Another article outlining a horrible practice, on the face of it for insurance (=financial) reasons. However, remember that some 4D denizens appear to have a high interest in animal genitalia (see Linda Moulton Howe's excellent work on cattle mutilations for an example, as well as various books & articles concerning hybrids). Might also tie into DNA research of various types. Then again, it could just be what it states...
Placentas taken, but moms were not told
Medical ethics - As many as 700 afterbirths, many involved in difficult deliveries, made their way to a Portland registry, records show
Sunday, February 12, 2006
Shortly before Angela Desbiens' first child was due, a doctor told her that excess amniotic fluid in the womb put her baby's life at risk. A week later, Desbiens said, she felt her fetus stop moving.
Worried, Desbiens made panicked calls and visits to the obstetrician's office and even took herself to the hospital. Though everyone assured her all was well, after two days a doctor determined the fetus was in distress. She underwent an emergency C-section.
The birth of McKenna Desbiens, now 6, was not a joyous occasion. She soon suffered a seizure, the first sign of a profound impairment that has left her unable to walk, talk or eat without a feeding tube.
As the 23-year-old mother struggled with the devastating news, Providence St. Vincent Medical Center was quietly preparing for a potential court fight. Within days, the hospital sent her placenta to a Portland institute created and financed by the insurance industry, in part to help health care providers defend against birth-injury lawsuits.
The pathologist at the institute, Cascadia Placenta Registry, analyzed the tissue and drafted a report contending that McKenna's cerebral palsy was caused by blood flow problems, not improper care.
It wasn't until Desbiens sued Providence, four years after the birth, that she first read the report and learned what had become of her placenta, the organ that transports blood, oxygen and nutrients to a fetus.
"I couldn't believe it," Desbiens said. "We were never asked. It's such a violation of privacy."
"I feel so deceived," she said. "You just assume the doctors and hospital are going to do the right thing."
Desbiens was not alone. Placentas from as many as 700 women from hospitals throughout Oregon, California and Washington were sent to Cascadia from 1996 to 2003.
Several Oregon hospitals and their parent corporations helped finance Cascadia and sent placental materials there, including Providence Health System, Legacy Health System, Adventist Health, PeaceHealth, Kaiser Permanente Northwest and Good Shepherd Health Care System. Many of the women whose placentas were sent to Cascadia were unaware of the practice.
"It seemed very underhanded to me that the hospital was trying to protect itself and not the patient," said Ann Morton, who discovered after she sued Sacred Heart Medical Center in Eugene that her placenta had been studied by Cascadia. Her son, 31/2, has cerebral palsy; Cascadia's report blames an infection, Morton said.
Lawrence Wobbrock, a Portland personal injury lawyer, said he's looked at dozens of Cascadia's reports over the years. "Not one of my clients ever saw the reports, and the doctors never told them about the reports," Wobbrock said.
Officials at Providence and the other Oregon hospitals involved defended using Cascadia, saying the placental analyses were conducted for "patient care." Consent forms signed by patients when they were admitted gave the hospital authority to perform any necessary pathological exams, the hospital officials said.
Experts said the hospitals' actions did not appear to violate state or federal laws. But their dealings with Cascadia raise questions about how explicit providers should be when seeking permission to use bodily tissues.
Although hospitals commonly conduct tissue examinations for patient care purposes, the fact that Cascadia was created and financed by malpractice insurers and providers sets it apart. Among doctors, lawyers, pathologists and medical experts contacted for this story, only one could cite a similar organization. That lab operated in Ohio but is now defunct, said Dr. Carolyn Salafia, a nationally known perinatal pathologist in New York.
One of the country's leading medical ethicists, Arthur Caplan at the University of Pennsylvania School of Medicine, said he had never heard of an institute that operated as Cascadia does. Caplan said it's not enough to rely on a patient's general consent when collecting tissues for purposes of a potential lawsuit.
"If you're going to take things from patients -- extract DNA or use them as potential sources of defense in litigation -- subjects have an absolute right to know that and must consent or not," Caplan said. "To have insurance companies collecting this stuff is very problematic."
Desbiens, Morton and other women disputed the assertion that placental exams were part of their care. The Cascadia reports, they said, were not provided to them until after they sued. Moreover, in an era when hospital bills carefully itemize every charge, the women said, it was notable that neither they nor their insurers was billed for Cascadia's work. Hospital officials confirmed they did not bill for Cascadia's services.
Other pathologists said they share the results of placental exams with women, especially those who plan more children, to alert them to possible complications. Desbiens' obstetrician says she told her patient about the exam.
Doctors v. lawyers
Placental exams are one weapon in an increasingly acrimonious confrontation between health care providers and trial lawyers. Obstetricians are frequently subjects of lawsuits that turn on the scientifically murky question of what, precisely, caused a child's injuries or deficits.
Potential targets of lawsuits have fought back. Hospital "risk managers" are alerted to difficult births so they can gather evidence. Hospitals, doctors and insurance companies have attacked what they call questionable science that blames physicians for fetal injuries and deaths that they contend most often occur before labor.
