January 5, 2010 Patrick J. Coates, M.D. Central California Bariatric Surgery 1401 Spanos Court Ste.

224 Modesto, CA 95355 Tricia Larson 710 Alden Glen Dr. Tracy, CA 95376 (209) 609-5075 larson_tricia@yahoo.com tmroyer10@gmail.com To Whom It May Concern: I have a serious complaint with Dr. Coates office staff, and the quality of post-operative care they administer. More specifically I have a complaint against Barbara, the R.N. who works in this office. I believe Dr. Coates office staff was negligent regarding my care, and I believe Barbara practices beyond the scope of her licensed abilityshe needs to be reprimanded by the board of nursing for her negligent malpractice!! Those who have allowed Barbara to practice beyond her scope also need to be held liable for negligent medical practice. I had the RNY gastric bypass surgery on November 5th, 2009performed by Dr. Coates. That first week after surgery went pretty well. I did everything exactly as orderedonly clear liquids, no sugar, and got the recommended amount of fluids in. The only thing that was bothering me was some pain in my stomach and I had developed thrush. At my one-week appointment, on November 12th, 2009, I talked this over with Diane. She felt my pain was normal and that I probably have a lot of inflammation that needs to heal. She said give it a week or two, and if Im still having pain I might have a stricture or something else they need to take care of. She gave me some oral Nystatin for my thrush problem, and after the normal discussion about taking vitamins and such, I left. **Some nurse, as Barbara watched and guided, took out my staples before Diane came in to see me. Diane also looked at my incisions during the visit. When I got home from this appointment I still had 3 staples in my stomach. I had to drive to Modesto twice that day, from Tracy, so they could remove the staples they should have removed at the first appointment.** One day later, in the evening on Friday, November 13th, 2009, I started to hurt pretty bad. My pain was mostly centralized in my lower to middle back (near my kidneys), and it radiated around my sides. My whole abdomen hurt as well, but most of the pain was in my back. It hurt to breathe deeply and brought me to tears. I reluctantly took some Tylenol with codeine because it hurt so muchI had weaned myself off of them a few days earlier, because I didnt want to become dependent on the pain killers. The Codeine didnt seem to help, because an hour after I took it I was still hurting. The pain must have gone away after about 2 hours, because I then fell

asleep and woke up in the morning. When I went to the bathroom that morning it hurt to urinate. I figured I had a bladder infection and would call the office on Monday to go get an anti-biotic. Later that afternoon, however, my back started to hurt really bad again and pain medication wasnt working. I started to worry that something may be wrong with my Kidneys and since I had just had surgery I didnt want to wait till Monday to find out what was going on. So, around 9pm on Saturday November 14th, 2009 I went into the Emergency Room at Memorial Medical Center. They admitted me very quickly and took a urine sample. Their diagnosis was a Urinary Tract Infection. They told me to call the Surgeons office on Monday and inform them of my U.T.I, and discuss any other problems. The E.D. docs didnt really have an answer for the back pain or abdominal pain and that is why they told me to follow up with the Surgeons Office. On Monday, November 16th, 2009 I called Dr. Coates office. I told the girl who answered the phone that I needed to follow-up with Dr. Coates, or the P.A., because I had a bladder infection diagnosed in the E.D. that weekend. She told me that I need to follow-up with my Primary Care physician. I asked her if she was sure, because the E.D. doctor told me that I needed to follow up with my surgeon. She said (for the second time), No, you need to follow up with your primary care physician. At that point I gave up, said ok and hung up the phone. Dr. Coates office did not follow up with me for my U.T.I or the pain I was having and it was never documented that I had had a U.T.I, abdominal/back pain, or that I had even called in. I had no desire to go to my primary care doctorI had only seen him once (to get my referral for bariatric surgery) and I felt there was no way he could address my unique problems sufficiently. My abdominal pains continued to get worse. On Wednesday, November 18th, 2009 the pain became suddenly so severe that it doubled me over while trying to get into the store. It hurt to breatheit hurt to move. So I called Dr. Coates office in hopes that they could help me. I explained to the girl who answered the phone that I had surgery almost two weeks prior and that I was having really bad abdominal pain. She transferred me to Barbara, telling me that she was a nurse that had had the surgery and that she could help me. I explained to Barbara that I was having horrible pains that doubled me over. She asked where the pains were coming from and I told her it hurt in my back, all around my sides and now I was getting stabbing pain in the middle of my abdomen. She asked me when my last bowel movement was. I informed her that I hadnt had any bowel movements since surgery, except for one 6 days ago after I had a glass of milkI immediately had diarrhea after I drank the milk. She told me I was definitely constipatedthat I needed to be having some sort of bowel movement at least every two days. [[While in the hospital (when I was re-admitted in December), Diane told me it was normal to have no bowel movements for the first week or two after surgery]] She told me I needed to go to the store and buy some milk of magnesia or that magnesium citrate drink I drank for the bowel prep, prior to surgery. I asked her if I took the bowel prep, would I have to drink just a little bit of it, or the whole bottleshe said the whole bottle. She told me I needed to drink either/or as soon as possible, before I became impactedshe said if I became impacted that Id need another surgery, so to go take that stuff right away. Barbara went beyond her scope of ability and

