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But the lungs can't be thoroughly searched unless the patient dies.
Three days after arriving at St. Mary's, Isabel underwent computerized axial tomography -- a CAT scan -- of her abdomen. That same day, a Touchette nurse wrote a memo stating that a hospital phone directory didn't include numbers for the anesthesiologist and his supervisor. Meanwhile, Ekwulugo says, he got a visit from Ballinger.
The CAT scan revealed two hematomas, collections of blood within body tissue. But the computerized image didn't help doctors figure out exactly what was ailing Isabel. There's also no clear answer as to what Ballinger and Ekwulugo talked about. Each physician tells a different story in court documents.
In an affidavit and a deposition, Ekwulugo claims Ballinger demanded that he rewrite Isabel's medical chart to show that the anesthesiologist had arrived promptly. He also says the head obstetrician insisted that the second surgery wasn't necessary because Isabel had sustained an unpreventable, unpredictable and virtually untreatable embolism.
Ballinger, Ekwulugo claims, was worried about legal liability.
Complications from amniotic-fluid embolisms include internal bleeding and can look a lot like what happens after a woman sustains a hemorrhage. The diagnosis of amniotic-fluid embolism is a common defense when an obstetrician is sued after a woman dies in childbirth. When lawyers say a woman died as a result of a hemorrhage associated with childbirth, the accused doctor often says an untreatable embolism caused the bleeding.
"Dr. Ballinger [said] he knew of a maternal death resulting from an amniotic-fluid embolism and that no suit had resulted from that incident and that since Ms. IH [Isabel Hernandez] had an amniotic-fluid embolism it would not matter whether the anesthesiologist was there or not and so it was OK for me to write in Ms. IH's notes that the anesthesiologist was present in the early hours of February 26, 1999," Ekwulugo says.
In a deposition, Ballinger insists he said nothing of the sort.
The head obstetrician says he doesn't recall just when he met with Ekwulugo -- indeed, in a deposition, he claims he can't remember the first time he read Isabel's chart but believes it was more than two weeks after she left Touchette. He acknowledges suggesting that Ekwulugo change the chart, but he insists he didn't tell the doctor to do anything improper.
Ballinger concurred with the diagnosis of amniotic-fluid embolism, but Ekwulugo had done a poor job of documenting Isabel's care. There were no postoperative orders on her chart to indicate what instructions Ekwulugo had given nurses. There was no explanation as to why Isabel needed the second operation. There were also no transfer orders to show when other doctors had taken over from Ekwulugo. Without accurate records, malpractice attorneys could have a field day.
"The mere fact that that chart is incomplete leaves the hospital and himself open for anything anybody could throw at them," Ballinger says.
Ballinger also couldn't understand why Ekwulugo hadn't kept trying to reach other doctors after he couldn't get help from the on-call anesthesiologist or the emergency room. "He could have called me," Ballinger says. "He could have called general surgeons. He could have called anybody in the hospital.
"He said, 'When you are in trouble, you don't want to get anyone else in trouble.'"
Ballinger says he told Ekwulugo to write down what really happened. "I said, 'If this is what you did, then put it in the chart, and don't be afraid of it,'" Ballinger recalls. "I am not going to tell him to lie. I am not going to tell him to misrepresent himself, because that will only get you in bigger trouble than telling the truth."
Ekwulugo says Ballinger repeated his demands in two subsequent meetings. Ten days after Isabel left Touchette, Ekwulugo changed the records.
Court documents don't show just what Ekwulugo wrote, but the doctor says his goal was to provide more details about the second surgery and "to be factually correct but not point fingers, which would create liability for the hospital because the anesthesiologist took over three hours to respond to his page."
The next day, Ballinger signed off on forms showing that he found Ekwulugo's care to be within hospital standards.
Unusual cases and ones in which doctors have provided questionable care are supposed to be reviewed, either in department meetings or in one-on-one sessions with department heads such as Ballinger. If care is substandard, department heads can refer the case to the hospital's medical executive committee, a group of high-ranking doctors with authority to launch investigations that can result in discipline.
Department heads are supposed to read medical charts before signing forms showing that a case has been reviewed. But Ballinger admits he may not have done that in Isabel's case. Nonetheless, he checked boxes marked "No further action necessary," indicating that he was satisfied with Ekwulugo's performance. He later said signing the forms was a mistake.
"I am trying to protect the doctor," he explained in a sworn deposition.
Protect him from what?
"From litigation," Ballinger answered in response to a question from Ekwulugo's lawyer.
Isabel started to improve the day before Ekwulugo amended her chart.