THE ONTARIO COLLEGE OF PHYSICIANS AND SURGEONS. WHEN HPARB RENDERS ITS DECISION AND PLACES IT ON THE PUBLIC REGISTER, THE SURGEON’S NAME IS REPLACED WITH HIS INITIALS “LK”.
SO, HOW CAN THE CITIZENS OF ONTARIO BE WARNED WITH RESPECT TO THIS SURGEON??
HPARB HAS MERELY CONTINUED THE COVER-UP OF NEGLIGENCE CAUSING DEATH.

Health Professions Appeal and Review Board
In reply please quote: File # 13-CRV-0052
July 31, 2013

Ontario
CONFIDENTIAL

Mr. Arnold Kilby Mr. Byron Shaw

Applicant Counsel for Respondent

Dear Mr. Kilby and Mr. Shaw
RE: COMPLAINT REVIEW - MEDICINE
ARNOLD KILBY AND LAZAR VICTOR KLEIN, MD
Enclosed herewith is a true copy of the Decision and Reasons of the Health Professions Appeal and Review Board in the above-noted matter.
While your file is now closed, please note that parties to Complaint Reviews of the Health Professions Appeal and Review Board have the right to request a judicial review of the Board's decision. You may wish to consider obtaining legal advice to determine what options are available to you. To request a judicial review contact the Divisional Court at 416-327-5100.
Yours sincerely,
HEALTH PROFESSIONS APPEAL AND REVIEW BOARD
ARNOLD W. KILBY -- THE HEALTH PROFESSIONS APPEAL AND REVIEW BOARD FAILED TO INVESTIGATE MY COMPLAINT. THEIR OWN PROCESSES AND UNTIMATE DECISION ARE “UNREASONABLE” AND “INADEQUATE”

SO, HOW THEY ARRIVED AT THEIR CONCLUSION THE COLLEGE’S THIRD DECISION WAS “ADEQUATE” AND “REASONABLE” IS AN ABSOLUTE MYSTERY??

Anna Dunscombe Case Officer
Encl: Decision dated July 31, 2013
cc: College of Physicians and Surgeons of Ontario (CPSO File # 86981)

I HAVE NOT STATED ANYTHING THAT WAS NOT INCLUDED IN MY THIRD APPEAL SENT TO HPARB
151 Bloor Street West, 9th Floor Toronto, Ontario M5S 1S4

Tel/Tele 416-327-8512 Toll free/Sans frais 1-866-282-2179
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151, rue Bloor ouest, 9° etage Toronto, Ontario M5S 1S4

File# 13-CRV-0052
HEALTH PROFESSIONS APPEAL AND REVIEW BOARD
PRESENT:
Thomas Kelly, Vice-Chair, Presiding Stephen Jovanovic, Vice-Chair Brenda Petryna, Board Member
Review held on June 5, 2013 at Toronto, Ontario
IN THE MATTER OF A COMPLAINT REVIEW UNDER SECTION 29(1) of the Health
Professions Procedural Code, Schedule 2 to the Regulated Health Professions Act, 1991, Statutes of Ontario, 1991, c. 18, as amended
BETWEEN:

ARNOLD KILBY

Applicant

and

Respondent
Appearances:
The Applicant:
Support for the Applicant:
Support for the Applicant:
Support for the Applicant:
For the Respondent:
For the College of Physicians
and Surgeons of Ontario:

LAZAR VICTOR KLEIN, MD
Arnold Kilby
Murray Kilby
Hilda LeBlanc
Maie Liiv
Katherine Booth, Counsel
Angela Bates (by teleconference)

DECISION AND REASONS
I. DECISION
1. It is the decision of the Health Professions Appeal and Review Board to confirm the decision of the Inquiries, Complaints and Reports Committee of the College of Physicians and Surgeons of Ontario to:

