A Deadly Epidural, Delivered by a Doctor With a History of Mistakes

Juwan Lopez and his daughter Khloe, 2, at a mural memorializing Sha-Asia Semple, his partner and the girlÕs mother, in Brooklyn, Jan. 12, 2023. (Desiree Rios/The New York Times)
Juwan Lopez and his daughter Khloe, 2, at a mural memorializing Sha-Asia Semple, his partner and the girlÕs mother, in Brooklyn, Jan. 12, 2023. (Desiree Rios/The New York Times)

NEW YORK — Dr. Dmitry Shelchkov, an anesthesiologist at a public hospital in a predominantly Black neighborhood in Brooklyn, would later say that his job was “straightforward” with “not a lot required.”

But when it came time to give an epidural to Sha-Asia Semple, a pregnant 26-year-old woman in labor, at Woodhull Medical Center on July 3, 2020, Shelchkov botched the routine procedure. The catheter to deliver the anesthesia should have gone about 4 inches into her lower back. Instead, he kept inserting the line, threading it in and up more than 13 inches, a state medical review board later found.

Then Shelchkov administered a full dose of anesthesia, without waiting to see how Semple responded to a small test dose, according to the state board. The anesthesia landed in her cerebrospinal fluid and circulated around her central nervous system.

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“I can’t breathe,” Semple said as her breathing grew labored, before stopping altogether. Another doctor rushed in to help.

“I can’t believe this is happening again,” the doctor screamed at Shelchkov, according to a federal hospital inspection report.

Her baby survived, but Semple did not. It was several weeks after George Floyd’s murder had set off a national reckoning on race, and Semple’s death sparked a demonstration outside the hospital and news coverage about how, in New York City, Black women like Semple are nine times more likely to die of pregnancy-related complications than white women, a much greater disparity than exists nationally.

Many factors contribute to that disparity, but Shelchkov’s career — he was stripped of his medical license in late 2021 — brings one of the factors into focus: large gaps in the quality of medical care at hospitals across the city.

Until now, the specific medical errors that caused Semple’s death have not been publicly reported in detail. Nor has it been reported that in the more than two years before her death, six other pregnant patients in labor at Woodhull “suffered adverse outcomes related to the administration of anesthesia,” according to the hospital inspection report.

In almost all those cases, Shelchkov was apparently involved, according to the report, which did not name him but described errors attributed to him in other documents.

In some instances, he pushed the epidural needle or the catheter that fits through it too far, which resulted in the anesthesia mixing with cerebrospinal fluid rather than remaining in a separate space near nerve roots, according to the report and the state medical review board’s findings.

Such mistakes, though rare, are usually caught quickly and corrected, but Shelchkov sometimes skipped a crucial safety measure — giving a small test dose and waiting to see the patient’s reaction before administering the full dose of anesthesia, a state medical review board found.

Despite the clear pattern, administrators and department heads at Woodhull did little to monitor him, federal hospital inspectors wrote in the report.

The document paints a disturbing picture of dysfunction at Woodhull, part of the city’s public hospital system. Nearly 1,500 women give birth there each year, about 85% of them Black or Hispanic. Under 10% are white. The majority of patients have Medicaid.

When rare complications from epidural anesthesia — which provides pain relief during childbirth — began occurring unusually often at Woodhull, the cases went unreported. Not until a patient died did hospital administrators even notice a pattern.

In a phone interview with The New York Times, Shelchkov said that when something went wrong, the anesthesiologist always made an easy target. “Everyone wanted to present themselves as the hero and that it wasn’t their fault,” he said. He said that Semple’s death and the trauma and exhaustion of working during the first wave of the coronavirus pandemic had left him feeling “devastated.”

In a statement, the city’s public hospital system noted that it had a range of programs aimed at reducing severe maternal morbidity and closing racial disparities. These include extensive emergency simulation programs to train labor and delivery staff, as well as bigger roles for doulas and midwives than exist in many private hospitals. The rate of cesarean deliveries at the city’s public hospitals is lower than the statewide average, a promising indicator.

Each year in New York City, more than 20 women die of pregnancy-related causes, and about 3,000 women nearly die. In 2017 and 2018, most of the women who died were Black.

Experts point to a range of factors to explain this, including a prevalence of underlying medical conditions, a lack of access to prenatal care or good medical insurance, and racial biases. Some providers fail to take some patients’ medical complaints seriously.

But racial disparities in maternal deaths are also linked to the fact that Black women are often more likely than white women to deliver at hospitals with a lower quality of obstetric care, research suggests.

In the interview with the Times, Shelchkov expressed pride that he worked through the pandemic, sometimes clocking 85 hours a week at Woodhull.

Shelchkov, 62, said the pandemic took a toll, affecting his focus and leaving him exhausted. A state medical review board said that was no excuse for what happened next.

According to the federal report, Shelchkov was called in to give an epidural to a 31-year-old woman at 3 a.m. May 22, 2020. “Give me air,” she said, before becoming unresponsive. She was intubated, and her baby was delivered via C-section. The mother recovered.

A state medical committee later concluded that the episode appeared to be another case of Shelchkov’s placing the epidural catheter too deep, an error that might happen in 1 in 1,000 epidural attempts, according to an anesthesiologist the state hired as an expert.

By the time Shelchkov’s medical license was revoked in late 2021, he said he had been disabled by a severe COVID-19 infection. Unable to work or afford to live here, Shelchkov moved back to Russia last year, after 25 years of practicing medicine in the United States.

Shelchkov said Semple’s death was the only time someone in his care had died during his four decades of practicing medicine. “I was just devastated,” he said, and described feeling “close to suicide.”

“A baby grows up motherless,” he said.

That baby is now 2. She loves gymnastics class and Silly Putty and slime. Recently, she asked her dad a question that knocked him silent.

“Where’s my mommy?”

Her dad, Juwan Lopez, remembered how excited Semple had been all through her pregnancy. How many times after her death had he shown his daughter maternity photos and the video of the gender reveal, in which Semple let loose all those pink balloons? “Who’s that?,” Lopez would ask. “Mommy,” Khloe would answer.

After a few moments, Lopez, 26, told Khloe that Mommy was in the sky watching over her.

On the night of Khloe’s birth, Lopez was in the room as Semple was dying. No one told him what was happening. “I think they need to watch who they hire,” Lopez said, holding Khloe in his arms.

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