Gosnell Grand Jury Excerpts: “It was beyond reckless for Gosnell to entrust this delicate and dangerous medical procedure to Williams or any of his other unlicensed, untrained, and unsupervised employees – particularly with no monitoring equipment and no doctor on-site to step in if there was trouble”

By Dave Andrusko

Page1re-216x300On Monday we began excerpts from that portion of the Grand Jury report that described the conditions leading up to the cardiac arrest—and subsequent death—of 41-year-old Karnamaya Mongar. Today’s excerpt talks about the terrible choice of drugs—and the excessive amounts– the absence of monitoring, and (once again) the use by Kermit Gosnell of untrained staff to perform duties they were not equipped to do properly, or safely.


Repeated injections of strong narcotics, administered in accordance with Gosnell’s standard procedures, killed Mrs. Mongar

Sherry West and Lynda Williams provided several contradictory and unreliable versions of what took place in the three hours between when they sent Mrs. Mongar’s daughter away from her mother and when the ambulance was called. (Both women chose not to testify before the Grand Jury but made statements to the federal authorities.) What is clear, however, is that they administered a combination of dangerous, sedative drugs, and they did so under Gosnell’s standard instructions and with his carte blanche approval – but without the doctor’s personal supervision or presence in the facility. Indeed, Gosnell had never met the 4’ 11”, 110 lb., Asian woman before allowing his unlicensed staff to administer the narcotics that put Mrs. Mongar into a deep sleep.

It is also clear that more than three hours passed from the time Mrs. Gurung was unable to rouse her mother and was told to leave the recovery room until the ambulance arrived at the clinic. Ashley Baldwin testified that just before Mrs. Mongar was taken into the procedure room, she was awake again and groaning in pain. Ashley called Williams, and Williams escorted Mrs. Mongar into the procedure room, put her on the table, and  placed her feet in stirrups.

Ashley said she expected that Mrs. Mongar would continue to be medicated until she precipitated [delivered the premature infant]. According to her testimony, she could tell that Williams did in fact sedate Mrs. Mongar after placing her onto the procedure table. The patient, who had been groaning in pain and moving around, suddenly became completely still and silent. Yet Mrs. Mongar was left alone. Williams, according to Ashley, sat outside the procedure room, even though no machines were monitoring the heavily sedated patient.

Williams acknowledged that, after she took Mrs. Mongar to the procedure room,  she gave the patient more sedating medication – this time the clinic’s “custom” dose. The “custom” dose, as described on the clinic’s anesthesia chart, consists of 75 mg. of Demerol, 12.5 mg. of promethazine, and 10 mg. of diazepam. [See Appendix A.] West told the FBI that, before Williams anesthetized Mrs. Mongar in the procedure room, she and Williams telephoned Gosnell, who had yet not arrived at the clinic.

According to Williams’s statement, Gosnell instructed her to “med her up,” meaning to medicate the patient and get her ready for the procedure. Williams said that Gosnell came down (she claimed that he was upstairs when she called him) to do the procedure about 10 to 15 minutes later.

Dr. Andrew Herlich, the Chairman of the Anesthesia Department at the University of Pittsburgh Medical Center, testified that even a single “custom” dose was a “very, very heavy dose” that would constitute deep sedation or even general anesthesia. He explained that the promethazine, although helpful in treating nausea, can have a multiplier effect on Demerol. Together with 10 mg. of diazepam, the drugs constituted a “very potent sedative.”

Dr. Timothy Rohrig, the Director of the Sedgwick County (Kansas) Regional Forensic Science Center, testified as an expert in forensic toxicology. Dr Rohrig’s testimony substantiated that Mrs. Mongar received either multiple (more than two) doses of 75 mg. Demerol or one extremely large dose. Still, Dr. Herlich was incredulous when asked, hypothetically, about the effects of two “custom” doses (each containing 75 mg. Demerol, along with smaller doses of promethazine and diazepam). The anesthesiologist could not conceive why a doctor would ever give two doses. Dr. Herlich opined that if average-sized adults, with no particular sensitivities to the drugs, were given two “custom” doses within four hours, “most would stop breathing.” Mrs. Mongar was 4’11’’ and 110 pounds – significantly smaller than average. And she did in fact stop breathing.

