Academic OB/GYN

Dr Onyeije

By Nicholas Fogelson, M.D. and Chukwuma Onyeije, M.D.

Early reports described the story of Tracy Hermanstorfer as a “Christmas Miracle”. It has also been described as  inspiring, heartwarming, and “wonderfully appropriate for the season.” Others have referred to her saga as a nightmare with a happy ending.

On Christmas Eve 2009, Ms. Hermanstorfer was admitted to Memorial Hospital in Colorado Spring, Colorado after her water broke.  Ms. Hermanstorfer suffered a cardiac arrest during labor with her child Colton.  After immediate resuscitative efforts failed, nearby Maternal Fetal Medicine physician (Dr Stephanie Martin) performed an emergency cesarean section.  In the minutes following the delivery, Ms Hermanstorfer regained circulation and breathing, and is now doing well. Her infant also went on to survive and is apparently well.

While it is clear that the heroic efforts from Dr. Martin and the team at Memorial Hospital were instrumental in saving two lives on the night before Christmas 2009, the story raises many questions. Some are satisfied to conclude that it was simply a miraculous event for which we should not expect an answer. Others are concerned about the chances that a perfectly healthy woman in childbirth could experience cardiac arrest. Finally, others will assume that there was some deviation from accepted practice at the hospital that lead to the events of that evening.

As expected, following this event, there has been a great deal of speculation what happened.   Many theories have been provided, but the underlying message in the mainstream media is that the reason for this event is, and will remain unknown.

The internet media has not been as humble.   There has been no shortage of conspiratorial theories and hypotheses in the blogosphere.  For the most part, such explorations into the cause of the Christmas Miracle are helpful as long as they are grounded in facts rather than opinion.  Many observers feel certain  that this event was due to a complication of an epidural, and used this reasoning to accuse the entire obstetrical model of malfeasance.  In comments on various sites, the authors of the current post entered the fray based initial accounts of the events, to state that we did not think this case was related to an epidural issue.  Our initial suspicions were  that Ms Hermanstorfer had a primary cardiac event of some kind.  Later accounts have provided a somewhat different story of the events, rekindling the possibility of an epidural issue.

As we have thought about this case in greater detail, we both recall one of the most important lessons in medicine:

When you are hearing about a medical case second hand, you never have the whole story.

Each of us can recall instances in which we heard about something that went amiss and felt that we had the answers that the people who were there were somehow lacking.  After giving these opinions in retrospect with some authority, we have both been humbled in finding that our initial impression was incorrect, when additional information became available.

These situations remind us that medical cases passed over voice communication are like a big game of telephone, and the details are always scrambled in the end.   The problem is magnified when information is carried by untrained people who often lack the medical knowledge to effectively communicate what happened in an unambiguous way.  Even medical charts can be ambiguous at times, particularly when they are constructed retrospectively after a critical event, when there is no time for contemporaneous documentation.

The truth is that what everybody has been talking about on the internet (present company included) is a theoretical case, based on information passed through multiple media sources about something that really happened.  Its like a movie based on a true story. They aren’t talking about the real Tracy and Colton Hermanstorfer.  The only people who can do that are the people who were there, and they have been the most humble of all, clearly admitting that despite a thorough workup they do not know what happened.

As outside observers, we do not have the answers to this case. However, as practicing OB/GYN physicians with experience in the field, we have the ability to use our familiarity with labor and delivery along with forensic research, review of the available information and some educated guesses to form hypotheses for what may have happened to Tracy.

All of the clinical information that we have at our disposal comes from the descriptions of the event in the media and online video interviews.  In order to provide our perspective to the current discussion, first let us go through what information we have about this theoretical case, and maybe create some educated theories on what might have occurred.

There have been a number of account of what happened, but mostly they come from an interview with Mr Hermanstorfer and ABC interviewer.

ABC – “You were holding her hand as Tracy got the epidural… when did you start to notice that there was a problem occurring.”

Mr Hermanstorfer – “Well we actually had her sitting up when she got the epidural and it wasn’t until afterwards that she laid down and said she was tired, and that’s when the nightmare started…. She started going numb and everything in her legs like you said and she laid down to close her eyes and take a nap…. We were in for a long day… and she wasn’t waking up.”

ABC – “When did you notice her breathing was getting shallow or her fingers were getting blue?”

Mr Hermanstorfer – “When I felt her hand it started getting cold, and one of the nurses noticed that the color in her face was completely gone, she was gray as a ghost.”