diagnosed me over the phone, and never mentioned or suggested that I should come in for an appointment. She never documented that I had called in, and never told the P.A. about my call or the problems I was having. I hobbled into the store, in pain, to buy my milk of magnesiabecause there was no way I was going to drink the bowel-prep again. I drank the recommended dose on the bottle, because Barbara had given no instructions besides go take some milk of magnesia. I decided to split it up into two doses because of my small stomach. I continued to have pain, and about 4 hours after I started the milk of magnesia (after both doses, totaling 4 tbsp.) I finally had a bowel movement. I had a couple black/tarry & sludgy bowel movements, and I passed everything I felt I needed to pass, which wasnt much. The pain stopped for a couple of hours, and then came back. November 19th and 20th, 2009 I continued to have abdominal pain and cramping and occasional diarrhea, but I figured the diarrhea was the left-overs of the milk-of-magnesia I was told to take. In the late evening, on Saturday, November 21st was when I really started to feel ill. The diarrhea became more noticeable and started coming on more frequently. The abdominal cramping and stabbing pains continued. It should be noted that I was following every recommended guideline in the book during this time, and up until this time. I never ate, and still do not eat sugar or fatty foods, I was getting my fluids and my protein in, and I was taking all my vitamins. I had done everything every doctor and/or nutritionist had told me to do. Sunday, November 22nd, 2009, I continued to feel this way, only the nausea started to set in. I felt nauseated, I was having abdominal pains/cramping, and I was having diarrhea. I was told that if I had diarrhea for more than two days that I should call the doctor, because it might be something more serious. So I decided to give it exactly two days (two days of severe diarrhea)until the evening on Monday, November 23rd. If I still had diarrhea, I would call Dr. Coates office when they opened the next morning. Well, I was still having diarrhea that evening, and I was so nauseated and in so much pain that it was next to impossible to get in all my protein and vitamin requirements. I was still doing somewhat ok on my water requirements, almost getting 64oz. of water in. November 23rd, was also the day I finished my course of anti-biotics for my U.T.I. So, in the morning on Tuesday, November 24th I called Dr. Coates office. I told the secretary I had had gastric bypass a few weeks earlier and Ive been having diarrhea for over two days now, and I was informed I was to call in if I was having diarrhea for that long. She immediately transferred the phone to Barbara. I informed Barbara that I had now had diarrhea for over two days. She said, take some immodium and if it doesnt go away call me back. I said ok and that was the end of the conversationshe hung up. She never asked how frequent my diarrhea was, she never asked if I had been getting in my fluids for the last 2 days that Id had severe diarrhea, she never asked if I had cramping or pain, she never asked if I was nauseatedand when she told me to take the Immodium, she never told me how much to take and never told me how long it would take for the Immodium to work, so I would know when I should call back. Once again, she went beyond her scope as a R.N., diagnosed me over the phone and did not

suggest I should come in for an appointment. Again, she did not document my call or notify the P.A. of my present condition. I used my own judgment and followed the directions on the bottle. I also decided that I should wait 24 hours to see if the diarrhea went away, after taking the Immodium. I took one chewable Immodium around 3pm, (I thought chewable was the only kind I was allowed to have and I didnt receive any directions from Barbara on the matter). After a few hours I had another bout of diarrhea, so I chewed another Immodium. I didnt have any diarrhea for about 12 hours, until the next day, in the morning on Wednesday, November 25th, 2009. On this day I was unable to meet my protein/vitamin/water requirementsI was still eating and drinking, but a very limited amount due to my nausea. I was drinking more than I was eating, but only about of what I was supposed to. I had only a little bit of diarrhea during the morning of November 25th, 2009, so I thought the Immodium was doing its job and Id be fine. Around 3:30pm, however, I had a severe bout of diarrhea, which came with a lot of pain and cramping. My stool was also black and tarry, which it hadnt been