Rising malpractice insurance rates have driven some hospitals and obstetricians out of the business of delivering babies. Settlements or verdicts can reach millions of dollars in cases where injured children need a lifetime of round-the-clock care. Birth injury cases have become a specialty in the legal field.
"It's a huge lottery," said Dr. James Affleck, former chairman of NORCAL Mutual Insurance Co., a doctor-owned malpractice insurer from California and one of Cascadia's primary underwriters.
"Errors are made, and families should be compensated," he said. "But there are other cases where it's quite clear -- particularly with cerebral palsy -- that they are not due to malpractice. But you have such a sympathetic witness with the damaged child that emotional awards are made out of proportion to fault or the damage done."
Affleck served on Cascadia's board until it closed in 2003 after nine years because of insufficient financing. He said the organization helped defeat at least five lawsuits and saved insurers at least $5 million. Although Cascadia no longer operates, its reports will continue to surface in Oregon, Washington and California as families sue over alleged injuries in past births.
Affleck said Cascadia saw no reason to inform women directly that their placentas had been sent out for study. "You don't give specific consent to have every blood test and every pathological exam," he said.
A new kind of registry
Widespread use of fetal monitors in the early 1970s gave plaintiffs' lawyers a powerful weapon: a written record of when babies were in distress.
Two decades later, malpractice insurers discovered a defensive weapon in what was once considered hospital waste. The placenta, they learned, could be equally powerful evidence that pre-existing conditions might explain a child's injuries or death.
Northwest Physicians Mutual, Oregon's largest medical malpractice insurer, created Cascadia Placenta Registry in 1995. The company, now called Northwest Physicians Insurance Co., joined four other insurers, two hospitals and a prominent malpractice law firm in Portland. Together, they contributed $179,000 to the start-up.
Cascadia opened its doors a year later in rented space at the Portland VA Medical Center. Its operations were supported by the original donors, which along with additional insurers and hospitals donated as much as $78,000 annually, records show.
The group hired Dr. Waldemar Schmidt, then an Oregon Health & Science University pathologist, to oversee the institute. Schmidt's daughter handled administrative affairs; his son-in-law was awarded a contract to provide computer support.
"Its purpose was rather idealistic -- to gather more information about the physiology of the placenta and how it related to birth injury," said Dr. Bob Taylor, who was medical director of Northwest Physicians Mutual at the time.
Cascadia's promotional materials, distributed to hospital risk managers and other health care professionals, told an additional story, suggesting its purpose was to help fight lawsuits.
"The burden on the physician can be eased when placental pathology provides evidence in court that poor outcomes are not the result of clinical care," one Cascadia brochure declared.
Much of the promotional material and Cascadia's financial records were disclosed as part of a civil suit in Multnomah County against Providence that alleges obstetrical mistakes are to blame for McKenna Desbiens' condition. They were kept under court seal until late last year, when Angela Desbiens' attorney, Jeffrey Wihtol, persuaded a judge to release them over Schmidt's objections.
Pathologist travels, testifies
Records from the Desbiens case and others show that, from its inception, Cascadia prepared to join the ongoing battle between patients and health care providers.
Cascadia paid for Schmidt to attend "witness school" in Portland to learn more about testifying in court. He also traveled to hospitals across the state to educate risk managers about placental pathology, Cascadia records show.
"My role was to examine the placentas and report the pathology as I saw it, whether it was favorable to anybody," Schmidt said in an interview. In 80 percent of the cases he reviewed, Schmidt said, he found problems that helped explain a baby's injuries.
Cascadia was stepping into a national debate. As the focus on the placenta grew, so too did the scientific dispute about the value of placental abnormalities in understanding fetal deaths or injuries.
The disk-shaped organ allows a baby to live and grow in the womb. Attached to the umbilical cord, it takes waste products from the fetus and exchanges them for oxygen and other nutrients in the mother's blood.
Because the placenta is present throughout the development of the fetus, it has been called a "diary of the pregnancy," said Dr. Ona Marie Faye-Petersen, author of the "Handbook of Placental Pathology."
"The placenta will tell a story or can help tell a story," said Faye-Petersen, an associate professor of pathology at the University of Alabama School of Medicine. "It is a critical component of understanding the pregnancy. Is it the only component? No. Can it tell you everything? No."
Flaws in the placenta are not irrefutable evidence that a baby has been harmed.
"Just like we have two kidneys, the placenta has some functional redundancy. Not every death of placental tissue is lethal," said Salafia, the New York pathologist. "My feeling is there's no one finding under a microscope that either saves a doctor or hangs a doctor."
Nothing was moving
By the time Angela Desbiens and her husband, Scott, showed up in the Providence emergency room the night of Feb. 10, 2000, they were nervous. Angela was seeing spots and hadn't felt movement in her womb for nearly three days.