(i) advise Lazar Victor Klein, MD, to continue to consider the use of prophylactic antibiotics at the time of conversion from laparoscopic procedure to open laparotomy based on the evolving standard of practice;
(ii) advise Lazar Victor Klein, MD, to individualize the use of pre-operative
prophylactic antibiotics for patients where it is warranted based on the evolving standard of practice; and
(iii) counsel Lazar Victor Klein, MD, on the timely documentation of discharge summaries.
2. This decision arises from a request made to the Health Professions Appeal and Review Board (the Board) by Arnold Kilby (the Applicant) to review a decision of the Inquiries, Complaints and Reports Committee (the Committee) of the College of Physicians and Surgeons of Ontario (the College). The decision concerned a complaint regarding the conduct and actions of Lazar Victor Klein, MD (the Respondent). The Committee investigated the complaint and decided to counsel and advise the Respondent as described above.
II. BACKGROUND
3. This is the third Review by the Board of this matter.
4. On July 21, 2006, the Applicant's daughter, Ms. Terra Dawn Kilby (the patient), died at the age of twenty-eight following her discharge from the Humber River Regional Hospital (the Hospital). The Respondent, a general surgeon, had performed an operation on her to remove a growth located in her abdomen.
5. After commencing a laparoscopy on July 11, 2006, it became apparent that the growth had attached itself to the patient's colon and kidney. The Respondent converted the surgery to an open operation and removed the mass and part of the patient's colon. 

 AWK—SURGICAL RECORDS SHOW HE KNEW BEFORE HE CONVERTED FROM LAPARASCOPIC TO LAPAROSCOPIC SURGERY.
6. The Respondent did not administer antibiotics to the patient before or during the surgery.
Procedural History
7. In June 2007, the Applicant complained to the College about the Respondent's care of his daughter. The College's Complaints Committee (the predecessor to the Inquiries, Complaints and Reports Committee) investigated the complaint and issued a decision on January 16, 2008.
8. The Complaints Committee summarized the Applicant's complaint by stating that the Applicant was concerned the Respondent failed to provide appropriate care in the management of his daughter, in that the Respondent:

• failed to provide adequate post-operative care to [the patient] as he did not regularly assess her or her wound;
• failed to provide the pathology results to [the patient];
• failed to increase [the patient]'s diet in a timely manner;
• released [the patient] from the hospital too soon as [the patient] was still
not eating solid food upon discharge.

9. After reviewing the Record compiled in its investigation, the Complaints Committee decided to take no further action. The Complaints Committee found that the Respondent provided appropriate care. It described the patient's case as "extremely unusual" and said that it "could find no information in the hospital chart or other medical records to predict the horrific outcome, nor any information to suggest that there were flaws in [the Respondent's] surgery or the care he provided that directly or indirectly resulted in [the patient's] untimely death."
10. The Applicant, dissatisfied with this decision, requested a review by the Board. The Board conducted a review and in a decision dated March 31, 2010 [A.K. v. L.V.K., 2010 CanLII 44390 (ON HP ARE)], the Board concluded that the Committee's decision was unreasonable and referred the matter back to the Committee "for further consideration, any further investigation it might in its discretion find warranted, and the issuance of a new decision." The Board found that the Committee's reasons lacked a level of detail to demonstrate that it considered all relevant factors in arriving at its conclusion that the physician's conduct was within acceptable standards, and outlined five points raised by the Applicant that the Board could not confirm the Committee had put its mind to:
• the Applicant pointed to consistent observations in the nursing charts of a
foul odour and an oozing incision with large, purulent discharge - commencing July 15 and continuing to the date of his daughter's discharge on July 20. He remained unclear as to whether this might have been an indication of something more than a superficial wound infection warranting further medical investigations;
• there are concomitant nursing notes documenting the patient's increasing
abdominal distension - from flat, to rounded, to large - leading up to the date of her discharge;
• the Applicant questioned whether his daughter ought to have been ordered
antibiotics when the incision became infected and queried whether the laboratory results of the swab taken revealed matters for concern;
• the Applicant had asked the College whether the infection his daughter
had might have caused disseminated intravascular coagulation (DIG); and
• the Applicant continued to question whether it would have been expected
for a physician to order an investigative diagnostic test such as a CAT
scan after an infection was first noted.
11. Following this decision, the Applicant supplemented his original complaint, and stated that, in the Respondent's care there had been:
• pre-operative negligence in that antibiotic prophylaxis was not given and
bowel cleansing did not occur prior to the surgery;
• post-operative negligence in that the patient's nutritional needs were not
met following the surgery, and as a result, her surgical wound could not heal.

