ASSEMBLYMAN GOTTFRIED: Okay if Patricia Donnelly, Ilene Corina, Ralph Specken, Pearl Korn and Leonard Joseph could come up they will be our next group of witnesses. If the stenographer will swear in all the witnesses.
Okay what we will do when we have a panel of witnesses like this we will have each of you make your opening remarks, identify yourselves and we will then after the group has testified if we have questions we will address them to you.
MS. CORINA: My name is Ilene Corina and I am the President of PULSE of New York. Would you like me to read the testimony now?
ASSEMBLYMAN GOTTFRIED: If you would like to, yes.
MS. CORINA: PULSE of New York which stands for Persons United Limited Substandards and Errors in Healthcare grew in 1998 while I was speaking to groups and organizations on patient safety issues and working to pass legislation now known as the Patient Health and Quality Improvement Act of 2000. During this time there were so many stories and people were begging to tell me their experiences of medical errors or poor care that we set up monthly meetings and serve as a support group on Long Island with chapters now throughout the county. People travel from throughout New York and New Jersey to these monthly meetings.
Tales of mistreatment and substandard healthcare became something so common that everyone seemed to know someone who had something terrible happen. The calls to PULSE come from throughout the country and we now get referral calls from legislators, lawyers, healthcare providers and the National Patient Safety Foundation, which was founded in 1997 by the MA. I and Dr. Speken are from PULSE and are on their Family and Consumer Advisory Council.
Because we focus on support after an adverse event we do not offer legal or medical advice or referrals. We encourage those who have had experiences to use their experience to educate and advocate for a safer system. We want to work with you and the medical community to help change the system using our real life experiences. The system as it is now after an adverse event of possible misconduct offers the patient and their family only three options.
Number one would be to forget it and get on with your life. This may cause very aggressive behavior and problems later to those who do not seek support or counseling.
Number two find a lawyer who may very well tell them your parent or child had no financial value. A lawyer is not a support system and usually will only take a case that will allow them a reasonable sum of money to at least cover expenses. The legal system is a business and headlines of large settlements offer false hope to those who are the survivor of a medical malpractice case, misconduct or substandard healthcare.
Number three another option is to go to our state for help and report the physician or physicians assistant to the Office of Professional Medical Conduct. The same system, which is expected to be there to protect the consumer from any wrongdoing.
What we have found over the last few years is that the OPMC, the only other option to have the complaint heard, investigated and seek justice to be sure it doesn't happen again is also not a counseling service but a business of men and women who are taking calls and handling complaints of people who may have been severely traumatized by an event. The child like trust that we have known for years with our health care provider has been lost or betrayed and now a phone call from an investigator is a reminder that the consumer has become a number, a case number.
There is an automatic assumption from the complainant that the seriousness of an injury or death will be looked into, will be well documented and will be corrected in the system. The injury or death will not be seen as in vain, if others are protected in the future.
Because I personally spend hours upon hours listening and reading about real life stories I can only share with you real life stories. Some of which you will hear today. But what you won't hear today or you might is the case of Mr. Debowy who died because of a massive dose of medication for his lymphoma when in fact no tests were ever done to see if he had lymphoma. The autopsy report shows that there was no lymphoma but a letter to Mrs. Debowy from the OPMC stated we are sorry that your husband died of lymphoma.
A case of Nancy Kruh-Meyer a young woman who was completely abandoned and lost a chance for more children after being diagnosed with an a topic pregnancy and almost bleed to death. After her case was closed we submitted a letter of coercion found in her file by two doctors and still the OPMC cold and callously responded that her case is still closed.
The people in these cases like many others I see are often more angry at the treatment they received after filing a complaint or trying to seek justice then they are at the actual healthcare community. As in any horrible tragedy, a time must be made for healing and many cannot when they are left in limbo.
How does a patient find the OPMC? It's not advertised in commercials, on the back of buses or in the doctor's offices. I get many calls from people who seek justice and are satisfied that they reported their experience to the AMA.
We can only believe that decisions are made in favor of doctors when there are more doctors as part of these committees. Fair committees cannot be chosen when the public is not even aware of becoming a member and part of these committees. Only one layman on the board of three when the other two are medical professionals is not acceptable.
I will give you an example. I was recently on a jury of a carpenter who committed fraud. I was able to listen to the case and cast a vote which was accepted in a court of law. Not being a carpenter I was forced to learn about building a staircase. Something I gladly did as it was my duty.
