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You Can’t Handle The Truth

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So many of you have asked and want to know what actually happened that morning in the operating room.  I should have posted this before now because I have left many scratching their heads.  The truth never really was told, but by reviewing the anesthesia records, sitting through depositions, expert opinions, and a five week trial it is obvious what happened and actual error was admitted by the certified registered nurse anesthetist who injected god knows what into my spinal that morning.

This is a tough one for me to write.  Maybe the reason why I have been putting off this post is because I have only written how I felt while going through the experience.  It is so very difficult to write about what they covered up and how they banned together to create the wall of silence and protection for all involved including the hospital.  I was raised to tell the truth and stand up.  I now know it doesn’t work that way for the other side in these situations.  It is truly a you against them war and once the wall of silence has been built by the hospital, insurance company, and defense attorneys it is a war where you are an army of one against what seems like an army of thousands.  You stand holding the water pistol and they hold an arsenal of weapons that could take out an entire country.

It did not take long for experts to pick up the anesthesia record and then meet with me to say that what happened was medical malpractice.  Over the course of three years the facts that the medical records and depositions uncovered pointed to an opinion of medical battery.  The reason for that opinion came from the CRNA’s deposition and if I were not present for that deposition I would have never believed what the CRNA said in that law office that sunny morning.  When I heard the words come out of his mouth I had to immediately get up and leave.  I was in shock and disbelief by his words and the sick reasoning as to why I had to suffocate in that OR for well over an hour.  It was horrifying hearing him describe why he put myself and my unborn son in such a state of peril.

He stated that he knew I was awake, he knew I could not breathe on my own but he thought that my husband and I were so excited about the birth of our baby that he wanted to keep me awake to hear my baby’s first cry.  Unbelievable!  He knew I was being tortured and he made a non-medical decision to not secure my airway and put me under so that I could hear my baby’s first cry!  Well I did hear my baby cry once and then never again in that OR.  I knew he was dead.  How dare he make that kind of decision for me!  The only reason I can think why he said that was to justify what he did to me or the defense team told him that a jury would be sympathetic to it.   It just makes me sick.  I guess they should have a check the box on the consent form that reads: Would you rather be tortured and you and your newborn almost die so you will be able to hear your baby’s first cry or would you rather be intubated and put under to keep you and your baby safe?

The puzzling part is that after my baby was born cyanotic, not breathing, and sent to the NICU why the CRNA would not have then called for help and intubate me if all he wanted was for me to hear my baby’s first cry?  What he did was wrong.  Every healthcare worker in that operating room that had seen hundreds probably thousands of cesareans were wrong for not speaking up and calling for help.  Also in that deposition he admitted to giving me the wrong medication in the spinal.  He said that he did not give Duramorph with the Bupivicaine (that was always my usual cocktail), but it was charted as given on one of the anesthesia records.  The OTHER anesthesia record notes that the Duramorph was wasted.  For the non-clinicians reading this there should not be two different anesthesia records!!!  Please see the anesthesia record in the Hospital Record and the Defendant’s Record that they provided during discovery. He was not sure which injection he gave, but he thinks he MAY HAVE injected Sodium Bicarbonate into the spinal per the Interdisciplinary Patient Notes.  That was the most benign choice off of the pharmacy records he had to choose from when recreating the anesthesia record.  That is my opinion. He had some time to ponder that one per the time he entered his post op note.  He MAY have given me a medication? MAY HAVE?  You either did or didn’t and you sure as heck should know which medication it was that you injected into my spinal. If you were not sure which medication it was then how do you know how much was administered.  After reading my pharmacy discharge summary I can see how he had the opportunity to say that it was Sodium Bicarbonate.  After reading the one or two studies on the subject of Sodium Bicarbonate injected with Bupivicaine for a spinal I can see why.  It is not studied because no does it and I have yet to find one that includes a patient population of parturients.

I reviewed the anesthesia record thousands and thousands of times.  If I did not understand something I studied it as if I were a medical student.  I traveled and studied at the Vanderbilt Medical Library too many times to count.  I read that anesthesia record like I was reading Nietzsche.  I took it word by word,  line by line, and stat by stat.  I relied upon my PharmDs and physicians that I called on to try and decipher what was written if I did not understand it already myself.  I knew if I read it enough that at some point it would somehow unlock a mystery.

