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More patients treated at private clinic tell of medical ordeals that occurred before the time window identified in a Toronto Public Health probe.

Michael Glass has no memory of three weeks of his life in the spring of 2012. But the scars that run down his spine attest that something awful happened during that time.

The 67-year-old man nearly died after developing a serious infection in his spine and then sepsis, a life-threatening inflammatory response to the infection.

According to hospital charts, the spinal abscess was likely caused by an epidural steroid injection he received two weeks before he fell ill. Other medical records show he received the injection, for relief of back pain, at Toronto’s Rothbart Centre for Pain Care.

A neurosurgeon who performed emergency surgery told Glass’ wife there was a good chance he wouldn’t make it.

He did survive — but with a much-diminished quality of life.

The Rothbart clinic was the focus of a probe by Toronto Public Health (TPH) later in 2012. It found nine patients had developed serious infections after getting epidural steroid injections there, a recent Star investigation revealed. It identified the outbreak as running from August to November 2012.

But Paul Harte, a medical negligence lawyer representing Glass, said his client’s experience — and that of others who have come forward since the story ran — indicates patients were getting infected much earlier than the time frame indicated by Toronto Public Health.

“Since the Toronto Star broke the story about the Rothbart clinic, we have heard from almost two dozen people with concerns about infections they say they contracted at the clinic, many outside the outbreak period identified by TPH,” said Harte, who has launched a proposed multimillion-dollar class-action lawsuit against the clinic and two of its doctors.

The new reports of illness raise questions about whether Toronto Public Health erred on the timing and scope of the outbreak.

“Mr. Glass’s case demonstrates that TPH got the outbreak window wrong. It appears certain that there were earlier cases. We have heard from patients with infections as far back as 2011,” Harte said.

TPH insists it carried out its investigation correctly.

The new reports of illnesses also raise questions about the effectiveness of the College of Physicians and Surgeons of Ontario (CPSO) inspection program for “out-of-hospital” premises such as the Rothbart clinic. The clinic passed a college inspection in December 2011.

Harte said there must be a better of way of sounding the alarm when patients develop serious infections at clinics, especially when the province is moving more services, such as pain treatment, out of hospitals and into community clinics.

Health Minister Eric Hoskins told the Star on Saturday that sweeping measures he is introducing to improve transparency in the health system should help address problems like this.

His plans include strengthening oversight of clinics like the Rothbart centre with the aim of ensuring patient safety. He has asked Health Quality Ontario to lead an evaluation of current oversight programs in such clinics and to make recommendations on improvements.

Glass, a retired postal worker from Scarborough, went to the Rothbart clinic on May 2, 2012, for an epidural steroid injection to relieve back pain, his medical records show. Ten days later he went on vacation to Phoenix, Ariz. He started feeling ill shortly after his arrival.

“My legs felt like they were on fire. I started getting delirious. From that point I have no memory,” he recounted.

His wife, Lorraine, picks up the story from there.

“We got there on a Saturday, and by Monday he was not making any sense. He was clammy and he could hardly walk. We couldn’t get him up,” she said.

Glass was taken by ambulance to hospital, where, according to his medical records, he was diagnosed with an epidural abscess — an infection on his spine — and with sepsis, a potentially life-threatening condition caused by infection.

He underwent emergency surgery to drain what his charts described as a “copious amount of epidural pus” and to relieve pressure that the abscess was putting on the spinal nerves.

“The surgeon said that when they opened him up there was so much infection it was just like pea soup,” Lorraine said.

The surgeon, she said, warned her that her husband might not survive.

“They gave him a two out of 10 chance to live,” she said, and the hospital chaplain was sent to comfort her. “I was a mess. It was a horrible, horrible experience. I thought I was going to have a nervous breakdown, I truly did.”

Glass said he spent 12 days in intensive care in Phoenix before doctors deemed him medically stable enough to be airlifted back to Toronto. He spent another week in the ICU at the Scarborough Hospital.

Fortunately, the couple had travel insurance. The bills for Glass’s care in the U.S. and his air ambulance flight totalled $390,000, they said.

Dr. Michael Finkelstein, Toronto’s associate medical officer of health, said TPH became aware in late November 2012 that three Rothbart clinic patients had developed meningitis.

Meningitis is a reportable disease: when hospitals and health professionals encounter a case, they are required to inform public health.

The meningitis cases sparked an investigation into the outbreak, which found that a total of nine patients developed serious infections, including epidural abscesses, between August and November 2012.

All had received epidural steroid injections at the clinic from anesthesiologist Dr. Stephen James, who told the Star he was unknowingly “colonized” at the time with Staphylococcus aureus.

About 25 per cent of humans are colonized with the bacteria, meaning it is present on the skin but does not make the person ill. But it can be potentially deadly if it enters a puncture in the skin.

The Toronto Public Health investigation found 170 deficiencies in infection control at the clinic, including inadequate hand hygiene and sterilization of equipment.

Finkelstein said TPH is not aware of any infections linked to the clinic prior to the outbreak. Asked how this could be, given that so many people have since come forward, he said infections such as abscesses are not reportable diseases to public health.

When asked if there should be a way to track non-meningitis infections at clinics, Finkelstein responded: “This is a provincial policy decision related to designating reportable diseases and patient safety issues.”

Harte charges that Toronto Public Health didn’t cast its net wide enough in its investigation.

“Had TPH issued a media release, they would likely have discovered earlier cases and done a more thorough investigation,” he said.

As part of its investigation, Toronto Public Health did a “look-back,” which involved attempts to contact 272 patients who had visited the clinic between Aug. 1 and Nov. 30, 2012, a time frame chosen to take into account the two-week incubation for meningitis.

