Torment is the best word I can find to describe an overnight 12-hour experience that I endured while a patient at the University of Virginia Hospital, in Charlottesville, in May of 2012. Only after nearly three years am I able to share this story calmly and without disruptive emotion.

The written records of the time tell the story. The first, THE COMPLAINT, is a letter of complaint addressed to the hospital officials. The second, THE RESPONSE, is a set of notes by my son, who received the hospital’s response by phone because they said they were unable to put it into writing. To my knowledge, no further action was taken other than an alleged reprimand to the responsible staff member.

We know that hospitals lose many lives through mistakes in treatment or failure to prevent the spread of infections. I have no idea how much these involve abuse as described here. As reported by the Charlottesville Daily Progress (December 23, 2014), the U.Va.Medical Center faces penalties for relatively high rates of hospital-acquired conditions such as infections, ulcers, clots, and injuries from a fall. In my own experience, my health declined steadily for three months after surgery, while the doctors told me to drink more water, until another hospital diagnosed and treated my problems as pneumonia, hypothyroidism, sepsis, dehydration, excess coumadin (an anticoagulant or “blood thinner”), and conjunctivitis.

The purpose in telling this story is to share an important lesson: Such things can and do happen in hospitals. The only apparent remedy is for family members or other advocates to accompany a patient who is too weak or confused for effective self-defense. The advocate must be familiar with what constitutes torment, and with the patient’s rights. Even though it is difficult to arrange stays beyond visiting hours, that is needed because torment can occur at any time of day.

One might visualize a time when hospitals provide truly conscientious advocates for patients who have none of their own, or when they might at least provide closer inspection of staff performance.  But, aside from technological advances, real progress in medical care is extremely slow.


Letter of complaint

Shortly before my discharge from the U.Va. Medical Center on May 17, 2012, I met with Jennifer B. Kane, Patient Relations Representative and Marcia White, RN, MSN/MHA CCRN, MA, Manager, TCVPO, University of Virginia Medical Center. I described the events of the night of May 13th, about which I wished to lodge a complaint. I was advised to put this account in the form of a letter to Ms. White. This would give her a basis for investigation, and she would inform me of the results of that investigation.

The resulting letter, dated May 19, 2012, and addressed to Marcia White, follows.


Waynesboro, VA

May 19, 2012

Marcia White, RN, MSN/MHA CCRN, MA
Thoracic Cardiovascular Post-Operative ICU Manager
PO Box 801444
Charlottesville, VA 22908-1444

Dear Ms. White:

I am an 85-year old retiree who recently underwent open-heart surgery, follow-on heart surgery, and emplacement of a pacemaker at the University of Virginia Hospital. I was most pleased with the successful results of the surgeries and the skillful, careful, and sensitive levels of treatment furnished by the surgeons, other doctors, and all staff members who took care of me throughout my ensuing stay — with one single exception. I must lodge a serious complaint about the treatment I received from one nurse, whose name I understood to be Dwayne, who handled my case for about 12 hours the night of Sunday, May 13.

That Sunday night was my first one awake after remaining under anesthesia through the previous two, which had followed two consecutive days of surgery. I was extremely tired and restless. Despite an initial error in recalling the year we were in, I do not believe that I was confused to any serious degree. I occupied a model of bed that several members of the ICU nursing staff later identified as uncomfortable and likely to promote restlessness. I recall tossing restlessly during the first hour or two with Dwayne, and thereby disarranging the bedcovers several times, and I recall once pulling off the glowing red finger clamp used to measure blood oxygen content.

Dwayne promptly grew hostile, said that I was being irresponsible for my health, that I was extremely uncooperative, and that I could not be trusted. He asked me why I had bothered getting heart surgery if I wasn’t going to protect the results. He quickly and surprisingly worked with an assistant to install restraining mittens on both hands. I told him I simply could not endure this confinement, and I asked him to remove them. After the mittens had remained in place about an hour, I began trying to remove one and I soon succeeded. He then quickly overwhelmed me and installed thongs tightly binding each wrist to opposite bedrails, spread-eagle fashion. This situation continued through the rest of Dwayne’s work shift, ending about 8:15 am on Monday. Total restraint time was close to 12 hours, and I do not recall any intervening periods of relief. I was coughing incessantly during most of the 12 hours. Dwayne said the coughing was good for me.

The following photos show the visible evidence of this ordeal that persisted until they were taken on Thursday, but the bruising was a minor matter compared to the physical and emotional discomfort that persisted through the period of restraint.

DSC00535                  DSC00533

This experience stands out as the most relentlessly brutal medical procedure that I have ever received in my lifetime. It remains my opinion that, if restraint were intended either as punishment for my “misbehavior” or as a means of teaching me a lesson, its duration was far out of proportion to the nature of the offense; and that if it were critically necessary to stop health-endangering motions permanently, then at least an attempt should have been made to follow shorter-term restraint with something else, ranging from two-way discussion to injection of a consciousness-lowering agent. I recall, in fact, that both these steps were taken – not as attempts to end the situation – but as steps followed quickly by abandonment while restraint continued long afterward. I noted long periods of abandonment under restraint, avoiding any opportunity to discuss the problem or further to resolve it.

