Standard of Care

When a childbirth went terribly wrong, the blame game began. Dodging responsibility was everybody's first order of business.

That may be the case with Touchette.

In a malpractice lawsuit filed the year after Isabel died, Thomas Q. Keefe Jr., lawyer for Isabel's father, Mario, says Touchette shouldn't have granted privileges to Ekwulugo because of incidences of negligence, substandard care and improper medical charting that were known to the hospital.

Emeka O. Ekwulugo
Emeka O. Ekwulugo
When Dr. Darrell Ballinger took a look at Isabel Hernandez, he knew her case was more than Touchette's doctors could handle.
Jennifer Silverberg
When Dr. Darrell Ballinger took a look at Isabel Hernandez, he knew her case was more than Touchette's doctors could handle.

Federal taxpayers, not Ekwulugo, could be on the hook for damages resulting from the malpractice suit.

Ekwulugo has been dismissed as a defendant because he was technically an employee of the federal government, which paid his salary through a public-health grant. Mario Hernandez has demanded at least $12 million.

Assistant U.S. Attorney James Hipkiss, who is defending the case in U.S. District Court in East St. Louis, declined to discuss the case. Richard Roessler, attorney for Touchette, also wouldn't talk. Although no gag order has been issued, Keefe also declined comment, saying that a judge has made it clear that lawyers shouldn't be talking to reporters.

In court documents, Keefe writes that neither Ekwulugo nor anyone else at the hospital controlled Isabel's bleeding during childbirth, nor did anyone summon a physician who could have saved her life.

Pathologists at St. Mary's concluded Isabel "most likely" suffered an amniotic-fluid embolism. On the basis of that autopsy, the St. Louis County medical examiner's office found that Isabel died of "multiple complications following disseminated intravascular coagulation [a blood-clotting disorder] and hemorrhagic shock after cesarean section." The official cause of death established by the county isn't much help, says Dr. Steven L. Clark, a Salt Lake City OB/GYN who is one of the nation's leading experts on amniotic-fluid embolisms.

"To some extent, that's like saying they died of cardiac standstill, which everybody does," Clark says. "She can bleed to death from standard obstetric causes, or she can bleed to death from amniotic-fluid embolism. Bleeding to death can mimic amniotic-fluid embolism, and amniotic-fluid embolism can mimic bleeding to death. You really have to go to the details in the clinical chart."

In Isabel's case, the chart has serious gaps and inconsistencies.

During a deposition in the malpractice case, Ekwulugo admitted that the first time he mentioned amniotic-fluid embolism in Isabel's records was ten days after she left Touchette and after he says Ballinger urged him to change the chart. Furthermore, the autopsy report prepared at St. Mary's on the basis of Touchette records doesn't match Ekwulugo's recollection. According to the autopsy report, Isabel was immediately returned to surgery after an anesthesiologist had trouble waking Isabel in the recovery room. Yet Ekwulugo says there was no anesthesiologist present and that Isabel didn't go back into surgery until more than five hours after her condition turned critical.

During the deposition, Keefe grilled Ekwulugo about clues pointing to a hemorrhage. Isabel's uterus wouldn't contract after she gave birth, which is the most common cause of postpartum hemorrhage. She was anemic before delivery, which meant she couldn't withstand the same level of blood loss as a normal patient. Blood gushed from her vagina five hours after she gave birth. Nursing notes show that Isabel was returned to surgery for repair of postoperative bleeding. And the autopsy showed Isabel had no amniotic debris in her lungs, which came as a surprise to Ekwulugo, who notes that a chart entry made at St. Mary's shows doctors found cells "possibly indicative of amniotic-fluid embolism" in a blood sample before she died. Isabel's autopsy report mentions no such finding.

Doctors are divided on whether an embolism is an appropriate diagnosis if pathologists find no amniotic debris in the lungs.

Dr. Kris Sperry, chief medical examiner for the state of Georgia, sees a bright line. "The absence of fetal squames [skin cells] and hairs and other amniotic debris would tend to make me look for other causes of deterioration and death, such as massive blood loss," says Sperry, who wrote an introduction to the 1986 republication of a landmark study of amniotic-fluid embolism in the Journal of the American Medical Association. Sperry, who has testified in malpractice cases involving amniotic-fluid embolisms, says he won't conclude an embolism has occurred unless there's proof that amniotic debris has entered the maternal bloodstream.

On the other hand, Clark says, the most exhaustive autopsy can come up empty, even when there's no question about the diagnosis. "We now know that depending on how many special stains you do and how many slices and cuts of the lungs you do, you can find a few of these things [debris] in just about anybody," Clark says. "By the same token, in at least a quarter of the women who die of what is indisputably amniotic-fluid embolism -- classic amniotic-fluid embolism -- even a carefully done autopsy doesn't find it."

Dr. Michael Benson, a Chicago-area obstetrician who has researched amniotic-fluid embolisms, says that a patient who lives for sixteen days after sustaining an amniotic-fluid embolism could metabolize debris so it wouldn't be found at autopsy. "There's a little bit of a debate as to whether you always need that material in the lungs to make that diagnosis," he says.

Like Clark and Sperry, Benson isn't familiar with Isabel's case or with Ekwulugo. But Benson says that physicians can't be trusted to police themselves.

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