Assistant Medical Examiner Dr. Gary Collins determined that Mrs. Mongar died as a result of an overdose of Demerol. He also confirmed Dr. Herlich’s testimony that the combination of diazepam and Demerol “work[ed] together to make her respiration or respiratory depression even worse.”

The medical examiner’s toxicology report showed that, approximately 18 hours after the paramedics were summoned (after which no further Demerol was given), Mrs. Mongar still had a Demerol concentration of over 700 µg/L (micrograms per liter) in her blood. When the toxicology expert attempted to draw a chart to illustrate the corresponding concentration level at the time the medication was administered, he literally pointed off the chart, saying: “The peak concentration is going to be off the scale way up here.”

Dr. Herlich was appalled not only by the dangerous mixtures of drugs administered, but also by the clinic’s procedures. He explained that it is absolutely essential for a doctor who is ordering anesthesia to meet with the patient beforehand. Different patients, he noted, react differently to the drugs, depending on factors such as height, weight, age, medical history, pregnancy, and race. (Mrs. Mongar’s small stature, her ethnicity, and her pregnancy were all factors indicating that she could be more sensitive to anesthesia than average adults.)

He stated that it was “incredible to” him that a doctor would have staff administer sedation when he was not on-site and had not seen and consulted with the patients. Dr. Herlich also emphasized that anytime sedation is injected intravenously – and especially when it is deep sedation, as was administered to Mrs. Mongar – the patient needs to be monitored. The standards of professional care require, at a minimum, that an anesthesiologist monitor blood pressure, heart rate, heart rhythm, oxygen in the blood, and breathing. No physician should proceed with a second-trimester abortion, Dr. Herlich said, without all of the appropriate monitors – including an electrocardiogram to monitor heart rhythm and a pulse oximeter to monitor the oxygen saturation of a patient’s blood. Performing such procedures without monitors, the anesthesiologist testified, “is offensive to me as a physician.”

Dr. Herlich explained that drugs injected intravenously, as Lynda Williams did to Mrs. Mongar, can reach the heart in 9 seconds and the brain in 16 to 18 seconds. It is crucial, therefore, not only to monitor constantly, but also to administer the medications slowly, a little at a time, and to watch carefully to see how the patient reacts. It was beyond reckless for Gosnell to entrust this delicate and dangerous medical procedure to Williams or any of his other unlicensed, untrained, and unsupervised employees – particularly with no monitoring equipment and no doctor on-site to step in if there was trouble.

The reckless practices that killed Mrs. Mongar were even more irresponsible and dangerous because of the drugs involved. Dr. Herlich testified that Demerol has been out of favor for 10 to 15 years because it has serious side effects and because there are better, safer drugs to use during procedures. Demerol is made more dangerous by mixing it with diazepam, he said, and its potency is multiplied by promethazine. One of the safer drug options the anesthesiologist mentioned is Nalbuphine, a drug that Gosnell sometimes used in his so-called “local” concoctions.

But Eileen O’Neill testified that Gosnell would substitute Demerol because it was “very cheap versus the Nalbuphine.” Massof also told the Grand Jury that Demerol “was easier to obtain at a better price.” The expert testimony substantiated that it was hazardous to have the untrained employees administering even the promethazine. Promethazine, Dr. Herlich testified, has a “black box warning” attached to it, meaning that it has “a side effect that is so terrible that you better be cautious about using it.” The side effect is that if the drug escapes the vein while being administered intravenously, it can cause tissue necrosis, a condition that looks like a burn or a crater.

In light of the testimony of Dr. Herlich and other experts, it is no surprise that the combination of callously reckless and illegal procedures, unlicensed and unsupervised employees, and outrageously excessive sedation at Gosnell’s clinic proved lethal to Mrs. Mongar.