Karnamaya Mongarpennsylvania, 40s, 20002009, inadequatedocuments, inadequateequipment, inadequateresuscitation, quackerySUMMARY: Karnamaya Mongar, age 41, died on November 20, 2009 after an abortion performed by Kermit Gosnell at Women’s Medical Society, Philadelphia, PA.
Just When Life Seemed Safe
Karnamaya MongarAt the age of 41, Karnamaya Mongar had survived nearly 20 years in a refugee camp in Nepal. What she was unable to survive was a visit to an American abortion clinic.
She and her family had been among the thousands expelled from their homeland of Bhutan following pro-democracy protests. Karnamaya, her husband, Ash, their three children and one grandchild arrived in the United States on July 19, 2009 as part of a resettlement program. Mr. Mongar had just found a job at a chicken factory near their new home in Virginia.Women’s Medical SocietyKarnamaya was more than 18 weeks pregnant when she asked a family friend, Damber Ghalley, to take her to a clinic in Virginia for an abortion. But the Virginia clinic, and another in Washington, D.C., did not do abortions that late in the pregnancy. One of the clinics referred Karnamaya to Kermit Gosnell’s Women’s Medical Society in Philadelphia because Gosnell had a reputation for performing abortions regardless of gestational age.
Mr. Ghalley drove Karnamaya and her daughter to the Gosnell’s clinic on November 18, 2009, and waited for them in the car. That afternoon, Latosha Lewis, who had completed a medical assistant course but had never been certified, conducted the clinic’s version of a “pre-examination.” This “pre-examination” was so scanty that nobody even bothered to weigh Karnamaya. Lewis performed an ultrasound, which showed that the patient was 19 weeks pregnant, and drew blood. No one provided any counseling to Karnamaya, as is required by Pennsylvania’s Abortion Control Act, to give her time to assess any information about risks and alternatives that might be presented to her.Kermit Gosnell mugshotGosnell did not even meet Karnamaya, although he had pre-signed a form entitled “24 Hour Counseling Certificate” that falsely certified he had counseled her, as was usually done with patients. Karnamaya’s initials, perhaps written by someone else, appear on other consent forms, including one that waived a right to claim that the informed consent had been inadequate. Karnamaya’s daughter, who like her mother spoke almost no English, was asked to sign as a witness.
After the “pre-examination” was done and the paperwork was completed, Randy Hutchins, a part-time physician’s assistant who worked without State Board of Medicine approval, inserted laminaria to dilate Karnamaya’s cervix and administered Cytotec to soften it. Hen then told Karnamaya to return the next day to complete the abortion.Drugged Up
Tina BaldwinKarnamaya arrived at the clinic on November 19 around 2:30 p.m., accompanied by her daughter and her daughter’s mother-in-law. At the front desk, Tina Baldwin gave Karnamaya her initial medication – a 200 mg. pill of Cytotec to soften the cervix and to cause contractions; and a 45 mg. pill of Restoril, a drug that causes drowsiness. Baldwin’s qualifications were that she had attended a course for becoming a medical assistant; and was certified some time in 2009. After giving Karnamaya the medicine, Baldwin told her to wait in the recovery area until the doctor arrived to perform the abortion. Lynda WilliamsLynda Williams and Sherry West, who were without any medical-related qualifications whatsoever, were supposed to medicate and attend to Karnamaya in the “recovery room” while she waited for Gosnell. Gosnell had assigned Lynda Williams this duty even though employee Kareema Cross had warned him at least a year earlier that Williams did not know what she was doing and routinely gave patients dangerously high doses of medications. Randy Hutchins, the physician’s assistant, also had expressed concern about Williams drugging patients in Gosnell’s absence. Gosnell assured Hutchins that “Williams was a trained professional and that it was not a problem.”
Speaking through an interpreter, Karnamaya’s daughter, Yashoda Gurung, told the Grand Jury that she waited with her mother in the recovery room for several hours. During that time, between 3:30 and 8:00 p.m., her mother was given five or six doses of oral medicine – pills that were placed between her mother’s lip and cheek, which is how the clinic administered Cytotec orally.
