Timeline of Care
• Dad began feeling tired 4/27-28. On 5/2 he went to the Sanford Downtown Walk-In thinking he had a sinus infection. He had congestion, cough, post-nasal drip and was tired. He was NOT tested for Covid but was prescribed an antibiotic and sent home.

Doctor Visit & Antibody Infusion 5/7
• He started feeling better but by 5/7 was still not well so my mom took him in to see his PCP, Micheal Henke, around 10am. His symptoms were cough, congestion, post-nasal drip, feeling very tired, not hungry. His vitals were: BP 108/66, Temp 96.7, Pulse 66, Resp 16, O2 90%.
Notes say chest clear. Both of my parents tested positive for Covid at this visit. Henke suggested the monocolonal antibody infusion and dad agreed. Mom says they were not told that the infusion was manmade nor experimental, but were under the impression he would receive convalescent plasma. Summary says labs were drawn and that dad was sent home with an oximeter, and that plan of care was inpatient. None of those things happened or were true at this visit.
• At the infusion appointment later that day, his vitals were BP 115/65, pulse 51, temp 97.1 and O2 89%. Notes say chest clear. He was not told this is an experimental treatment nor was he given info on it nor asked to sign anything. The notes say he was given an info page, but it was on being Covid-positive.
• Also, the EUA for Regen-Cov excludes patients who require O2 therapy.
Emergency Department 5/7
• Within a few hours of coming home from the infusion, Dad became very weak, breathless, shaky. When we got to ER around 5:20pm, his O2 was 83% and temp was 99.2.
• His first sepsis score was 5.8 and jumped to 8.8 within an hour and stayed around 8.6 while in ED.
• His first labs indicated infection/sepsis and acidosis:
◦ CRP 149.6
◦ Procalcitonin 0.44
◦ WBC 10.7
◦ Seg Neut Abs 9.9
◦ Imm Gran Abs 0.09
◦ INR 3.5
◦ CO2 15
• He was not given antibiotics and it does not look like he was started on fluids, but he was given Ducolax and Senokot despite having had diarrhea most of the week.
• His O2 improved on oxygen and he was started on dexamethasone then admitted.
Hospital Stay 5/8 – 17
• 5/8 6:11am: WBC 17.5, SNA 14.9, Procalcitonin 3.96. Still no antibiotics started.
• 5/9 5:28am: WBC 13.6, CRP discontinued. Why? Still no antibiotics. Since Dad had bad sleep apnea, we dropped off his mask to help with his fluctuating O2 levels. Respiratory were unable to make it work for him until the evening of 5/10.
• 5/9 11:46am: Cardiology is consulted. Cardiologist says consult is not indicated.
• 5/9 12:02pm: Infectious doctor Noe Mateo notes Dad may benefit from convalescent plasma and antibiotics. Neither are ordered.
• 5/10 5:54am: INR 4.0, WBC 11.6, Procalc 2.33. Still no antibiotics. Brain Nature Peptide at 698 which could indicate heart failure or sepsis. Judging from his other elevated labs, sepsis is the more likely diagnosis. No discussion of this in his chart.
• 5/10 6:37am: Kathryn Stensgaard notes “add antibiotics”. Rocephin and azythromycin are started at about 8:30am. Dad has been in the hospital with an infection for 62 hours when antibiotics are finally started.
• 5/10 notes from respiratory say FiO2 should “always” be 100%
• 5/10 Dad is visited by PT, ST and OT because he’d mentioned a fall the previous week. He’d tripped when his flip-flop caught on a step. He was not someone who fell often or regularly, he was not clumsy nor dizzy nor uncoordinated. When he complained to my mom that the OT and ST were unkind and treated him as though he was stupid, even suggesting he needed to be taught how to feed himself, she asked his PCP through My Chart to stop therapy. The nurse who replied said that these therapies were normal for Covid patients (see my standard of care note at the end) and that Dad would have to cancel them himself. First, my mom is his Power of
Attorney and second Dad was sedated before he next saw the therapists.
• The last time our family was able to speak or text with my dad was at 8:23pm when Dad said he wanted to go to bed but was told he needed to wait for his meds. He was worn out from all the visitors that day and respiratory had finally gotten his CPAP and oxygen figured out.
• 5/10 11pm nurse notes he’s agitated and wants to remove the HiFlo mask
• 5/10 11:15pm my mom texts him, asking him to call because she’s been unable to reach him by phone.
• 5/11 1:15am nurse gives dad seroquel and ativan after consulting with Dr. Dendy
• 5/11 QT interval goes from 348ms to 514ms.
• 5/11 8:45am precedex is started. Zyprexa is also given on 5/11.
• 5/11 UTI discovered. Mom messages PCP through My Chart as she has been doing since admission and Stensgaard calls in response to her message. Says he’s sedated but doing well and reiterates that any time Mom has any questions or concerns to contact them, they’re “here for her.” This is the last conversation Mom has with Dendy/Henke’s office as nurse Heather Weaver then stonewalls her, telling her in My Chart that she cannot reach the providers that way but in no way helping her reach a doctor. At no point did Henke nor Stensgaard indicate Dad was critical. And, it was in this last conversation with Stensgaard when my mom said that Dad worsened after the infusion and Stensgaard said it was probably coincidental. Seems odd that after this no one from that office ever spoke with my mom again.
