For the week of May 25, 1999  thru June 1, 1999  

WRMC nurses concede mistakes in care of mother and unborn child

No one noticed baby in trouble until too late

In first week of malpractice case, experts fault care given by nurses and doctors.


By GREG MOORE
Express Staff Writer

There’s no question: Tragic mistakes were made on the night of Aug. 16, 1995, which Sandy Kirkland spent at the Wood River Medical Center in Hailey, carrying a fetus that was slowly losing half its blood. Her baby, Bryce, was delivered through emergency cesarean section the following day with severe brain damage.

The questions now being debated in a civil trial in federal court in Boise are: Who made those mistakes and how much are they worth?

Part of the first question was answered last week when a spokesperson for the hospital acknowledged that nurses there should have reported a disturbing graph unscrolling from a machine measuring fetal heart rate.

That graph clearly showed the baby inside Sandy Kirkland’s uterus was in trouble. But no one noticed its warning for 12 hours.

By then, the damage was done.

Sandy and her husband, Quinn, are suing the medical center; its owners, Blaine County and the city of Sun Valley, as well as Dr. Ross Donald and Dr. Randall Coriell.

The plaintiffs’ economic losses alone, they claim, will amount to as much as $6 million. That and any additional award for pain and suffering will be decided by an eight-woman jury.

Unlike most civil cases, which pit a plaintiff against a defendant, this trial features a triangle of adversity. The plaintiffs are in one corner. Dr. Donald and the hospital, who are insured by the same insurance company, are in a second corner; and Dr. Coriell is in a third corner.

That means that each witness has to endure cross-examination from two attorneys. The plaintiffs’ attorneys often watch while the two defendant entities cast blame on each other.

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According to court documents and testimony, Sandy was admitted to the medical center Aug. 12 due to possible premature labor. She was 34 weeks pregnant.

Dr. Coriell, a family practice doctor acting as her physician, directed that she be given drugs to control her contractions.

However, the drugs had painful side effects and Sandy requested that they be discontinued.

Before the drugs were to be withdrawn, though, Dr. Coriell wanted to make sure that the baby’s lungs were developed to the point that the baby could survive a premature birth.

To that end, he directed that Sandy undergo an amniocentesis—a process by which amniotic fluid is withdrawn from the uterus through a syringe and analyzed.

Dr. Coriell sent Sandy to Dr. Donald, an obstetrician at the hospital’s Sun Valley campus, for the procedure. Dr. Donald determined that due to the baby’s position, he would need to insert the syringe needle through the placenta.

During the amniocentesis, a fetal blood vessel in the placenta was punctured, a fact that has not been disputed in the case to date.

Dr. Michael Heymann, a fetal physiologist at the University of California in San Francisco called by the plaintiffs as an expert witness, told jurors there’s no doubt that the damage to Bryce’s brain was caused by a hemorrhage that began during the amniocentesis.

But Bryce could have been delivered in time to prevent damage, Heymann said. Why he wasn’t depends on who’s telling the story.

According to one of the plaintiffs’ attorneys, Joel Cunningham, Sandy testified in a deposition that Dr. Donald told her nothing about the risks of performing an amniocentesis. Dr. Donald testified in a videotaped deposition shown to the jury that he "explained to this couple very carefully what can happen in an amniocentesis."

According to Cunningham, Quinn testified in his deposition that he saw a syringe full of blood withdrawn from Sandy’s uterus. But Dr. Coriell testified that Dr. Donald told him in a phone call after Sandy had returned to the hospital’s Hailey campus that he had drawn only a small amount of "skin blood." Dr. Coriell also said he asked Dr. Donald whether he had to go through the placenta to tap into the amniotic fluid. Dr. Donald told him, "No," Dr. Coriell said; Dr. Donald said he did not recall Dr. Coriell asking him any such question.

In a fax Dr. Donald sent to the Hailey hospital campus a few hours after the amniocentesis, and read there by Dr. Coriell and the nurses on duty, Dr. Donald described the procedure as "uneventful."

But Dr. Steven Clark, a professor at the University of Utah School of Medicine who specializes in maternal-fetal medicine and who was called as an expert witness by the plaintiffs, told jurors that no amniocentesis that requires inserting the needle through the placenta should be described as "uneventful."

"The final thing, which was a definite violation in the standard of care, was performing the amniocentesis in the first place," Clark testified. "(Dr. Donald) had no right going through the placenta in this case because the risks outweighed the benefits."

Clark also faulted Dr. Donald for allowing Sandy to return to Hailey immediately after the procedure.

Instead, Clark said, she should have been monitored at the Sun Valley campus for at least an hour. He pointed out that that was particularly the case since Dr. Donald had stated he did not believe the nurses at the Hailey facility had been adequately trained to read fetal heart monitoring strips.

Other than in his videotaped deposition, Dr. Donald has not testified and has yet to present his side of the story.

