VMC

VMC
VMC Renton, Washington: where death happens and no one seems to care

I keep finding UW VMC errors

Each and every time I review more of Mark’s medical records I uncover even more errors. Not only is this totally unacceptable it breaks my heart. After Mark’s death, when I started reviewing my notes from Mark’s hospitalization and comparing to the medical records I was at 28 pages of errors/issues. Today, I am at 41 pages and I’ve only just begun to uncover all the errors. As a patient at UW Valley Medical Center (VMC) in Renton, Washington, you should be VERY concerned; as I hear from others around the country you should be equally concerned as “these types of errors happen all the time.”

What really happened: Mark did not stand a chance of living after being admitted to UW VMC. As I read through the first 3 days of hospital “Focus Notes (handwritten notes by the doctors and staff)” I now realize the eminent danger Mark was in and I never realized it until today. The doctors involved were “too busy” with other patients, they did not call Swedish or review the hospital computing system for Mark’s medications prior to his hospitalization, they did not adequately tie-in or follow through with their peers, and their serious lack of Project Management skills leaves each ICU patient in danger. This is what I call practicing “Silo Medicine.”

On the first day of Mark’s hospitalization I made the 3rd Floor nurse (Desiree) revise Mark’s medication records on the computer system in his room. While those records were updated in the computer system, 3 days later the doctor’s dictation still has the wrong medications listed in their Focus Notes. What is interesting is that
Dr. Daniel O’Neill mentions that Mark has been taking an MAO inhibitor for quite some time; this same MAO inhibitor is not in that list of current medications.

The drug combinations given to Mark on those first days at VMC were deadly and gave Mark the toxic side effects the staff were noting (respiratory depression, decreased blood pressure – sepsis; flu like symptoms; confusion, agitated, combative, anxious – delirious; etc.) and caused Mark to stop breathing. Mark was given a respirator to breathe (intubated) and also given 3 hospital acquired bacteria into his lungs (MRSA, Enterobacter and Burkholderia) at this same time (Pseudomonas shows up later after a tracheotomy and peg tube surgeries). This deadly combination of drugs on those days consisted of (a history of taking an MAO inhibitor), Mark not receiving his Gabapentin and Sensipar (withdrawal), Dilaudid, Fentanyl, Versed and Lorazepam. Come to find out, the Fentanyl should have never been given to Mark because of the MAO inhibitor. Any healthy person would have died with that combination of drugs or worse been intubated by UW VMC staff.

UW VMC gave Mark drugs he shouldn’t have received and didn’t give Mark the ones he needed to fight their bacteria and prevent withdrawal symptoms.

A lot of you have told me that I won’t make a difference; thousands of people and families have already been down this same road. I do agree that organizations like the Joint Commission (formerly the JCAHO) and the Leapfrog Group are only into collecting metrics and not being a beneficial resource for a patient. They protect hospitals so hospitals will give them information; the same is true of the State of Washington Department of Health and collecting error and infection information from hospitals.

A lot of you have also said that my letters to Federal and State agencies will go unheard or I’ll get that “generic” letter that is useless but polite. That has been the case with some but I am still in communications with other agencies. You cannot give up easily.


Look for Mark’s story on Facebook in the near future.
Karie (Mark’s mom)

17 comments:

  1. Ok, I had to laugh when I read this post (down in the blog) trying to criticize me. Talk about totally oblivious to anything other than themselves, the words selfish and pathetic came to mind.

    “Someone should follow you around your place of work and blog about all the issues there. I would love to read that you fruit cake”

    You gave yourself up Scooter! You are about 60 years old, a nurse and obviously work at VMC! No one uses the term “fruit cake” any longer (a homosexual male, one sandwich short of a picnic, quite insane, etc.)! Ok, now I’ll stop laughing.

    Now, think back…
    I sat in Mark’s room (#403 in the corner) all 68 days to be with him. I never followed anyone around. My blog is what I saw and heard while sitting in his room and reading his medical records (and meetings/discussions with VMC doctors and staff). Had I followed you around that 68 days I’m sure my blog would be HUGE. If I came up with 40+ pages of findings in just Mark’s care alone can you possibly imagine what else I would have uncovered?