• 5/12 12am: precedex stopped according to medication administration log.
• 5/12 6:50am: Dendy notes precedex stopped because of bradycardia and that he is instead given ativan, trazodone and zyprexa. Henke’s notes from same visit say Dad is on precedex.
• 5/12 9:40am: precedex resumed according to medication administration log.
• 5/12 4:31pm: procalc 1.03
• 5/12 5:12pm: Dr Argwal says “precdex resumed” and notes say precedex restarted at 5:54pm.
But the medication administration log says it was resumed at 9:40am and increased throughout day.
• Unclear as to whether azithromycin and rocephin are stopped on 5/11 or 5/12, but notes indicate they were stopped due to QT interval prolongation.
• 5/12 Cipro and cefipime are added.
• 5/13 6:03am He’s on precedex, zyprexa and benadryl.
• 5/13 7:51am Dendy says “sedated”
• 5/13 8:07am Dendy & Henke say “alert & oriented”
• 5/13 10:11am Dendy & Henke say “alert & oriented”
• 5/13 FiO2 is at 65%. It is unclear as to whether he’s been at 100% since 5/10 or if it had been dropped down sooner.
• After 5/13 there are no notes from infectious disease.
• 5/14 4:34am He’s on precedex and ativan.
• 5/14 8:37am Notes indicate “weaning precedex” and FiO2 at 40%
• 5/14 After not being able to talk to anyone but his nurse since 5/12, we email Patient Relations and ask to be contacted. The clinic nurse (Heather Weaver) is stonewalling us and not helping my mom get in touch with the attending physician. Dendy/Henke were no longer attending as of 5/13(?) and Sarrigiannidis is attending. Mom did speak with Sarrigiannidis on 5/13 after asking Shanae (RN) to have him call her. This is the first time that we are told Dad is in such bad shape and has 70% chance of dying. Mom specifically asks to see him, says she’s already had covid, and is denied.
• 5/14 4:30pm-ish Mom spoke with his nurse again, and again around 8pm. Both of these calls are initiated by mom. No one from care team has contacted her without her contacting them first. She has not heard from a doctor since her talk with Sarrigiannidis on 5/13. No response from patient relations.
• 5/15 2:50am precedex is increased
• 5/15 8:50am bradycardia “due to precedex and sepsis”
• 5/15 My mom and I visit dad through the glass. Maria (RN) had told mom that morning that we could visit through the window after she had seen us praying outside the building. This was the first time we were told we could do this. We were told he’d be less sedated/somewhat awake and turned to face us so he could see us. She also told us that we’d be able to FaceTime him, etc.
When we visited him around 10:30 that morning, his coloring was good but he had a fever and a cough. He was sedated and did not open his eyes to see us.
• 5/16 2:25am Dr Malish notes Dad had a mucous plug. Notes “good tidal volume”. Increases
FiO2 to 100%, adds mucomyst and vest. Dad woke up when precedex held.
• 5/16 2:51am Dad has a fever. He’s given ativan, benadryl, precedex.
• 5/16 12:09pm “infiltrates improved”
• 5/16 3:28pm “pneumo improving” Temp is 101.4, FiO2 80% and he’s on precedex.
• 5/17 11:53am precedex and maxipime
• 5/17 around noon Dr Malish calls mom. He is the first doctor to call mom without her asking.
He took initiative and was first doctor to do so! He explains that he thinks dad will need to be intubated. Mom asks him to hold off as long as possible. Dr Malish is compassionate and professional.
• 5/17 at 1:16pm: Mom speaks with Shayla (RN) and asks if we can visit. Told that she’d check with infection control. We didn’t hear back.
• 5/17 3:20pm “infiltrates have improved”
• 5/17 Notes say there was written consent given, there was not. Only verbal over the phone. At no time during Dad’s stay were my parents asked if Dad had a Power of Attorney, which he did. That was my mom. She was never consulted on anything until Dr. Malish on 5/17.
• 5/17 3:57pm Dr Malish diagnoses “acute hypoxemic respiratory failure” and Dad is intubated some time around 3:57 – 4:05pm.
• 5/17 Monee Quast has my notes from the intubation and contact timeline, our dealings with Dan Sweeney, etc.
• 5/17 6:42pm Dr Malish diagnoses “septic shock”
• 5/17 10pm: Dad is released to the wrong mortuary. We requested Eastgate, that’s what’s in notes, but he was released to Bismarck Funeral Home. Doug called around 10pm and when he learned of Sanford’s mistake, said he’d handle it for us.
• 5/18 CDI emails re: sepsis. Did he come in with it? Or did he acquire it in hospital? From the chart, it looks like he was septic – or near it – upon arrival to Emergency but that Sanford did not treat it until antibiotics were started 62 hours later.