since I took the milk-of-magnesia. So, I called Dr. Coates office back around 4:15pm this day, after I got off the toilet. I told the Secretary, and she remembered me from the day before and she said, what am I going to do with you? Its 4:20pm the day before Thanksgivingeverybody but Diane is gone and shes with a patient...why couldnt you have called this morning? I told her it wasnt my fault that I was sick right nowBarbara had told me to wait, so I waitedI said I had called in previously, what am I supposed to do? She said, well, Ill leave a message with Diane that youve called and that the Immodium didnt work. At about 10 minutes to 5:00pm I called back, wanting to get confirmation that someone was going to call me back that night. The girl who answered the phone said, well, I left a message on Dianes desk to call you. About 5-10 minutes later, Diane calls me. I dont remember every detail of the conversation, but I do remember telling her that Id been having diarrhea for over 4 days now and that I was concerned because I was now passing this yellowy, snotty, mucus looking stuff in my stool. I asked her if this was normal? She said, yes, its normal, especially if all you are taking in is heavy vitamins and water. She said I wasnt taking the Immodium properly (but no one had ever told me how much to take in the first place) and that I needed to take two Immodium on the first loose stool and then one Immodium after each additional stool. The thought horrified me, because the chewable Immodiums were disgusting and I was so nauseated. Diane didnt ask me if I was nauseated or if I had been getting in my fluids during the last 4 days of diarrhea, and it didnt occur to me to tell her. She said, our office is closed the rest of the weekend, for the Holidayjust start taking that Immodium, and if you are still having diarrhea by Monday (which would have made 9 straight days of diarrhea) then youll have to come in and well have to take a stool sample, etc. That evening I really started pumping in the Immodium. I took 2 pills about 15 minutes after our conversation (the first stool) and about an hour later I took another pilland about an hour later I took another pill. I then went to bed.

Thursday, November 26th, 2009, (Thanksgiving Day) I woke up and had a little bit of diarrhea and took an Immodium. I felt the urge to have more diarrhea throughout the day, but Id go to the bathroom, and nothing much really came out. I joined my family in Thanksgiving festivities. I was a little nauseated, but wanted to enjoy food with others. I ate an egg, some cheese, and a little turkey throughout the course of the day. Around 6pm, because I still needed a lot of protein grams, I drank a lactose-free protein shake (I had realized from an earlier experience, that regular milk did not sit well with me). Immediately after drinking that shake I got completely nauseated and had massive diarrhea. I was in the bathroom every 15-30 minutes for the rest of that night. I didnt get any sleep during Thursday evening (Thanksgiving), on into Friday, November 27th. I couldnt eat protein or vitamins, and I could only barely sip on watermost of the time I spent in the bathroom having horrible bearing-down pains. I continued to have diarrhea every 15-30 minutes all day Friday and all night Friday (didnt sleep more than an hour that night as well). I didnt eat anything all day Friday. I was sipping on water as best I could and the thought of taking another Immodium sickened me, so I stopped taking those as well. On Saturday, November 28th, it became even worse. I wasnt just having diarrhea, but I would have these massive bearing-down pains like I needed to have something come out, but nothing (or very, very little) would come out. This happened every 30 minutes all day and night Saturday, and all day and night Sunday. I didnt eat anything all day Saturday or Sunday either. Fluids were becoming almost non-existent. I was at my breaking point. I started refusing to sip on water because it was so nauseating. I had been having diarrhea for 9 straight days without a break, the last 4 days having bouts every 15-30 minutes. I considered going to the E.D., but decided to make it through one more night, because the next day was Monday, and I could just go into Dr. Coates office and get help. So, Monday, November 30th, 2009, I headed down to the office first thing in the morning. I started vomiting and dry heaving early that morning and I could barely make the drive to the office. I had to pull over several times due to dry-heaving/dizziness/nausciousness. I finally made it to the office, told them that Diane wanted to see me because my diarrhea hadnt stopped. They got me in, in about 30-45 minutes (which to me was a lifetime, because I was so sick and thought I was going to keel over). Barbara was the one who escorted me back to the patient room. As we were walking back, she stated, in a very condescending mannerimplying that I was over-reactingSoyou got a little stomach flu, huh? Barbara had no clue what I had been suffering or what my true problems were, and for her to say that was extremely insensitive and arrogant on her part. Diane comes in, I tell her Im still having diarrhea, she asked if I had been taking the Immodium. I told her I wasnt really taking it anymore because it was nauseating. She chastised me for not taking it like she told me to. I told her I hadnt eaten or drunken anything for about 3 days. I told her I started to dry heave that morning on the way here. I told her about having black/tarry stools a week prior. She said, are you sure that wasnt just the Iron in your vitamins?I said I didnt know. ((How am I supposed to know if my stools are black from vitamins or blood?I still

