Newyork

A Deadly Epidural, Delivered by a Doctor With a History of Mistakes

Dr. Dmitry Shelchkov, an anesthesiologist at a public hospital in a predominantly Black neighborhood in Brooklyn, would later say that his job was “straightforward” with “not a lot required.”

But when it came time to give an epidural to Sha-Asia Semple, a pregnant 26-year-old woman in labor, at Woodhull Medical Center on July 3, 2020, Dr. Shelchkov botched the routine procedure. The catheter to deliver the anesthesia should have gone about four inches into her lower back. Instead, he kept inserting the line, threading it in and up more than 13 inches, a state medical review board later found.

Then Dr. Shelchkov administered a full dose of anesthesia, without waiting to see how Ms. Semple responded to a small test dose, according to the state board. The anesthesia landed in her cerebrospinal fluid and circulated around her central nervous system.

“I can’t breathe,” Ms. Semple said as her breathing grew labored, before stopping altogether. Another doctor rushed in to help.

“I can’t believe this is happening again,” the doctor screamed at Dr. Shelchkov, according to a federal hospital inspection report.

Her baby survived, but Ms. Semple did not. It was several weeks after George Floyd’s murder had set off a national reckoning on race, and Ms. Semple’s death sparked a demonstration outside the hospital and news coverage about how, in New York City, Black women like Ms. Semple are nine times more likely to die of pregnancy-related complications than white women, a much greater disparity than exists nationally.

Many factors contribute to that disparity, but Dr. Shelchkov’s career — he was stripped of his medical license in late 2021 — brings one of the factors into focus: large gaps in the quality of medical care at hospitals across the city.

Until now, the specific medical errors that caused Ms. Semple’s death have not been publicly reported in detail. Nor has it been reported that in the more than two years before her death, six other pregnant patients in labor at Woodhull “suffered adverse outcomes related to the administration of anesthesia,” according to the hospital inspection report.

In almost all those cases, Dr. Shelchkov was apparently involved, according to the report, which did not name him but described errors attributed to him in other documents.

In some instances, he pushed the epidural needle or the catheter that fits through it too far, which resulted in the anesthesia mixing with cerebrospinal fluid rather than remaining in a separate space near nerve roots, according to the report and the state medical review board’s findings.

Such mistakes, though rare, are usually caught quickly and corrected, but Dr. Shelchkov sometimes skipped a crucial safety measure — giving a small test dose and waiting to see the patient’s reaction before administering the full dose of anesthesia, a state medical review board found.

Despite the clear pattern, administrators and department heads at Woodhull did little to monitor him, federal hospital inspectors wrote in the report, which is in a database of federal hospital inspection reports created by the Association of Health Care Journalists.

The document paints a disturbing picture of dysfunction at Woodhull, part of the city’s public hospital system, which serves many of New York’s most vulnerable mothers. Nearly 1,500 women give birth there each year, about 85 percent of them Black or Hispanic. Under 10 percent are white. The majority of patients have Medicaid.

When rare complications from epidural anesthesia — which provides pain relief during childbirth — began occurring unusually often at Woodhull, the cases went unreported. Not until a patient died did hospital administrators even notice a pattern. While medical mistakes can happen at any hospital, the case of Dr. Shelchkov was extreme, both in the sheer number of errors he made and in the fact that it took so long for someone to intervene.

Woodhull Medical Center, where Ms. Semple was treated, is known for its mixed safety record.Credit…Michael Kirby Smith for The New York Times

The federal hospital report does not refer to Dr. Shelchkov by name, instead calling him “Staff A,” but his identity is clear when Staff A’s description is compared with other documents, including a subsequent ruling by the State Board for Professional Medical Conduct, which in 2021 found Dr. Shelchkov to have practiced medicine with negligence and incompetence.

“It is only as this issue occurred” — Ms. Semple’s death — “that I became aware of the other incidents” involving pregnant patients, the chief of the anesthesia service at Woodhull later told federal hospital inspectors.

In a phone interview with The New York Times, Dr. Shelchkov said that when something went wrong, the anesthesiologist always made an easy target. “Everyone wanted to present themselves as the hero and that it wasn’t their fault,” he said. He said that Ms. Semple’s death and the trauma and exhaustion of working during the first wave of the coronavirus pandemic had left him feeling “devastated.”

