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Wednesday, November 30, 2011

No More Clipboards

There are over 100 jackets in The Walking Gallery; many of them depict medical errors and family tragedies.  A few of these paintings depict multiple errors.  Eunita’s Winkey’s Jacket “No More Clip Boards” is one of these. 
No More Clipboards: Eunita Winkey's jacket
I met Eunita in a comment section of a blog.
In the December 2010, Susannah Fox posted a blog post that had an embedded video of Alice Tolbert Coombs, MD.  In that video she described the story of a patient. The patient, a black 70-year-old life-long insulin dependant male, presented to an internist (who was not his regular doctor) with toe pain on February 1st 2010.  The doctor said that from the patient’s description of his pain it sounded like gout.  The doctor prescribed a medication for gout without ever removing the man’s sock.  The doctor then offered the patient an alternative medicine to insulin.    

On February 25th, 2010 the patient returned with complaints of increased toe pain and generally not feeling well.  The doctor ordered another medicine for gout.  

Once again the doctor did not remove the sock.

He recommended the patient to a physical therapist down the hall.  The patient walked down the hall and the therapist asked him to remove his shoe.  He mentioned to the therapist he had some residual weakness from a prior stroke, therefore he was unable to bend over to remove his sock.  She untied his shoe pushed his sock down a bit and attached an ultrasound device used to test diabetics.

She never took his sock off.

By March 5th he was in so much pain he went to see a podiatrist- a foot doctor.  He was admitted to the hospital.  His leg was amputated.  He died less than a year later from the complications of his illness.   

This man was named David Bynum and he was Eunita’s father.

So, on Eunita’s jacket I paint her father with one foot in a coffin.  He is wearing a patient gown and is reaching up trying to help Eunita, but he cannot reach her.  His other foot is in the open air.  His sock is lovely and white and for all of eternity never taken off. 
This would be enough pain for any jacket painting, but there is more to Eunita’s story.

Remember the pain game?  When my sister and I were little children hanging the laundry on the clothesline, we would often rest between our labors.  Standing in the Oklahoma sunshine we would take turns placing clothes pins on our fingers.  If we were in the house working on homework we would forego the clothespins and settle for a handy clipboard.   Each of us would place our fingers underneath the cold steel with its tight spring and watch and wait.  Who could take the pain the longest?

As I learned more of Eunita’s story, I thought of clipboards.  In this painting Eunita is stretched taunt, her wrists caught beneath the steel of the board’s clip.  She is dressed in a wedding gown.

In 1997 at age 38, Eunita started trying to conceive a child by taking Clomid fertility drugs. Eunita was a newly wed in 1998 and at the age of 39, she attempted an in vitro fertilization procedure. In 1999, the IVF physician signed a report stating that she was 49 years old, which was 10 years older than her correct age of 39.  No date of birth was listed on the report to bring attention to the error.  In addition, the IVF physician stated that Eunita had previously taken two cycles of Clomid treatments in 1987.  Eunita did not begin treatment until 1997.  Her chances of becoming a mother at 39 would have been far greater than at 49. 

Unfortunately, due to lack of records access she did not learn of this error until 3 years later. When she was able to read the entire medical record she was aghast. Out of the 15 doctor visits, her name was miss-spelled 10 times. The first and last names were completely misspelled; these were not just typos.  Treatments and other information were also incorrectly recorded in the Ob/Gyn’s notes.  Treatments that she requested were never noted.  In addition, the hospital that performed her eventual surgery listed another person’s name on her record.

Due to the 10-year error in Eunita’s age and other erroneous statements noted in her medical records, she was given a total hysterectomy (removal of uterus, cervix, both ovaries, and fallopian tubes). It left her scarred for life.
Pinned to a board and lost
So, in this painting her womb is removed and her arms are pinned down and held in place by a clipboard engraved with the words: “Medical Records.”  

Eunita has lost so much in life because of errors, neglect and poor management of her medical record.  She could have given in to despair.  But instead she created a non-profit organization: Atwinds.   Within that organization she promotes a Medical Records Awareness Campaign.

I thought of Eunita when I was first followed on Twitter by a PHR company named @NoMoreClipboard.  I even sent them a photo of her jacket. 

 On November 17th I had the honor of seeing Jeff Donnell, 
president of NoMoreClipboard present a speech on a panel at the ONC Annual Meeting.  The panel was entitled “Educating and Engaging Individuals in Their Care.”