dont understand why she asked me that??)) She mentioned/offered to give me SalineI didnt understand what Saline wasshe said they would inject it in me, but I assumed it was injecting me with something for my diarrhea, so I just kind of looked at her like I didnt want it. She didnt mention anything about hydration, which I felt I really needed because I hadnt really drank any fluids for 3 days. So, I said, I do feel Im dehydrated and need help. She told me to get up on the table and that shed check to see if I was dehydrated. She listened to my stomach, and then she checked my pulse. She said my pulse was normal so she wasnt going to send me in for hydration. I didnt have energy to argue with her, but I did feel I needed to get some I.V fluids because I couldnt take any in orally. Diane said, well, its hard to know whats going on with you because youre having diarrhea and nausea and nausea is not really part of it. Im not sure what she meant by that, but she did want to send me in for a stool sample to see if I had Clausdridum Difficile Colitis. Although I was not pleased that I wouldnt be sent in for hydration, I took the lab slip and tried to walk over to the lab at Memorial Medical Center. As I was walking over there, I decided to stop over at my Moms office because I just couldnt make it the whole way. I could barely walk I was so weak, and barely made it into my Moms office. My Mom asked if I was going to go get hydrated. I told her that the P.A. said that my pulse was fine so that I didnt need hydration. I expressed to my Mom that I felt that that was a mistake because I felt I needed hydration, but I didnt have the energy to disagree with her. So, my Mother called the office. She asked to speak with Diane, but of course Barbara decided she would be the one to help and said that Diane was busy with a patient. My Mother laid into her about how I was just in there and that I have not eaten or drinken anything in 4 days and how could they send me out of there without getting hydratedshe said that I couldnt even make it to the lab I was so weak. Barbara immediately passed the phone to Diane, which was surprising given that Diane was apparently busy with a patient. My Mom and Diane talked for a few minutes and after that conversation Diane phoned over an order for me to get hydration. Some relief finally came when I was able to get some anti-nausea medicine while getting hydrated. I was still going to the bathroom every 30 minutes, but at least I wasnt so nauseated. The nurses who gave me hydration said I was definitely dehydrated. My blood pressure was around 98/52. They were so nice and gave me tons of warm blankets and talked to me about Cdiff, even though it wasnt diagnosed yet. Someone took my blood pressure in Dr. Coates office, and no one told me what it read, but if it was indeed that low, it makes no sense to me why they didnt automatically order me to get hydrated. I got done with all my stool samples while in hydrationbecause I had to go to the bathroom so much. They sent out my stool sample and my blood sample while I was in hydration. My blood test came back before I left. My Creatinine level and my fluid-balance level was abnormal. The nurses informed Diane at Dr. Coates office and asked them if I should stay until they get the stool sample back and stay since my levels were abnormal. But Diane told the nurses to release me and to tell me to keep taking that Immodium. So, Diane released me before the stool results came in, which in my opinion, was another mistake. If she waited a little longer and could have seen I had a positive C-diff stool samplethey could have just hooked some anti-biotics up to the I.V. I already had in, and I

could have started my healing much faster. I had told Diane that I started vomiting and dryheaving that morning, so if I was positive for C-diff then it only makes sense to give me I.V. anti-biotics because I wouldnt be able to keep down the oral tablets. But, she sent me home with orders to shove down the Immodium. {{Ive since learned, from the head nurse in the bariatric wing of the hospital, that Immodium is one of the worst things to give a patient with C-diff. Immodium makes the C-diff spread/grow at a faster pace and makes you more sick. She agrees that I should have stayed in the hospital on that Monday and they should have hooked me up with I.V. antibiotics right away}} I barely made the drive home after being hydrated and immediately started vomiting again when I got home. I continued to have diarrhea, or at least the bearing down pains like I was going to have diarrhea, every 30 minutes. That same night, Monday November 30th, Dr. Coates called me. He told me I tested positive for Clausdridium Difficile and that he was sending over some oral anti-biotics for me to take. I went straight over to the pharmacy to get the anti-biotics, and took one that night. He also gave me anti-nausea medicine. However, it seemed every time Id take an anti-nausea med, it would make me vomit more. Tuesday and Wednesday, December 1st and 2nd, I was still unable to drink very much, I