12. The Committee received further submissions from the parties and a report from an independent opinion provider and issued a decision on July 15, 2011. In this decision, the Committee counseled the Respondent on timely documentation of discharge summaries and suggested that he may wish to consider the use of pre-operative antibiotics for bowel surgery in future. The Committee took no further action.
13. The Applicant, dissatisfied with this decision, requested a second review by the Board.
The Board conducted a review and in a decision dated November 25, 2011 [AK v LVK,2012 CanLII 39837 (ON HP ARE)], decided to return the decision to the Committee and require it to further consider and clarify its decision concerning the use of pre-operative antibiotics and the standard of practice. The Board confirmed the Committee's decision to counsel the Respondent on timely documentation of discharge summaries and to take no further action on the other aspects of the complaint.
The Committee's Decision
14. The Committee carried out further investigations that included further submissions from the parties and the independent opinion provider (IOP) and in a decision dated,
November 22, 2012, determined to
(i) advise the Respondent, to continue to consider the use of prophylactic
antibiotics at the time of conversion from laparoscopic procedure to open
laparotomy based on the evolving standard of practice;
(ii) advise the Respondent to individualize the use of pre-operative prophylactic
antibiotics for patients where it is warranted based on the evolving standard of
practice; and
(iii) counsel the Respondent on the timely documentation of discharge summaries.

III. REQUEST FOR REVIEW
15. Dissatisfied with the decision of the Committee, in an e-mail letter dated January 18, 2013, the Applicant requested that the Board review the Committee's decision of November 22, 2012.
IV. POWERS OF THE BOARD
16. After conducting a review of a decision of the Committee, the Board may do one or more of the following:
a) confirm all or part of the Committee's decision;
b) make recommendations to the Committee;
c) require the Committee to exercise any of its powers other than to request a Registrar's investigation.
17. The Board cannot recommend or require the Committee to do things outside its jurisdiction, such as make a finding of misconduct or incompetence against the member, or require the referral of allegations to a discipline hearing that would not, if proved, constitute either professional misconduct or incompetence.
V. ANALYSIS AND REASONS
18. Pursuant to section 33(1) of the Health Professions Procedural Code (the Code), being Schedule 2 to the Regulated Health Professions Act, 1991, the mandate of the Board in a complaint review is to consider either the adequacy of the Committee's investigation, the reasonableness of its decision, or both. AWK---HPARB FAILED TOTALLY AND THUS DID NOT FULFILL ITS OBLIGATION UNDER THE ABOVE CODE AND ACT!
18. The Board has considered the submissions of the parties, examined the Record of Investigation (the Record), and reviewed the Committee's decision.

Adequacy of the Investigation
20. An adequate investigation does not need to be exhaustive. Rather, the Committee must seek to obtain the essential information relevant to making an informed decision regarding the issues raised in the complaint. 

 AWK—SO, WHY DOES HPARB COMPLETELY DISREGARD THE SURGICAL RECORD THAT PROVES DR. KLEIN KNEW ABOUT THE COLON RESECTION PRIOR TO CONVERTING TO OPEN ABDOMINAL SURGERY —“PROCEDURE ONE CLEARLY INDICATES – LAPARASCOPIC SURGERY FOR COLON RESECTION.” ????
21. The Committee had before it the following documents:

• Original investigation Record before the Committee in July 2011;
• Committee decision of July 2011;
• HPARB decision of June 2012;
• Addendum report from the Independent Opinion Provider (IOP), received
September 10,2012;
• Correspondence with the IOP;
• Further Information from the IOP, received September 12,2012;
• Response from the Respondent, received October 4,2012;
• Additional information from the Applicant

22. The Applicant submitted that the Committee required a colorectal surgeon on the panel due to the particular complexity and issues of this case.
23. The Board notes that the Committee was a specialized surgical panel which sought and obtained a report from an IOP who is a surgeon and whose practice consists of 80 to 90% colorectal surgery.
24. The Board finds that the Committee obtained the necessary specialized expertise in the form of a report with addendum information from a colorectal surgeon and that it was therefore not necessary for the Committee to have a colorectal surgeon as a member of the panel.  

