Wednesday, August 03, 2022

August 3: Delayed Transfer Leads to Death

Dr. Orrin Moore
Dawn Mack, a 21-year-old accountant from Stamford, Connecticut, had an abortion performed at National Abortion Federation member facility Eastern Women's Center  on August 2, 1991.  Dawn, the mother of an infant, was about 15 or 16 weeks into her pregnancy. A doctor inserted laminaria to dilate Dawn's cervix then sent her home. 

She returned the following day for the procedure. During the abortion, Dawn went stopped breathing. Her oxygen saturation level dropped to 88%. The anesthesiologist, Dr. Aurel Calalb, administered oxygen and Dawn's oxygen level returned to normal. Calalb did not make a note of this incident, nor did he mention it to Dr. Orrin Moore, who was performing the procedure. (Moore later let his New York license expire and relocated to Kansas.)

Dawn was declared stable, with her blood pressure recorded at 8:55 a.m. as 130/80. She was sent to the recovery room just down the hall where her blood pressure was recorded as only 96/60 and her pulse 96. In spite of this alarming sign that Dawn was in severe trouble, nurse Linda Wissbrun noted that Dawn was unusually drowsy then left the recovery room. 

Several other nurses were present with Dawn, who was at the time the only patient there, but nobody documented attending to the young woman in any way. When Wissbrun returned five minutes later, she found Dawn completely unresponsive. She tried to find a pulse and sent for help.

Location of Eastern Women's Center
Eastern's nursing supervisor arrived about five minutes later and began mouth-to-mouth resuscitation. There was no crash cart or ambu bag immediately available. Dr. Elena Raftopol, another anesthesiologist, arrived at around 9:07 a.m. and began to administer oxygen by ambu-bag, then took Dawn to the operating room where she intubated her and began CPR. Dawn was not transported to a hospital until 10:00 a.m., nearly an hour after staff first noted that she wasn't breathing. Dawn was pronounced dead at 4:30 pm.

An autopsy noted that she had suffered an amniotic fluid embolism. All of the defendants in the case filed by Dawn's survivors argued that an amniotic fluid embolism can not be prevented or treated and thus Dawn would have died no matter what they had done. The jury found that the clinic and nurse Wissbrun were 100% liable.

Eastern Women's Center also provided fatal abortion care to Dawn Ravenelle and Venus Ortiz.

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