He was hilarious and was one of the most patient-centric speakers on a panel of patient-centric speakers.   He talked in a down to earth fashion about the challenges patients face when they try to access their data.  He promoted the concept of “free range humans.”  Your medical data should not be kept in a cage.   He spoke of how pop culture can affect workflow, for example when a new version of Call of Duty is released, it very much affects the cognitive ability of his staff.  I could tell that Jeff and the folks at NoMoreClipboard understood life is messy, hard to quantify and often painful. 

I am glad there are individuals out there like Eunita and businesses like NoMoreClipboard advocating for us.  I am glad that when they see a clipboard they want to overcome it and make a better system.

And I know if I played the pain game against Eunita I would lose.  


  1. Regina,

    This is an honor for our story to be shared at the U.S. Health and Human Services Office of the National Coordinator for Health Information Technology(ONC)Annual Meeting. I hope our story will help to save millions of lives as we raise Medical Record Awareness and No More Clipboards. In memory of my father David Bynum, I thank you! Eunita Harper Winkey

    (DECEMBER 22, 1936-JANUARY 15, 2011)

    The article link states that “New England Sinai hospital, which traces its roots back to 1927, opened as a nonprofit health care provider for patients who could not pay. It managed to do so for many decades, but the financial losses of recent years were a sign of changing times. ” I don’t know the history of the hospital other than what I have learned from the Internet after my father David Bynum’s death on January 15, 2011. David Bynum’s sister-In-law and health care advocate for many years Dr. Alice Coombs, the former 2010-2011 President of Massachusetts Medical Society referred him to New England Sinai hospital. David Bynum was a wealthy businessman so he could not have contributed to the financial losses as a patient who could not pay. Read More! UngnwqWE9rHLjZn7p5icEK/ story.html
    In a September 2010 speech at the Mayo Clinic, Dr. Coombs shares her brother-in- law David Bynum’s chilling story by the name of Patient B.
    A Man’s Sock
    “The first indelible image offered to 500 plus attendees was projected over a vast stage by the speaker, Dr. Alice Tolbert Coombs, the president of the Massachusetts Medical Society. It was a photograph of a man’s enormously swollen left toe, oozing pus and colored in angry red and blue hues. Seeking relief, Dr. Coombs explained, the man who owned this toe had gone to see a doctor and several other health care workers. Each had listened to the man and then prescribed different remedies, not a single one of which was appropriate to his actual condition – diabetic gangrene. The simple reason why all these health care professionals missed easy diagnosis: none of them had bothered to remove the man’s sock. Common sense could answer a lot of health care questions, Coombs suggested. That and education, on the patient’s part especially.”
    My father David Bynum was a successful entrepreneur from Brooklyn, New York, and he would have been 75 years old today. According to Dr. Coombs (2011), the former 2010-2011 President of Massachusetts Medical Society Vital Signs article states that “a little more than two months ago, my brother-in-law, a middle-aged black man with diabetes, died. When he presented with foot pain, a physician failed to remove his sock and examine his foot. That set in motion a tragic cascade of misdiagnosis, preventable hospitalizations, amputations, a sacral decubitus ulcer, and eventually a fatal infection.”
    David Bynum was transferred from a Brooklyn, New York Hospital to New England Sinai Hospital, Massachusetts in July 2010. I learned after my father’s death from an article on the Internet that “New England Sinai Hospital in Stoughton, which provides long term care to the seriously ill, stopped admitting new patients today, after public health officials found that staff were not properly caring for patients' wounds and, improperly restraining others, and had mistakenly placed an intravenous line in a patient's foot.” My father David Bynum was admitted to New England Sinai Hospital in July 2010 and was discharged on January 10, 2011, and sent to his Brooklyn, New York home under Hospice care. On January 15, 2011, he died in his Brooklyn, New York home and the cause of death was listed as natural cause. Thanks to Regina Holiday and others who continue to promote the memory of David Bynum and the health care issues in America.

    Eunita Winkey and David Bynum (The Walking Gallery)
    “No More Clip Boards”
    By: Regina Holliday

    Merry Christmas & Happy New Year!

  3. Great post, Your article shows tells me you must have a lot of background in this topic. Can you direct me to other articles about this? I will recommend this article to my friends as well. Keep it up.

    1. I am curious to know how you learned about the blog and story. Where are you located?

  4. Thank you for reading my post. The article/link below will direct you to other articles and comments posted.

    “They never took his sock off”: a parable of patient empowerment, resourcefulness, and literacy

  5. I am in tears just reading yours and your fathers story. My son almost died because of a medical error/ this day I still cannot talk about it without crying and feeling pain. I pray that one day we can all have peace in our hearts.