AWK—WHY DOES HPARB PLACE ABSOLUTELY NO CREDIBILITY TO THE OVER 100 SURGEONS’ OPINIONS THAT I PROVIDED AND THE FACTUAL INFORMATION THAT I SUPPLIED??? THE COLLEGE PROVIDED NO SUPPORTING FACTUAL INFORMATION FOR THEIR OPINION.
25. The Board further notes that the IOP report was sent to the parties for comment before the Committee came to its decision in this matter.
26. The Board finds that the Committee's investigation covered the events in question and yielded relevant documentation to assess the complaint regarding the Respondent's conduct and actions. 

AWK— “WHAT REVELANT DOCUMENTATION? ALL THE COLLEGE HAS EVERY SUBMITTED ARE OPINIONS, NO FACTUAL DOCUMATION, NOTHING TO SUPPORT THEIR OPINION.
27. There is no indication of further information that might reasonably be expected to have affected the decision, should the Committee have acquired it. Accordingly, the Board finds that the Committee's investigation was adequate.
****************
AWK—HOW ABOUT THE TRUTH--- DR. KLEIN KNEW ABOUT THE COLON RESECTION THAT WAS REQUIRED, TRIED IT LAPARASCOPICALLY AND THEN CHANGED TO OPEN ABDOMINAL SURGERY!!!!!! AND WHAT HAPPENED WITH REGARD TO THE COLLEGE’S OWN WORDS FOUND IN THE SECOND DECISION:
Page 6 of College’s Second Decision
“The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by Dr. Klein in this case. The Committee would suggest that Dr. Klein consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case.”
Page 5 of College’s Third Decision  

AWK—HOW CAN HPARB IGNORE THE WORDS ‘NEGLECTED’ AND ‘OVERSITE’

• “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by Dr. Klein in this case. The Committee would suggest that Dr. Klein consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case.”
PLUS THE OTHER EVIDENCE THAT CLEARLY CONTRADICTS THE COLLEGE’S THIRD OPINION THAT DR. KLEIN DIDN’T KNOW THAT HE HAD TO DO A COLON RESECTION UNTIL AFTER HE CONVERTED TO OPEN ABDOMINAL SURGERY!!!!!
In response to a request for further information from the College, the IO provider also set out the following information:
• The standard of practice would be to administer prophylactic antibiotics in connection with laparoscopic procedures if the bowel were involved; however, in this case, Dr. Klein believed he would be dealing with a cyst only and not opening the bowel, so the standard would not require administration of prophylactic antibiotics for the laparoscopic procedure.
 

Note the Procedure Desc.
“Laparoscopic Colon Resection Attempted For Mesenteric Mass”

And from Dr. Taylors’(the College’s I.O)letter to Angela Bates May 8th, 2011,
“During the surgery on July 11 2006, Dr. Klein realized that the mass was not separable from the colon or retroperitoneum and obtained consultation with a colleague and went ahead with an open right colectomy. This is well documented in the operative note on page 48.”

OPERATIVE PROCEDURE I-/ Diagnostic laparascopy
2-/ Open right hemicolectomy and excision of mesenteric cyst.
PROCEDURE;
At the time of laparoscopy, a large cyst could be seen in the mesentery of the right colon. It was densely adherent to the bowel as well as densely adherent to the lateral abdominal wall. It felt very solid and not at all in keeping with a simple mesenteric cyst. We therefore made the decision to convert to an open procedure.
************************************
Reasonableness of the Decision
28. In considering the reasonableness of the Committee's decision, the question for the Board is not whether it would arrive at the same decision as the Committee, but whether the Committee's decision can reasonably be supported by the information before it and can withstand a somewhat probing examination. In doing so, the Board considers whether the decision falls within a range of possible, acceptable outcomes that are defensible in respect of the facts and the law.  

AWK---HOW ON EARTH CAN HPARB FIND THE DECISION REASONABLE WHEN THERE WAS ABSOLUTELY NO SUPPORTING INFORMATION? --- ACTUALLY THERE WERE SOME CONTRADICTORY STATEMENTS.
29. The Board returned the previous decision to the Committee, "to further consider and clarify its decision concerning the use of pre-operative antibiotics and the standard of practice".
30. The Committee in its 2011 decision sought and obtained an opinion from an IOP. After receiving the Board's 2011 decision, the Committee asked the IOP to clarify his opinion and asked him the following question:
Can you please clarify your statement about antibiotic administration at the time of conversion to an open procedure, and whether failure to do so amounts to a failure to meet the expected standard of the profession?