Yashoda also saw her mother receive medication by injection through an IV line in her hand. This was consistent with Gosnell’s standard practice, which was to keep the second-trimester patients asleep while the Cytotec induced cramping and labor, in the hope that the women would expel their babies without the use of medical instruments. As usual, no equipment was available to ensure proper monitoring of vital signs. Given how heavily the patients were being sedated, the standard of care would require a heart monitor. Gosnell’s clinic didn’t even have a pulse oximeter, which is clamped on the patient’s finger to monitor pulse and how much oxygen is in the blood.
Yashoda did not know what drugs her mother was given, but typically employees gave repeated injections of the concoction of sedative drugs that Gosnell referred to as a “twilight” dose. Each of these “twilight” doses, repeated a number of times at the discretion of the unlicensed workers, consisted of 75 milligrams of Demerol, 12.5 milligrams of promethazine, and 7.5 milligrams of diazepam.
The standard practice was for Gosnell’s untrained staff to give repeated doses of sedative and pain-killing drugs to the patients, without regard to a woman’s size or weight, whenever it was deemed necessary by the untrained staff. For example, if the woman started moaning, she was presumed to be in pain, and would be given another dose of drugs. Karnamaya, at only 4’11” in height and 110 lb. in weight, would have been endangered by a dose appropriate for an average-sized women, much less by the massive doses administered at Women’s Medical Society.
A little before 8:00 p.m., West and Williams told Karnamaya’s daughter that she would have to leave the recovery room. Gosnell was not yet at the clinic, but they told her that he would be arriving soon. Yashoda tried to wake Karnamaya before she left her, but was unsuccessful. West and Williams told her not to disturb her mother because the medicine was supposed to keep her asleep. Yoshada was sent to another waiting area. She was left there, with no idea what was happening to her mother until the ambulance arrived after 11 p.m.Sherry West mugshotSherry West and Lynda Williams administered a combination of powerful, dangerous under Gosnell’s standard instructions and without his supervision or presence. Indeed, Gosnell had never even met, much more examined, his patient before allowing his unlicensed staff to administer the narcotics..
Ashley Baldwin, the teenage girl who had drawn up the anesthesia dosage chart used in the clinic, testified that just before Karnamaya was taken into the procedure room, she was groaning and moving around in pain.Williams and West called Gosnell, who had still not arrived at the clinic. Williams said that Gosnell told her to “med her up,” meaning to get Karnamaya drugged and ready for her abortion.
Williams helped Karnamaye into the procedure room, put her on the table, placed her feet in stirrups, and drugged her again, this time with the clinic’s “custom” dose of 75 mg. of Demerol, 12.5 mg. of promethazine, and 10 mg. of diazepam. Ashley Baldwin reported that Karnamaya immediately became silent. The heavily drugged patient was then left, unattended and with no monitoring equipment, alone in the procedure room. Gosnell arrived to attend to Karnamaya between ten and fifteen minutes later.Cardiac Arrest
Eileen O’Neill mugshotSherry West told detectives that, some time after sedating Karnamaya, Williams came out of the procedure room, yelling for help. West said that when she later entered the procedure room, Gosnell was there trying to perform CPR on Karnamaya. Lynda Williams summoned Eileen O’Neill , an unlicensed medical school graduate who worked at the clinic, from her second-floor office.
O’Neill told the Grand Jury that she thought Karnamaya was already dead by the time she got to the procedure room, but she took over administering CPR because Gosnell wasn’t doing it correctly. Gosnell, meanwhile, left to retrieve the clinic’s only “crash cart” (the emergency kit to treat a cardiac arrest) from the third floor. After returning with the kit, however, Gosnell did not use any of the drugs in it to try to save Karnamaya’s life. Instead he just looked through them and seemed pleased that they were up to date. He seemed purely interested in keeping outsiders from finding out that the crash cart had been nowhere near the procedure room while patients were being sedated. He also repositioned Karnamaya’s body to give the impression that she had suddenly stopped breathing during a procedure in process.
