I got a call around 3 a.m. that I should come to the hospital because she was fully dilated and would start pushing. When I got there, she pushed for several more hours and finally opted for a C-section. Her sister, Lauren, who's a pediatrician, went into the OR with Jennifer.
About 20 minutes later, I saw a medical team running past me in the hall. Lauren came out crying, saying the team was doing CPR on the baby. I went into the OR and saw the team, consisting of a neonatology fellow, a nurse practitioner, a nurse,and a medical resident, doing chest compressions on the baby. They couldn't detect a heart rate.
I asked the fellow if he was sure the endotracheal tube was properly placed, and he said he was. I wasn't seeing any chest rise. I've been resuscitating babies for 29 years, and 99 times out of 100 the reason the baby's heart rate won't come up is lack of effective ventilation.
My initial instinct was to hip check this guy out of the way and do what I needed to do. But I knew I could be charged with battery and lose my medical license for intervening where I don't have authority. It was horrible.
Then the attending physician, a world-renowned neonatology researcher, comes in. My first reaction was, finally there's someone who's going to do what needs to be done. I was so relieved.
But the attending doesn't say anything, and no one says anything to him. Finally, I informed him this was a routine C-section. He looks over but still doesn't say or do anything. He didn't check the tube or touch the baby.
I was shocked. I expected him to bump the fellow out the way and go right for the tube. I've done that with my residents on numerous occasions.
Then someone said the baby's abdomen is getting distended, and I asked if the tube is in the esophagus instead of the trachea. Then the baby made a little gasp, an agonal breath. They called code.
It was horrific. I had to go over and tell my niece and her husband that their baby died. A couple hours later, the attending and the fellow came into the room and said they had no idea what happened, it was very unusual, and they'd do an autopsy.
Isaac, cradled in his father's arms for the first and last time.
I followed the attending out of the room and told him I didn't think the tube was in and no one checked it. The most damning piece of information was that the umbilical cord arterial blood gas was normal, and there was no fetal distress. The attending had this absent look on his face.
I called the neonatology chairman, whom I knew because he offered me a job a couple years earlier. He immediately became defensive, saying he trusted his team 100% and he couldn't talk about the case because of HIPAA. I replied that I hoped we could talk as professionals, and then sit down with the family. But he cut me off.
I was afraid the family would think this was some rare disorder that caused the baby to die and that it would happen to their other kids. So I told them I was 99% sure that it was a medical error.
The family asked to speak with someone from the hospital. They sent the chief medical officer, who's a neonatologist, and a risk-management attorney. I was there, and I went through everything. The CMO acknowledged nothing.