31. The IOP replied as follows:
The issue of antibiotic administration at the time of conversion to an open procedure is really not relevant to the outcome for this patient. Antibiotics administered preoperatively prior to laparoscopic or open colorectal surgery are used by most general and colorectal surgeons, as they have been shown to reduce the incidence of wound infection, but really have no bearing on the incidence of anastomotic leak. Prophylactic postoperative antibiotics are thought to be unnecessary by many people. They really have very little impact on wound infection. 

AWK---BUT DID HPARB CONSIDER THE FACT THE COLON RESECTION BROKE DOWN DUE TO THE TISSUE DYING (CORONER’S REPORT) AND THAT THERE WAS A TEST RESULT THE CAME BACK –‘MANY GRAM NEGATIVE BACILLI’ AND THE ABDOMINAL INCISION WAS INFECTED (HOSPITAL RECORDS) REMEMBER—TERRA RECEIVED ABSOLUTELY NO ANTIBIOTICS WHAT-SO-EVER!!!!
32. Upon receipt of this report, the IOP was telephoned and asked for clarification, " if it was considered the standard of practice to administer prophylactic antibiotics in connection with (a) laparoscopic procedures not involving the bowel; and (b) open bowel
resections."
33. He replied:
The standard would require administration of prophylactic antibiotics in connection with laparoscopic procedures if the bowel were involved; however, in this case, Dr. Klein believed he would be dealing with a cyst only, so the standard would not require administration of prophylactic antibiotics for the laparoscopic procedure.
The standard of practice for open bowel resections is to provide antibiotic prophylaxis. However, he further clarified that such administration would not reduce the risk of anastomotic leak.
34. The Committee considered the lOP's comments. It noted that at this time there is no consensus in the medical community based on available research to support that antibiotics should be administered at the time of conversion from a laparoscopic procedure to an open laparotomy. As such, the Committee agreed with the IOP that the administration of antibiotics at the time of the conversion would not be required to meet the standard of practice.  

AWK---DID THE COLLEGE EVER PROVIDE WRITTEN DOCUMENTATION TO SUPPORT THEIR CLAIM ABOVE??? NO!
35. Having determined that the standard of practice did not require the administration of antibiotics at the time of conversion, the Committee did however note that there might eventually be developments in medical research that will provide definitive support for the use of antibiotics at the time of conversion. It determined that it would advise the Respondent to continue to consider the use of prophylactic antibiotics at the time of conversion from laparoscopic procedure to open laparotomy based on the evolving standard of practice.
36. The Committee further acknowledged that the Respondent indicated that he did appropriately consider the risks and benefits of administering antibiotics at the time of conversion, and ultimately determined that the risks outweighed the benefits. AWK---WHAT ARE THESE RISKS? THEY WERE NEVER MENTION IN ANY OF THE THREE COLLEGE DECISIONS NOR DURING ANY OF THE THREE HPARB MEETINGS!!
37. In addition, the Committee noted that, as supported by the IOP, the lack of antibiotics did not influence the unfortunate outcome given that there was no evidence of sepsis at the time of discharge from hospital.
38. The Committee did however determine to advise the Respondent to individualize the use of pre-operative antibiotics where it is warranted based on the evolving standard of practice.
39. The Board has considered the Committee's conclusions in this regard and finds them to be reasonable for the following reasons.
40. As noted in the procedural history, the Committee has considered this matter on three separate occasions and the Board has considered the matter twice.
41. It was returned to the Committee to "further consider and clarify its decision concerning the use of preoperative antibiotics and the standard of practice."
42. The Committee reasonably requested that the IOP clarify his previous report, which he has done by opining that the standard of practice would require the administration of prophylactic antibiotics in laparoscopic procedures only if the bowel were involved. In this case, he noted that the Respondent believed that he would be dealing only with a cyst and that the standard would thus not require the administration of prophylactic antibiotics.
*************************
AWK---ONCE AGAIN, THERE IS DOCUMENTED PROOF THAT DR. KLEIN KNEW EXACTLY WHAT HE WAS DEALING WITH!
from Dr. Taylors’(the College’s I.O)letter to Angela Bates May 8th, 2011,
At the time of laparoscopy, a large cyst could be seen in the mesentery of the right colon. It was densely adherent to the bowel as well as densely adherent to the lateral abdominal wall. It felt very solid and not at all in keeping with a simple mesenteric cyst. We therefore made the decision to convert to an open procedure.

