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Nurses and the hospital operator paged the on-call anesthesiologist several times after Isabel reached the recovery room, Ekwulugo says, but got no response. The doctor says he also asked for help from the emergency room. No luck. A recovery-room nurse was told "that as long as the patient had a pulse, the emergency-room physician, according to hospital policy, could not come and assist," Ekwulugo says in a sworn affidavit.
Ekwulugo was on his own.
At 4:30 a.m. -- more than four hours after Isabel lost blood pressure -- the anesthesiologist answered a page, the doctor says. He and his supervisor were at the hospital in twenty minutes, taking over from Ekwulugo to stabilize Isabel's condition so she could be taken into surgery. "[T]hey were managing the patient," Ekwulugo says. "I am just a general obstetrician. I don't deal with critical care."
At 5:30 a.m., a nurse reported that a "large amount" of blood had gushed from Isabel's vagina when her abdomen was gently pressed. Ekwulugo says that's normal for a woman six hours after giving birth -- just blood clots coming loose, he insists. By this time, Ekwulugo says, he was pretty sure that Isabel had sustained an amniotic-fluid embolism.
An amniotic-fluid embolism occurs when fetal cells, hair or debris from the amniotic fluid, which surrounds the unborn child, enters the mother's bloodstream and blocks vessels in the lungs. It's rare, unpredictable and usually fatal -- the mortality rate is between 60 and 80 percent.
Despite Ekwulugo's suspicions of an embolism, Isabel was wheeled into the operating room at 6:20 a.m. The doctor says he needed to rule out the possibility of internal bleeding, which would explain the decreasing blood counts and lack of blood pressure. Ekwulugo made the first incision at 6:27 a.m. Exactly 27 minutes later, the operation ended. So far as Ekwulugo was concerned, the mystery was over.
"I found out there was no bleeding," he says. "The uterus was dry and the abdomen was dry, so at that stage I was completely sure I have eliminated everything and the only thing remaining was the amniotic-fluid embolism."
It had been a harrowing night.
With Isabel in the intensive-care unit, Ekwulugo went home to take a bath.
Teresa Hernandez, Isabel's mother, has difficulty understanding English. But she didn't need a translator when she saw Ekwulugo come out of the operating room with the anesthesiologist.
Teresa says she was in a waiting room when a nurse brought out her newborn grandson and told her that everything would be fine. Then she spotted Ekwulugo. "Dr. Ekwulugo threw up his hands and said, 'I don't know what happened, I don't know what happened,'" Teresa says through an interpreter.
Teresa says it was her first inkling that something had gone terribly wrong with her daughter.
Dr. Darrell M. Ballinger, Touchette's head obstetrician, says Ekwulugo didn't mention Isabel when he called later that morning and said he wouldn't be coming in for his regular shift.
"He just said he had a tough night," Ballinger recalls in a deposition.
About an hour later, Ballinger received a call from a resident physician who was undergoing the final stages of her medical training at Touchette. The resident told Ballinger that one of Ekwulugo's patients was having trouble in the ICU.
"I said, 'Fine, I've got patients to see,'" Ballinger recalls telling the resident. "'I don't have time to talk about it. I will come over at lunchtime and find out about the situation.' ... I mean, I am busy. I've got my own schedule, got my own patients, and there is nothing I could do for the patient."
Ballinger says he didn't bother looking at Isabel's chart when he reached the ICU at noon. One look at Isabel told him that she was more than Touchette doctors could handle. "I could just look ... and see that they are pumping blood in her, they can't get a blood pressure up, they tell me her hematocrit [the percentage of blood composed of red blood cells, which carry oxygen] is dropping," Ballinger recalls. "I said, 'This lady is critically ill.'"
At Ballinger's suggestion, Isabel was airlifted to St. Mary's Health Care Center in Richmond Heights that afternoon. St. Mary's doctors reported that her heart was racing between 140 and 240 beats per minute. She had a fever. She didn't respond to pain. Her pupils were unequal in size. Sometimes she recognized her relatives and could answer questions. At other times, she was completely unresponsive. Her lungs, kidneys, liver and central nervous system were failing, which doctors believed was being caused by hemorrhagic shock, a condition that results from heavy blood loss.
Unable to pinpoint any source of bleeding, St. Mary's doctors weren't sure what they were dealing with. Possible diagnoses ranged from retained placenta to postpartum uterine infection to various types of blood infections to pneumonia.
St. Mary's doctors also checked for evidence of an embolism but reported finding no sign of amniotic debris in blood they took from a femoral artery.
Diagnoses based on blood aren't definitive. Contaminants within the lungs are considered the surest sign of amniotic-fluid embolism.