law rights & civil resource

posted by admin on Mar 10

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1 of marked variability or tachycardia before she has to

2 call the doctor?

3 A. Well, I don’t think with marked

4 variability, which doesn’t last very long anyway in

5 this case, that the nurse ever has to call the doctor.

6 The tachycardia would be at some point

7 important for the doctor to know has occurred, assuming

8 that she has noted it for a long period of time. So

9 sometime between 12:10 p.m. on the 7th and ten o’clock

10 that night I think the physician needs to know that

11 there has been an ongoing tachycardia.

12 Q. Okay. But my question was how long, in

13 your opinion, does the standard of care allow the nurse

14 to watch the monitor for tachycardia before she’s

15 required to call the doctor? I mean –

16 A. There is nothing — there is nothing

17 sacredly written down as a time interval. I think it’s

18 a judgment call. But certainly after an hour or two of

19 tachycardia, I think the nurse needs to let the

20 physician know that there is tachycardia. He may –

21 Q. Well, is the –

22 A. Excuse me. He may well know that this

23 is — that this could easily be part of the terbutaline

24 therapy too, which I really failed to mention, so let

25 me mention it now.

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1 Terbutaline, which has been given to the

2 patient, is a — is a very significant cause of fetal

3 tachycardia. So the nurse has to understand that this

4 is either a core temperature problem of the fetus or

5 terbutaline therapy that’s being administered. And

6 while I answered earlier that more likely than not it

7 was a core temperature problem, I’d have to put the

8 terbutaline issue right up there with it as an equal

9 partner, so to speak, in causation for fetal

10 tachycardia.

11 So assuming that the nurse is convinced

12 that this heart rate is up because of the terbutaline,

13 she really doesn’t have to call the doctor.

14 You only call the doctor if you think there

15 is some change that needs to occur; that somebody needs

16 to do something — either evaluate, come in and

17 deliver, change course of — change course of direction

18 in management. And I don’t really see that here. I

19 think the average, prudent nurse would think that with

20 an afebrile mother that this is either a core

21 temperature problem or a terbutaline problem, at worst

22 it’s fetal stress, but there’s no evidence of hypoxia

23 or distress. And I’m not really sure that she needs to

24 notify the doctor that this is — this is occurring.

25 Q. Sir, I thought you told me a few answers

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1 ago that a nurse is not allowed to make a diagnosis;

2 she just has to inform the doctor about what’s going on

3 and he makes the diagnosis.

4 A. Well, technically that’s exactly right, but

5 nurses do make diagnoses in their head. I mean,

6 they’re not — they’re professional individuals who

7 have a considerable amount of intelligence and can

8 figure these things out. I’m talking about that

9 they’re not — their job description is not to

10 diagnose. Their job description is to monitor and to

11 let physicians know of events as they occur in a manner

12 that would allow the physician to intervene

13 appropriately. But, of course, nurses diagnose, but

14 they wouldn’t put down, “Impression, abruptio placenta”

15 or, “Impression, fetal distress.” They would put down

16 “fetal heart rate bradycardia,” knowing that that’s

17 fetal distress, but they wouldn’t necessarily put that

18 down.

19 Q. Okay. So did the standard of care here

20 allow the nurse to assume that the tachycardia was due

21 to terbutaline and not call the physician?

22 A. Oh, absolutely. Or even that the

23 temperature might be slightly elevated. As long as the

24 mother’s temperature is not demonstrating a significant

25 problem, then I think it’s okay.

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1 For example, at ten — I believe at ten –

2 one second. I want to check something.

3 What I’m looking for is there was a point

4 where the temperature went to 100.4 and the doctor –

5 Dr. D. was notified. And that was — (pause)

6 I’m looking for the time when her — when

7 the mother’s temperature went to 100.4. I just can’t

8 locate it at this point, but I have written a note to

9 myself, which you have in front of you too, from my

10 notes, that the doctor was notified about that, which

11 is an appropriate thing to do. I’ll keep looking while

12 you’re asking me other questions.

13 Q. That’s fine.

14 Sir, would you agree with me that a

15 physician would expect his nurse to call him when a

16 patient has tachycardia and inform him of that and

17 allow him to make the determination if it may be due to

18 terbutaline or an increased core temperature or

19 infection or what have you?

20 A. Yes. I think nurses need to let their

21 doctor know when there is a fetal tachycardia and let

22 the physician make that particular call.

23 Q. That’s part of the standard of care for

24 nursing; correct?

25 A. I believe that it is a standard of care for

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1 nurses to keep doctors upgraded — or updated.

2 For example here, I’m looking at notes

3 where the nurse wrote, for example, at two o’clock in

4 the afternoon — I assume that’s the 7th — Dr. D.

5 aware that fetal heart rate is 160s to 170s.

6 So I assume that the nurses are letting the

7 doctor know. At 3:30 Dr. D. was there looking at

8 the strip. I’ve never, in reviewing this, felt that

9 the doctor was not informed as to this particular fetal

10 heart rate tracing. And the level of concern that

11 started later, in the early morning hours of the 8th,

12 the nurses are appropriately calling and updating in a

13 more frequent manner.

14 Q. Sir, what is the basis for your opinion

15 that you told me earlier that it could be even one to

16 two hours of fetal tachycardia before a nurse is

17 required to call a physician and inform him that his

18 patient has tachycardia?

19 A. Well, I’m giving you a generic time line.

20 If the physician has been in and has reviewed the

21 record and nothing much has changed, then the nurse can

22 watch the tachycardia for hours and hours, which I

23 think is happening here.