At some point the investigative committee must also be an oversight committee to protect the consumers of New York State from what we know as bad medicine.
I know all too well that many complaints may be considered a personality issue or a misunderstanding. We have taken many calls and intervened on behalf of a caller to discuss bad bedside manner, the high cost of medication, speeding of test results and at times we have just been the strength for a patient to leave a practice after many years.
These complaints though important to the complainant may often be handled by a completely different class of people. By offering impartial trained counselors and offering support services and sensitivity, training complaints may be reduced and avoided all together with immediate intervention by trained professionals.
The investigative process kept secret from the complainant offers no potential to a follow up and no opportunity for the accuser to face the accused. Final decisions are made based on record keeping which we all know may be inaccurate. A victim impact statement must be permitted as a closing step to a case to allow the accuser to have a final word or explain where these accusations are actually stemming from if the complainant so desires.
As an agency which has been established to protect the consumer, more attention must be made at including the public as part of this process. To not allow the accuser to take part in this process is like having a lawyer represent a client without the client being there. It is unethical and not acceptable but as it stands now it's the only system we have.
I believe that the employees of the OPMC may want changes to help the people but they are following the law and as our lawmakers I beg of you to change these laws and protect and help the people of this state.
ASSEMBLYMAN SULLIVAN: I have to excuse myself briefly. I hope to be back a little later.
ASSEMBLYMAN GOTTFRIED: Next.
DR. SPEKEN: The name is Ralph Speken. I am a physician psychiatrist and work for the City of New York for many years. In the interest of time I want to abbreviate my testimony and not read so much but to give some observations.
A little over a year ago justice, Chief Justice Kaye in the Supreme Court appointed a special investigator, Appellate Court appointed a special investigator to look into the question of improprieties in the court system. That individual Cheryl Spratts the fruits of her labors are just starting to come forth and corrections have been made in the State Supreme Court system.
I was fascinated today to hear that the legislators are in a position of having to try to understand what this opaque agency has been doing. I think the bottom line of my testimony is I think that you should call upon Commissioner Novella to appoint a similar investigative body with neutral people, with outside people who don't have a take in this. With honest people, not all physicians. To give a complete understanding of what the OPMC is doing or how they are doing it. I am sure they are all well intentioned people. But you as our legislators before you pass bills and what not to revise them you have to have deep knowledge of what they are doing.
Because I am here to tell you that what you heard today from them sounded very impressive. I am sure many times it's the case but we can show you case after case after case of clear cover-ups that they have been doing and not following due process that is fair and equitable treatment of victims. We will present some of these cases today. My wife Stephanie being an investigator who got to the bottom of these things. That's my chief plea.
The second thing I would like to talk about. This is not a, I was in (inaudible) a commercial that one of the unions was proclaiming that we have the world's best health care system now because there is some more money flowing down the pipeline and what not. I was very amused by that because the World Health Association last year said we are about 37th down in terms of best health care systems. In terms of our ability to bring good healthcare to our population or our public. It's just not true. We do not have the best health care system.
As a matter of fact, Dr. Leap has shown us if you are familiar with his work, Art Levine who is here today is one of the descendents of Leap's work with the 44 to 98,000 people who died because of medical error. Dr. Leap has shown us eleven years ago that the rate of death due to medical negligence in New York State is about $7,000 a year. That was for the year 1984.
Dr. Leap also showed that of every complaint of every case that comes out, there are seven cases that are never known to anybody. So that if we take the figure of almost 7,000 complaints coming to the OPMC, multiply that by 7. As Tip O'Neill said we're getting into some serious numbers there now. Maybe a minimum of 50,000 true complaints should come through them.
There is a vast issue in here as a culturally having fully faced. It's time I think we should look at what other cultures have been doing in the regulation of medicine. We have an observer here from the (inaudible), Ms. Hagen who is knowledgeable about medical regulation, regulatory issues in Germany. I have been particularly impressed by the German system of medical regulation. How they go about the same issue we have been dealing with and I would request that someone on the committee speak to Ms. Hagen and get some further information on these things.
In any case that's pretty much my statement. I won't read about our case. My son died at the age of 23 at a hospital. He was tied up for 66 hours. It's all on the internet. We have had thousands of people look at our website. The OPMC directly covered up the case by using what is called in the law the Thin Skull Defense. They said well of course it was wrong the way he was treated but he should have been able to take it so therefore we are not going to blame anybody. That's what's called the Thin Skull Defense. The case of a man who died and got his head bashed in. His lawyer tried to say well if his skull was thicker he would have lived. It didn't work. They convicted him anyway. The New York State Office of Professional Medical Conduct used the Thin Skull Defense against me and washed away the case at that point. I don't want to, it's on the internet. It's in my testimony.
