posted by admin on Mar 10
71
1 the heart rate in a normal pattern. So as they’re
2 searching and trying to get this baby to either lie
3 still or to find the heart in a more consistent manner,
4 they are continuously being updated with heart rates as
5 they’re searching. They may not be able to print it
6 out in a continuous fashion, but I think that they are
7 assuming that there is no bradycardia going on here and
8 that they can continue with that particular process.
9 Q. Now, what allows them to assume that, sir,
10 if when one looks at these fetal monitor strips just
11 like you see these patterns of 120s there’s also rates
12 down to 90 or below or even to 200 or above.
13 A. Well, as long as the nurses are hearing for
14 a period of time rates in the 120 — 110 to 160 range,
15 which is what they’re doing, they’re not obviously
16 hearing the rate sustained for a period of time at the
17 200 level or the 190 level. The machine sometimes will
18 go up and down based on a doubling or halving of heart
19 rate patterns.
20 And clearly at, say, 10:20 — I’m sorry –
21 12:20, you’re right, there are some markers there at
22 180, and there are some markers down there at 70 beats
23 per minute. So one can’t be sure whether the heart
24 rate is being doubled or halved or what’s going on. So
25 there’s a continued time where the nurses are looking
72
1 for this fetal heart rate, which they find somewhere
2 around twelve — it looks like about 12:28.
3 Q. Is there any harm, sir, during this half an
4 hour of the nurses searching for an accurate fetal
5 heart rate to calling Dr. D. and notifying him?
6 A. Well, of course not. And there was no harm
7 in not doing it, because we know when we look at the
8 tracing after 12:30 that there’s moderate variability,
9 some accelerations present. And whatever was going on
10 during that time when the doctor was not being notified
11 was nothing to cause this fetus any harm.
12 Q. Sir, have you heard of cord compression
13 being partial and some — and then total or partial and
14 then recovering and then partial again?
15 A. Well, first of all, no one really knows
16 whether cord compression is total or partial. Unless
17 you put a clamp on the cord, you don’t know that. You
18 can assume if the heart rate is 60 for 15, 20 minutes
19 and dropping down below 60 to 30, that it’s more than
20 likely more complete and total than it is partial. But
21 you never know that while you’re monitoring a fetus.
22 If you understand the pathophysiology of cord
23 compression, then you have to understand that there’s
24 no way to be certain whether it’s partial or complete.
25 But, of course, cord compression is a very
73
1 common phenomenon in a laboring patient. In this
2 particular patient we have no labor. So if the cord is
3 being compressed, it’s being compressed because the
4 fetus is doing it him or herself. In this case I
5 believe it’s — (pause)
6 Q. Do you want to know if it’s a boy or a
7 girl? Is that what you’re looking for?
8 A. Yeah, yeah. I lost my — it’s a boy –
9 sorry — him.
10 So we don’t really know whether any of this
11 is cord compression. I think more than likely it is
12 not, because she’s not in labor. We really haven’t
13 seen any cord compression.
14 I don’t know what’s going on here, quite
15 F.ly. I’m looking at a heart rate. I’m not looking
16 at any specific patterns. So I don’t know how anybody
17 could look at this and come up with an, “I know exactly
18 what’s happening” phenomenon here.
19 Q. Sir, again, if you don’t know what’s going
20 on; you wouldn’t expect a nurse for this half hour to
21 know what’s going on. Why wouldn’t you expect her to
22 at least call the physician pursuant to standards of
23 care, and maybe he can help her out as to what’s going
24 on?
25 A. Well, I don’t have a problem with that –
74
1 if they wanted to call Dr. D..
2 But as I interpret what the nurses are
3 doing during this time — and they certainly write
4 notes to give on an almost minute-by-minute basis to
5 explain what they’re doing — they’re turning the
6 patient. They’re trying to position to find a heart
7 rate that they had been having for hours and hours
8 prior to that. And I don’t find that this is a
9 violation of the standard of care that for 28 minutes
10 or 25 minutes they do that on a continuous basis until
11 they establish a pattern that is more recognizable.
12 Because, (a), they’re listening to the baby
13 periodically and, (b) — very importantly — there’s no
14 link to causation. Because once they get the heart
15 rate, it shows no evidence of fetal deterioration or
16 hypoxia.
17 So I don’t — I don’t have any criticism
18 for the nurses in how they’ve handled this patient. It
19 seems to me they’re doing a rather normal job of
20 following this patient in the middle of the night, who
21 is on terbutaline and who they’re trying to establish a
22 continuous heart rate pattern. But they’re not
23 expecting any nefarious event to be occurring.
24 Q. Sir, prospectively at midnight would the
25 nurses, while they’re trying to work this transducer,
75
1 know they would get the heart rate pattern back at
2 12:30 approximately?
3 A. I don’t think they know anything. They’re
4 just — they’re acting to try to reestablish a normal
5 baseline rate on a piece of paper. I assume that they
6 think they’re going to, because periodically they get a
7 rate.
8 If you look at 12:10 and up to 12:20, it
9 seems to me that any minute they’re gonna get it. And
10 then at 12:20 there’s a period of about another ten
11 minutes where — or six minutes, rather, it’s a little
12 bit more difficult. And then all of a sudden they get
13 it at about 12:28.
14 Q. Sir, if prospectively the nurses don’t know
15 when they’re gonna get back a stable heart rate pattern
16 again, why doesn’t the standard of care require them to
17 call the doctor in the interim?
18 A. Well, every time you have a patient who
19 you’re doing continuous monitoring on who is not in
20 labor and you’re having trouble establishing baseline
21 because of technical things, if they call the doctor
22 every time, that would create a real problem throughout
23 this country.