I PERSONALLY DO NOT BELIEVE THAT THE HPARB PANEL TRULY STUDIED MY SUBMISSION,
OR
THEY WERE FOLLOWING INSTRUCTIONS TO PUT AN END TO MY CONTINUED ATTEMPTS TO HOLD THE COLLEGE TO FULFILL ITS DUTY TO PROTECT PATENTS.
************************
43. The Committee further noted that there is no consensus in the medical community to support that antibiotics should be administered at the time of conversion of the procedure.
44. In addition, the Committee noted the lOP's opinion that the administration of prophylactic antibiotics for the laparoscopic procedure, as it involved only a cyst and not the bowel, would not be required to meet the standard of practice. AWK---SEE PREVIOUS COMMENTS WITH REGARD TO THE BOWEL??
45. Having come to these separate conclusions, the Committee nonetheless decided to advise the Respondent to consider the use of prophylactic antibiotics in both situations.
46. The Committee exercised its medical expertise in this matter, and relied on the opinion of the IOP in coming to its conclusions.
47. The Board thus finds its decision to advise the Respondent to individualize the use of pre- operative prophylactic antibiotics and to consider the use of them at the time of conversion from laparascopic procedure to open laparotomy to be reasonable.
Issue: Timely Documentation of Discharge Summaries
48. The Committee noted that it issued a counsel to the Respondent on the timely documentation of discharge summaries, which the Board accepted as reasonable in its 2011 decision. The Committee therefore included that counsel as part of its current decision.
49. There were no submissions made at the review regarding this counsel.
50. The Board notes that the Committee explained its rationale for this counsel in its July 15,
2011 decision. In that decision, the Committee stated that it was troubled by the
Respondent's five month delay in completing the patient's discharge summary and concluded that a counsel was warranted in the circumstances.
51. The Board finds the Committee decision to issue a counsel in this regard to be reasonable as it addresses the area of concern identified by the Committee and provides guidance to the Respondent in his future practice.
52. The Board wishes to extend its condolences to the Applicant.
VI. DECISION
53. Pursuant to section 35(1) of the Code, the Board confirms the Committee's decision to:
(i) advise the Respondent, to continue to consider the use of prophylactic
antibiotics at the time of conversion from laparoscopic procedure to open
laparotomy based on the evolving standard of practice;
(ii) advise the Respondent to individualize the use of pre-operative prophylactic
antibiotics for patients where it is warranted based on the evolving standard of
practice; and
(iii) counsel the Respondent on the timely documentation of discharge summaries.
AWK -- THE HEALTH PROFESSIONS APPEAL AND REVIEW BOARD FAILED TO INVESTIGATE MY COMPLAINT. THEIR OWN PROCESSES AND UNTIMATE DECISION IS “UNREASONABLE” AND “INADEQUATE”

SO, HOW THEY ARRIVED AT THEIR CONCLUSION THE COLLEGE’S THIRD DECISION WAS “ADEQUATE” AND “REASONABLE” IS AN ABSOLUTE MYSTERY??

LET’S NOT FORGET FROM THE BOOK DR. KLEIN CO-AUTHORED:
“Safe implementation of laparoscopic gastrectomy
in a community-based general surgery practice”
Peter K. Stotland Æ Shea Chia Æ Jamie Cyriac Æ
John A. Hagen Æ Lazar V. Klein
Received: 22 December 2007 / Accepted: 5 April 2008 ! Springer Science+Business Media, LLC 2008
If this applies to laparoscopic gastrectomy it certainly applies to open abdominal surgery for colon resection.
“Our standard practice was to routinely administer prophylactic antibiotics and subcutaneous heparin (5000 IU) 1 h prior to induction of anaesthesia. Subcutaneous heparin was continued in the postoperative period until the patient was discharged from hospital.”

ISSUED July 31,2013

Thomas Kelly
Stephen Jovanovic
Brenda Petryna

Terra Dawn Kilby
      "An Angel In Our Lives"
         April 22/78 to July 21/06
http://anangelinourlives-awk.blogspot.ca/