An anesthesiologist at a public hospital in Brooklyn, Dr. Dmitry Shelchkov, described his job as straightforward and not demanding.
However, when administering an epidural to Sha-Asia Semple, a pregnant woman in labor, at Woodhull Medical Center on July 3, 2020, Shelchkov made a mistake.
The catheter used to deliver the anesthesia was inserted too far, more than 13 inches, instead of the intended 4 inches, according to a state medical review board.
Additionally, Shelchkov administered a full dose of anesthesia without first testing a small dose, as per the state board’s findings.
As a result, the anesthesia reached Semple’s cerebrospinal fluid and affected her central nervous system.
As Sha-Asia Semple’s breathing became labored, she exclaimed “I can’t breathe” before losing consciousness. Another doctor intervened.
The doctor expressed disbelief and screamed at Shelchkov, as stated in a federal hospital inspection report.
Semple’s baby survived, but she did not. Her death occurred during a time of national conversation about racial disparities and sparked a demonstration outside the hospital.
Black women in New York City are nine times more likely to die from pregnancy-related complications than white women, a significant disparity compared to the national average.
This disparity is caused by various factors, but Shelchkov’s case highlights the disparities in the quality of medical care among hospitals in the city. He lost his medical license in late 2021.
The specific medical errors that led to Semple’s death have not been publicly disclosed.
Six other pregnant patients at Woodhull experienced adverse outcomes related to anesthesia administration in the two years prior to Semple’s death.
Shelchkov was reportedly involved in almost all of these cases.
The report found that Shelchkov had pushed the epidural needle or catheter too far in some instances, resulting in the anesthesia mixing with cerebrospinal fluid instead of remaining in a separate space near nerve roots.
These types of errors are typically caught and corrected quickly, but Shelchkov did not always follow safety procedures by giving a small test dose and waiting for the patient’s reaction before administering the full dose of anesthesia.
Woodhull administrators and department heads did not adequately monitor Shelchkov despite the pattern of errors.
The report depicts a concerning level of dysfunction at Woodhull, which is part of the city’s public hospital system.
Woodhull serves a diverse population, with the majority of patients being Black or Hispanic, and the majority of patients have Medicaid.
When complications from epidural anesthesia began happening frequently at Woodhull, they were not reported, and it was not until a patient died that administrators noticed a pattern.
In an interview with The New York Times, Shelchkov stated that when something went wrong, the anesthesiologist was always an easy target, and that staff tried to present themselves as heroes instead of taking responsibility.
He also mentioned that the death of Semple and the stress of working during the first wave of the coronavirus pandemic had left him feeling “devastated.”
The city’s public hospital system stated that it had several programs in place to reduce severe maternal morbidity and close racial disparities, including emergency simulation programs to train labor and delivery staff, and a greater role for doulas and midwives. The rate of cesarean deliveries at the city’s public hospitals is lower than the state average, which is a promising indicator.
Each year, over 20 women die from pregnancy-related causes and around 3,000 nearly die in New York City, with most of the deaths in 2017 and 2018 being among Black women.
Factors contributing to this include underlying medical conditions, lack of access to prenatal care or good medical insurance, and racial biases. Some providers fail to take some patients’ medical complaints seriously.
Research suggests that racial disparities in maternal deaths are also linked to the fact that Black women are more likely to deliver at hospitals with lower quality of obstetric care.
In an interview with the Times, Shelchkov stated that he was proud of working through the pandemic, sometimes working 85 hours a week at Woodhull.
Shelchkov stated that the pandemic affected his focus and left him exhausted, but a state medical review board stated that this was no excuse for what happened.
According to the federal report, Shelchkov was called to administer an epidural to a 31-year-old woman at 3 a.m. on May 22, 2020, and the woman became unresponsive and had to be intubated, and her baby was delivered via C-section. The mother recovered.
A state medical committee later found that the episode appeared to be another case of Shelchkov placing the epidural catheter too deep, an error that occurs in 1 in 1,000 epidural attempts, according to an anesthesiologist hired as an expert.
By the time Shelchkov’s medical license was revoked in late 2021, he stated he had been disabled by a severe COVID-19 infection and moved back to Russia after 25 years of practicing medicine in the United States.
Shelchkov stated that Semple’s death was the only time someone in his care had died during his four decades of practicing medicine and that he was devastated by it and felt close to suicide.
He mentioned that a baby was growing up motherless.
The baby is now 2-years-old and loves gymnastics, Silly Putty and slime, and recently asked her father where her mother is.
The father, Juwan Lopez, remembered how excited Semple had been throughout her pregnancy and how many times he had shown his daughter maternity photos and the video of the gender reveal where Semple let loose pink balloons, he would ask her “who’s that” and she would answer “Mommy”
Lopez said that on the night of Khloe’s birth, he was in the room as Semple was dying, no one told him what was happening and he thinks they should be more careful when hiring people.