    The sad part in all of this is that YOU are only worried about yourself and the mistakes I saw you make. Never mind that those types of systemic errors killed my son, you are totally numb to death and should not be working in a hospital.

    What the VMC staff is also missing in all this is that you work in a so-called regulated industry. Each day, each patient, everything you do should be done in accordance with the regulations and VMC internal processes. You should treat each patient as if they have HIV; each procedure (and clean up) should be thorough and sterile. You should be audited and perform self-assessments all the time. Why don’t you guys get it; you think you above the law.

    I would welcome the opportunity to be audited on a daily basis. It would be fun to have an auditor follow me around and document everything I do. The only way you can fix a broken process or systemic issue is to hear from others (be audited), take that advice (listen and build a corrective action plan), and improve (revise the processes – give training) based on the findings. BTW, I am a certified, 3rd party Quality System internal auditor so be glad I’m not working at VMC. Obviously, you are doing something wrong in your job which is why you are so “irritable” about getting audited from someone outside of the health care industry. Maybe it’s time for you to move on to another profession.

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  2. This was posted down in the blog, but I felt it important to be put here also:

    "Everyone in this world wants to have someone to blame. This way we never have to point the finger at ourselves. Since you are apparently much smarter than any doctor, why didn't you treat mark yourself??? Mark had a complex medical history. It wasn't like he walked in with a cold and just died. Move on with your pathetic life."

    You are obviously a doctor working at VMC and nailed it right on! What is so pathetic about your comments are that if Mark had been YOUR son these errors would not have happened. I can only imagine what you would have done being in my shoes.

    “Everyone in this world wants to have someone to blame. This way we never have to point the finger at ourselves.”

    Your statement is so true of the VMC ICU doctor arrogance, lack of basic project management skills and the inability to have a tie-in system in place to support a working quality system and ensure patient safety and health. I can count the number of times your statement above was used (it’s not my fault); I’m sure the “finger pointing” continues and a process is now in place at VMC to define how this “rolls downhill” to the patient (customer). It has to be the patient’s fault because they got sick (never mind all the medication and procedure errors along with giving Mark 4 bacteria, all of which was preventable and all of which caused his death).

    I also think you need to put down the crack pipe (which is in violation of RCW 18.130.180); we all know who and what is to blame in this tragic hospitalization and the loss of Mark’s life. I guess you haven’t read the medical records (yet).

    “Since you are apparently much smarter than any doctor, why didn't you treat mark yourself???”

    I never said I was smarter than “any doctor” however; it does appear I am smarter than some that work at VMC. I have had the great honor of working with some very talented doctors on the “Seattle’s Best Doctors” list (voted by their peers as being the “cream of the crop”). I did my research before selecting them for my families care; not just taking the first appointment based on what my insurance would pay for. I’ve even had a chance to discuss the issues I bring up in my blog with some of them.

    BTW, VMC does have a couple great nephrologists that could hold their own in the real world; I’ll bet in the years to come I will find them on the Seattle’s Best list and no longer working at VMC. The same comment applies for the night shift ICU nurses, some nurses on day shift and some of the respiratory folks. Great people, very talented, personable and knowledgeable; they even read Mark’s chart (unlike most of the doctors). They too will move on.

    Mark would have had a better outcome had I been allowed to have him transferred; Mark would have also stood a better chance having our dog’s vet treat him in his veterinary clinic. Great vet, his father also died at VMC because of medical errors. My vet and I have discussed this blog in great detail; I’m sure he would never hire a VMC ICU doctor to work at his practice.

    Mark’s medical history wasn’t that complicated; it got complicated because of VMC systemic errors. Since you are a doctor go back and read Mark’s medical records; the data is there and you’ll see what you missed. If I found it, why can’t you?