Rather than relying entirely on my own memory to assess this event, I would appreciate any extracts from your records that would help me assess what went on, such as:

  1. Names and titles of any additional persons involved in the case that were present during Nurse Dwayne’s assignment, indicating whether in supervisory, advisory, collegial, or supportive capacity toward Dwayne.   .
  2. Medications or other treatments attempted, and indication whether these were successful, or failed, or involved repeated attempts.
  3. Any application of balm, relief, repair/recovery from treatment effects, or independent checks by others regarding need for same.

I am confident that each of the other nurses serving on my case after Dwayne would give positive feedback about my responsibility and cooperativeness in medical matters. I am also quite sure that my Internist, Dr. S.A. Tatar and my cardiologist, Dr. R.S. Gibson, both of whom have known me for many years, would give equally favorable witness on such matters and would also provide highly positive comments on my character, sense of responsibility, and trustworthiness when involved in matters of medical stress.

I am deeply grateful for your attention and assistance in this matter.

Sincerely yours,

James R. Burns

Copy to:
Jennifer B. Kane, Patient Relations Representative
Patient Relations Department
PO Box 800678
Charlottesville, VA 22908-0678


Results of investigation 

On May 31, The ICU Manager conveyed the following message in an email to Mr. Burns: “It took some time for me to review the chart and to talk to everyone involved in your care, so I apologize for the time it has taken for me to get back to you. I will try to call you tomorrow afternoon to discuss.”

Jasper Burns (James K., son of James R.) replied on June 1, saying, “My father asked me to respond to you. He does not feel that he is up to a phone conversation with you about something so important to him. He is afraid that he will not remember what you tell him or be alert enough to ask the pertinent questions.

“Perhaps you could email the information to him or call me instead.”

In the late evening on or about Saturday, June 2, The ICU Manager spoke with Jasper by telephone. She indicated that she had been trying all day to put the results of the investigation into writing, but without success. She found it repeatedly necessary to delete the items she had written. It was agreed that the matter would be handled by phone with Jasper, and that took place several days later. Jasper’s notes on the conversation follow.

Summary of a conversation on or about Friday, June 8, 2012 between Jasper Burns and Marcy White, Manager, TCVPO University of Virginia Medical Center.

The ICU Manager was following up on a complaint filed by James R. Burns concerning his alleged mistreatment while in the University of Virginia Hospital TCV ICU by a nurse named Dwayne during a 12-hour period from May 13-14. Mr. Burns had undergone open-heart surgery on May 11, and follow-up surgery for continued bleeding on May 12.

The ICU Manager stated that she had spoken with everyone involved. She said that her conclusions after discussing the matter with everyone were that significant nursing and physician errors were made while Mr. Burns was under Dwayne’s care. These errors included the following:

  • Contrary to hospital policy, no physician authorized the prolonged close restraint that Mr. Burns was subjected to, extending over a period of approximately 12 hours. The restraint was approved by the “nurse practitioner”, or “LIP”, rather than a physician.
  • Dwayne should not have encouraged Mr. Burns to cough and breathe deeply as narcotics were being withheld and weaker painkillers (e.g. Tylenol, Toradol (if kidney function was adequate) had not been prescribed. Coughing and deep breathing would have been very painful under these circumstances.
  • The ICU Manager expressed the opinion that pain management should have been “more aggressive”.
  • A delirium assessment should have been done before any decision regarding restraints was made – this did not happen.
  • Inasmuch as Mr. Burns was subjected to restraints for 12 hours, a sitter should have been assigned to observe his condition and comfort.
  • Nurse Dwayne should not have “scolded” Mr. Burns for disarranging his bedclothes and being restless.
  • Greater attention should have been paid to Mr. Burns’s dry mouth.

When informed that Mr. Burns continued to remember his ordeal and had experienced vivid nightmares about it after leaving the hospital, she said that she regrets this very much. She suggested that, if Mr. Burns has difficulty getting over the trauma, he might consider attending a “Mended Hearts” support group meeting.

The ICU Manager stated that Dwayne was reprimanded for his actions while treating Mr. Burns, and that Dwayne “feels terrible” about the distress that Mr. Burns experienced and continues to experience.

James K. (Jasper) Burns
June 12, 2012



  1. Poor Jim! Your story brings your ordeal vividly to life. As usual, your writing, your telling of it, in that calm tone, heightens the drama. I trust, appearing in your blog, the incident will now catch the attention of some high-ups at UVa, and lead to serious reforms. Thanks for that, Jim. At times like this, weather-wise, you are in the right place! C

  2. Is it possible that this blog had an effect on patient treatment at the University of Virginia medical center? If so, I believe that my “speaking up” was well rewarded.
    A friend underwent surgery similar to mine, at the same hospital, in September 2015. I understand that her relatives were welcomed into the ICU at all hours. I also understand that, on the wall of her room, a prominently posted sign spelled out patients’ rights with respect to restraint.

  3. Hi Jim, I’m doing a poster on restraint reduction and would like to use the photos which you have posted here to illustrate the damage that they can cause. May I?

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