was still vomiting and dry-heaving and I was still having to go to the bathroom every 30 minutes. I dont even remember those two days very much, but I know my Mom dragged me into the E.D. on Wednesday night, December 2nd, 2009. Dr. DAgostino was attending on Wednesday night. When he came in to see me I told him all I had been experiencing. Many things started happening. An I.V. was put in and pain meds, antinausea meds, and fluids were administered. I was finally starting to get relief after being in pain for so long and after 6 days of not being able to eat or drink hardly anything. Sometime in the midst of all this a girl came in and ran an EKG on me. 10-20 minutes later I heard Dr. DAgostino talking about me to the R.N. who was helping me. Dr. DAgostino said, This EKG is clearly abnormalgood call on ordering the EKG, you just saved her life tonight A few minutes later Dr. DAgostino came in and said, well, you havent had a heart attack, but your heart is under severe strain...we typically see this kind of EKG in patients above 45 years of age. He also told me my potassium was depleted, and my electrolyte balance was off. I was admitted to the hospital that night, December 2nd, 2009 and remained in the hospital until the following Wednesday, on December 9th, 2009. After being admitted to the telemetry floor of the hospital, Diane came to visit me the next day or so. Diane said, I didnt know Tricia was having any problems until that evening right before Thanksgiving. I think I need to talk to Barbara, because sometimes she takes a little too much upon herself without consulting me. I hear her on the phone with patients and usually she does really good in helping, but there has been times when Ive had to talk with her and tell her she needs to consult with me first. Diane clearly stated that there was no communication that I had been having any problems until November 25th, 2009. I was clearly having problems, and started notifying the office that I was

having problems, on November 16th, 2009. I was brushed aside and not taken care of for 9 daysno one ever advised me to make an appointment during those 9 days. There was absolutely no communication between nurse and P.A about any of my problems for 9 days. When the P.A. became aware of a problem (and she had no idea that I had been suffering for 9 days prior), I was told I had to wait five more days (until after the holidays) to get help. Due to the lack of communication in the office, and due to faulty priorities (wanting to go enjoy holiday time, rather than help a patient), I was made to suffer for two weeks without an appointment. Those two weeks were a critical time period. I had just had major abdominal surgery, I was not getting fluids down (because I was so sick), I was vomiting, I was having diarrhea. I could have easily died if I hadnt taken matters into my own hands and gone to the E.D.my mother who was watching my condition closely and the excellent E.D. staff at Memorial Medical Center saved my life. If I had trusted in Dr. Coates office staff to take care of me, I probably would not have survived!! At the end of my hospital stay, right before I went homeDecember 9th, 2009Dr. Coates came in to talk with me. He said, Im not sure why exactly you are in the hospitalI dont think it was the C-diff that brought you inwhen you are losing weight your body goes into toxicity and its very important to drink fluids. In this toxic state, if you are not drinking enough fluids, you become nauseated and vomit and then it makes it even harder to drink fluidsthe c-diff is what eventually caused the dehydration, but make sure you are drinking your fluids. Im not sure exactly what Dr. Coates meant by this comment, but I believe he was implying that I was not doing what I was supposed to (i.e. drinking all my fluids), which is what originally got me sick, and then when I developed C-diff, it just pushed me over the edge so to speak. If this is what he was implying, I highly resent it and it is totally inaccurate! I was having severe, stabbing, abdominal pains since November 16th, 2009, which Diane told me in my appointment on December 15th, 2009 was due to C-diff. She also told me on that appointment that, because I was still having problems with nausea and eating, that she is almost positive that I have an ulcer. The ulcer, according to Diane, is probably what had been causing my nausea all along. So, not only did I have a bladder infection and C-diff, I had an ulcer on top of it. I followed every guideline given to me by Dr. Coates and his office. I got in every ounce of fluid I was supposed to, up until I had been sick for so long, that I couldnt orally get them down any longer. It was the C-diff and the ulcer that made me so sick I could not get my recommended fluid amount inAND it was because of the lack of communication in the office that I had to suffer needlessly for so long. It is because of the lack of communication in the office that my condition progressed to the point that I needed emergency medical care. It was because of how the office handles the care of post-operative patients that my heart became severely strained, my potassium levels became depleted, my fluid levels were imbalanced, and I had to be readmitted in the hospital for 7 days!! These problems were in no way my fault! The severity of these problems occurred because of the negligence of Dr. Coates office staff!

