Thursday, December 08, 2022

December 8, 1994: Blood-Spattered OR Team Can't Fix "Screw-Up"

Headshot of a bearded, balding, bespectacled man of Indian ethnicity.
Suresh Gandotra
The California Medical Board knew something about Dr. Suresh Gandotra that 23-year-old Magdalena Rodriguez didn't know. Had they acted on their knowledge, she wouldn't have died.

On December 8, 1994, 23-year-old Magdalena travelled from her home in Tijuana to Suresh Gandotra's clinic, El Norte Clinica Medica, in San Ysidro, California. Magdalena had an appointment for a safe, legal second-trimester abortion. She didn't know about what he'd done to another woman three years earlier. 

That young woman, age 22, had also travelled to San Ysidro from Tijuana. She had been 18 weeks pregnant. Gandotra made an unsuccessful attempt to complete an abortion and sent her home, hoping "the fetus would drop." She returned the next day with an infection because Gandotra had torn a hole in her uterus and pulled out a portion of her bowel. When he realized how seriously injured his patient was, he sent her to UC San Diego Medical Center rather than the nearest properly equipped hospital. The patient arrived in shock, having lost 40% of her blood. The doctor who performed emergency surgery to save this patient's life said, "The damage was so extensive it was difficult to identify the anatomy." Gandotra's comment on the case was, "I guess I screwed up."

The medical board screwed up as well. The case sat forgotten somewhere in their offices. As for Gandotra, he had a similar comment about his care of Magdalena: "I knew I screwed up."

Madgalena's abortion started at 10:00 in the morning. Struggling to remove all the fetal parts, Gandotra realized that something had gone terribly wrong. He later told the medical board that he had delayed calling an ambulance because he had no admitting privileges and Magdalena had asked to be released so she could walk home -- to Tijuana. Clearly Magdalena was already in shock and unable to grasp the situation she was in.

It wasn't until 3:24  p.m. that Gandotra called the University of California San Diego hospital and asked for directions to send Magdalena there by car. The staff at the hospital insisted that Magdalena should be transported by ambulance. They began to assemble an expert team for the expected catastrophic injuries.

In the mean time, Gandotra left Magdalena unattended while he did abortions on other patients. When he finally called an ambulance, he did not inform them of the hospital that was awaiting her arrival with a team ready to treat her.

When the ambulance crew arrived at 4:33 p.m., they found Magdalena lying on the floor in a pool of blood, pulseless and in ventricular fibrillation. Gandotra didn't tell the medics about the hospital that was awaiting this critically injured patient, so they took Magdalena to Scripps Chula Vista Hospital rather than to the hospital that had prepared a specialized team for her. She arrived at around 5:15 that evening.

Gandotra also didn't provide a medical history or any information about her condition or what he'd done to her. The hospital staff were totally unprepared for what they found when they examined her. Magdalena had no vitals on arrival at hospital. She was unresponsive with fixed, dilated pupils.

When the surgeon at the hospital opened Magdalena's peritoneum, it was so distended that the operating room was spattered with the escaping blood. Magdalena's uterus was ruptured, with a fetal limb protruding into her abdomen. Her cervix, uterus, bladder, and colon were lacerated. The mangled and partially dismembered fetus was of approximately 30 weeks gestation. In spite of the surgical team's heroic efforts, Magdalena was pronounced dead from massive blood loss at 10:17 p.m.

Upon autopsy her death was attributed to "complications of the acute pelvic injuries which consisted of lacerations of the lower uterus, vagina, bladder and colon." As the autopsy describes the unborn child, "the body of the baby was not complete when autopsied. Both arms had been cut off; the heart, lungs, liver, and other organs had been cut out, the front of the chest and abdomen were missing, the right femur was fractured, the head was intact except for an area on the scalp which had been taken off from the back of the head."

Gandotra's attorney said, "We don't believe this was below the standard of care nor do we believe it was malpractice." In contrast, a  nurse at the hospital that tried to save Magdalena's life said, "I've never seen anything like this before and I don't want to again."

After Magdalena's death, investigators went to the clinic and found that Gandotra had no means of providing transfusions, only had first-trimester consent forms even though he did second-trimester abortions, did not take after-hours calls, did not keep adequate records, and did not speak Spanish although 95% of his patients were Spanish-speaking.

Gandotra performed about 100 abortions per week at his clinic. He had previously served five months of a fifteen-month sentence for committing Medicaid fraud and allowing non-licensed people to perform medical procedures at his facility.  Eventually a homicide warrant was signed out against him for Magdalena's death and he fled to his native India. As far as I can determine he remains there, a wanted man on Interpol's list, and going about his business.

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