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Aurora Ortegon calmly entered the emergency room at Park Plaza Hospital on a Wednesday morning suffering from nausea and dehydration. She hadn't been able to eat much the night before and had vomited several times.
Ortegon, 70, didn't think it was serious, but her family took few chances with her health. Years earlier, Ortegon had been diagnosed with heart disease and had a pacemaker installed.
"We had to treat my mom very delicate," says Tish Ortegon, Aurora's 40-year-old daughter. "We thought it was just a virus. We never thought it was life-threatening. I just wanted to take care of my mom; that's what I always do."
The original diagnosis in the emergency room was sepsis, a condition caused by severe infection in the body. Doctors admitted her into the intensive-care unit, and after several days of tests and treatment — antibiotics and steroids — Ortegon's condition improved.
A final procedure was performed in the ICU — inserting a tiny camera down Ortegon's throat to make sure everything was okay — before she was transferred to a recovery room. Doctors wanted her to stay in the hospital for a couple days of physical therapy.
"They were getting ready to discharge because she was ready to go out," Tish says. "But all the sudden...she didn't make it."
One day out of ICU, Ortegon's leg went cold and numb. It swelled like a balloon. Doctors discovered a blood clot in Ortegon's thigh and ordered an emergency procedure. The clot was removed, but after surgery, Ortegon seemed confused and aggressive. Medical records describe her as "combative."
"She was screaming, and she was very disoriented. She was already seeing dead people, dead relatives," Tish says. "She wanted the hell out of that hospital. She told me, 'Take me out of here, mija. I don't want to live like this.'"
Over the following week, an array of doctors at Park Plaza, located southwest of downtown, gave the family several different diagnoses. Doctors cited nephrotic syndrome, a condition that can cause kidney failure, and later, family members were told that their mother was suffering from liver failure, a condition far worse than the woman's original emergency-room diagnosis.
Dr. Gerardo Bueso, Ortegon's primary doctor, took the family into his office and explained that she had possibly slipped past the point of recovery.
"That was the first time that...she was not going to pull through," Tish says. "As hard as that is to accept, let's keep her comfortable."
Tish could not believe her mother's condition had deteriorated so fast. Worse, she says, each doctor offered a different explanation than the last.
"We didn't know what was going on, but what else are you going to do?" Tish says. "You have to have faith in the doctors, and we did."
Doctors began administering pain medicine to keep Ortegon comfortable and sleeping. The family kept Ortegon in her normal room, refusing to move their mother back to the ICU.
One evening as the family waited in Ortegon's hospital room, she woke from her morphine-induced sleep and spoke for a final time.
"The only thing she was able to say was 'I love you' to each and every one that was in her room that day," Tish says. "That was enough. That was taking so much of her."
Days later, Ortegon died. Dr. Bueso signed her death certificate and listed the cause of death as liver failure.
"I wish we never would have taken her to that hospital," Tish says.
Following her mother's death, Tish was a wreck. She couldn't eat, and she had to take a leave of absence from her job with ExxonMobil.
"She tried to get back, but she couldn't concentrate," says Amy DeVore, Tish's girlfriend. "She would call me because she couldn't send a simple e-mail."
Tish then remembered an encounter with a doctor who did not serve on her mother's medical team. According to Tish, the doctor took her from her mother's hospital room one morning at about 3 o'clock, telling her that he needed to talk.
"You know, I owe this to your mother," Tish says the doctor told her. "Your mother should not be in there. If your mother gets out of here, make sure her chart gets seen by an outside doctor."
The doctor talked to the Houston Press and asked that his name not be used, saying he feared retribution from other doctors. He said he did not remember what exactly was said during his conversation with Tish, but confirmed that it took place.
"I told the daughter I was unhappy with the care (Ortegon) was receiving," the doctor says. "Most doctors try to hide; I told them everything."
Tish says the conversation planted a seed. She soon went back to Park Plaza to get the examination files and doctors' charts from her mother's stay.
After obtaining the records, Tish rarely left her condo. For months, she combed through the stack of documents daily, searching for answers. Soon, she found one.
On June 13, about a week before her death, Tish's mother was given a large dose of WinRho, a drug that is supposed to help clot blood. Tish was unaware that the drug was given to her mother, and realized that it was days after this that Dr. Bueso met with the family to explain Ortegon's dire condition.