My real plea is to look at what other cultures have done on this issue particularly Germany and please appoint a real investigative committee.
Thank you.
ASSEMBLYMAN GOTTFRIED: Thank you. Next.
MS. DONNELLY: I am Patricia Donnelly. I am sorry if I was late. I was told 2:00 to be here. Shall I use the microphone right here?
ASSEMBLYMAN GOTTFRIED: Yes.
MS. DONNELLY: Good afternoon especially to Assemblyman Gottfried who I think is such a wonderful man who was very instrumental in the passage of the Patient Health Information and Quality Improvement Act so that as of January 2nd you will be able to look up your doctors work record as well as a report covering hospitals and doctors. So I am especially fond of Assemblyman Gottfried for what he did. Because without him we wouldn't have that law.
I am here as a grandmother. My grandson was just under his fifth birthday when he went in for minor surgery to a hospital, Hudson Valley in Westchester County. It was just tubes to be out in his ears and removal of the adenoids. He died right on the table. So my son pursued of course through the Office of Professional Medical Conduct and in the end it was said well there was 27 doctors there trying to save his life. But as he lay dying and when he needed oxygen to his brain there were only two doctors there. Both of the doctors who made grievous mistakes on him.
We really, we're not really empathetic to the Office of Professional Medical Conduct. Part of the reason is that it's really run by the physicians. There is one, I understand that there is one consumer elected by the board and the three other people on the board evaluating the doctors case against him is always another physician. So again it's peer evaluating peer.
So I would recommend, strongly recommend a complete overhaul of the Office of Professional Medical Conduct and have an equal number of consumers as you have physicians on the board.
Also I don't really know beyond that. I would have to turn to Assemblyman Gottfried to say is it really the Office of Professional Medical Conduct, is it completely their fault? I don't think so. Because whenever you question them about something they say see the lawmakers. They make the laws. So maybe we would have to turn to Assemblyman Gottfried and say, implore you, what can we do to make it a fairer process.
Now I don't like to keep you too long. But I did notice one of the questions here it mentioned should the physician be informed of the original complaint. I don't think so and the reason I don't is I have mentioned to hundreds and hundreds of people. Here is the number I tell them, here is the toll free number. Call the Office of Professional Medical Conduct. And they say will my doctor know? Because if he knows I am afraid that you know then he wouldn't treat him anymore. I really don't want him to know so maybe I better not do it. And I say well no your privacy is respected. So therefore I don't really think it's wise at the beginning when the case is being investigated to make the doctor aware of the complainant.
I am happy that this transpired today and I am looking to Assemblyman Gottfried to make constructive positive changes to further protect the patients in New York State.
Thank you.
ASSEMBLYMAN GOTTFRIED: Next.
MR. JOSEPH: Good afternoon. My name is Leonard Joseph. As you can tell I have an accent. I represent 40% of New Yorkers anywhere. Since 40% of New Yorkers are immigrants.
I have been a victim of medical error twice. The second time resulted in the death of my friend, my high school sweetheart of 27 years, my soul mate, my bride, Marlene Joseph.
On July 24, 1999 I drove my wife to the hospital to deliver our third child. We were under the care of a private attending OB/GYN.
During the course of labor while the attending physician and the labor nurse were within proximity, the anesthesia department was called and a resident was sent to perform the procedure. I later learned the procedure was an epidural. She rushed into the room introduced herself as a doctor and asked me to leave. I thought that my wife was going to be prepared for delivery and I would return with a sterile gown into a sterile environment. My wife and I were not aware that she was about to have a procedure done on her.
Although the attending was not in the room and without a signed consent and without any regard for my wife, the unsupervised resident proceeded to perform the epidural. Not only did she perform the epidural incorrectly and ignored my wife's complaints of severe headache and numbness she made three separate mistakes that ended in the death of my wife.
The first error the unsupervised resident missed and hit the spinal cord. She got air in the line and gave my wife an excruciating headache. She then proceeded to continue and give a high spinal, which resulted in her death.
To add insult to injury a code was sent in for the baby and never for my wife. The emergency personnel who came attended to the baby. My wife was hand ventilated long enough to allow my daughter to be born by C-section right on the stretcher.