In a statement, the city’s public hospital system noted that it had a range of programs aimed at reducing severe maternal morbidity and closing racial disparities. These include extensive emergency simulation programs to train labor and delivery staff, as well as bigger roles for doulas and midwives than exist in many private hospitals. The rate of cesarean deliveries at the city’s public hospitals is lower than the statewide average, a promising indicator.

Woodhull has plans for a new birthing center, and, according to documents submitted to federal hospital inspectors, the hospital has strengthened its review of serious mistakes and adverse outcomes.

Mayor Eric Adams and the City Council have rolled out several policies aimed at improving maternal health, particularly for Black women, in recent months.

Each year in New York City, more than 20 women die of pregnancy-related causes, and about 3,000 women nearly die. In 2017 and 2018, the last years for which New York City has released data, most of the women who died were Black.

Experts point to a range of factors to explain this, including a prevalence of underlying medical conditions, a lack of access to prenatal care or good medical insurance, and racial biases: Some providers fail to take some patients’ medical complaints seriously.

Khloe’s mother, Ms. Semple, died in childbirth at Woodhull when the anesthesiologist administered a full dose of anesthesia into her cerebrospinal fluid, according to an investigation.Credit…Desiree Rios/The New York Times

But racial disparities in maternal deaths are also linked to the fact that Black women are often more likely than white women to deliver at hospitals with a lower quality of obstetric care, research suggests. In New York City, the differences in hospital quality may account for nearly half of the racial disparity in severe maternal morbidity rates, a 2016 study found.

The poorer quality of care at such hospitals can take many forms, ranging from lower-performing doctors to understaffing, which forces patients in distress to wait longer. Or the hospitals may lack rigorous guidelines and protocols for responding to severe bleeding during childbirth.

Woodhull Medical Center is one of 11 public hospitals run by New York City. The crown jewel of the city’s medical system is Bellevue Hospital, with Woodhull at the other end of the spectrum. A rust-colored behemoth at the edge of Bedford-Stuyvesant, a predominantly Black neighborhood in Brooklyn, it is known for the Keith Haring mural in the lobby and a mixed safety record.

Safety data from 2014 to 2017, made public by USA Today, shows that women delivering at Woodhull had serious emergencies — such as severe bleeding, strokes and anesthesia complications — at two-and-a-half times the rate of hospitals statewide, though that was lower than some other Brooklyn hospitals. The women who deliver at Woodhull have higher rates of conditions like hypertension and obesity that raise the risk of complications, doctors noted.

A memorial garden for Ms. Semple in Bedford-Stuyvesant.Credit…Desiree Rios/The New York Times
Ms. Semple was excited about her pregnancy, her partner said.Credit…Desiree Rios/The New York Times

In an interview, and in testimony to a state medical board, Dr. Shelchkov insisted that some of the errors attributed to him occurred during the pandemic’s first wave, when hospitals were overwhelmed and the standard of care dropped.

But the records indicate that troubling scenes had begun cropping up before that.

In August 2018, not long after he began working at Woodhull, Dr. Shelchkov placed an epidural for a 42-year-old woman who was 39 weeks pregnant, according to the federal hospital inspection report. Shortly after, her blood pressure dropped and she became unresponsive. The obstetrician, interviewed by hospital inspectors a few years later, remembered that Dr. Shelchkov “was just standing there.” The patient, who later recovered, was intubated and had an emergency C-section.

The interim chief of anesthesiology at the time concluded that Dr. Shelchkov had apparently given a full dose of anesthesia without an initial test dose and had placed the catheter incorrectly, according to the federal report. After that, the chief described having “monitored him constantly” until the summer of 2019 when a new doctor took over as head of the anesthesia service.

The new doctor later told investigators that he had never been warned about any issues involving Dr. Shelchkov.

The city’s public hospital system has long outsourced much of its physician staffing to private hospitals and medical schools. Dr. Shelchkov had technically been hired and employed by NYU Langone Medical Center, a top Manhattan hospital, though he did not work at any of its facilities — only Woodhull, according to an NYU Langone spokeswoman, Lisa Greiner.

In the interview with The Times, Dr. Shelchkov expressed pride that he worked through the pandemic, sometimes clocking 85 hours a week at Woodhull. “People needed my help,” he said. “It was like a war.”

