Tuesday, November 08, 2022

Steven Chase Brigham and "Jane" from "Lime 5"

Dr. Steven Chase Brigham
A 20-year-old mother-of-one identified as "M.B." by the New Jersey Medical Board (document here) as "Jane" beginning on page 28 of Lime 5, contacted Steven Chase Brigham's practice in Voorhees, New Jersey to schedule a second trimester abortion. Since at that time, 1993, New Jersey required that second-trimester abortions be performed in hospitals, the clinic referred Jane to Brigham's office in Spring Valley, New York.

For some reason Jane did not schedule the abortion promptly. At last she made an appointment. She was accompanied by her husband, identified as "B.B" by the Medical Board. I'll refer to him as "Brent."

Jane and Brent arrived at Brigham's office on the afternoon of November 10, 1993. Jane completed paperwork and did an intake counseling and review of her medical history with nurse Wendy Jacquet. A man who was introduced to the couple as a "medical assistant," "Dr. Dan." This was Dan De la Pena, who was only licensed to practice medicine in the Philippines. He did the blood and urine testing.

Nurse Jacquet explained the 2 to 3 day procedure and provide Jane with a fact sheet which listed potential complications. Brigham then introduced himself and answered Jane's questions about possible complications. 

The decision to go forward

After verifying that Jane still wanted the abortion, in the presence of Brent, Brigham examined Jane. He noted that Jane's cervix was "very short-lipped and with a long cervical canal" and that she had "a very long vagina, and her obesity made exam a little difficult." Brigham performed an ultrasound and estimated the baby to be about 26 weeks of gestational age.

Brigham injected Digoxin into the amniotic fluid to kill the fetus, then inserted 12 laminaria into Jane's cervix to start dilation. Jane was observed in recovery then given antibiotics and told to return the next day.

The abortion

When Jane returned, Brigham removed the laminaria and decided that her cervix was sufficiently dilated to perform the abortion safely. He had a staff member named Michelle Smith assist him throughout the abortion, with assistance "in part" by nurse Jacquet and another nurse identified only as M. F.

An IV line was started. Jane was given local anesthetic to the cervix and conscious sedation through the IV. 

"Dr. Brigham performed a modified Dilation and Evacuation procedure in his routine manner, and the procedure appeared to be normal. According to Dr. Brigham's record, the fetus dismembered easily, but there was some resistance in extracting the fetal skull." Brigham "noted that fetal skull plates were extruding from the side of the decompressed fetal skull," which was normal for this type of procedure at this stage of pregnancy.

After the abortion was finished, Brigham observed no bleeding and assumed that the procedure had gone off without any complications. 

But there had indeed been complications. "It is more likely than not that as the fetal bones were being withdrawn through [the] cervical canal..., a sharp bone such as a skull plate lacerated the endocervical canal. It is also more likely than not that the sharp bone severed the uterine artery. There can be little doubt that the severed uterine artery must has spasmed quickly, retracted, and thrombosed, limiting the initial blood loss to an insignificant amount.

Jane's condition deteriorates

Jane seemed to be recovering well. Shortly after 11 am she was able to dress and to walk to the recovery room, pushing her IV pole and accompanied by her husband and Ms. Smith.

Jane sat on a sofa, drank some juice, and ate some cookies. "Dr. Dan" monitored her vital signs regularly. At around noon, Jane was able to walk to the bathroom unassisted.

At around 12:15, "Dr. Dan" noticed blood on the pad Jane had been sitting on and asked a staff member to summon Brigham to the recovery room. Brigham asked Jane to stand up and when she did, about 100 to 200 cc of blood gushed out of vagina onto the floor, which alarmed Jane. She became unsteady on her feet.

Brigham and "Dr. Dan" had Jane sit on a wheeled chair and brought her back to the procedure room. Her vital signs were within normal range. Jane "was awake and alert, but frightened and confused by the situation." Though she was pale, she was not ashen nor cyanotic. Brigham examined her and noticed the cervical laceration. It did not strike him as serious. He used a curette to remove any possible retained tissue and to feel for signs of a perforation. 

At around 1:10 pm, Brigham performed an ultrasound to look for internal bleeding but didn't note any. He applied silver nitrate to stop any bleeding in small blood vessels. He asked two of his nurses to view the laceration, then had one push down on Jane's uterus to move it closer to the vaginal opening and the other pull on the lip of the cervix so that Brigham could suture the laceration. After only one suture, Brigham noted, "Abandoned attempt to suture cervix. Difficulty in suturing cervix was threefold: 1) Pt has a very long cervical canal which makes it difficulty to reach the cervix, 2) Pt is obese. Due to obesity later vaginal walls obscured cx. 2nd speculum used. 3) The patient has a very small external cervix. All of these combined together to make transvaginal repair of Cx difficult."

Just before 2:00 Brigham noted that Jane had no more vaginal bleeding and her vital signs still seemed normal. By 2:30 he was confident that there was no internal bleeding. She was also passing urine, which was a good sign that she was not suffering from blood loss.

Things took a sudden turn for the worse at around 2:35. Jane's pulse sped up and her blood pressure began dropping. By 2:40 pm her blood pressure was 80/50 and her pulse was 112. She was awake and able to talk but was "woozy." Staff continued to monitor her, but at 2:55 Jane sat up, felt dizzy, and had a gush of blood from her vagina. Her hematocrit was done to 18%, an 11 point drop in just 15 minutes. 

