Code Blue: The Consequence of Truth Telling

Blessings all. This last week has been a particularly rough one. This past Friday, nearly one year after the passing of my Sun Kali Ra, I was finally able to connect with a registered nurse with over 19 years experience in Labor & Delivery (L&D) to go over my son's fetal heart rate (FHR) monitor strips. We met for over two hours, reviewing the strips together page by page. The nurse appeared awestruck by the obvious neglect and marked deviation from the "standard of care" reflected in the medical records. She showed me page after page, full of troubling FHR monitor anomalies, any of which could have easily made a case for intervention.  Instead of intervening, the team attending me allowed my son and I to linger until he used up all his reserves and eventually expired as a result of fetal hypoxia…  Going over the FHR monitor strips, it is clear that there was more than ample time to respond to the arrhythmia patterns that first became markedly visible at 06:33 on 08/11/2016.  The FHR was no longer detectable at ~13:14 and I was finally taken to the operating room for an emergency cesarean at 13:39 (over seven hours after the first instance of marked fetal arrhythmia)…

It was great validation for me to learn that my perception of events as birth trauma survivor and grieving mother is supported by the FHR monitor evidence.

Prompted by meeting the L&D nurse this past Friday, I decided to go back through the ~1,600 pages of medical records with a fine tooth comb.  I ended up spending the majority of the weekend reviewing and taking notes, yet I still haven’t passed page 300 of > 1,600.  It’s slow going, but I consider it a labor of love, both revealing and validating. 

Instead of changing diapers, I find myself changing between highlighters and keyboard strokes in an effort to grasp the full extent of malfeasance that transpired before and after the death of my Sun.  

I was born for this work and I can feel the spirit of my beloved Kali Ra coursing through my finger tips as I write these words and endeavor to raise awareness so that other families do not have to suffer unnecessarily as mine has.

Going through the records, I’ve been taken aback to see instance after instance of apparent oversight, omission of pertinent data and blatant neglect.  For instance, when my son was born, he had no heart beat.  That was never a point of dispute.  He had suffered and struggled through hours of worsening FHR decelerations and obvious and significant fetal bradycardia (abnormally slow heart rate) before his heartbeat was no longer detectable and my attending OB finally agreed to take me to the OR…  When he was removed from my womb he was floppy and blue, with no reflexes, muscle tone or respiration of any kind. 

When I was taken to the recovery room, my bed was surrounded by medical personnel (most in suit and tie) and I was told that my son was “born with no heart beat,” but that it did return “after 10 minutes of resuscitation.”  The doctors attending me explained in no uncertain terms that my son had been without a heartbeat for “at least 10 minutes,” not including time spent absent a heartbeat in utero (before being removed from my abdomen).  My partner who was not permitted entry into the operating room was separately approached in the NICU and informed about this grim reality.

Many months ago, when I first reviewed the “Neonatal Code Blue Record” I overlooked the obvious fact that the record had been modified from its original version.  When I first waddled out of Children’s Hospital with the 1,600 pages of medical records, I was completely unfamiliar with the “Code Blue” protocols, the “Neonatal Resuscitation Program (NRP),” or “APGAR (Appearance, Pulse, Grimace, Activity, and Respiration)” tests given as standard for all infants born in hospital.  I thought nothing of the fact that my son’s “Code Blue” record had clearly been altered after its original recordation, signified by a single line crossing through particular APGAR test values and being replaced with different numbers.  However, after months spent researching my birth trauma, I now realize exactly how significant these seemingly innocuous APGAR values are.  So, it came as quite a surprise when I looked back over the "Neonatal Code Blue Record" and noticed that the APGAR values had clearly been altered…

A bit of background-- Immediately after birth, an “APGAR” test is performed as standard hospital protocol, wherein five factors are used to evaluate a baby's condition.  Each factor is scored on a scale of zero (0) to two (2), with 2 being the best score.  For instance, the “P” (or Pulse) factor represents the baby’s heart rate, with a value of “0” being assigned in the case of an absent heart beat, a “1” being assigned if the heart rate is below 100 beats per minute (bpm), and a value of “2” being assigned if a baby’s heart rate is above 100 bpm. APGAR values are typically assigned at 1 minute and 5 minutes postpartum.

Kali APGAR spoliation.jpg

My son’s heart rate APGAR scores were originally assigned as “0” at 1 minute, “0” at 5 minutes and “0” at 10 minutes after birth.  This “0” value assignation correlates with the fact that my son was “born with no heart beat,” as reported to both my partner and I separately and immediately postpartum.  A value of “0” was also assigned to the categories of “A” (appearance), “G” (grimace or reflex irritability), “A” (activity/muscle tone) and “R” (respiration) for minutes 1, 5 and 10, respectively.