It is my wish today to request a change in the way residents identify themselves and to address some of your questions regarding the disciplinary process. I am not anti-doctor. I am not anti-resident. As a matter of fact I have been working in the healthcare environment for quite a number of years. I do hope that the hearing today will result in better delivery of care. Those of us who are hurt by doctors have one common plea. We do not want this to happen to anyone else.
Because of time constraints I will not read the questions in the handout. The first question you ask my answer to it is it depends on the severity of the injury. An injury that results in incapacitation of death in my view is criminal and should be automatically referred to the Attorney General's office.
In regards to my wife the error proceeded to become a criminal act when the resident delayed getting help because she was too busy trying to cover up her error. I went back into the room when I heard my wife complain of numbness. She collapsed on her back and was kept in that position all the time. She was still conscious and opened her eyes twice when I called out to her. What was the resident doing? She was too busy covering up her error. The code was called after I yelled at her as to what she did to my wife. She lied to the emergency personnel and told them my wife complained of a headache and collapsed before the epidural was administered. The autopsy proved different. Question number two. I believe the decision makers should have the facts of the case available. The data should be verifiable. The responsibility of the staff would be to obtain all the data used for the case therefore, the extent of the knowledge, the authority and the responsibility should not be limited since that would eliminate the question of fairness to both the doctor and the patient.
Question number three. The ratio of two physicians and one layperson appears to be biased in favor of the doctor. It should be equal. At least in appearance. It could be two physicians and two laypersons or two physicians, one layperson and one parahealth professional.
And to the question number four. The Administrative Law Judge should be chosen as one who has a track record of being a fair individual. He must also be knowledgeable in medicine and understand medical data and jargon. An example would be a Judge who has presided over many medical malpractice cases.
Question number five. The doctor may want to see the origin of complaints to refresh his or her memory. However, the written facts in the medical records or notes are what they are. Whatever the doctor wrote or failed to write does not change the facts. An act of omission is as bad as an act of commission.
I will skip question six and go to question seven. I believe the last thing a doctor would want is public exposure of disciplinary action against him. In fairness doctors need a fair hearing. They do not need basically a public hearing. Non-complainant patients should know who is reviewing their confidential medical records. Patients who are complaining about services should receive the same courtesy that is applicable to doctors.
Question number eight. The only way scientific literature can help is if it clarifies that particular case. It should not be a fact of law if doctor x wrote it. We should understand what the scientific data is saying as a whole and not use parts to bias either side.
Question number nine which I think is the most interesting cases. There are classes of physicians that are at greater risk for investigation. It's obvious. One has to only look at the malpractice premiums for certain specialties like OB/GYN. The protection comes from the delivery of care. Doctors have to be more careful and take less risks in treating their patients. Unfortunately for my first born my wife's doctor decided to use a labor inducing drug instead of doing the pre-determined medically necessary C-section. My son as a result is delayed. He is eight years old and still wears pampers.
The question does not address classes of patients however. Minorities and the elderly are prone to be victims of medical malpractice much more than any other ethnic group. A Daily News article dated Friday, June 8, 2001 mentioned that a study conducted at Albert Einstein College of Medicine in the Bronx said that of the 192 pregnancy related deaths in New York City between 1988 and 1994, 114 of the women were black and 60 were Hispanics. Caribbean women in New York City have high maternal death rates. When it comes to every area of public health in New York City Caribbean women are the most vulnerable. Should it surprise you to learn that my wife was from the Caribbean and was killed at Albert Einstein Hospital in the Bronx? The priest at her funeral referred to her killing as a crucifixion.
Question ten. If the doctor can challenge the decision of the OPMC and can request a review then in my opinion the patient should have the same privilege. It should work both ways.
Question eleven. I think it's a trick question really. The discipline cases take too long from start to finish. As a result they may error on the side of the doctor since the patient has a longer memory. The cases can be expedited if depending on the severity of the injury, the doctor is put on some form of modified and supervised work. That would be one way to avoid another medical error in the making.
In conclusion when a patient becomes a victim of medical error the very first response would be to protect others from harm. We need to do something in order to prevent this from happening to someone else. The time has come for reform. Let us expedite the cases so that the doctor is not given the chance to make another medical error. Let us change the OPMC. Let us have victim impact statements also.
Thank you.