    Finally, I feel sorry for you since you are a doctor and missed the points entirely. You have a systemic issue at VMC. If you think bringing up these types of major medical errors is pathetic, then I will remain that way and continue to be a loud voice in the health care community and upcoming reform. Continue down your “trickle all blame down to the patient’s getting sick” and see how that will work for you, and VMC. Hopefully, the regulatory world will give you the training you obviously need. At least there are other non-regulated industries you could find a job in that doesn’t involve caring for patients. Good luck to you, you really need it.

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  3. I am so sorry about the loss of your son and of anyone else who has suffered this painful journey. I found your blog by researching VMC because I'm soon to have surgery for what looks like ovarian cancer and my doctor wants to do the surgery at Valley Medical Center. I've heard some stories...was wondering if I should try to get this thing started at Swedish instead. Any feedback would be helpful.

    Having worked briefly in the medical field some years ago I saw how OSHA requirements and other mandatory and common sense procedures were blatantly disregarded. This terrifies me knowing that I'm at the mercy of staff who sees me as one more procedure to get through. I'm not sure what I should do...do you think Swedish would be the better choice?

    God bless you ...can you please tell me your twitter ID? Mark was young and deserved a long life...people who "practice" medicine are earning a good living while patients are vulnerable guinea pigs and so call "oversight" committees aren't stepping in to help the consumer. Our voices must be heard!

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    Replies
    1. Anonymous11:56 AM

      Go to Pacific Gyneocology the gyn docs there are also oncologist, My wife had uterine cancer and had a total hysterectomy at Swedish with the Da Vinci robot and walked out of the hospital in 21 hours

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    2. Gia, I know it's been some time and I would like to know how you are doing. I actually researched Pacific Gynecology some time ago - I totally agree with this gentlemen's statement.

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  4. Gia,

    Thank you for your comments but unfortunately not a lot of folks will put the energy into speaking up against Valley even though their loved ones died as a result of mistakes there. They just move on with their lives. I’ve heard so many tragic stories. I have also noticed that when it came their turn to be hospitalized, they made a different choice for their medical care.

    Myself, I would never go to Valley for anything. I would never allow some of the VMC ICU doctors to touch my precious dog. I am actually relocating to a different city so that in the event of an emergency an ambulance would never take me there. I’ve also informed my employer of my wishes.

    These are only my opinions based on what I my son went through, what I saw and what I have heard from others. If I was in your shoes, and I’m not, and I had what might be ovarian cancer I would be looking at doctors based on their peer reviews, which hospital the doctor is affiliated with, where they were educated, how long have been in practice and how many like surgeries they have performed. I am sure you have already done this same research. Please also realize the value of getting an unbiased 3rd party second opinion BEFORE (if you chose to go to Valley) you are hospitalized as Valley will do everything to prevent another opinion from an outside doctor. http://www.seattlemag.com/article/top-docs-10-gynecologic-oncology-80

    Trying to locate information on hospital error and bacterial infection rates is out there but hospitals only report what they are required to and a lot of the mistakes are never recorded. As a side note, I’ve also seen non-fatal mistakes at Swedish Hospital in Seattle.

    Gia, I am not saying that all Valley doctors are bad – the hospital is a different story. To go into the hospital for one condition and end up getting another or dying as a result of “preventable adverse events” is enough to scare anyone. I used to have a doctor associated with Valley but changed this in the event I ever need hospitalized (and get cancer). This Valley doctor was good; the Valley hospital reputation is not. I personally associated myself with this group based on my research http://www.pacificgyn.com/default.asp

    The sad part about choosing a doctor and hospital affiliation goes back to discussions I recently had with 4 Swedish Hospital doctors (my son’s doctors) and all have told me that these types of things happen all the time, no one says a word, and life goes on at the hospital. These doctors also told me to stay the course for changes to be made; they also want change. The regulatory agencies that are out there to protect us, well, they don’t.

    An important note for you is that Valley may be one of the safest hospitals in this area now (hopefully not temporary) because of all the visibility (Federal and State) from my formal complaints. If you do chose to go there go to my other blog http://vmc-patientadvocate.blogspot.com/ and print items to bring to the hospital for your family member – patient advocate and have someone there at all times with you. I also would be available to go there in the event you need additional support even though Valley would not like that (me either). I don’t want to see this happen to someone else. When you decide, please let us all know what decision you have made. I wish you the very best and a very healthy future.