Following these events, resuscitative efforts started.  30-45 seconds after nearby Dr Martin arrived Tracy’s heart stopped.  A cesarean was performed a few minutes later, and at some point after delivery Tracy recovered a heartbeat.

A number of physicians have been called upon to speculate on what occurred, but no physician has yet claimed to know exactly what happened, outside of saying that she experienced a cardiac arrest.  Childbirth Educator Henci Goer, on the other hand, has decided that this was certainly the result of a high spinal anesthetic that lead to respiratory collapse and cardiac arrest.

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So let’s go through a few possibilities, how they happen, and why or why not they might have occurred here.

HIGH SPINAL ANESTHESIA

A high spinal anesthetic occurs when anesthetic drugs intended to remain in the lower part of the spinal cord travel up to the top of the cord, creating greater anesthesia and paralysis than is intended.  This can occur either in the epidural space, above the duramater, where an epidural catheter is supposed to be, or in the subarachnoid space, beneath the durameter, where the catheter can (rarely) be inadvertently placed.

A high spinal has a characteristic presentation.   With a high spinal, after  dosage of the spinal or epidural anesthetic the patient’s level of numbness and weakness progressively rises.  Once it reaches the level of the chest, some of the breathing muscles become paralyzed, giving the patient the sensation of not being able to breathe, despite continued motion of the diaphragm.  If the level reaches C3, the diaphragm will become paralyzed, rendering the patient unable to breathe.  A high enough spinal also blocks the sympathetic nervous system, which speeds up the heart and is part of how we maintain blood pressure.  This can lead to lower blood pressure and pulse rate.  All of these things together, if untreated, could eventually lead to a cardiac arrest.  The medical literature does describe cases of cardiac arrest following high spinals.

After reviewing what information we have, we feel it is possible that this is what happened in this case.  However, there are some problems with this theory.   First of all, if this had occurred, Ms Hermanstorfer would have had progressive shortness of breath and eventual respiratory collapse.  Nothing in the transcripts indicates that this happened.  The only mention of “shallow breathing” is by the interviewer, and was not corroborated by any source that was actually there.  In fact, no-one but the interviewer ever mentioned shortness of breath at all.  Her husband mentioned that she felt tired and wanted to go to sleep, which is not what someone short of breath would do.  In fact, shortness of breath is a very strong stimulator of the central nervous system, and nobody would want to sleep in that state.

And most telling, there is not one mention of a high spinal anywhere in any story, nor by the physicians treating the patient, or by physician commenters.   A high spinal is something that is not hard to recognize.  If it had happened, we wouldn’t be talking about a mystery at all – and if it had made the news at all it would have been reported as such.

LIDOCAINE TOXICITY FROM EPIDURAL ANESTHESIA

A rare complication of epidural placement is placement of the epidural catheter into a small vessel in the epidural space.  If this is done, the local anesthetic lidcoaine can be infused directly into the venous system and thus into the heart.  In adequate quantities, this can cause cardiac arrest.

Some have speculated that this might have occurred, and it is worth considering.   But there are two big problems with this theory.  First, it is standard procedure when placing an epidural to use a test dose of anesthetic mixed with some epinephrine.  If the catheter is intravascular, that small amount of epinephrine will quickly cause tachycardia, alerting the anesthesiologist of the issue.  We don’t know if that was done in this case, but most likely it was.   The other issue is that like the high spinal issue, this case doesn’t really fit a lidocaine poisoning profile.   Lidocaine toxicity can cause cardiac arrest, but first it causes seizures.  Ms Hermanstorfer did not have seizures.

PRIMARY ARRYTHMIA

It is possible that Ms Hermanstorfer had a primary cardiac arrythmia, possibly due to a congenital heart defect or conduction pathway aberration.  I imagine that this has since been investigated with tests to evaluate the structure and function of her heart such as an EKG and an echocardiogram.

AORTOCAVAL COMPRESSION

Aortocaval compression syndrome, is a condition caused by the compression of the two major blood vessels in the back of the mothers abdomen (the abdominal aorta and inferior vena cava) by the pregnant uterus when a woman lies on her back.  Aortocaval compression is a frequent cause of low maternal blood pressure, which can in result in loss of consciousness.  In extreme circumstances it can also lead to a significant decrease in blood flow from the mother’s heart which can result in cardiac arrest and fetal demise.