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Dr. Coriell told jurors that just after Sandy had returned to the Hailey campus about 4 p.m. and been placed back on the fetal heart monitor, he visited her in her room. But, according to Cunningham, Quinn and Sandy placed him there at closer to 6 p.m.

Dr. Coriell said Dr. Donald also told him during their phone call, which Dr. Coriell said he made about 4:15 p.m. right after seeing Sandy, that he wouldn’t have the lab results on the amniotic fluid until the next day. In the videotaped deposition, Dr. Donald said that he didn’t learn that fact until 6 p.m. and so couldn’t have talked to Dr. Coriell until then.

The timing is significant: If Dr. Coriell didn’t see Sandy until after 6 p.m., the monitor would have been recording for at least two hours at the time of his visit, enabling him to note its warning.

The monitoring machine records the baby’s heart rate at frequent intervals.

Contrary to lay logic, a healthy fetal heartbeat is constantly speeding up and slowing down, witnesses ackowledged. Thus, the monitor’s graph should show many peaks and valleys, indicating good "variability"; when it shows a straight line, the baby may be in trouble.

Joan Anderson, a nurse on duty Aug. 16 from 4 p.m. to 11:30 p.m., said she talked to Dr. Donald on the phone about 7 p.m., and that he told her nothing about a risky amniocentesis.

The strip monitoring Bryce’s heart rate showed some flattening as soon as Sandy was hooked up to it at 4 p.m., and became even flatter after about 6 p.m.

Anderson acknowledged in testimony that she did not adequately monitor the strip during that time and did not tell Dr. Coriell of any problems. She said she assumed he had already reviewed the strips.

Leslie Chapman, a nurse who was on the night shift between Aug. 16 and 17, testified that she had not been informed that Dr. Donald had needed to go through Sandy’s placenta to tap the fluid, and was not alerted of the need to be especially watchful.

Chapman said she turned off the monitoring machine at 12:30 a.m. to let Sandy sleep. She said she was acting in response to a verbal order from Dr. Coriell to monitor only for half an hour every two hours, rather than continuously, as long as Sandy’s contractions hadn’t worsened.

Chapman said she did not look closely at the monitoring strips because she had no reason to believe the fetus may be in trouble; she was primarily concerned about Sandy’s premature labor and focused on monitoring her contractions, she said.

"If you could go back in time, you would do things differently, wouldn’t you?" plaintiffs’ attorney Paul Luvera asked Chapman.

"Oh, yes, definitely," Chapman responded. "I did miss it. I’m sorry I missed it."

Cunningham questioned Debbie McCoy, Wood River Medical Center director of clinical services who spoke for the hospital.

Cunningham asked if it were true that that the hospital is not contesting liability about actions taken by the nursing staff after Sandy was placed on the fetal heart monitor.

McCoy said, "We concede there was a duty to notify a physician."

Chapman said she turned the monitoring machine back on at 3:30 a.m. At 4:30 a.m., she said, she called Dr. Coriell and told him that the strip was showing "no long-term variability" and added that Sandy had reported that she hadn’t felt the baby move since before the amniocentesis. She said Dr. Coriell told her to follow certain procedures to prompt more fetal activity and to call him in an hour if things hadn’t changed.

Dr. Coriell testified that Chapman told him only of a "decrease" in variability and fetal movement. Cunningham pointed out that a nurse’s note written at 4:30 a.m. reported "no variability."

In any case, an hour later nothing had improved and Chapman called Dr. Coriell again. He said he would come in immediately. When he did, an emergency C-section was performed and Bryce was delivered.

By that time, Bryce had lost about half his blood, and brain damage, caused by a lack of oxygen delivered to the brain, was irreversible.

According to Heymann, Bryce probably could have been delivered as a premature but otherwise normal baby if the C-section had been performed hours earlier by 10 to 12 p.m.

Kim Ingram, a registered nurse who specializes in obstetrics was called as an expert witness by the plaintiffs. She told jurors that the nurses’ care of Sandy amounted to "an extreme deviation from the standard of care."

Clark told jurors that after reading depositions by all the parties involved, he had concluded that violations in the standard of care had been committed by Dr. Donald, Dr. Coriell and the nurses.

However, he acknowledged that the extent of each of those violations depends on whose story is true.

According to one of the attorneys at the trial, it has not yet been determined how specifically liability must be pinpointed upon each defendant. The plaintiffs’ attorneys have asked witnesses several questions about the "team" concept of medical practice in an apparent attempt to persuade the jury that all the defendants should be held culpable if negligence is proved.

The plaintiffs are scheduled to wrap up their presentation by tomorrow. The trial is expected to last until mid June.

Since Bryce’s delivery, all obstetric care at Wood River Medical Center has been consolidated at the Sun Valley campus.

Hospital administrators deferred until after the trial all questions about whether that change had anything to do with the Kirkland incident or about whether additional changes had been made.

 

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