law rights & civil resource

posted by admin on Feb 10

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1 Q. Well, is there some way you can look at the

2 fetal monitor strip and tell whether or not it’s

3 doubling?

4 A. Not in this case I can’t.

5 Q. Okay.

6 A. I mean, I don’t see any evidence that it’s

7 doubling.

8 Q. Do you see any evidence that it’s not

9 doubling? Or you don’t know one way or the other?

10 A. In my opinion — it is my opinion, based on

11 a reasonable medical probability, having been reviewing

12 tracings and studying fetal monitors for all of my

13 academic life, that there is no halving or doubling of

14 the fetal heart rate in this particular case. And I do

15 that by observations of the tracings, experience, and

16 background. But I don’t know of any other way to say

17 that. Anything is possible, but I go to a medical

18 reasonable probability, and that’s, I think, all I’m

19 required to state to you or anybody else.

20 Q. What’s the basis of your opinion on the

21 monitor, say, even between 12:00 and 12:30 or 12:40

22 that there’s no doubling?

23 A. Well, you’re — well, first of all, look at

24 it yourself. Doubling would be from 60 to 120.

25 Halving would be 120 to 60. Where do you find any data

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1 on that fetal monitor strip that would indicate that?

2 You don’t.

3 Q. Would it be more accurate to say that the

4 folks present at the time would have better data on any

5 of this fetal monitor strip to determine whether

6 something was doubling or halving, rather than you

7 looking at the records years later?

8 A. Well, they’re looking at the same tracing

9 I’m looking at. Unless they had an ultrasound machine

10 that would look at the heart rate and compare it to

11 what’s going on to the fetal heart rate pattern that’s

12 coming out on the monitor paper, I don’t see how they

13 could tell.

14 Q. How about by listening? Can one listen to

15 a fetal heart rate monitor and determine whether it’s

16 doubling or halving?

17 A. If you’re listening and it’s — you’re

18 listening and you hear 60 and the paper is registering

19 120, that would be evidence that there’s doubling.

20 And, conversely, if you had 120 and you

21 were listening and you heard consistently 60, that

22 would be consistent with halving.

23 I’m just not convinced that any of that was

24 present here.

25 Q. Okay. Well, do you know what was heard by

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1 Nurse Martin or any of the other nurses taking care of

2 this patient at the time?

3 A. Only what they wrote in their nursing

4 notes.

5 Q. Would it be fair to say that they

6 accurately wrote in their nursing notes what they

7 heard, what they saw, what it appeared to be to them?

8 A. Absolutely.

9 Q. Okay. Let’s continue reading the fetal

10 monitor strips, if we could, until the end.

11 (Recess taken.)

12 BY MR. GERSHON:

13 Q. Okay, Doctor, if we can just continue

14 reading these strips until the end, I think we’re at

15 about 12:30.

16 A. Right. Well, from here, 12:30 through

17 12:42, we have what appears to be a rate of about 120

18 with accelerations, moderate variability. And whatever

19 has been going on prior to that, this particular area

20 of the tracing makes me believe that clinically this

21 baby is still not demonstrating any signs of fetal

22 hypoxia. And I say that because of rate and

23 variability and accelerations.

24 The heart rate looks like it once again is

25 lost there at about 12:42-ish. And I notice that

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1 there’s an exam that occurs after the monitor belt has

2 been adjusted, and Dr. D. is called it looks like

3 about probably somewhere around 12:43 to 12:45.

4 So following that, there is a monitor strip

5 of about four minutes with a rate of 150 and minimal

6 variability. I can’t say much about that strip other

7 than it just demonstrates a rate of about 150. There’s

8 nothing reassuring about it, and there’s nothing

9 ominous about it. It doesn’t have the moderate

10 variability that we had been seeing up to 12:42. And I

11 can’t explain — I can’t explain that at all.

12 And then you’ve got Dr. D. called at

13 12:50-ish, and then knee chest — patient is turned to

14 the right side. Maternal pulse is 100. They’re again

15 searching for the fetal heart rate, and again they

16 finally pick it up at — let’s see what time it is.

17 I’m not sure what time it is, but it’s right before

18 95169. And once again the rate appears to be 120 beats

19 per minute with moderate variability. It’s different

20 from the maternal pulse. The mother wrote — I mean,

21 the nurse wrote — writes on the paper “pulse 64,” and

22 the rate seems to be dropping slowly to 110.

23 And then by the time Dr. D. gets there,

24 the monitor strip looks as if the rate is 170, and he

25 does an exam, calls for a cesarean section, and we have

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1 some evidence of a rate of 120 at about 1:18 and

2 1:19 a.m. And then again just coming off the monitor

3 at 1:28 we have about a two-minute interval where there

4 is a heart rate of about 120 with what appears to be,

5 oh, minimal to moderate variability. It’s hard to be

6 sure, because we’re only looking at two minutes.

7 And then she’s taken over and undergoes a

8 cesarean section with delivery at 1:46 a.m.

9 Q. Now, looking at the last fetal monitor

10 strip we have, how would you describe that two minutes?

11 A. Like I said, it looked — it’s hard to tell

12 much with two minutes, but the rate is certainly not in

13 the bradycardic range; it’s a hundred and — about 120

14 beats per minute. I can’t tell if that’s moderate

15 variability or a mild cord compression. I just don’t

16 know what that is. But it is reassuring in that the

17 rate is 120.

18 Q. Well, if it’s so reassuring, why was she

19 taken over for a C-section?

20 A. Well, I think Dr. D. was convinced –

21 reading his note — that there was an element of fetal

22 heart rate instability. I mean, they’ve gone through

23 several of these patterns where they’ve lost the heart

24 rate and searched for it and then finally found it.