O’Neill testified that Gosnell told her not to administer Narcan, a drug that could have reversed the effects of the Demerol. She said that Gosnell told her it would not work on Demerol – which is not true according to the toxicology expert who appeared before the Grand Jury. O’Neill also said that she tried to use the defibrillator to revive Karnamaya, but that the paddles did not work.Emergency Services
Women’s Medical Society procedure roomIt was after 11 p.m. – long after O’Neill had decided that Karnamaya was dead and returned to her office – that Lynda Williams finally asked Ashley Baldwin to call 911. Ashley then went into the procedure room and found Gosnell alone with his dead patient. He told Ashley to turn in the pulse oximeter, which they should have been using all along to monitor Karnamaya’s pulse and blood oxygen. This surprised Ashley, since Gosnell knew that the pulse oximeter had been broken for months. Evidently he didn’t want emergency personnel to arrive and find no signs whatsoever that anybody had been monitoring the patient.
Emergency personnel responded to the cardiac arrest call within two minutes, arriving at the 11:13. They found Karnamaya lifeless in the procedure room. Paramedics reported that Gosnell was just standing there, not doing anything. The paramedics immediately intubated Karnamaya to give her oxygen, and started an intravenous line to administer emergency medications, since for some reason clinic staff had removed the IV line they’d been using all day to drug their patient. They also failed to tell the paramedics about the drugs they had administered, depriving emergency personnel of vital information that they could have used to try to save Karnamaya’s life.
The medics hooked Karnamaya up to a heart monitor, confirmed that her heart was not beating, and began CPR. They were surprised that, in a medical clinic, basic steps had not already been taken before their arrival. After twice administering medication and using their defibrillator, they were able to restore weak heart activity. But they still had the onerous task of getting her out of the building so they could take her to a properly equipped hospital.The locked emergency exitThis task was needlessly and dangerously time-consuming because the emergency exit was locked. Gosnell sent Ashley to the front desk to look for the key, but she could not find it. Ashley told the grand jury that a firefighter needed to cut the lock, but “It took him [20 minutes]… because the locks is old.”
Yoshada and her mother-in-law ran outside, crying, and watched the firefighters struggling to get the door open while Karnamaya lay motionless. After cutting the locks, responders had to waste even more time struggling to maneuver through the cramped hallways that could not accommodate a stretcher.
Once the EMTs finally got Karnamaya into the ambulance, they continued to administer medication and use the defibrillator. Sherry West went to the hospital with Karnamaya’s companions in their car. West told them that Karnamaya was unconscious, but not to worry.
When the ambulance arrived at the Hospital of the University of Pennsylvania shortly after midnight, Karnamaya had no heartbeat, no blood pressure, and was not breathing. After 45 minutes to an hour of aggressive resuscitation efforts, doctors were able to restore a weak heartbeat. Karnamaya was then sent to the Intensive Care Uni, where she remained on life support until family members could make the trip from Virginia to say good-bye. She was pronounced dead at 6:15 p.m. on November 20. She had died of a massive overdose of Demerol.
Dr. Andrew Herlich, the Chairman of the Anesthesia Department at the University of Pittsburgh Medical Center, testified that even a single “custom” dose was a “very, very heavy dose” that would constitute deep sedation or even general anesthesia. He explained that the promethazine, although helpful in treating nausea, can have a multiplier effect on Demerol. Together with 10 mg. of diazepam, the drugs constituted a “very potent sedative.”
Dr. Timothy Rohrig, the Director of the Sedgwick County (Kansas) Regional Forensic Science Center, testified as an expert in forensic toxicology. Dr Rohrig’s testimony substantiated that Mrs. Mongar received either multiple (more than two) doses of 75 mg. Demerol or one extremely large dose. Still, Dr. Herlich was incredulous when asked, hypothetically, about the effects of two “custom” doses (each containing 75 mg. Demerol, along with smaller doses of promethazine and diazepam). The anesthesiologist could not conceive why a doctor would ever give two doses. Dr. Herlich opined that if average-sized adults, with no particular sensitivities to the drugs, were given two “custom” doses within four hours, “most would stop breathing.” Mrs. Mongar was 4’11’’ and 110 pounds – significantly smaller than average. And she did in fact stop breathing.