I will say that what happened to me was way out of the ordinary.  It was atypical.  It was something that no one in the operating room had ever seen before with the exception of the CRNA at least that is what he told my husband that morning in the OR.  He was very matter of fact about the situation to my husband at the time this was all happening.  The reason I know this is because I was awake and heard everything between my paralyzed screams of course.

Lets begin with how I presented.  Almost immediately after my spinal was administered the circulating nurse grabbed my legs and the CRNA began to turn me so that he could assist me laying back onto the operating room table.  As the CRNA began to lay me back onto the table my husband was escorted in by one of the nurses.  I would say I was at a 115 degree angle when I became frantic.  I said I could not breathe.  The CRNA told me it was anxiety.  Mind you this was my third cesarean section and I know that feeling of anxiety.  I even know what it feels like when the spinal gets a little high. It was a warm sensation traveling up my body at the speed of a freight train.  It is a feeling I will never be able to erase from my memory.  My husband was to my right and the CRNA was to my left.  I began to viciously claw at my neck to try and breathe.  My husband grabbed my right arm, so that I could not claw my neck and I then clawed and dug at his forearm.  The CRNA could not get to me as quick so I managed to claw the left side of my neck pretty good and once he grabbed my arm I then clawed and dug into his forearm.  I could not speak, I could not open my eyes, I could not move.  The terrifying part was the fact that I could not breathe and I could not communicate my horror.  I became completely unresponsive, but I was awake and very aware of my dire circumstances. I immediately went into a hypertensive crisis with my blood pressure being 205/100  .  My pulse rate skyrocketed to 120 and I was sweating.  I was not just sweating, but it was like I had jumped into a pool type of sweat.  Sweat was pouring.  I could feel it only dripping down the very top of my head, but my husband said I was drenched.  I also began to lacrimate.  Tears streaming from my eyes.

After hearing the experts opinions that includes my experts and their experts including the founder and president of the anesthesiology group.  This was an emergency which required immediate intervention/intubation.  Securing my airway should have been priority number one for my safety and my unborn child.  It has been described as a high spinal, but many nave concluded it was a total spinal.

I was a pregnant, unresponsive patient unable to breathe on her own.  I was at serious risk of aspirating and/or having a stroke.  What is normal about this situation?  The anesthesiologist claims he was in the room at the time the spinal was given and assisted laying back onto the OR table.  He claims that he saw that I was stable and then left.  That was the anesthesiology groups policy for him to do so.  That man was no where in that operating room at any time that the spinal was given or during the almost hour that I was manually bagged with room air.

My son was delivered cyanotic and not breathing.  I heard him cry once and then never again while in that operating room.  I knew he was dead.  I screamed! I sobbed!  I cussed!  I was at the point of knowing we were leaving this world forever.  I just wanted to see and kiss my baby.  I wanted to kiss, squeeze and hug my husband, two daughters, mom, dad and brother.  I wanted to tell them how much I truly loved them and all the things you never say until you know that you are going to die.  I was being terrorized, but at the same time grieving and screaming for the loss of my family and that I would never lay my eyes or lips on again.

I heard my ob-gyn announce that he was performing the tubal ligation and I screamed for him not to do it and to save me, but he proceeded.  He completed the tubal and exited the operating room.  The man who delivered my first two children. The man who just delivered my third child.  The man who looked me in the eyes after this happened and told me he was scared out of his mind and did not think I was going to make it that morning in the OR left me.  He left me unresponsive and not breathing wide open on an operating room table with a room full of nurses, scrub tech, surgical tech and my husband.  He did stay to dictate his Operative Report (which is quite a piece of work itself), but left to go see patients at his office.  He abandoned me.  The only reason that I can come up with why he left me is that he knew I  was dying and wanted me to pass away postpartum rather than with him in the OR.  There is just no other way to explain why he did what he did.  I would really like to believe otherwise, because he was my friend.