All rows and columns were tallied and a final APGAR score was calculated and assigned, totaling “0, 0, 0, 4, 4” at minutes 1, 5, 10, 15 and 20, respectively.   Only after the final APGAR score of “0, 0, 0, 4, 4” was assigned can we see that the APGAR chart is then modified by the recorder.  The only values which were altered were the “Heart Rate” values at minutes 1, 5 and 10.  The “0” value is clearly replaced by a value of “1.”  These intentional changes are striking and reveal an attempt to designate a live born infant, instead of the lifeless and heart beat absent body, which in fact was removed from my abdomen at 13:54.  

So why would the hospital want to change the APGAR values?  Perhaps they want to keep their mortality rates down?  That would be disturbing enough-- Yet, the rational for this instance of document tampering could also be inferred when referencing landmark case law Broadnax v. Gonzalez (2004), wherein the New York State Court of Appeals held that “a woman may recover damages for emotional injuries resulting from miscarriage or stillbirth.”  However, no cause of action for emotional injury can be made by a mother who gives birth to a live infant (even if that infant dies only a short period of time postpartum, due to complications arising from physician negligence).  To add insult to literal injury-- Since New York state wrongful death law revolves around an archaic common law statute from 1894 (see Butler v. Manhattan Ry. Co., 38 N.E. 454 [N.Y. 1894]), it is impossible to bring a wrongful death suit when a baby is stillborn.

So, to summarize:

  • No wrongful death cause of action can be brought for a stillborn baby;
  • No wrongful death cause can be brought for an infant born alive, who dies a short time postpartum;
  • And, no cause of action can be brought for emotional damages to a mother who delivers a live baby who then dies soon after birth as a result of physician negligence/malpractice in utero…

So, it appears, one of the only avenues made available to grieving parents is through an action brought for emotional distress of the mother when a baby is stillborn as a result of negligence and/or medical malpractice in utero...

I am quite confident that the big wigs over at Kaleida Health’s “Corporate Risk Management Office” are well aware of these parameters and the worrisome implications of having a stillborn baby delivered in one of their operating rooms via an unmedicated, extraordinarily delayed emergency cesarean.  Talk about emotional distress and harm.  Any number of the therapists and professionals I have consulted postpartum can attest to the post-traumatic effects of enduring such an ordeal.

And the flagrant violations don’t stop there.  In my research I have noted several more instances wherein records have been altered or data omitted to reflect a more favorable record of events (stay tuned for those bomb shells dropping soon)...

Kali Ra was delivered without a heartbeat on August 11, 2016. After 10 minutes of "Code Blue" resuscitation efforts his heart started pumping again.  He remained on life support for four days suffering multiple organ failure, and without any decipherable brain activity.  Life support was removed on August 14, 2016 and, again, his little heart stopped beating 90 minutes later.

Kali Ra was delivered without a heartbeat on August 11, 2016. After 10 minutes of "Code Blue" resuscitation efforts his heart started pumping again.  He remained on life support for four days suffering multiple organ failure, and without any decipherable brain activity.  Life support was removed on August 14, 2016 and, again, his little heart stopped beating 90 minutes later.

Again, although it is validating to know my perception of events is supported by the facts and that my research has been able to uncover various discrepancies in documentation (omission and spoliation of evidence), I regularly feel overwhelmed and debilitated by the task at hand.  Despite all the well wishes, the fact is I walk alone in the pursuit of justice and accountability for my beloved Sun.

The evidence may very well support my position moving forward for justice, but publicizing the facts and revealing the identities of the birth team members will expose me to a whole new level of vulnerability and attacks on my character and credibility. The truth is going to be a very difficult pill for many to swallow. 

And, although it will ring loud and clear, the burning truth that fuels my passion cannot protect me from an onslaught of disparagers and defensive efforts devised by desperate persons endeavoring to silence a truth teller.  I am no stranger to smear campaigns, geared toward defamation and suppression of truth tellers.  The majority of my heroes were social outcasts, maligned by society for their authenticity and refusal to shrink under the threat of certain annihilation by the powers that be.  How naïve it would be to think the truth I hold wouldn’t bring hellfire upon me the very instant I start speaking it to those same powers.    Yet, I was built for this work.  And whether the onslaught destined for me leaves me with breath in lung or takes my last, this work will be done.

For every fact or figure that’s ever been fudged;
For every mother who has felt silenced or dishonored;
For every child whose life was lost unnecessarily;
And, for every survivor who has succumbed to their despair...

The truth will be told. 

And in so doing, I ask that my soul posse surround and protect me and my loved ones as I open to speak this truth and embark on the next phase of my path. Let me be a pure vessel for Great Spirit and the objectives set forth in the manifestation of that divine being Kali Ra.  Help me avoid the allure of malice or animosity, as they only cloud the path.  In my solitude, let me feel your hand on my heart, dulling its ache and urging me to keep moving this instrument of mine with inspired word and action. 

Blessed be and let it be so.