...The Rest of the Story

Some of you may be old enough to remember Paul Harvey and his radio program called The Rest of the Story. Paul Harvey's intent was to reveal the part of the current news story that never made it to the regular news broadcasts. In many ways, my Substack articles are my efforts to tell the rest of the story.

I recently read yet another article about the death of a pregnant women for lack of medical care. In this ProPublica article, Cassandra Jaramillo and Kavitha Surana tell the story of a woman in Texas who died after the hospital said intervening in her miscarriage would be a crime. I've written here before about the stories of women dying because hospitals refuse to treat miscarriages, but new stories seem to appear each week. 

ProPublica reporters speak highly of their investigative journalism, and the ability to speak truth to power, but this ProPublica article is more about gathering ammunition, much like the government organizations which go after individual physicians to make their points rather than going after the large organizations responsible for most of the fraud or mismanagement.

I’d like to say that I am definitely not a fan of politicizing healthcare. This is a very dark road which we should under no circumstances continue to be going down. Ken Paxton, or any other attorney general, governor, legislative body or police force, including the Department of Justice (DOJ), Federal Bureau of Investigation (FBI), or Centers for Medicare and Medicaid Services (CMS), should have absolutely nothing to do with interfering with physician medical decisions under the pretense of maintaining good healthcare.

We don’t need politicians making political decisions about health care whether it’s dealing with pregnancies or whether it’s the police state created by Medicare and Medicaid fraud units. Think about it. Physicians already have a ton of politics and politicians in each visit from the insurance companies, pharmaceutical companies, Medicare, and Medicaid requiring approval of care physicians believe their patients need. The preapproval brick walls brick walls are a constant barrier to physicians being able to provide care patients need.

But back to ProPublica's story of Josseli Barnica and how the interference of the Texas State Attorney General, legislators, and police enjoyed way too much influence in this patient’s care. So, in that way, the ProPublica article is correct.

From this article, I can understand why every single provider was scared of the political aspects of those caring for Josseli Barnica, which could result in a 99-year prison sentence, revocation of their medical licenses, and ruination of their hard earned careers. Yes, they had real scepters of danger in the room that to the providers were more dangerous than the dangers presented to the patient. This in no way resembles healthcare.

And if there is a point to the ProPublica article, it is this. These doctors were scared to death for very real reasons, and because they were so afraid for themselves and the politics of healthcare in this instance, they did not concentrate on the care of this patient. And that brings us to the next point. What should the care of this patient have been and what was her diagnosis? Let’s start with what probably should have been her diagnosis.

I discovered in 1979 that pelvic infections can be very obtuse, extremely hard to recognize, but easy to treat if you find them early, difficult to treat if you find them late, and deadly if you overlook their presence. Before I get into exactly what this patient probably had and what should have been the treatment, I want to talk a little bit about the evolution of pelvic infections.

In my first practice, I discovered early on the importance of finding and treating pelvic infections and the difficulty in treating them. I had good success in diagnosing pelvic infections in women who had had repetitive miscarriages, those women who had lost one, two, or three children to mid-trimester miscarriages. I diagnosed and treated their infections and they subsequently carried babies which survived, not always to term, but to at least 34, 35 or 36 weeks.

Josseli Barnica presented to the hospital at 17 weeks and 4 days according to the ProPublica article. She presented in labor with a baby who had a fetal heart rate. This is a classic presentation for a patient who has a uterine infection. If her going into labor at 17 weeks had been a fetal problem, she probably would have presented with no fetal heart rate, or at least some signs of a congenital anomaly (defect).

We are told nothing of the mother’s temperature, her white count, her sedimentation rate, her physical examination, abdominal pain, and tenderness. It certainly appears that the possibility of a uterine infection did not enter the picture. The reason I am harping on uterine infection is that this patient, according to the post-mortem report, died from sepsis, a blood infection which in all likelihood came from her infected uterus.

Again, these infections are extremely difficult to diagnose, but if you don’t at least think of them, or have what we call a “high index of suspicion,” those infections can’t be found or treated. I’m going to play devil's advocate here. My suspicion is that if this infection had been identified and treated soon enough, mother and baby could both have been saved. That’s an issue which has not been brought up in the ProPublica article.

A plethora of writing is one huge consequence of having a police state in the patient room. Based on what I can see from this article, there is a ton of writing that has to do with protecting the doctor and a dearth of writing regarding the patient’s diagnosis and treatment plan. The more aggressive and invasive the police state is in the exam room, the more writing is done to foster self preservation for the providers.

CMS and other payers deny payment when there isn’t enough writing or the right kind of writing with required buzzwords. As a relatively old physician, I know from experience that you can either do something for the patient or you can write about doing it. In my experience, the adage “if it wasn’t written it wasn’t done” is just an excuse for not paying for services rendered.