Assistant Medical Examiner Dr. Gary Collins determined that Mrs. Mongar died as a result of an overdose of Demerol. He also confirmed Dr. Herlich’s testimony that the combination of diazepam and Demerol “work[ed] together to make her respiration or respiratory depression even worse.”
The medical examiner’s toxicology report showed that, approximately 18 hours after the paramedics were summoned (after which no further Demerol was given), Mrs. Mongar still had a Demerol concentration of over 700 mcg/L (micrograms per liter) in her blood. When the toxicology expert attempted to draw a chart to illustrate the corresponding concentration level at the time the medication was administered, he literally pointed off the chart, saying: “The peak concentration is going to be off the scale way up here.”
Dr. Herlich was appalled not only by the dangerous mixtures of drugs administered, but also by the clinic’s procedures. He explained that it is absolutely essential for a doctor who is ordering anesthesia to meet with the patient beforehand. Different patients, he noted, react differently to the drugs, depending on factors such as height, weight, age, medical history, pregnancy, and race. (Mrs. Mongar’s small stature, her ethnicity, and her pregnancy were all factors indicating that she could be more sensitive to anesthesia than average adults.) He stated that it was “incredible to” him that a doctor would have staff administer sedation when he was not on-site and had not seen and consulted with the patients.
Dr. Herlich also emphasized that anytime sedation is injected intravenously – and especially when it is deep sedation, as was administered to Mrs. Mongar – the patient needs to be monitored. The standards of professional care require, at a minimum, that an anesthesiologist monitor blood pressure, heart rate, heart rhythm, oxygen in the blood, and breathing. No physician should proceed with a second-trimester abortion, Dr. Herlich said, without all of the appropriate monitors – including an electrocardiogram to monitor heart rhythm and a pulse oximeter to monitor the oxygen saturation of a patient’s blood. Performing such procedures without monitors, the anesthesiologist testified, “is offensive to me as a physician.”
Dr. Herlich explained that drugs injected intravenously, as Lynda Williams did to Mrs. Mongar, can reach the heart in 9 seconds and the brain in 16 to 18 seconds. It is crucial, therefore, not only to monitor constantly, but also to administer the medications slowly, a little at a time, and to watch carefully to see how the patient reacts. It was beyond reckless for Gosnell to entrust this delicate and dangerous medical procedure to Williams or any of his other unlicensed, untrained, and unsupervised employees – particularly with no monitoring equipment and no doctor on-site to step in if there was trouble.
The reckless practices that killed Mrs. Mongar were even more irresponsible and dangerous because of the drugs involved. Dr. Herlich testified that Demerol has been out of favor for 10 to 15 years because it has serious side effects and because there are better, safer drugs to use during procedures. Demerol is made more dangerous by mixing it with diazepam, he said, and its potency is multiplied by promethazine. One of the safer drug options the anesthesiologist mentioned is Nalbuphine, a drug that Gosnell sometimes used in his so-called “local” concoctions. But Eileen O’Neill testified that Gosnell would substitute Demerol because it was “very cheap versus the Nalbuphine.” Massof also told the Grand Jury that Demerol “was easier to obtain at a better price.”
The expert testimony substantiated that it was hazardous to have the untrained employees administering even the promethazine. Promethazine, Dr. Herlich testified, has a “black box warning” attached to it, meaning that it has “a side effect that is so terrible that you better be cautious about using it.” The side effect is that if the drug escapes the vein while being administered intravenously, it can cause tissue necrosis, a condition that looks like a burn or a crater.Karnamaya Mongar and her husband
In light of the testimony of Dr. Herlich and other experts, it is no surprise that the combination of callously reckless and illegal procedures, unlicensed and unsupervised employees, and outrageously excessive sedation at Gosnell’s clinic proved lethal to Mrs. Mongar.
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