    Karie Turnage(Mark’s mom)

    Gia, I also need your advice: I really haven’t figured out how to do the Twitter thing yet - is this a benefit or should I continue setting up my Facebook account?

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  5. Gia,

    Thank you for your support as this has been and will continue to be a long journey; I will stay the course. Your comments are so very, very true and I saw it live. I really felt like my son was in a 3rd world country while hospitalized at Valley and I really believe my son would be alive now had I been allowed to transfer him to Swedish. Hopefully now the top leadership at Valley (Rich Roodman, the highest paid public employee in the State of Washington – made $1,134,837 in 2010) has had the time, unlike his doctors, to get engaged with all these issues. After all, we pay his salary (the taxpayer), the patient is the customer and we have a right to expect Rich and his staff to perform according to our expectations. Patient Safety and Health should be number 1, not 10.

    These charts tie into what you are saying and what most people ignore or don’t want to believe has happened in the US:

    The data won’t set you free: http://healthcare-psi.org/hospital-truth-in-advertising-campaign/

    Gia thanks again for your great comments. I wish more people were as educated and informed as you are.

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  6. Anonymous7:19 PM

    Errors are going to happen no matter what the job since we are human. You can put all the process and procedures in place and it will not eliminate human error. You are simply on a vendetta because of your loss. How do you know with 100% certainty that mark would have done better at swedish?? You do not know this and will never know this answer.

    One question i have is what good has become of your personal vendetta?

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  7. Your comments really concern me ”Errors are going to happen no matter what the job since we are human. You can put all the process and procedures in place and it will not eliminate human error.”

    If you’re flipping burgers, work in a department store or are an analyst, an error and not following a process can be overlooked; the first time. My blog is not discussing 1 error or 1 process failure that resulted in the death of my son; we are talking about a total healthcare system failure at VMC.

    Do you really believe that 40+ pages and growing of errors that I found is ok and should be overlooked because they were human? That is insane and if I had not spoken up (set up this blog and filed complaints) these types of errors would be happening to someone else as I type this.

    Health care “adverse events (error, death, infection, etc. rates)” should be as low as flying on an airplane. End of story. At a recent workshop with the Washington QA Commission a chart was presented and compared these two industries. Going into the hospital is more dangerous than bungee jumping or mountain climbing. In a comparison of these industries that would be 1.5 - 747-8 airplane crashes each day. Hospital leaders, doctors and staff still don’t get it – the adverse events keep occurring.

    Your comment: “How do you know with 100% certainty that mark would have done better at swedish?? You do not know this and will never know this answer.”

    I know now that with 99% accuracy that Mark would have lived. I have not posted my latest findings of Mark’s record review because of HB 1493 and my revised complaints to various agencies within the State of Washington. My analysis and documentation is almost complete and will be presented to the Department of Health (DOH) on Friday. You will be receiving your copy soon. I am surprised that you VMC staffers still haven’t gone out there to review the records and what was missed – you wouldn’t keep posting these notes if you had. I’ll be posting the new information on my blog as soon as VMC receives it. The public has a right to know who made the mistakes that killed Mark.

    If you had let me transfer Mark to Swedish on those first days we would not be having this conversation. Just like the 2nd opinion request I made to you, you turned it around so that Mark couldn’t get one. That was because the doctor at Swedish would have found the information you and your peers “missed” and the additional errors you didn’t want to disclose.

    There is a difference between a vendetta (revenge) and a mission. One is legal, the other is questionable. I think VMC and select doctors involved in Mark’s care need to be spanked and hard. If I was on a vendetta I would treat you and your peers just like you did Mark – no different than what I found in the records.

    My mission is different: I can sue; I will not sign a gag order. Legislation is now in work. Thousands of people and advocacy groups from all over the world are reading this blog. They know these same things can happen to them. People also go out to the internet and search for reviews of VMC and their doctors to see what the public is saying. I have not had a chance to post my reviews yet. Note: My comments will only be based on facts and data. This is next and I hope you and your peers read them. This is the good that will come out of my mission – to inform the public.