Lawyers, judges, courts, and juries love to talk about proximate cause. In other words, that thing which caused the problem or the death in a given case. I cannot possibly communicate how much I despise having politicians or police actions virtually in the exam room, and the fact that their virtual presence makes treatment more difficult. In reality, the abortion issue is neither the proximate cause of the demise of this baby nor the mother.

Let me explain.

In my 40 plus years of experience, I suspect this is what probably happened according to the story as written in ProPublica. First, there was a uterine infection which spread to the sac, the placenta, the amniotic fluid, and the baby. Second, Josseli Barnica's labor started because her body did the only thing it could do to save her life...that means her body went into labor to jettison the baby and infected placenta, fluid, and membranes.

Again, there’s absolutely no evidence, according to this article, that there was any attention given to the most likely possibility that this labor and miscarriage resulted from an overwhelming uterine infection, which then spread to her blood, and then killed her.

Eventually the baby died and was delivered. There is no mention of the placenta or the membranes being completely or incompletely delivered. Again, there was no mention of hemoglobin, a white count, cultures taken from the baby or the placenta or a path report of the placenta cord and membranes. The baby was delivered around 4 a.m., September 5, some 40 hours after Josseli had arrived at the hospital and the fetal heart rate could no longer be detected. The note says that the fetus was delivered, but makes no mention of anything else.

Dr. Joel, Ross the OB/GYN, who oversaw Josseli's care, discharged the patient after 8 more hours. There is no mention of instructions given to Josseli for home, follow up, or indications for a return. Her vaginal bleeding continued, but when Josseli called the hospital, she was told that bleeding was normal. Two days later, the bleeding was heavier yet. On September 7, two days after her delivery, her husband rushed her back to the hospital as soon as he got home from work.

There were multiple opportunities to save Josseli Barnica's life. She could have been given IV antibiotic’s on her first presentation to the hospital. That would have been the best time to save everybody, mom and baby. But she was sent home with no firm indications for return. She did return later and but as far as we know, was still not given antibiotics.

She eventually delivered, but as far as we know, was still not given antibiotics. As a matter of fact, we have no evidence that anybody was even thinking about an infection, which was most likely her primary diagnosis.

Although I’m not certain about all the ins and outs of the Texas abortion regulations, I would imagine that even the most draconian legislators, governors, and attorneys generals would allow treatment to save the life of the mother. But here’s the rub. That life saving treatment could have been given either before or after the baby was delivered.

Although there are many side issues involved with this case, the main problem here is very probably failure to diagnose the uterine infection and failure to treat it. As far as I know, not even Texas has laws against antibiotic treatment to save a mother’s life. The hospital certainly could have easily made a case to give antibiotics to save Josseli Barnica's life.

The overall issue here is, as it is in so many of the cases that ProPublica presents, many deaths result from the dismissiveness built into our current healthcare system. That’s when the providers don’t take what the patient is saying seriously. Not believing your patient, not taking your patient seriously, is a great departure from the Hippocratic oath. Even after Josseli Barnica was discharged, she called about her heavy bleeding. According to the article, “she was told ‘that was expected.’” Again, that was another missed opportunity for life-saving treatment.

I have always known that the phone is a really complicated way to take a message to try to understand what is happening to patients. The problem is you can’t see the patient. You don’t know what their labs are. You don’t know what their blood pressure is. You don’t know what their temperature is. You don’t know what an examination would show. So, the best thing you can do is to say, “Come on in and let’s get your blood work done. Let’s do an examination and some further testing.”

Now, I want to make this perfectly clear. When I speak of police presence in the exam room I’m speaking figuratively not literally. I know that generally speaking there are no police in the exam rooms. But I do know that oftentimes there is a heavy and unseen virtual presence dictating what physicians do and must not do in the exam rooms.

Although the policing presence is not something that we signed up for when we entered medical school, we have come to understand its perverse and pervasive presence, and the difficulty that presence adds to our patient care and to the distress of our day. This ProPublica article about Josseli is a case in point. Nevertheless, most of us learn to work with government adversity and perversity and try to do a good job in spite of it. So, no matter what the legislators, the attorney general and governor in Texas say, there is not any excuse for providing second-rate care or worse, none at all. We must do our very best, and perform well, in spite of the adversity and perversity which grows greater on a daily basis.

Finally, I would ask all of the policing activities, including Medicare, Medicaid, Medicaid fraud services, DOJ, FBI, CDC, and FDA, health insurance carriers, med mal carriers, legislators, attorneys general, governors, and presidents be stopped immediately from making medical decisions. Physicians should be making medical decisions, not legislators without any medical education. I would ask them all to put on their thinking caps at this time and to try to understand the damage that they are doing to healthcare with draconian legislation, and their omnipresent pervasive threat to patients and physicians trying to provide needed healthcare.

…And that's the rest of the story.

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