And Another Old Lichtenberg Death

On March 25, 2000, Maria Rodriguez went to Steve Lichtenberg's Albany Medical Surgical Center for a late second trimester abortion. Lichtenberg estimated her pregnancy at 18 weeks and went ahead with the what a later expert consultant called "a seemingly uncomplicated (albeit short) procedure.

At about 9:00 a.m., Maria was showing signs of shock from hemorrhage. The expert consultant pointed out that Lichtenberg had failed to notice that he had ruptured Maria's uterus. Her hematocrit (a measure of red blood cells) was 32% after surgery, but it had fallen to 25%. (About 38% is normal for a woman.) Lichtenburg flushed out her uterus with a dilute solution of Vasopressin, a hormone used sometimes to control bleeding. He also had pressure applied to her uterus. But, the consultant noted,"At no time were further attempts made to ascertain the cause of the bleeding or to explain the discrepancy between the marked decrease of hematocrit and the seemingly moderate blood loss."

Lichtenberg diagnosed DIC, a clotting disorder caused by triggers such as amniotic fluid in the blood stream. He started treating Maria with Fresh Frozen Plasma (FPP) at 9:34. She was given a total of 14 units of FPP, but her hematocrit continued to fall, and she was showing abnormal EKG readings. Her heart was racing and she was continuing to bleed. She wasn't given a transfusion, or transported quickly to a hospital so that a transfusion could be administered there. Lichtenberg also didn't administer any additional medications to help control Maria's bleeding.

At around 10:15 a.m., Maria appeared to have been somewhat stabilized, but "no attempt was made to determine the cause of the bleeding with ultrasound evaluation" or to tie off the bleeding artery. By 10:30, her hematocrit had fallen to 15%, meaning she had less than half the red blood cells needed to carry oxygen to her brain. This was a sign that her condition was rapidly deteriorating. Finally, an hour and a half after Maria suffered her life-threatening injury, and an hour after Lichtenberg had diagnosed the dangerous clotting disorder, it occurred to somebody to call 911 and have Maria taken to a properly equipped hospital.

By the time she arrived there, her hematocrit was 3.5%, less than 10% of what it should have been. Doctors at the hospital tried to save her, to no avail, she died that evening.

Maria left behind a four-year-old daughter.

N.B. At a National Abortion Federation Risk Management Seminar in the 1990s, Michael Burnhill of the Alan Guttmacher Institute scolded Lichtenberg for "playing Russian roulette" with patients' lives by performing risky abortions in an outpatient setting and treating serious complications on site in his procedure room rather than transporting them to a hospital. Evidently Lichtenberg chose not to listen to Burnhill's warning.