A Deadly Epidural, Delivered by a Doctor with a History of Mistakes
By Joseph Goldstein
Twenty-six-year-old Sha-Asia Semple died after receiving an epidural during labor at Woodhull Medical Center in Brooklyn, New York, on July 3, 2020. In what should have been a routine procedure, Dr. Dmitry Shelchkov, an anesthesiologist at the public hospital, was found by a state medical review board to have inserted the catheter to deliver the anesthesia more than 13 inches, rather than just four inches, into Semple's back. The state board also said Shelchkov administered a full dose of anesthesia, instead of a small test dose, which entered her cerebrospinal fluid and circulated around her central nervous system. The hospital inspection reported that six other pregnant patients in labor at Woodhull "suffered adverse outcomes related to the administration of anesthesia." Shelchkov, who lost his medical license in late 2021, was not named in the report, which described errors attributed to him in other documents, indicating that he was involved in nearly all those cases. Mistakes in which the anesthesia mixes with cerebrospinal fluid are rare but generally are caught because patients are first administered a small test dose to gauge their reaction – a critical safety measure that Shelchkov reportedly skipped. In the report, federal inspectors accused administrators and department heads at Woodhull of failing to monitor Shelchkov despite the pattern of errors. The report brings to light gaps in care quality at hospitals across New York City. Close to 1,500 pregnant patients give birth each year at Woodhull, one of the city's 11 public hospitals, with a majority of patients being Black or Hispanic and on Medicaid. According to safety data from 2014 to 2017, pregnant patients at Woodhull experienced severe bleeding, strokes, anesthesia complications, and other serious emergencies 2.5 times more than hospitals statewide. Pregnant patients at Woodhull also have higher rates of hypertension, obesity, and other conditions that increase the risk of complications.
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