The nine infected patients were found several ways: through the look-back, by interviewing James about patients he knew had fallen ill, by looking at a provincial system that tracks reportable diseases and from hearing from other health professionals about infected patients.

“We were satisfied there wasn’t anybody else out there,” Finkelstein has previously told the Star, explaining that Toronto Public Health’s job was to ensure the outbreak was under control.

He said TPH issues media releases about outbreaks only when it is trying to find others who might be at risk. But if it can reach them directly — through a look-back, for example — there is no need for a media release.

“It is not our routine practice to make these outbreaks public,” he said, explaining why investigation results were not posted on TPH’s website.

Finkelstein said that TPH is exploring ways to provide more information about outbreaks in future.

Glass thought his infection was an isolated case until he opened up the Star two weeks ago.

“I couldn’t believe it,” he said. “Nobody contacted me from the health department or the clinic. If not for reading the paper article, I wouldn’t know anything about it.”

In addition to Glass, the Star has heard from a number of other former patients who say they got bacterial infections at the clinic. One is a 51-year-old Scarborough woman who asked that her name not be published.

She said she was diagnosed with an intramuscular abscess at the base of her skull after getting an occipital nerve-block injection for neck pain from James on March 15, 2011.

A week later, she was admitted to hospital after showing up at an ER with severe pain in her neck and a fever. Her entire body had turned red.

“I was really sick. I thought I was going to die that first night in the ER, that’s how bad I felt,” she said.

She spent a total of eight days in hospital, undergoing surgery to drain a staph A-filled abscess, she said. Her doctors told her it was related to the nerve-block injection.

She then developed Stevens-Johnson syndrome, an allergic reaction to antibiotics, she said. It causes the top layer of skin to die and shed.

The woman said she informed both Dr. James and a nurse at the Rothbart clinic about her illness.

James told the Star that health privacy laws prohibit him from discussing any patients.

The college’s 2012 report on its out-of-hospital premises inspection program states: “The public can be reassured that those premises that receive an inspection outcome of ‘pass’ are meeting a high standard of practice.”

Harte said the fact the Toronto Public Health inspection confirmed nine patients of the Rothbart centre developed serious bacterial infections less than a year after the clinic passed a college inspection is cause for concern. So is the fact the investigation found 170 infection-control deficiencies.

What’s even more troubling, he said, is that so many other former patients have come forward saying they developed infections as far back as March 2011.

Based on the passing inspection grade, “the public was told the Rothbart clinic was meeting a high standard of practice when it had substandard infection control practices,” Harte said.

“We need a public review of the CPSO inspection process to determine what needs to be fixed to re-establish public confidence in the system.”

Asked how the Rothbart clinic could have passed an inspection in December 2011, given all the problems that subsequently came to light, college spokesperson Kathryn Clarke said inspection outcomes reflect the conditions found when college officials do assessments.

“Inspection-assessments are point-in-time reviews and the expectation is that the premises will keep to the standard which earned them a pass,” she said.

Clinics are typically inspected every five years to ensure patients are kept safe with appropriate infection controls and with proper equipment and staff. But college officials will go back in sooner if, for example, they get a report from public health officials of problems.

In the case of the Rothbart clinic, the college has done four more inspections since 2011. It passed three “with conditions” related to improving infection control measures. It was given a full pass on the fourth inspection last month.

The college’s online register makes no mention of the 170 infection-control deficiencies found during the Toronto Public Health inspection. Nor does it mention that TPH confirmed nine people developed serious infections during an outbreak.

Clarke said the college’s bylaws do not permit it to make public any more information about clinic inspections than is already posted.

But, as Harte sees it, the lack of transparency compounds the problem: “Because so little information is provided, the public is entirely reliant on CPSO inspection results and there is now real reason to doubt that the CPSO inspections are being done adequately.”

The lack of transparency was highlighted in another recent Star story that showed the CPSO and TPH have also not made public three hepatitis C outbreaks at colonoscopy clinics since 2011.

Glass said his life has drastically changed since he got sick: “It has really affected the quality of my life because I was a pretty active guy before.”

He said he has lost nerve sensation on the left side of his back and has constant pain in his lower back. He takes 28 pills a day, many of them painkillers.

He feels most comfortable when he is lying down, so he spends 80 per cent of each day in bed, watching a lot of television.

Sleep is difficult, Glass said, explaining he usually gets only two or three hours a night. He often gets up during the night to take Epsom salt baths to relieve the pain.

He has difficulty getting around and must use a cane if he has to go long distances, he said. “If I go to Costco, most times I get a motorized cart because I can’t walk for a long time.”

Glass and his wife used to take two or three vacations a year but travel is now out of the question.

“I’m pretty well confined because of all the problems,” he said.

He has gained weight, lost sexual function and suffers cognitive impairments, he said.

“I had a very sharp memory and I was very good with figures. It has affected my penmanship. I’m a lot shakier now,” Glass said. “My speech at times slurs if I am talking for awhile.”

His mood has also been affected, he said, explaining he is often irritable.

“I have gone from a cheerful person to kind of angry now, all the time,” he said.

Lorraine said she is grateful her husband survived the ordeal.

“The quality of his life will never be the same. However, he is still with us, he’s still with our family, and we have to feel fortunate for that,” she said.

She said it’s difficult to understand why the infection problems at the clinic weren’t picked up sooner:

“It is so unnecessary that this had to happen to all these people. It is really sad to think it might have been prevented.”

Source: http://www.thestar.com/life/health_wellness/2014/10/05/rothbart_centre_outbreak_might_have_started_earlier_lawyer.html