Our questions concerns:

Antibody Infusion
• Considering Dad’s symptoms after the antibody infusion, seems as though that’s what made him worse. https://www.fda.gov/media/146054/download
▪ Subsection 5.2 “Clinical worsening after REGEN-COV administration” was added to communicate that clinical worsening of COVID-19 after administration of REGENCOV is reported, the causality assessment, and that some events required hospitalization, as follows: “Clinical worsening of COVID-19 after administration of REGEN-COV has been reported and may include signs or symptoms of fever, hypoxia or increased respiratory difficulty, arrythmia (e.g., atrial fibrillation, tachycardia, bradycardia), fatigue, and altered mental status. It is not known if these events were related to REGEN-COV use or were due to progression of COVID-19.”
▪ Page 8:
Patient reported to develop ARDS about 1.5 hours after the infusion ended, requiring intubation. A complicated hospital course ensued including sepsis, MRSA lung infection, acute kidney injury.
▪ https://www.regeneron.com/medicines/casirivimab-imdevimab
Worsening symptoms after treatment: You may experience new or worsening symptoms after infusion, including fever, difficulty breathing, rapid or slow heart rate, tiredness, weakness or confusion. If these occur, contact your healthcare provider or seek immediate medical attention as some of these events have required hospitalization.
It is unknown if these events are related to treatment or are due to the progression of COVID-19.
Sepsis
◦ Since it appears Dad was septic, or near it, upon admission, it begs the question if the sepsis could have been better treated not limited to beginning IV fluids (did this even happen?) and starting antibiotics immediately (not almost 3 days later), but also by NOT sedating him. With few exceptions, my dad was sedated from 5/11 1:15am until an hour before his death on 5/17. He never had any breathing trials and was restrained so mobility wasn’t an option.
All of this is in direct conflict to the AMA’s suggestions for surviving sepsis with severe Covid-19.
▪ https://www.ama-assn.org/delivering-care/public-health/sepsis-survival-has-lessonssevere-covid-19-care-recovery
• “prioritizing sedation minimization, daily breathing trials, early mobility and other evidence-based practices,”