MS. KORN: My name is Pearl Korn. I was medically battered by my doctor and my rights regarding equal protection under the law were completely violated. I was not provided due process. The OPMC did everything possible to protect the provider.
My doctor is considered one of the leading experts in his field of surgery. His articles on the subject along with his lectures and teachings based on his articles prove that his rehabilitation of me following my surgery was a sham. He went completely counter to his articles by deliberately and repeatedly injuring me by prescribing very aggressive rehabilitation. Much too early in the postoperative period. Where was prudent care of me, his patient?
Along with the doctor's blatant disregard for my health he did not order an MRI nor was there informed consent. My surgery was done by two residents and a fellow and the anesthesiologist was also a resident administering drugs to me while she was unsupervised. The OPMC protected this criminal stating he was pursuing the minimal standard of care while chiding me for not changing doctors from the time of the initial consultation until surgery. Obviously at that point nothing had happened. A minimum standard of care excuse as described by the OPMC must go. Doctor must be held to a very high standard. My doctor was clearly above the law and was made untouchable. I myself had no rights.
My injuries were also premeditated and these same injuries were begun three days after surgery in the hospital. My arm was lifted straight over my head by this doctor and as I was leaving the hospital he ran into my room with a physical therapist and a long stick and had her show me how to lift the stick straight over my head with extended arms. He also handed me a prescription for physical therapy. I was told on an out patient basis to start on pulleys at home unassisted. His articles clearly state that the arm should not be lifted above the head plane of 140 degrees. Of course these criminal acts do not appear in his notes. Nor does he say in his notes that he told me to swim and hit tennis balls on a wall just three months after major shoulder surgery.
The OPMC completely ignored the two prescriptions my doctor wrote clearly and early following surgery putting me on pulleys, elastic resistant bands and weights. The doctor himself writes that pain and early aggressive physical therapy are responsible for the failure of such surgeries. The procedure itself is high risk with a high failure rate. This doctor pressured me and wanted to do a resurgery in order to have subject matter for his students. Doctors maim and kill with impunity and the OPMC looks the other way by not setting standards, protocols, accountability and the regulation of medicine. Medicine is like the old west where anything goes.
In October I sent the proof of the criminality of my case to OPMC. It included copies of the prescriptions and copies of the doctor's articles clearly showing what he did to me and he went counter to his own articles in my treatment or should I say mistreatment. Dr. Ansel Marks of OPMC completely ignored the proof he received from me once again dismissing the truth and the facts.
OPMC also ignored the physical therapy notes that showed I was in constant pain throughout the months of physical therapy that was stopped and started once again. Yes this doctor is a modern day Dr. Mengele and is a sociopath. How could the OPMC not have turned my case over to the District Attorney? How could they permit a patient to be battered by a doctor?
Immediately we can and must change what informed consent is and what it contains and also how doctors take notes. My suggestions on the note taking process could eliminate countless litigations. I would be happy to discuss that with you. Let us resolve these cover up tools quickly. It would be a beginning.
And finally it took the OPMC a year and a half to review my case, which would be long enough for the statute of limitations to run out. Also since they do not share their findings with the victims, which must be done, they once again protect the doctors.
The lack of due process extends into the legal system overseeing medical malpractice cases. But that's a continuation of the story.
I do have three suggestions if I may to perhaps begin to nip some of the cover ups and some of the things that doctors do which really covers them rather well. May I?
ASSEMBLYMAN GOTTFRIED: Yes.
MS. KORN: Thank you. One of the things would be to create a medical victims unit in the police department or DA's office. There are way too many medical criminal cases. And, give the public access to a such an office. Stephanie Speken and I tried the DA. We tried the Attorney General. They would barely talk to you. We were just about dismissed so things have to be done in that area.
And an informed consent that describes the failure rate of the surgery, the disability following the surgery and the time needed to recover and signed by two witnesses and no sooner than two weeks before the surgery unless an emergency. Many of these so called informed consents, and generally they're not even being used, are phony. They are signed by office clerks, which after five years one of mine turned up. I never knew I signed it. They're usually done the morning of the surgery. Mine was signed at 6:45 A.M. and since it was the only thing that was signed it was stuck in and among the insurance papers and I signed it with my initial and my last name. I never signed anything that way. I didn't think it was anything terribly important and so I did that. There were no witnesses at all and the doctor did not sign it. There is a scribble from the receptionist.