24 But I don’t think that — that was a very

25 generic term, assuming that an hour or so has gone by

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1 of fetal tachycardia and the doctor did not know that

2 tachycardia has been ongoing, then I think the nurse

3 should be calling. But that was more of a generic and

4 not specifically related to this case.

5 Q. So in this specific case, sir, is it less

6 than an hour or two that you believe tachycardia can go

7 by before the standard requires the nurse to inform the

8 doctor of it?

9 A. Well, the only reason I’m hesitating is

10 that, you know, there is nothing written down in any

11 kind of national standard that says that after 60

12 minutes a nurse has to call the doctor with an

13 unexplained tachycardia. It could be — it could be

14 two hours. It could be thirty minutes. Everybody is a

15 little different on this. So there is really no

16 specific standard.

17 I’m telling you, from my point of view,

18 that somewhere around an hour to two of an unexplained

19 tachycardia should be brought to the doctor’s

20 attention, assuming that there isn’t some very obvious

21 reason that had already been ongoing and discussed.

22 And in this particular case, being on

23 terbutaline, which is a — which is a very common cause

24 of fetal heart rate tachycardia, I think these nurses

25 are watching this tachycardia and assuming that the

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1 doctor understands what’s going on.

2 Q. But, of course, it existed earlier in the

3 day.

4 A. Yes. It starts at around 12:10, and we

5 know that the doctor has been in to see the patient,

6 that the nurses have communicated with the doctor. So

7 I’m assuming that nothing else has changed. And when

8 you look at the monitor strip, nothing has changed.

9 And when it does change, they do call him.

10 Q. Why, sir, if the terbutaline is causing the

11 fetal tachycardia, why isn’t it a continuous fetal

12 tachycardia from 12:10 until the delivery of this baby?

13 A. I’m not sure I understand the question.

14 Could you repeat it?

15 Q. Sure. Was not the patient receiving

16 terbutaline from 12:10 on?

17 A. Yes. Well, let’s see. Yes. At 11:30

18 terbutaline restarted, and at 4:15 it was stopped. And

19 then sub q terbutaline was given.

20 So in one form or fashion, yes, it was

21 being given. And that would explain –

22 Q. And so if terbutaline is the cause of the

23 fetal tachycardia, why isn’t it constant?

24 A. Oh, babies adapt. It’s a physiological

25 event that I don’t think anybody could really explain

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1 to you or anybody else with satisfaction. We have

2 patients who are on terbutaline that never get fetal

3 tachycardia. And we have patients that have fetal

4 tachycardia, and then the fetal tachycardia goes away.

5 We have patients who have fetal tachycardia and never

6 get rid of their fetal tachycardia. We really don’t

7 have any reason for why babies change their baseline

8 despite being on terbutaline. It may be an adaptive –

9 it may be an adaptive thing that the heart rate adapts

10 to this or the receptor sites are all filled and you

11 get an early tachyphylaxis or downgrading of receptor

12 sites. But that’s a very physiological answer to a

13 clinical situation that doesn’t really portend an

14 ominous outcome or change in therapy.

15 Q. If the reason was the tachycardia went away

16 is because the fetus adapted to the terbutaline, why

17 did the tachycardia recur in this fetus who adapted?

18 A. Well, you’re asking some very interesting

19 questions, and I suggest you join us in research,

20 because we just don’t know. I mean, I wish I knew, but

21 I don’t.

22 Q. Why, sir, when I asked you at the earlier

23 onset of the deposition, with a reasonable degree of

24 medical probability, as to the cause of the

25 tachycardia, you mentioned the core temperature

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1 increase in the fetus but left off terbutaline on that

2 list?

3 A. That was a — an error on my part. It just

4 somehow didn’t enter my brain until all of a sudden I

5 realized that that was an important parameter. And I

6 just failed to mention it and wanted to correct that

7 for this deposition. It was an error on my part.

8 Q. Did you know, sir, at the beginning of this

9 deposition that this mom was on terbutaline?

10 A. Of course. Take a look at my notes. I’ve

11 got it written all over my notes. I just — in

12 speaking and trying to answer — looking at a phone,

13 for some reason or another that bit of information just

14 didn’t reach the right cells in my brain. And I

15 quickly corrected it as soon as I realized that I had

16 left it out.

17 Q. Okay. Prospectively could the nurse

18 determine whether the fetal tachycardia was due to

19 terbutaline or due to infection of the fetus or a

20 raised core temperature of the fetus?

21 A. Not really. I don’t think anybody can

22 really tell that with any real accuracy. Obviously, if

23 the mother’s temperature is normal, that puts it more

24 in the realm of terbutaline being the cause. And if

25 the temperature is elevated, it could be a combination

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1 of the two.

2 Q. Are there any treatments or measures that

3 the physician would do for his patient if he knew that

4 the fetus had a tachycardia due to either infection or

5 due to, say, an increase in core temperature?

6 A. Well, if the health care provider, like

7 Dr. D., knows that there is an amnionitis present,

8 then he obviously has to take a different approach to

9 therapy.

10 But just looking at a fetal heart rate in a

11 patient such as this would not allow him to do that

12 unless he did an amniocentesis to look for white cells

13 and bacteria in the amniotic cavity.

14 Q. Have you ever done such a thing?

15 A. Sure.

16 Q. How would you do — how would you even know

17 to do such a thing on your patient unless you knew your

18 patient had a fetal tachycardia?

19 A. Well, you can have babies that are infected

20 that don’t have fetal tachycardia, so that isn’t the

21 driving force.

22 There are doctors who at 34 weeks might do

23 an amniocentesis to look for signs of infection.

24 That’s not necessarily the standard of care. The

25 standard is to treat the premature labor, give