Standard of Care
◦ My own husband was hospitalized at Sanford 2/19 – 2/27 with Covid and pneumonia. His PCPs are Dendy/Henke. He was treated by the same respiratory therapists, had many of the same nurses and was also seen by Dr Arthurs (who by the way was fantastic). From the time of admission, he was given antibiotics (his Procalc was slightly higher than Dad’s), dexamethasone, Remdesivir, and Ivermectin. And his breathing exercises started soon after admission. My dad didn’t receive antibiotics for 62 hours despite his labs and an infectious disease doctor noting “he might benefit” nor was he given Ivermectin nor breathing exercises. Why was the care so different? Why does it seem as though my 72-year-old dad’s life was not as important as my 56-year-old husband?
◦ Further, my husband was never seen by any therapists other than respiratory therapist yet my mom was told that the visits from PT, OT and ST were usual for all Covid patients for their post-discharge care by a nurse in Dendy’s office via My Chart.
◦ My husband had a full recovery and that’s due to the treatments and care he received. At his his post-hospitalization visit the week after his discharge, Henke commented that his lungs sounded like he’d never even had Covid. At his doctor visits two months later, 3 doctors (PCP, Cardiologist and Cardiac Surgeon) could not believe how good he was doing and how clear and good his lungs are. Too bad my dad didn’t get the same care and treatment.

Oxygen Toxicity
◦ FiO2 of 100% should not be sustained for more than 12 hours. From the chart, it looks like Dad was on FiO2 for 3 days, possibly longer.
https://anesthesiageneral.com/oxygen-toxicity/
http://rc.rcjournal.com/content/57/11/1887
◦ What role did this play in Dad’s mental state and did it harm his pulmonary function?
◦ Symptoms of oxygen toxicity that my dad seems to have experienced:
▪ hyperventilation
▪ irritability
▪ atelectasis
▪ breathing trouble
▪ dysphoria
▪ coughing
▪ visual & auditory disturbance (delirium?)
▪ ARDS
▪ pulmonary edema

Sedation
• In addition to the ignorance of the AMA’s advice to minimize sedation in sepsis/Covid19 patients, Precedex is not recommended for use longer than 24 hours. My dad was on it, with a few interruptions, for 175 hours.
• Side effects of precdex Dad appears to have suffered:
◦ low blood pressure
◦ bradycardia
◦ irregular heartbeat
◦ fever
◦ agitation
◦ high blood sugar
◦ complete or partial collapse of a lung
◦ acid accumulation in the body
◦ fluid in the lungs
https://labeling.pfizer.com/ShowLabeling.aspx?id=4404
https://www.rxlist.com/precedex-side-effects-drug-center.htm
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=548a88c0-afda-427e-75ac-5af0cfa2224c

QT Interval Prolongation
• One of the conditions my dad developed while in hospital was a prolonged QT interval.
The notes mention that this could have been related to various drugs. As it turns out, my dad was on 9 different medications which can cause prolonged QT intervals:
◦ Venlafaxin
◦ Furosemide
◦ Promethazine-Codeine
◦ Azithromycin
◦ Dexmedetomidine
◦ Olanzapine
◦ Diphenhydramine
◦ Quetiapine
◦ Ciprofloxacin
• Additionally, macrolides like azithromycin interact with statins (Dad was on Crestor) to cause myopathy, quinolones (like cipro) to cause QT prolongation and antipsychotics (seroquel and zyprexa) to cause/worsen QT prolongation.
• Plus, the antipyschotics he was on (why?) also decrease WBC production and cause restlessness.
Malnutrition
• Dad lost more than 12 pounds while hospitalized.
• There are notes in the chart from CDI regarding malnutrition
• While he was not eating as much at home and not feeling well, that would not have caused him to drop so much weight AFTER hospitalization.
• He was on Lasix only a short time from what I can see and no one noted any edema so I don’t think the weight loss was water weight.
• These points suggest that the was malnourished while under care.
Other Questions & Notes
• All communication with hospital and clinic staff was initiated by my mom except for the call from Dr Malish. I have the phone records to prove it. My Chart messages included in the files.
• Why was Dad not seen by infectious disease past 5/12?
• Why was Dendy/Henke replaced by Sarrigiannidis?
• Why didn’t anyone consult my mom while dad was sedated? It’s noted he’s unable to make decisions in that state but she was not consulted. And no one ever asked if he had Power of Attorney.