Symptoms that precede loss of consciousness from aortocaval compression include  a rapid heart beat, sweating, nausea, low blood pressure and dizziness.  Aortocaval compression is very common in pregnant patients and would not be related to anesthesia.  However, it would be extremely rare for aortocaval compression to result in cardiac arrest as seen in this case.

AMNIOTIC FLUID EMBOLISM

An amniotic fluid embolism occurs when amniotic fluid enters the maternal vascular system.  This can cause massive cardiovascular problems, including sudden cardiac death, even in very small amounts.  This is certainly high on the list of what could have occurred in this case.  Some have claimed that her lack of bleeding and clotting abnormalities rule out this possibility, but we would point out that we actually don’t have this information.  She very well may have had some of those signs later.  Though a large embolism does reliably cause more long term illness, a very small one could present this way.    AFE is a very difficult thing to study, as large ones are frequently fatal, and non-fatal ones are hard to confirm, as the only real confirmation is through autopsy.  Thankfully we are spared that confirmation in that case, and so this possibility remains.

PULMONARY EMBOLISM

This is when a clot breaks off inside a vein, usually a leg vein, and ends up in the lungs.  A large enough clot can block all blood flow out of the heart in the lungs (called a Saddle Embolus), causing cardiac arrest and sudden death.  Though this was mentioned by a few newscasts, the fact that she did not have persistent shortness of breath and hypoxia after the recovery pretty much rules this out.  A small embolus wouldn’t have stopped her heart, and she would not have recovered quickly from a long one.

AIR EMBOLISM

This is when a large amount of air gets into the venous system.  This can act very much like a  pulmonary embolism, as it can block blood flow through the heart.  However, as the major components of air are blood soluble, this typically will be absorbed and the patient will recover.  The question in this case would be how the air got into the system, if that were what occurred.  Epidurals and IVs can’t deliver enough air to cause this issue.  If her membranes had been ruptured, this could have happened through the uterus, but that would be a very strange occurrence.   But this case is strange, so who knows.

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Finally, we think it is prudent to clear up some misconceptions which have been propagated in the media reports of this case.  The first issue concerns the status of the child at birth.  Some reports have indicated that the child was born lifeless and that the resuscitation of the infant was part of the miracle of the birth.  While we cannot deny the fact that it is a beautiful thing that Colton survived this harrowing birth, we do feel that it is not fair to the pediatric staff who performed the resuscitation to simply dismiss their actions as a byproduct of some larger miracle.  Indeed, when a fetus has an abnormal heart rate or a delivery is done as an emergency, it is not uncommon for the child to appear “lifeless” at birth.  It is a testament to the diligence and professionalism of pediatric care specialists that such infants are routinely resuscitated successfully at the time of delivery.

Secondly, many reports which have indicated that Ms. Hermanstorfer “died” and then came back to life miraculously.  While this certainly makes for sensational headlines, physicians are reluctant to make such claims.  Certainly when a persons heart stops beating, there is a presumption of cessation of life, but it is important to distinguish clinical death/cardiac arrest (which is reversible via CPR and other medical procedures) from biological death (which has no cure from a medical standpoint).  Tracy was clinically dead but not biologically dead.

It is possible (as Dr. Martin has indicated) that the act of delivering the fetus relieved pressure on the aorta and vena cava and provided the impetus for Ms Hermanstorfer’s heart to resume beating.  There is also a condition known as electromechanical dissociation in which the electrical activity of the heart continues but cannot be detected in the patient’s heart beat or pulse.

Another important issue concerns the time that Ms Hermanstorfer was in cardiac arrest.  Initial reports indicated a period of 15 minutes; however, subsequent interviews with Dr. Martin suggested 4 to 5 minutes.  This 10 minute difference is huge from a medical perspective because the likelihood of reversing cardiac arrest drops significantly the longer a person is in arrest.

In the end, we have an insufficient amount of information to determine why the “Christmas Miracle” occurred.  Based on what we know, the  most likely cause is either is an unusual form of aortocaval compression or a  primary cardiac arrythmia leading to cardiac arrest.  These conditions are highest on the list of medical problems that would lead to such rapid decline, and potentially recover as was seen in  this case.

Although we cannot say whether this case could have or should have been handled differently, we join with others in congratulating the medical staff at Memorial Hospital in Colorado Spring, for their rapid, life-saving action and wish all of the best to Tracy, Colton and their family.

Nicholas Fogelson, MD

Chukwuma Onyeije, MD