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Doctors weaned her from her ventilator. Her fever went down. She was talking -- relatives say she often said, "Mama." She could smile, blink her eyes and squeeze hands.
But she was still very sick. Although she was partially paralyzed, she needed wrist restraints at night and was given a drug to control seizures. The day after Ballinger signed the forms, her fever returned. She had trouble breathing. By March 12, 1999, she was back on a ventilator. Surgeons opened her skull that day in an emergency operation to treat a hematoma that was pushing against her brain.
But Isabel was too far gone. She died the next day.
About two weeks after Isabel died, Ballinger says, he decided Ekwulugo posed a risk to his patients.
By then, the head obstetrician had reviewed Isabel's chart. In a meeting with hospital administrators, Ballinger said his concerns went beyond Isabel. Ekwulugo had provided questionable care in several cases, he says.
"In the interest of our patients, it was agreed that we must take some form of action," administrators decided, according to meeting notes.
Administrators told Ballinger to put together a list of cases in which Ekwulugo's performance had fallen short. One week later, they called Ekwulugo into a meeting and gave him a chance to resign. At the meeting, Ekwulugo was handed a letter from Ballinger to Dr. Jose G. Ramon, Touchette's chief of staff.
In his letter, Ballinger listed 24 women, including Isabel, who had received questionable treatment from Ekwulugo. The cases dated back to 1996, with allegations ranging from poor recordkeeping to downright bad doctoring.
Ekwulugo was given two days to respond to Ballinger's letter. Otherwise, there would be a full-blown investigation.
He didn't make the deadline.
Ekwulugo was granted an extension but still didn't respond -- he says he was busy with continuing-education classes. He also says the hospital wouldn't give him medical records so he could prepare a response to Ballinger's accusations. On April 22, 1999, Ekwulugo's privileges were suspended by the hospital's medical executive committee. The committee also voted to begin a formal investigation.
Suspension meant more than just not being able to practice medicine at Touchette. Federal law requires hospitals to report suspensions of longer than 30 days to the National Practitioner Data Bank, a list of physicians whose care has been found wanting or who have been defendants in malpractice lawsuits that were settled or won by plaintiffs. The databank is maintained by the U.S. Department of Health and Human Services in an effort to prevent substandard doctors from job-hopping. The databank is accessible only to employers and insurance companies.
The formal investigation could also spell trouble for Ekwulugo. Once a hospital begins an investigation, a doctor can't resign to avoid being reported to the databank, even if the investigation ends with the physician's resignation. Hospitals are also supposed to report physicians who resign in return for the hospital's not starting an investigation.
Four days after the committee suspended Ekwulugo, he met with Ramon.
Ekwulugo told Ramon that he hadn't been given a chance to respond to Ballinger's concerns. Ramon told Ekwulugo that he'd been given time to respond informally so that an investigation could be avoided. Now, the hospital had no choice but to begin formal proceedings that could cost him his job, Ramon said. He also suggested that Ekwulugo resign before an investigation reached any conclusions.
Emphasizing the seriousness of the situation, Ramon told Ekwulugo that one patient had died and another had nearly died in the cases Ballinger brought to the medical executive committee's attention. Meeting notes do not specify which cases Ramon was talking about.
Ekwulugo wouldn't quit. The medical executive committee retroactively converted his suspension to a leave of absence, deciding that Ekwulugo should have a chance to review medical records. But less than two weeks after converting the suspension to a leave of absence, the medical executive committee recommended tough punishment after hearing from an OB/GYN hired to review Ekwulugo's performance.
"Based on this review, the MEC [medical executive committee] finds that you have demonstrated: 1) poor documentation of patient records; 2) poor judgment in your medical practice; 3) an inability to recognize when you are exceeding your capabilities and when you should request assistance from others; and, 4) standards of care deemed unacceptable by your peers and colleagues," wrote Robert Klutts, hospital CEO, in a letter to Ekwulugo.
Besides recommending that Ekwulugo's privileges be suspended for one year, the committee said the doctor should not be allowed to return to Touchette until he'd gone back to medical school, obtained a year of obstetrical training and produced a letter from a med-school supervisor stating that he was competent.
Ekwulugo demanded a hearing before a panel of five Touchette doctors so that he could present a defense.
The deliberations of the hearing panel and exactly what evidence it heard aren't part of the public record. Under federal law, such peer-review proceedings are secret. The panel voted not to consider eleven of the cases after a doctor hired by the hospital reported that Ekwulugo's care in those cases was within hospital standards. After four hours of testimony and nearly three months after Isabel died, the hearing panel unanimously voted to recommend that Ekwulugo's privileges be immediately reinstated, with the requirement that he take a course in documenting medical care.