How doctors take notes is one of the really crucial issues in the cover ups. My suggestion is very simple and it's this. Have two pieces of paper with a carbon copy between the papers and as the doctor talks to the patient he or the patient takes the notes and signed by both patient and doctor and the patient would leave with a copy thereby having a running file on their medical activity. Doctors note taking has become too creative with lies and omissions. This would signal to the patient to run and find another doctor immediately if the omissions or statements are glaring. This system would also force doctors to keep honest and straight notes.
Finally no industry in America is as
under-regulated as medicine and that must change. The betrayal of trust is crippling our nation. Since we cannot trust our doctors who can we trust?
MS. SPEKEN: My name is Stephanie Speken before I start reading somebody else's case, I am reading the case of, well let me tell you something first. My husband barely touched on it but our son died because a state health law was broken passed by the legislature. Where do you begin? This was totally ignored by the courts, by the DA, by the health department. Totally ignored.
Now I am going to read the testimony of Dora Debowy who is recovering from a stroke. Her husband died in 1990.
ASSEMBLYMAN GOTTFRIED: Let me interrupt. We have a list of people who have been invited to testify who are scheduled to testify. She is not one of them. I am happy to have her testimony submitted for the record but we can't simply have -
MS. SPEKEN: Excuse me I had submitted it.
ASSEMBLYMAN GOTTFRIED: People showing up and deciding to testify.
MS. SPEKEN: No, no, no it was submitted. I also gave it to the person at the desk also.
ASSEMBLYMAN GOTTFRIED: Right. It will be part of the record but that doesn't mean it gets to be orally delivered.
MS. BERGIN: Originally Dora was supposed to come up. I thought and I could have misunderstood. I understood that she wasn't coming so I took her off the list.
MS. SPEKEN: She specifically wanted me to talk about also her son the Judge.
ASSEMBLYMAN GOTTFRIED: We have told people who are not going to be testifying in person that their written testimony will be included in the record of the hearing. I don't think at this point it is right to be adding people to be doing oral testimony who are not on the list. Because if we start opening it up in that fashion we will be here, the people who are, I mean I don't mind how late we are here tonight. I am going to stay until the end. But, I don't know if all the people who are scheduled to testify feel that way. So I am going to have to insist on that. But we will certainly include that testimony in the record.
MS. SPEKEN: Okay can I make one comment please?
ASSEMBLYMAN GOTTFRIED: Okay.
MS. SPEKEN: This woman who is 83 years old had a stroke following the latest blow off letter from the OPMC.
ASSEMBLYMAN GOTTFRIED: Thank you.
MS. DONNELLY: Assemblyman Gottfried may I please add one thing?
ASSEMBLYMAN GOTTFRIED: Sure.
MS. DONNELLY: Because I rushed in because I thought it was 2:00. I'm sorry. I would just like to say that when my grandson's case went before the OPMC both doctors simply got a verbal warning. That was it. There was no retraining. There was no don't use uncalibrated neosynephren.
They used uncalibrated, the otolaryngologist used uncalibrated neocynephren. It brought Harry into shock. The anesthesiologist was not in the room. She was in the antiroom. This is all a fact. She rushed back in. She gave the absolute wrong drug to revive my grandson. She gave labetelol.
So the only thing that Barbara DiBona did who was then the Commissioner is she did send a letter to every doctor in New York State to never use labetelol to bring down the blood pressure. The point being that they only got a verbal warning.
I believe as I said last week, I was at the Agency for Healthcare had a symposium at the Sheraton on medical errors. I approached the joint commission and the people at Hudson Valley Hospital in Peekskill and I said are those doctors, were they retrained. Were they retrained so that they don't repeat? That's the whole key with this medical error problem. Don't keep repeating it. No there was no retraining. In fact the anesthesiologist was back in the operating room the very next morning.
So that's my concern. Mistakes are made. They do result tragically in death. But the fact is pull them out. Retrain them. Give them mandatory continuing education so that it doesn't happen again. That was my main point.
ASSEMBLYMAN GOTTFRIED: Okay. Thank you. I don't know if there are other questions. I appreciate each of you coming here today and telling us about the cases that have brought you here. I know it takes extraordinary courage and strength to come to a forum like this and reopen and talk about the kinds of tragic circumstances that many of you have been talking about. It is very important to our understanding and appreciation of the nature of the issues here that people do that. Questions? No. Okay. Thank you very much. Okay our next witness is Jerry Conway. Before he speaks I am going to have to step out for a couple of minutes. But rather than say that we are taking recess if we could all just stay here I will try to be right back.