As she waited to be admitted, Angela filled out paperwork. Amid the boilerplate phrases was this sentence: "To the extent that is advisable for my care, I consent to anesthesia, blood products, pathology laboratory services, radiology services, prescription drugs or other medication as authorized by my physician."
Within hours of her birth, McKenna suffered a seizure several minutes long, her parents said. Doctors and nurses realized the baby was in grave trouble and told the couple their daughter faced serious problems. Desbiens' placenta was collected and sent to the hospital's staff pathologist, who later testified he had found no abnormalities.
Eight days after McKenna was born, the risk management office at Providence sent the placenta to Cascadia.
Diane Waldo, one of Providence's obstetrical risk managers, later testified in a deposition that Desbiens had given the hospital permission to send her placenta to Cascadia when she signed the consent form.
However, Waldo said, she could not identify any medical reason for Cascadia's tests. "I'm not aware of any patient care issue" she said in the deposition.
Under questioning, Waldo also acknowledged that she did not know of any Providence patient whose medical care had been affected in any way by reports from Schmidt, Cascadia's director.
Placenta sliced up
Until a few weeks ago, the remains of Angela Desbiens' placenta sat in a broken plastic container in her attorney's office, along with slides of the tissue that had been prepared by Schmidt.
Schmidt had sliced the placenta into several small chunks, according to his deposition in the Desbiens case. Wihtol said that made it difficult to find another pathologist to examine the material and gave the hospital a legal advantage.
Several pathologists said there are ways to examine the organ without compromising its integrity. Salafia said one method, called breadloafing, involves cutting carefully, with slices that do not go all the way through, to keep the placenta intact.
Asked for comment, Providence officials said they could not discuss a pending lawsuit. Schmidt said that even though the placentas had been cut into pieces, they were still usable. "The specimens are not destroyed and are available for examination," he said.
When Desbiens finally read Schmidt's report in 2004, she was startled. The report said blood flow through her placenta showed signs of "compromised maternal/placental circulation," and it asserted that McKenna had suffered from a "true knot" in her umbilical cord, a potentially fatal condition that cuts oxygen to the fetus.
But there was more: Desbiens was a genetic accident waiting to happen, the report claimed. Her sister had suffered spina bifida, a disorder that can cause paralysis and mental retardation. And an uncle had "fragile X," a genetic disorder linked to retardation, the report said.
Desbiens said she was never informed of any of these conclusions. The on-call obstetrician who delivered McKenna, Dr. Lisa Thum, said in her sworn testimony that she discussed the report with Desbiens a month after the birth. The report contained "nothing new" about the cause of McKenna's problems, she said.
In her deposition, Thum also acknowledged that Cascadia's report was full of errors that she did not correct. She testified that McKenna never had a true knot and that statements about Desbiens' family genetic background were wrong. Records show that the hospital mistakenly sent another patient's genetic history to Cascadia.
Salafia said the report should have been shared immediately with the patient.
"This is a potentially recurrent problem," Salafia said of the circulation problems cited by Schmidt. "There are studies we can do before a woman gets pregnant a second time to improve risks, and tests we can do to assure problems aren't happening twice."
Salafia and another pathologist reviewed Schmidt's report at The Oregonian's request.
Salafia said the document lacks evidence to support its findings. While asserting that Desbiens' placenta showed signs of poor blood flow, the report does not identify an underlying cause, she said.
Dr. Randall Craver, a professor of pathology and pediatrics at Louisiana State University Health Science Center in New Orleans, called the report "either sloppy or misleading" and said that Schmidt is "taking the diagnoses and drawing conclusions that aren't based on his pathologic findings."
Schmidt defended his work, saying it is impossible for critics to judge his reports without access to the samples, slides and other materials he had at the time. "Among pathologists, differing opinions are common," he said.
Schmidt operates a consulting business doing similar placental exams -- mostly for risk management purposes for hospitals in Oregon. He is no longer funded by insurance companies.
What went wrong?
During a recent interview in Wihtol's Portland office, McKenna Desbiens sits on her father's lap.
At age 6, she weighs 32 pounds and still wears diapers. She has silky brown hair cut page-boy style and dazzling blue eyes. Despite her disabilities, she is social and makes giggling noises, even though she doesn't speak.
The dispute over her mother's placenta continues. Wihtol's suit against Providence argues that McKenna's cerebral palsy was caused primarily by a delay in her delivery. Doctors, he contends, should have moved more quickly after Desbiens' first report that her fetus wasn't moving.
Providence denies any wrongdoing in McKenna Desbiens' case. A trial is set for April in Portland.
Last month, the Desbienses received a letter from Providence raising another issue of medical privacy.
In it, the health system said McKenna was among the 365,000 current and former Providence patients whose medical records were on computer backup tapes that had been stolen from an employee's car in December.
"We try very hard to earn your trust at Providence," said the letter, addressed to McKenna. "And that includes protecting sensitive information about you."
Susan Goldsmith: 503-294-5131; email@example.com