    I’m almost positive I know who you are – so when are you leaving VMC?

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  8. Anonymous12:22 PM

    Why do you think every person that disagrees with you is from VMC, you seem very paranoid. I'm very sorry for your loss but there is no one option for medical treatment.

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  9. I too am sorry for my loss; I am more sympathetic for Mark who lost his life due to preventable hospital errors. Mark was a wonderful, compassionate person – a son that most parents would dream of having as their child.

    Most folks that have posted comments on Mark’s blog are not from UW Valley Medical. These folks have either gone to UW Valley Medical and been injured, their family member has died because of preventable errors or they are looking for reviews of UW Valley Medical (and their contracted doctors) for care and/or hospitalization. Some are in the middle of a lawsuit.

    Comments I have disagreed with deal with errors that CAN and COULD HAVE been prevented – because of what these folks posted it is obvious they were there during Mark’s hospitalization or they are from other hospitals and see the same types of errors all the time. Of course, they blame it on the fact that we are human and make mistakes – that attitude is why preventable hospital error rates are escalating out of control in the US. If you believe these rates are going down, please read further and do your own research.

    What concerns me is the preventable errors that occurred during Mark’s hospitalization should have been reported to the Department of Health – they were not. How can any hospital fix something if they refuse to acknowledge (and record) it happened? Do you really think going into the hospital is safe?

    A couple of other comments posted were from folks in the medical profession that noted an inaccuracy (doctors writing on 1 focus note; the other dealt with information on the internet about Fentanyl) – I made those corrections. Another person posted a comment that there are many inaccuracies – I’m in the process of re-reviewing this blog but haven’t found any. What I have posted thus far is only the tip of the iceberg of what happened during Mark’s hospitalization.

    If you disagree with something I posted: why not share that information and who you are (your name and why you are an expert)? I am sure folks would like to see a post from a nurse or doctor that has something logical to contribute. Even if I don’t agree with it - I don’t delete comments.

    My last response to you is from your comment: “there is no one option for medical treatment.”

    There are defined traditional approaches to “practicing medicine” that have worked for many years. I thoroughly understand that not all approaches work for each individual (depending on the condition i.e. cancer). Where I disagree with you is that the “one” option for medical treatment that should have been followed (but wasn’t) is LEADERSHIP. Had any hospital LEADERSHIP existed at UW Valley Medical when Mark was hospitalized, I would not be typing this now and Mark would be alive.

    I’ll give you an example of “one” option for medical treatment (the one event that put Mark’s life in jeopardy):

    What does a hospital do when they know a patient has been taking drugs for many years?

    Is it traditional to cut off all previous drugs and let the patient go through medication withdrawal?

    Is it traditional to intubate a patient going through medication withdrawal until those symptoms go away?

    What is the “one” option for drug addicts (illegal drug use – Heroin as an example) going through medication withdrawal? Do we intubate them until the withdrawal symptoms go away or do we (the State) pay for clinics that provide other medications to “soften” medication addiction/withdrawal?

    The one approach that solves this is to taper the medications down over time.

    This blog is about preventable errors and a hospital that is out of control. Is anyone at UW Valley Medical driving the bus for the patient’s safety and well-being?

    I am looking forward to your response.

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  10. Anonymous12:09 PM

    Karie, I have a friend who was infused with someeone elses antibiotic in out patient clinic and had a grandmal seizure as a result. This was at VMC. Anne Arundel hospital killed my mother several years ago . It was the same old story compounded mistake after mistake. Then to eliminate the problem a thoracic surgeon removed my mothers chest tube and she drowned within 24 hours . It is pitiful the stuff they get away with. Good luck and I am sorry for your loss

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  11. I hope that you share this blog with your friend that had the grandmal seizure because of receiving someone else's antibiotics. I would like to hear their story - they can always email me privately at karieturn@comcast.net. I am so sorry about your mother and can't believe what she, you and your family had to go through then, and even now thinking about it. Just thinking about what you say sends a chill up my spine to know how horrible her death was; she drowned. What you say is so true and the "template to disaster (even in aviation);" it's always a series of small mistakes (compound mistakes) that lead up to the disaster (death). Thank you for sharing your thoughts. Good luck to you too, and I am so sorry for your loss.