Soon after Dr. Coates finished talking to me, on the day of my dischargeDec. 9th, 2009I had another really bad diarrhea episode. It came on so suddenly I didnt make it to the bathroom and had to change all my clothes. When the nurse came in to go over my discharge papers, I asked him if this was normal after taking the anti-biotics for about 10 days. He told me I needed to call Dr. Coates office and ask them. So, I called Dr. Coates office, around 1pm, and asked to speak with Diane. The girl who answered asked why I was calling. I told her I was in the hospital and would be discharged in a few hours and I just had another really bad diarrhea episode. I told her I wanted to ask Diane if this was normal (before I left the hospital) and how long I could expect diarrhea in my recovery. The girl who answered said, well, we usually filter all our calls and questions through Barbara, shes had the surgery, do you want to talk to her? I said, No, I do not want to talk to Barbara, she is the reason Im currently in the hospital, I want to talk to Diane. The girl said she would leave a message for Diane and she would return my call. I left the hospital around 4:45pm, without hearing from anyone from the office. Diane called around 5:05pmI didnt hear the phone ring, as we were in the car driving back to Tracyand said I could call the next day with my question, as the office was now closed. My appointment with Diane, on December 15th, 2009, went well. She spent adequate time with me going over all my concerns and my continued problems. She said she is convinced I have an ulcer because of my continued nausea problems. She said, It would have been nice if they just scoped you while you were in the hospital for 7 days. I agreed that that indeed would have been more convenient. I had nurses come in, while I was in the hospital, and tell me they thought I should be scoped, but unfortunately Dr. Coates and Diane never ordered me to be scoped and thus it never happened. I was kind of irritated that it was never ordered for me, because I was clearly having problems eating, and both Diane and Dr. Coates were fully aware (for at least 3-4 days before I left the hospital) that I couldnt eat anything without drinking Maalox or some other stomach-coating agent first. Nevertheless, Diane ordered a scope for me at this appointment and told me Barbara would be calling me with my appointment time. I told Diane that I would be going back East for 2 weeks, for the holidays, and expressed concern because I still couldnt really get the vitamins down, because it hurt my stomach. She said, I know we tell all of you how vital it is to take your vitamins, but dont worryif you dont take your vitamins for a couple weeks it will be okwell fix you all up when you get back in January. She gave me a lab slip and told me to go get blood work done before I leave, so that they could have the results when I got back into town. Today is January 4th, 2010 and I still have not been called with my appointment. I go into the office today, however, to receive my Vitamin-B shot, and I will ask them when my appointment will be and if progress is still being made in this department. The procedures for how post-operative patients are handled in Dr. Coates office needs to change. The current policy or procedure is to give all patient complaints to Barbara and have her solve the problemsdiagnose them over the phoneso that the P.A.s and the surgeon dont have to do it. All post-operative care, and the responsibility for such, is given to an R.N. and a P.A. There is NO professional physician to talk with if you are a patient with unique problems.

There is NO ONE to recognize medical problems beyond the scope of an R.N, or a P.A. In my case, I had no one to talk over my problems with, besides an R.N. who, in my opinion, believes she knows more than she really does, and is clearly negligent in practicing beyond the scope of her licensed ability. If I had drunk a full bottle of magnesium citrate (Bowel Prep), like I was instructed to do by Barbara, I could have become severely de-hydrated a lot faster and I believe I would have died. If my Mother had not dragged me into the E.R. on Wednesday, December 2nd, 2009, I could have easily had a heart attack (as my heart was under such severe strain) and died. I am aware of other patients, under the care of Dr. Coates, who have died from this surgery deaths caused by dehydration. Im sure in the record it states that the patient was extremely negligent, and that the patient was purposefully and negligently not drinking the fluids they needed. If I had died, I wonder if this is what would have been said about me? There may have been other dehydration deaths that were not caused by patient negligence, but caused by how the office staff handles post-operative care. If I had been older, in a weaker condition, and living alone, I probably would have had a heart attack and diedbut it would not have been my fault, it would have been because of the negligence of Dr. Coates office staff!! The procedures in this office need to change before something more serious happens to someone else!! Tricia Larson cc: Julie Meyers, Regional Director, Integrated Quality Services Deana Chiarchianis, Manager, Memorial Medical Center Bariatric Program Candy Canga, Manager, Memorial Medical Center Nursing Administration California Board of Registered Nursing 1625 North Market Boulevard, Suite N-217 Sacramento, CA 95834-1924 Phone: 916-322-3350 Fax: 916-574-8637 January 6th or 7th this letter got sent to Dr. Coates and all those indicated at the bottom of the letter!!! Update: January 4, 2010, I went into the office to get B-shots, to see when Dianne wanted to see me about my labs that I got done in December, and to find out why I still had not been called about getting an Endoscopy. I told the girl that I was here for BOTH reasons. I waited in the office 45 minutes and then they took me back to get my B-shots. I went backsomeone took my blood pressure and then gave me my B-shots (B1 & B12). She then said you are all donehave a nice day. I said, wait a minuteIm also here because no one has called me about my Endoscopy