“I was intubating 20 patients a day,” he added. “It was pure horror, people screaming.”

Dr. Shelchkov, 62, said the pandemic took a toll, affecting his focus and leaving him exhausted. A state medical review board said that was no excuse for what happened next.

Mr. Lopez often shows Khloe pictures of her mother so she will know who she is.Credit…Desiree Rios/The New York Times

According to the federal report, Dr. Shelchkov was called in to give an epidural to a 31-year-old woman at 3 a.m. on May 22, 2020. “Give me air,” she said, before becoming unresponsive. She was intubated and her baby was delivered via C-section. The mother recovered.

A state medical committee later concluded that the episode appeared to be another case of Dr. Shelchkov’s placing the epidural catheter too deep, an error that might happen in one in 1,000 epidural attempts, according to an anesthesiologist the state hired as an expert. Anesthesiologists are usually quick to recognize such mistakes and correct them — before administering a full dose of anesthesia. But Dr. Shelchkov didn’t catch his errors in time.

In June 2020, a pregnant woman complained that Dr. Shelchkov took an hour to place the catheter for an epidural and that she was bleeding heavily from the attempts and unable to walk straight. In response, hospital administrators decided that going forward Dr. Shelchkov should ask colleagues for help after three unsuccessful attempts, according to the federal report.

Dr. Shelchkov, in an interview, claimed the epidural catheter took seven minutes to place, not an hour. In interviews, anesthesiologists noted that placing a catheter sometimes takes a few tries, and that some patients experienced sudden drops in blood pressure or other adverse reactions, regardless of an anesthesiologist’s skill or care.

On July 2, 2020, Ms. Semple arrived at Woodhull a few days past her due date to give birth to her first baby, according to the report. Her partner had recently bought an engagement ring and planned to propose a few days after the birth. They had chosen a name for the baby: Khloe.

The following night, Dr. Shelchkov placed an epidural catheter. Two minutes later Ms. Semple had no pulse.

For a moment, Dr. Shelchkov stood seemingly frozen, according to statements later given by a doctor and nurse to federal inspectors. Then he tried to put Ms. Semple on a ventilator. But, according to the state medical review board, instead of placing the breathing tube down her trachea, he sent it down her esophagus — a mistake he later blamed on the fogged-up goggles worn as a Covid-19 precaution. The ventilator pumped oxygen into her stomach, not her lungs.

Failed intubations are more common among pregnant patients, but they are usually discovered quickly. It was 29 minutes before the error was recognized and the breathing tube was finally inserted correctly.

Mr. Lopez got a tattoo of Ms. Semple’s name.Credit…Desiree Rios/The New York Times

The following week protesters gathered in front of Woodhull, many carrying signs demanding justice for Ms. Semple. In 2021, the state’s Office of Professional Medical Conduct held a disciplinary hearing in which a lawyer for the Department of Health, Daniel Guenzburger, called Dr. Shelchkov “a ticking time bomb.”

By the time his medical license was revoked in late 2021, Dr. Shelchkov said he had been disabled by a severe Covid infection. Unable to work or afford to live here, Dr. Shelchkov moved back to Russia last year.

Dr. Shelchkov said Ms. Semple’s death was the only time someone in his care had died during his four decades of practicing medicine. “I was just devastated,” he said, and described feeling “close to suicide.”

“A baby grows up motherless,” he said.

That baby is now 2. She loves gymnastics class and silly putty and slime. Recently, she asked her dad a question that knocked him silent.

“Where’s my mommy?”

Her dad, Juwan Lopez, remembered how excited Ms. Semple had been all through her pregnancy. How many times after her death had he shown his daughter maternity photos and the video of the gender reveal, in which Ms. Semple let loose all those pink balloons? “Who’s that?” Mr. Lopez would ask. “Mommy,” Khloe would answer.

After a few moments, Mr. Lopez, 26, told Khloe that Mommy was in the sky watching over her.

On the night of Khloe’s birth, Mr. Lopez was in the room as Ms. Semple was dying. No one told him what was happening. “I think they need to watch who they hire,” Mr. Lopez said, holding Khloe in his arms.

Kirsten Noyes contributed research.

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