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Monday, December 21, 2020

December 21, 1997: A Typical Lack of Diligence

Dr. Earl McLeod
On December 20, 1997, 27-year-old Jennifer Halner went to Potomac Family Planning for a safe, legal abortion, to be performed by D&C. She was 6 weeks pregnant. Dr. Earl McLeod's anesthesiologist, Dr. Jo-Anne Kelly, started an IV, and Jennifer was hooked up to monitors. 

The procedure took about five minutes.

Jennifer  was transferred to recovery at 10:10 a.m. She was put on an oxygen mask but given only a blood pressure monitor. Her blood pressure was 112/60, her pulse 103. The blood pressure monitor was then removed and placed on another patient. Kelly went back to the procedure room without awakening Jennifer.

Ten or fifteen minutes later a nurse noticed that Jennifer was still unresponsive. She started to ask an assistant to go to the procedure room and ask Kelly to approve a dose of Zoloft (and antidepressant), then changed her mind and asked another nurse to get approval for a dose of Zofran (an antiemetic). 

Neither McLeod nor Kelly assessed Jennifer, but instead Kelly verbally complied with the odd request even though Jennifer was not suffering from nausea or vomiting. The nurse gave a dose of Zofran intravenously at about 10:25, and, of course, Jennifer remained unresponsive.

The nurse then requested Romazicon, a drug that would actually reverse the effects of anesthetics, and again, without assessing the patient, Kelly, gave her okay. The nurse administered the medication but again got no response. She put the blood pressure cuff back on Jennifer and only then noticed that the young woman had no pulse. She checked Jennifer's pupils and found them dilated. She fetched Kelly, who stared a second IV and began to perform CPR, using a pediatric-sized bag-valve mask totally inadequate for an adult patient. It was, however, the only bag-valve mask the clinic had on the crash cart. Meanwhile, McLeod performed two other procedures before entering the recovery room and finding his staff performing inadequate CPR on his patient. 

McLeod ordered Epinephrine, Ephedrine, and Lidocaine be administered. He didn't document oxygen saturation because nobody had put a pulse oximeter on Jennifer. He later claimed that Jennifer had been hooked up to a cardiac monitor, but he didn't document cardiac rhythm, respiration, or a neurological evaluation.

It wasn't until around 10:42 a.m. that McLeod told somebody to call 911. Paramedics arrived and  immediately began appropriate resuscitation, including intubating Jennifer -- a step that McLeod or Kelly should have taken. They switched to an adult bag-valve mask, administered Narcan, epinephrine, and atropine, and hooked Jennifer up to a cardiac monitor and defibrillator. They defibrillated Jennifer. 

The medics transported Jennifer to Shady Grove Adventist Hospital. Upon arrival her pupils were fixed and dilated. After aggressive resuscitation efforts by ER staff, Jennifer's heart was restored to a stable rhythm, and she was admitted to the Intensive Care Unit. She died there at 4:15 a.m. on December 21.
 
The appalled paramedics reported McLeod to the medical board, which faulted him with failure to provide adequate and readily-available post-operative monitoring equipment, and failure to provide adequate emergency supplies. The board also required him to get his staff properly certified in CPR. Dr. Kelly was disciplined by the medical board as well.


McLeod also ran the Hillcrest abortion mill in Harrisburg, Pennsylvania, where Kelly Morse had died in 1996 after being inadequately resuscitated.

Watch Out of Sight, Out of Mind on YouTube.

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