The CRNA claims that he asked for the circulating nurse to call the anesthesiologist about 5 minutes after the spinal was given for help, but conveniently the anesthesiologist never received the page.  If he did request the call which I doubt he did,  why did he not ask her to call again and again and again over the course of that hour?  It took the circulating nurse calling her nurse supervisor to report my situation before the anesthesiologist arrived to assist.  He stated in his deposition that the only reason he came back to see me was not because of a page or call, but he figured that the surgery was complete and I was already in the recovery room and he wanted to check on me.  He wanted to come and see me in recovery room because I was such a lovely and delightful patient that he felt the desire to come and see me in the recovery room.  Very thoughtful on the anesthesiologists part, but this was my third cesarean section and I had been under general anesthesia several times before for minor surgeries and I have NEVER had an anesthesiologist nor CRNA EVER come and follow-up with me after the procedure.  He did not find me in the recovery room, so the his next ‘logical’ place to look was in the operating room and not ask a nurse if I had been sent to my room?  I am sorry that was one of the most laughable cover ups that came out of the entire discovery process.  He did not realize that my in-laws saw him sprinting down the hallway toward the operating rooms.  He was pretty eager to see me!  I must have just one of ‘those’ personalities that sends doctors sprinting to see me in recovery to chit-chat.

The anesthesiologist came into the OR and asked where the chart was from the CRNA.  The CRNA then stated that he had not had time to fill out the anesthesia record, because he had his hands full with me.  The anesthesiologist then turned his attention to me.  He began slapping my face.  I do not think he was slapping me hard.  I could not feel the slaps, because I was paralyzed but I could hear them.  He kept telling me to wake up.  I was screaming that I was not asleep and he was not bagging me at that time.  I was suffocating to death!

After trying to wake me unsuccessfully he asked my husband to leave, so they could try and help me.  My husband left and at this point I was hysterically crying for him not to leave me to die alone.  I was slipping into that big black hole of nothingness.  My husband was gone.  I heard someone say “What do we do?” and I thought this is it I am going to die.

I was then intubated.  I could not feel it, because of the paralyzation but they did not give any amnestic.  As logically as I could think at that moment I knew I was intubated and supposed to be receiving oxygen, but when you are paralyzed and your respiratory system is paralyzed you feel like you are suffocating.  The sensation is still there.  I felt or didn’t feel the sensation of a stick being in my throat as I suffocated to death as everyone watched.  I screamed internally for help.  I screamed for them to not let me die.  One of the females in the room said why does this always have to happen to the nice ones.  In my mind that comment was my death sentence.

I tried with all my might to move or to signal to them that I was awake.  Believe it or not it is very hard to hear when you are screaming inside your own head.  From that point on all I heard were beeps, clicks, ticks, and air.  I tried with all of my might to move for what seemed to be hours.  It was not that long and I will never know how long I was in that state.  I finally felt as if I were spitting from my mouth and thrashing my head from side to side at least that was what I was trying to do.  I obviously did something to get their attention, because I heard someone say “Oh my God she is awake!” and poof I woke up in the recovery room hysterical.

I was told by the anesthesiologist the next day that I had a high spinal.  The only way I remember this is because of reading it in my hospital record.  I do not remember, because they had me on morphine.  He was extremely nervous and came in to see me at least 2 times a day for my entire 5 day stay.  His associates would also pop their heads in and look at me in my room announcing themselves as an anesthesiologist with the group.  I was like the three-headed lion at the side show.  Everyone just stared at me.  I was in a state of shock, so I did not put two and two together at the time.  I was getting way too much attention.  It took weeks for me to see that what happened in that OR was a screw up.  A BIG screw up!

I was told in recovery that I was given Narcan, so that they could wake me up.  They told me that is why I was in so much pain, because the Duramorph was no longer in my system.  They needed to get the medicine out of my system, but that is no where within the chart.  The Duramorph is noted as wasted in the hospital’s copy of the anesthesia record.  Why give me Narcan if I did not receive Duramorph?

Like I stated earlier, I will never know the truth about what happened that day.  Maybe I cannot handle the truth and neither can you. I can promise you this!  My mission is to help patients understand how important it is to be in control and know what is going on with their medical care.  Ask questions? Study up before the procedure and quiz those that will be involved in caring for you.  They work for you!  You are paying them!  You have rights and you are KNOT just a patient.



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