Jane goes to the hospital

Brigham called an ambulance then contacted Nyack hospital and explained the situation to Dr. Rausch, the ER physician. He called the office of a surgeon named Dr. Jakus, asking that he be paged at the hospital. "He did not utilize his backup agreements with area physicians, choosing instead to have [Jane] admitted through the emergency room."

Though Jane was "confused, lethargic, pale and agitated" when medics arrived, Jane did not appear to be in shock. They "spent 16 minutes at Dr. Brigham's office without doing anything of therapeutic value, indicating that there was a lack of urgency in the situation." Brigham rode in the ambulance with Jane, who "was awake and talking on the trip," and able to give verbal informed consent for surgery at the hospital "although she was unable to sign a written consent form."

The triage nurse charted her as awake, alert, and oriented, but "extremely pale." Her blood pressure was 88/52 and her pulse 113. Since this was not significantly different from her vitals before she was loaded into the ambulance, she did not appear to be suffering from active internal hemorrhage.

Brigham recommended a transfusion and surgery, but the ER doctor just had her monitored as he attended to other patients and checked on her from time to time.  

The surgery

Jane went to the operating room at 4:30 pm. Surgeons spent 45 minutes examining Jane and trying to repair the laceration vaginally. Jane was given her first transfusion at 5:05 pm. At 5:15, surgeons made an incision in Jane's abdomen. They did not notice any blood in the abdomen. However, Jane's "uterine artery was found severed and retraced and thrombosed in the retroperitoneal cavity, and that cavity held about 350 c.s.s of blood and clots." There was a hole in her uterus, and a tear in her cervix up into the uterus, about 4-5 to 5 centimeters long. A total abdominal hysterectomy was performed, with [Jane's] normal ovaries left in place."

Jane had suffered a hole in the lower portion of her uterus and a 4.5 - 5 cm laceration of her cervix into the uterus.

Disagreeing doctors

 A doctor reviewing the case faulted Brigham with doing a 26-week abortion in his office rather than an inpatient setting because of the need to have adequate backup in place in case of a catastrophic injury. The uterus is softer than earlier in the pregnancy, and the fetus is larger and thus the crushed skull pieces larger. This doctor also asserted that Jane's obesity, and the long vagina and cervix, increased her risk of cervical damage. 

This doctor also faulted Brigham with curetting the uterus, thus risking enlarging the tear, before suturing it. The difficulty Brigham had in putting sutures in place was an indication that he should have hospitalized her at that point. This doctor believed that Brigham hadn't severed the artery at the time of the abortion but rather when he had been poking around exploring the injury later.

A second doctor who assessed the case also faulted Brigham for only doing a one-day dilation on Jane given that she was 26 weeks into her pregnancy. He believed that Brigham had rushed the dilation by inserting 12 laminaria on the first day. This, he asserted, resulted in the inadequate dilation that led to the injury as Brigham was extracting the bony fetal skull. This doctor also said that when Brigham "encountered resistance in extracting the fetal skull, he should have realized that the cervix was only partially dilated." He also noted "a great likelihood of injury to the uterine artery from the bony fetal skull coming through an inadequately dilated cervix." 

This doctor also doubted that Brigham had actually not observed the cervical laceration as he completed the abortion. He faulted Brigham with deciding to just monitor his patient at that point rather than transport her to the hospital. At the very least, this doctor felt, Brigham should have transported her as soon as he verified that there was a laceration. "In his opinion, the hysterectomy could have been avoided if Dr. Brigham had timely transferred [Jane] to the hospital." He "characterized Dr. Brigham's efforts [to treat Jane in his office] as acts of desperation, and he opined that [Jane] was in a life-threatening situation by the time she reached the hospital."

Dr. Michael Policar, a prominent physician in both the National Abortion Federation and with Planned Parenthood, disagreed with the other doctors who asserted that a 26-week abortion should have been done in a hospital. He noted that New York didn't require that "late second trimester abortions" be performed in hospitals and that "while some patients' conditions dictate hospital care, the reality is that most of the procedures are done in an office setting, consistent with good standards of care." He admitted that most Planned Parenthood abortion facilities were not doing abortions past 20 weeks, "but that relatively conservative limit was due to self-insurance and legal protection concerns, and not became of ethical or medical considerations."

Policar thus had no issue with Brigham performing the abortion in his office, nor with him inserting 12 laminaria on the first day, saying that he often did this himself. He defended Brigham's assertion that Jane's cervix had been adequately dilated. He also found no fault in Brigham's handling of Jane after the abortion and the discovery of the laceration. He noted that he'd had a patient of his own who had required a hysterectomy because a piece of fetal skull had lacerated her uterine artery and considered this a normal abortion complication and to be expected from time to time.

A doctor identified as "Dr. A.K." testified that he himself performed abortions in New York as late in the pregnancy as the law allowed and did them in his office. He also found no fault with Brigham's handling of Jane's case. He said that he himself performed outpatient abortions on patients as far advanced in pregnancy as Jane was, and with the same anatomical issues that caused the other doctors to balk at the idea of an outpatient abortion. 

The board's verdict

The medical board eventually sided with Brigham, evidently on the grounds that since other specialists in late abortions considered his treatment of Jane appropriate, it was indeed appropriate.

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