25 There’s been tachycardia. We’ve got a long way to go

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1 with this lady. I think that he was trying to be

2 cautious and deliver this child at this time when it

3 appeared that it had made it through whatever had been

4 going on since about twelve midnight.

5 Q. But it sounds like, from what you’re

6 telling me, because again you think the fetal heart

7 rate is fine, that there is no need for an emergency

8 C-section now.

9 A. Well, I think — I think if continuous

10 fetal monitoring could have occurred — in other words,

11 he would have had to rupture the membranes and put an

12 electrode on this baby’s scalp, which would, of course,

13 put her into labor and she would have delivered anyway,

14 there was really no way for him to continue assessing.

15 And I think he used as risk-benefit ratio

16 indicating that she’s 34 weeks — most 34-week babies

17 do very well. He had given her — he had given — he

18 had made an attempt to stop her labor with terbutaline;

19 that had not worked to his satisfaction. He had given

20 steroids that had been on board for a little while,

21 which may have done some good.

22 And I think the decision to go ahead at

23 this time was absolutely appropriate. He could have

24 done it earlier and still been appropriate, and he

25 could have done it later, had he been able to reassure

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1 himself that this fetus was not having any

2 decelerations of any significance. But since that was

3 becoming more and more problematic since midnight and

4 now it was already 70 minutes later, I think he made a

5 wise decision to deliver by cesarean section.

6 Q. Then from what you’re telling me, it did

7 not need to be an emergency section; correct?

8 A. Unless he’s got a bradycardia or evidence

9 of fetal distress, which would be absent variability

10 with repetitive lates or variable deceleration, that’s

11 exactly correct. But all I’ve got here is a couple of

12 minutes, and prior to that I have no information. And

13 prior to that I have a little bit of information, and I

14 think he was — I mean, the last normal strip we have

15 looks to be about one — let me see what time this is.

16 When Dr. D. gets there at 1:10, he has

17 a tracing after that for a few minutes which I

18 mentioned which looked pretty normal. So there’s

19 really no rush. There’s no absolute emergency. But

20 following that, the heart rate is difficult to pick up,

21 and I think his decision was let’s go ahead and do this

22 to avoid any problems down the road. I think he

23 probably was very surprised with this finding of an

24 APGAR of 0 and 1.

25 Q. Sir, the bottom line is, with reasonable

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1 medical probability, in your opinion it did not need to

2 be an emergency C-section; correct?

3 A. Well, it depends what you mean by the word

4 “emergency.” Did they have to start the case from

5 incision to decision within thirty minutes? Well, I

6 think that I would have liked to have seen a little bit

7 more information to absolutely assure myself that speed

8 wasn’t important. Being the fact that it was — that

9 they were there, that there was no reason to wait some

10 obligatory time just because of the option of being

11 able to do so, I think they needed to do it as soon as

12 possible, which is what they did.

13 As far as the classic real emergency,

14 looking at that last minute — couple of minutes of

15 tracing of 120, I don’t think it was an absolute

16 classic emergency. But I think they needed to do it as

17 rapidly as possible.

18 Q. Okay. Sir, do you have an explanation in

19 panel 13667, with a reasonable degree of medical

20 probability, as to why the variabilities decreased?

21 A. No.

22 Q. Do you have an opinion, with a reasonable

23 degree of medical probability, why in panel 13666 they

24 tried putting the patient on her side and giving her

25 oxygen by mask?

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1 A. Well, I think that they were under the

2 impression that the heart rate was dropping, as you can

3 see prior to that. As the heart rate goes from 120,

4 there’s sort of a downward trend look. And I think

5 they were concerned that maybe they were dealing with a

6 deceleration, because they examined the patient on her

7 back and then turned her to her side, gave her oxygen,

8 and called Dr. D..

9 I think that there was, you know, a –

10 frequently nurses can handle one or two of these

11 episodes, but after a while they become — they get to

12 the point where they feel like they definitely need

13 physician input, and I think that’s what happened here.

14 To be cautious, they turned her to her side and gave

15 her oxygen.

16 Q. What about during the half hour between

17 midnight and 12:30? With a reasonable degree of

18 medical probability, why do you feel that the nurses

19 didn’t give oxygen or put the patient on her side then?

20 A. Well, I can only assume that they didn’t –

21 they didn’t think that it reached the level of need. I

22 mean, otherwise it’s so easy for nurses to do that.

23 It’s not like it’s something difficult or

24 time-consuming or any of those kind of things.

25 Q. You don’t think they violated the standard

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1 of care by not giving the patient oxygen for that half

2 hour between midnight and 12:30?

3 A. No, I don’t.

4 Q. Well, what was it about the fetal

5 monitoring strips as you see them in panel 13666 that

6 required oxygen for this patient?

7 A. Well, I’m not sure that I feel like it was

8 absolutely required.

9 You know, there’s a lot been made about

10 this oxygen, and it’s a lot of exaggeration. There has

11 only been a few studies that have looked at PO2s of

12 babies whose mothers were given oxygen and compared

13 before and after maternal oxygen. And, in fact, you

14 raise the PO2 of the baby very slightly.

15 You can take the mother’s PO2 and take it

16 over 200 and you’re not gonna really change the fetal

17 PO2 much. It’s very much like the fetus and Mount

18 Everest theory that gets described in your major

19 pathophysiology textbooks on the fetus.

20 So I think we do it because it’s a little

21 like chicken noodle soup; it can’t hurt. But I’ve

22 never been impressed that it really does anything in

23 those instances where you have significant fetal stress

24 or distress problems. So the –

25 Q. Do you still give oxygen?