appointment and I need to know if there is progress in that department? The nurse told me to hold onshe left and came back a minute or two later. She said, Im sorry, the front desk forgot to tell Barbara to talk to you about it and Barbara went to lunchwe can have her call you. I said, no, this office does not do a good job at returning my callsits not my fault that the front desk forgot to tell Barbara, Im sitting here until someone comes to talk to me about why I still dont have an Endoscopy appointment scheduled. Nurse leaves, 1-2 minutes later Barbara walks in and said, Unfortunately I, because you have Blue-Cross Medi-cal, could not refer you to get an Endoscopy, so I called your Primary Care Physicians office, who is the only one that can refer youthey werent going to refer you, but I convinced them that you definitely needed a scopeso they referred you, and an appointment was set-up on December 29th, 2009, but you were a no-show. I told Barbara I was never called about anything and that it would have been nice if I was called. She re-iterated the fact that she wasnt able to refer me due to my insurance. I asked her if this is going to take longer now, because my Primary Care doctor never called me. She said I had been referred, so it shouldnt take long at all. Barbara gave me the phone number of the Gastroenterologist I had been referred to and I called as soon as I got out of Dr. Coates office. I also inquired Barbara about my labs, because Diane said she wanted to see me when I got back. Barbara looked at my labs and said, looks like we just got them todayit looks like you are doing really good, although your thyroid hormone is a little lowDiane will review your labs and well call you about it later. Later that day, Barbara called me and asked if the Gastroenterologist got me in quicklyI said yes, this Thursdayshe said, good, if they didnt get you in quickly, I would have called and bugged them for you. I told her that was nice of her. Im not sure if it was this day, or another day, but Barbara called me back again, and said that Diane had reviewed my labs and that my potassium was a little lowDianne ordered me to take one potassium pill a day, and one Vitamin D pill a day. Nothing was said about my Thyroid (TSH) levels being off and no new medication for my thyroid was prescribed. Dianne told me in the hospital that my TSH levels were not normal and asked if I had been taking my medicine. Besides the time that I was readmitted in the hospital I had beenno one in the hospital had been giving me my thyroid medicine, so I wasnt taking it. Ive wondered why, if my TSH levels were off at the hospital, and off on these labs as well, WHY did my Levoxyl Medication not get increased?? (Between the Dec. 15th appointment, and the Endoscopy on January 18th, my daily nausea went away, and I no longer needed to drink Maalox before every-time I ate.) January 7, 2010 Went to Dr. Canale, in Turlock, for a consult for my Endoscopy. My Endoscopy was scheduled on January 18, 2010 at 3:45pm. January 18, 2010 Endoscopy procedure performed. Found a significant stricturethey took care of it. January 19th, 2010

Scheduled Endoscopy follow-up on Monday, February 1, 2010. Also scheduled my 3-month follow-up appointment with Dianne, in Dr. Coates office, on Monday, February 1st since Id be down in Turlock on that day (wanted to save gas money). January 21, 2010 Picked up an Exempt form from my State Social Worker. The previous day I discussed with her all the medical problems I had been having and thats why I wasnt able to do my work experience program the last few months, and I still needed recovery time. I asked her if it was possible to become exempt from the program. She said I could, I would just need the P.A. or the surgeon to sign an exempt form. So I picked it up from her on this day. January 22, 2010 I called Dr. Coates office regarding my State Exempt form that I needed Dianne to sign for me. They said I could drop it off, and that theyd review it and it would get back to me within a few days. I wrote Dianne a letter and attached it to the formI explained why signing this form was important. I dropped off the form in the officethe girl at the desk informed me that Dianne wouldnt be back until Monday. I said fine and left. January 26, 2010 I called Dr. Coates office to inquire about my form, because no one had called about it yet, and the office informed me Id get it back within a few days. Barbara answered the phone and I inquired of my letter/form and if it had been signed yet. She put me on hold.when she came back she said, Dr. Coates wants to see you, are you available this Thursday? I informed her that I would be out-of-town on Thursday. I then said, Well, I have an appointment with Dianne this next Monday, on Feb. 1st. Barbara then said, Well, were going to cancel that, because Dr. Coates wants to be the one to see you. Are you available the following Thursday, February 4th? I told her I was available. She set an appointment for me, with Dr. Coates, on February 4th @ 4:45pm. She was about to hang-up after scheduling the appointment, when I said, wait, I need to know about my letter/form? She said, Dr. Coates will discuss that with you when you go in for your appointment. I said, So I cant get my letter until I see Dr. Coates? She said, So do you not want the appointment? I said, Well, I need a 3-month follow-up, so of course I want my appointment. She said, Would you rather have it this Thursday? I said, I told you, Im out of town this Thursday, would you like me to cancel my trip?....Obviously, you are not understanding meI need my form signed.My State worker said she needs it by the end of the monthwhen I dropped the letter/form off last week, you guys said you could have it to me within a couple of days.can I get my form, or do I have to wait for this appointment with Dr. Coates before I can get it? Barbara put me on hold. 1-2 minutes later she got back on and said, yes, you can come get your form tomorrow, after 12:30pm. January 27, 2010 I went to Dr. Coates office and picked up my State Form with no problems. I dropped it off with my State worker later that day.