24 I mean, you don’t understand how often this
25 happens where nurses have a patient on the monitor –
76
1 she’s been on it since 6:30 in the evening of the 6th
2 of September. It is now, what, 36 hours later — or
3 whatever the number of hours is. She has had
4 continuous fetal monitoring. She’s had a change in
5 baseline many times. There have been occasional areas
6 of dropoff where they were unable to find the fetal
7 heart rate and they’ve had to reposition the patient.
8 I don’t see this as anything so unusual. I
9 know that in this case you’re alluding to the fact that
10 this is some terrible violation of the standard of
11 care. I just don’t see it that way.
12 Q. During any of the prior day and half where
13 she had continuous monitoring, sir, was there ever an
14 extended period of time at this time where the nurses
15 needed to get the fetal heart rate and supposedly there
16 was a transducer problem?
17 A. Well, I think it’s always been that. Even
18 this particular case here it was a transducer problem.
19 Because we finally get a rate that looks pretty normal
20 at 12:30, so nothing happened.
21 Q. How do you know it wasn’t a cord
22 compression that was not compressed any longer?
23 A. Well, it could have been.
24 Q. The fetus moved, for example.
25 A. It could have been, but no harm came of it.
77
1 That’s –
2 Q. That’s a separate question.
3 A. Well, it’s not to me, because I admit that
4 it could be cord compression, but it wasn’t sufficient
5 to cause any problems. I don’t think I’d put that high
6 on my list of etiologies.
7 I mean, why all of a sudden is there a cord
8 compression? The patient is not in labor. She doesn’t
9 have ruptured membranes. The fetus has not shown any
10 elements of any significant variable decelerations.
11 There have been some mild ones occasionally, but
12 nothing to support anything more dramatic than that.
13 So why would the nurse think that all of a
14 sudden we have a terrible cord compression and the
15 doctor needs to be notified to come in and hurry up and
16 do a cesarean section?
17 Q. Even if the nurse doesn’t think cord
18 compression, why wouldn’t she call the doctor because
19 she doesn’t know what to think is going on?
20 A. Well, I think she thinks that it’s a
21 transducer problem, and if she works long enough and
22 hard enough she’ll recapture the heart rate, which is
23 what she does.
24 Q. Why during this half an hour was there
25 essentially a half-hour transducer problem and during
78
1 the day and a half prior we never had a half hour of
2 alleged transducer problems?
3 A. I don’t know.
4 Q. Sir, you told me that since there was a
5 heart rate of 120 during certain points in time during
6 this half hour that it was okay to continue trying to
7 adjust the transducer. Would you agree with me if the
8 heart rate, say, was 60 and went up to 180 or was 180
9 and went back down to 60 at some point in time it’s
10 gonna pass through 120?
11 A. I have no idea what you’re talking about.
12 What do you mean “pass through”?
13 Q. Well, as you look at a fetal monitor, sir,
14 whenever you see the stylus and the heart rate is 60 at
15 one point in time and the next point in time it’s 180
16 and the stylus connects the dots, will you not pass
17 through the number “120″ at some point in time?
18 A. Oh, just as a pass-through, of course. But
19 if the machine is doubling, 60 doubled is 120, not 180.
20 And half of 180 is not 60; it’s 90.
21 So I don’t really know what’s going on
22 here. The monitor is searching for the heart, and the
23 baby has moved away. That would be the most likely
24 explanation, because I don’t see any harm that’s come.
25 I don’t — I see the monitor searching for a rate. It
79
1 finally finds it at twelve — it looks like about
2 12:28. And prior to that there were episodes, around
3 12:10, for example, for about five or six minutes where
4 there’s the appearance of a heart rate of around 120
5 beats per minute. So I don’t know what’s going on
6 here.
7 Q. Sir, you did mention that about 12:30 there
8 was a heart rate reestablished. And you also mentioned
9 something about doubling. How do you know the heart
10 rate that was reestablished was not doubled?
11 A. It doesn’t appear that way. The monitors
12 have built-in mechanisms to really avoid putting a rate
13 of 120 when it’s really 60. They’re much more
14 sensitive.
15 The doubling and halving that I’ve taught
16 about or worked with have been in patients in the older
17 monitors. The new computer technology with
18 autocorrelation really avoids that most of the time.
19 And so I really don’t think we have doubling or halving
20 of heart rates here.
21 What we had at the — when you saw prior to
22 that — at 12:20, when you saw a rate of 70 or a rate
23 of 120, I think the machine is just searching for the
24 heart and not finding it. That’s all I think is going
25 on here. I don’t think there’s a doubling or a halving
80
1 going on.
2 Q. Okay. So in your opinion, on this tracing,
3 until the baby delivered, the monitor did not appear to
4 be doubling; is that correct?
5 A. That’s my opinion, yes.
6 Q. So what type of monitor was used in this
7 case, sir?
8 A. It appears — the paper says “Corometrics
9 Medical Systems,” so I assume that it was a Corometrics
10 machine.
11 Q. And how old was the machine?
12 A. I’m not sure. But it certainly is old
13 enough — or new enough to have autocorrelation on it.
14 The tracing itself looks very much like the type using
15 the new autocorrelation. And to my knowledge, the
16 older machines are all gone.
17 Q. When were the older machines gone, to your
18 knowledge?
19 A. Gone from labor and delivery? I wrote an
20 article on autocorrelation as late as 1984 — ‘86, so
21 certainly by ten years later all of those machines
22 would be gone by then. So autocorrelation came into
23 being in the mid-’80s, and by the early ’90s I would
24 think most, if not all, of the fetal monitors that were
25 not using the new autocorrelation technology were gone.
Leave a Reply
You must be logged in to post a comment.