Conclusion
I realize that this complaint is likely more complicated and a good-deal more developed than any other complaint you’ve received How. My dad always said I should have been a doctor. I’ve spent wellover 40 hours going through his records (more than 800 pages) since his death and I was actively reading his chart and his labs while he was in the hospital.ever, because we were never allowed to see him, nor did we receive any sort of regular updates to his state nor care from his physicians, neither my mother nor I were ever given the opportunity to advocate for my dad. Patient Relations never even followed up with us until I contacted Tamera Flemmer after his death. And though Monee and her colleague were sympathetic and interested in what I had to say, it was just a little too late. Thus, these pages are a labor of love, my testimony to how I would have fought for my dad if only I’d been given the chance by the corporate machine called Sanford. It should be noted that my family is featured in the fundraising materials for the Sanford Foundation because in 2019-20, Henke’s office and Dr Russell saved the life of my husband. Now, some 17 months later, I feel strongly that my dad’s life was not valued nor preserved at Sanford.

Points Discussed with Monee Quast – 6/2/21
Providers who were competent, compassionate and professional: Ali, Preston, Maria, Shanae (RNs) and Dr Malish

Horrible experiences with:
Heather Weaver: from 5/12 – 14, Heather responded to my mom’s My Chart messages basically telling her that she could not talk to clinic staff because dad was hospitalized. Up through 5/11, mom had been using My Chart to reach his PCPs who had then called her in response to her messages. Heather did nothing to help mom reach attending physician and was rude and uncaring. (nurse at Dendy/Henke office)
Dan Sweeney: the chaplain contacted mom twice between 5 and 5:20pm. The first time was to tell us to come right away, which we did. The second time was when we were en route to the hospital and he wanted permission to stop CPR. He was cold and uncaring. It felt like he was exasperated with us. When it was too much for my mom to handle she gave me the phone. I pleaded with him to keep doing CPR as we were only minutes away. His response was “don’t expect a good outcome.” At the hospital, he herded us like cattle and was very rude. We were a bother to him. He was not only unsympathetic but unprofessional and lacking any amount of compassion. He offered no emotional support, no spiritual support to the family. At one point, he asked if my mom wanted him to commend dad to heaven. I’m not sure what faith that is, but we are Protestant Christian and that is not our faith.
Dan did not act like a man of God.

Communication:
• Until 5/12, mom would message PCP through My Chart and they would call her back. On 5/11 Stensgaard told her to contact them any time. That was the last time mom was able to reach them. (see note above on Heather)
• No communication was ever initiated by providers or staff except for Dr. Malish’s call on 5/17 to discuss intubation.
• 5/14 email to Patient Relations went unanswered by Patient Relations. Mom talked to nurses on 5/14 and to Maria on 5/15 but all of those calls were made by mom.

Covid Protocol:
• He was severely sick and had 70% chance of dying according to Intensivist yet he was being seen by OT, ST and PT even after sedation. Covid is so contaigious that his family (½ of whom have had Covid and the other half have been vaccinated) couldn’t visit him, but accessory services like these therapies can see him?
• We told multiple nurses and Intensivist that we’d had Covid and asked if we could see him. We were told no. Only Shayla said that she’d check for us but Dad died before she got back to us.
• We asked to let our Pastor visit on 5/11 but were told “only through the glass” but the hospital chaplain could come when he was intubated and possibly before?
• Records do not indicate he was informed that the antibodies were experimental nor did he give any authorization for experiment treatment.

Prognosis/Visitation:
• Until 5/13 call with Dr Sarrigiannidis, no one had said dad was critical. None of his PCPs nor the nurses indicated that.
• On that call, mom asked to see dad and was told no.
• If he was in such bad shape, near death for 4+ days, why were unable to see him to say goodbye?
• Why on the 17th when Dr Malish asked about intubation, were we not allowed to see him?
• Chaplain was there at 3:57pm for intubation, but we were not notified of intubation until 4:40pm and not told to come until after 5pm.
Power of Attorney – Durable
• Pretty sure all of this would have happened differently if someone would have asked if dad had a POA, which he did.
• My mom could have refused therapy, refused sedation, asked for different care and doctors. She would have been consulted regularly.
• Even without POA, once dad was sedated, she should have been contacted regularly. She was not.