January 28, 2010 Someone from Dr. Coates office called and said that Dr. Coates wouldnt be in the office on Thursday and asked me if I could re-schedule. They re-scheduled me for Wednesday Feb. 3rd @4:45pm. February 2, 2010 Someone from Dr. Coates office called again and said that because of Surgery schedules, my appointment time will have to be moved. They moved me to 11:30am on Feb. 3rd. I expressed my extreme annoyance at being moved around for this appointment 4 times. I told them that I had another appointment at 1pm that day (follow-up with my Endoscopy) and that if they could promise that I would be out of there by 12:30pm, Id set the appointment. The girl said, well, we cant see into the future and I have no way of predicting whether or not Dr. Coates will get out of surgery on time. I expressed my annoyance, kept the appointment and hung up. I then recalled the office, asking to have Dianne call me. They asked why. I told them, I want to know why I am no longer allowed to see Dianne? She said, I dont know what youre talking about, you have an appointment with Dr. Coates tomorrow. I said, yes, I realize that, but I had an appointment that was supposed to take place yesterday, but Barbara told me that Dr. Coates wanted to see me personally, and I was forced to cancel that appointmentand now my appointment has been dicked around with 4 timesand I want to know whycan you please just have Dianne call me? She told me shed give Dianne the message. Dianne never called me. February 3, 2010 I arrived at Dr. Coates office early @ 10:58amjust in case he got done with surgery early, so that I could get out of there earlier. I filled out some paperwork and then @ 11:40am or so, they got me back into the officetook weight and blood pressure. I then waitedI waited until about 12:15pm. The front office girl came in and told me that Dr. Coates had to go do an emergency procedure and wasnt able to be back at the office until 1pm. I said, well, then Id like to get my B-shots and then leave. She said ok. I waited another 5-10 minutes and no one came in to give me my shots. Finally I went out into the hall. I saw one girl in a back office and told her I needed to be on the road shortly and I need my B-shotscould she help me find someone to give them to me as soon as possible. She said she could do it. She grabbed the syringes and was in the room in about 15 seconds. She said, Are you Tricia?I said, Yes. She asked if this was everything for me todayI told her not really, Dr. Coates didnt show up and I told her how Id been moved around 4 times and Im sick of it. She said that she was sorry I had a hard time. I told her I wasnt coming backshe said are you going to go to your primary care then? I said I didnt know, I had only seen my primary care once and I didnt feel he could take care of me adequately. I told her I may have to find some other surgeon or something. She said, well, if you change your mind, come back! I went to the front desk and told the same girl (that informed me that Dr. Coates wouldnt be arriving) that I want a copy of my entire file/chart. She said it would be $15.00. She did not seem in the least bit surprised. I also said, I found someone to give me the B-shots.just in case you were wondering!she said nothing. I then told her

that I want the records mailed to me, because I didnt want to drive all the way back here just to pick up papers. She said shed have to charge me and I said fine. She is the main person who schedules follow-up appointmentsshe did not ask me when I wanted to re-schedule!!! Im convinced that they, because I wrote this letter, were purposefully making things difficult for me, and purposefully trying to get me to walk away and never come back. They were not surprised that I wanted copies of everythingthey had no intentions of scheduling me for my follow-up. They are putting my health in danger!!