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  12. I don't have all the details, but I rushed to WA from Oklahoma by driving 28hrs non stop due to my father who was admitted to Valley Death the 50th time over the course of 10 years I believe. Long story short, the rehabilitation facility across the street Talbot Rehabilitaion Center is where he was kept for 10 years for a simple stroke. Obiviously leaving him in there was the worst decision my Sister could ever make. We from them not caring for him properly, i.e. turning him in the bed, keeping him cleaned up or keeping his tubes free of bacteria..he grew very ill. Under the care of Valley Medical Center, from what I was told; they could not do anything further. Infection was throughout his body from his catheter and feeding tube. Why couldn't the infection be beat when this had occurred over the past 10 years as often as almost monthly...I don't know. But I haven't been able to get any answers since my sister is in charge of everything and doesn't care. Well he passed last June on the 19th. Ironically I ended up in ER from an injury that occurred on the job. I heard a POP in my left calf, went to ER to be treated like crap!!! My leg was 6x the norm and a nurse in ER put a full blown fiber cast on it!!! I was sent home. I cried all nite from pain in which I was only given 10 Vicadin with Tylenol that did absolutely nothing form my pain. When I went back to ER the new doctor that seen me, had a look on his face like "What did those idiots do yesterday?" He immiediately cut the cast off, had a nurse check for blood clots with an Ultra Sound, place a Ace Bandage type wrap on and sent me home. Who puts a Fiberglass cast on a huge swelling? I finally visited my primary for the first time, he introduced himself after seeing my last name, as the doctor who had cared for my Father.. :{ (continues on bottom)

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  14. To hell with how long it take, I have a huge blood clot in my leg! After that visit, I was only given instructions to apply heat. I was never contacted by my primary again. So I took it upon myself to book an appt. for one, where is the follow-up, 2 what do I do, when do I go back to work...and my leg is killing me! At nite I would get Charlie Horses back to back, which obviously put strain on the already swollen area of my calf. When I went to visit my primary, his words were.."Oh, it look a lot better, you made it seem like it was worse" I informed him of how much it hurt and the Charlie Horses, he just kind of looked at me and told me to apply ice again, I told him the specialist said heat, so he then said ok heat then. Ugh, I swear these doctors are something else. I asked him what do I do about the pain, so he prescribed me muscle relaxers. From that month (July) until recently, I never heard from him again. I have been living with this pain after the swelling where it just throb during the nite, hurt to walk etc. But the fear that I have of possibly obtaining blood clots is what has me worried. I mean, neither of them were able to explain where this blood clot would go and when? Upon researching and talking to other family members in the field, I've been asked why wasn't I given blood thinners to be safe? I recently set an appointment for a new concern that started to occur a few months ago, but waited to see my doctor because of the previous dealings. But the pain grew to be unbearable and my blood pressure is sky high. Our first visit, again..he sat behind the computer and listened to my concerns, never examined me like I am beneath him or something and within 5 minutes of the visit pulled out a sheet with excersises on it and told me he believe I have Bursitis? My pain is along my whole righ side, it feel like my hip is dislocated and my right arm in the inside of the elbow hurt to bend daily. At nite pain shoot up and down them both to where I sit up in bed and cry. I have bought every kind of ointment, icy hot etc. There is no way I can do these weird exercises when I can hardly squat to use the restroom. This has pissed me off to the point to where I recently decided to search for a new doctor because I informed him that since last June my previous injury is killing me, it hurt so bad along with this new issue. All he told me is that it can take up to 1 to 2 years for a Hemotoma to go away. He didn't perform an ultra sound or any kind of exam to see how it is doing. That bothers me! I absolutely can't stand this man, because besides all of this that I am trying to remember and mention, he look at me like I am bothering him, and I can't stand the way I am treated. I am so afraid of possibly having blood clots, I wan this new pain explained and can't get any answers. I just begged him to order an MRI after completely loosing it.

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