The Death of Tori Bowie, Pregnancy and Social Determinants of Health

Let me put it right out there. I am the daughter of a schizophrenic, so I am well-versed in discussing mental health issues.

My beloved mother battled schizophrenia from adolescence until well into her adult life. Because of the graciousness of her sisters, who allowed me to live with them, I did not end up in the “system” (aka foster care) despite their limited resources.

Tori Bowie, like me, was not raised by her mother but by her grandmother. We do not know the circumstances, nor is it necessary. She was an Olympian in track and field, and as the mother of two cross-country state champions, I understand that journey well. The discipline. The perseverance. The pressure to be perfect in a very imperfect world.

Tori was found dead at the age of 32, pregnant and alone. It took a well-check visit by law enforcement to discover her death. How does a 32-year-old woman end up dying at home alone while giving birth?

Initially, people speculated that this tragedy resulted from a home birth gone wrong. However, the objective evidence does not support that if you dig deeper, and as a physician and MSW, I did.

The Orange County Coroner’s report states Tori weighed 96 pounds on a 5’9 frame. The calculation of her BMI (Basal Metabolic Index) results is 14.2, meaning she was significantly underweight during her pregnancy. Her weight is the type of weight you see in cancer patients.

Orange County Coroner also reported that Tori also had a medical history of Bipolar Disorder. This objective evidence is a glaring red flag that my poor sister had some deep issues. One of her friends commented that Tori’s world was becoming “more and more isolated.” “People had disappointed her.”

Her agent, Kimberly Holland, commented that Tori “did not trust hospitals.” That statement broke my heart because, as a Black woman, her reasons were valid. But back to her weight and her friend’s comments. Did the father of Tori’s baby abandon her? Was her weight loss reflective of depression? We will never know these answers. I’m not trying to pry into Tori’s personal life, but her case represents teachable lessons for the future. It demonstrates why addressing the social determinants of health of pregnant women, especially women of color, is so important.

Tori Bowie’s case highlights the importance of checking in on friends and family even when they don’t want us to. Even if it means getting on a plane, especially if they’re pregnant, it may mean you get your feelings hurt, and I have borne witness to that regarding a personal family issue that I will not discuss.

Yes, Tori died from complications of pregnancy that included eclampsia and respiratory failure, but I suspect my sister also died of a broken heart.

 

The Deadly 17 Minute Cesarean Section: In Memory of Kira Johnson

The public should be wary of certain physicians, and the late Kira Johnson’s physician is one of them.

According to Case No. 800-2016-021723, the California Board of Medicine received six complaints of medical negligence against Dr. Arjang Naim, who is a board-certified obstetrician-gynecologist who practices in Los Angeles and Beverly Hills, California.

On April 12, 2016, Johnson entered Cesar Sinai Hospital for an elective C-Section accompanied by her family but left the hospital without her.

I attended medical school and did my internship with men like Arlang Naim and know them well. Cowboys is what we called them back in the day. They took pride in whizzing through operative surgeries like they were in a race against time. Safety rules did not apply to them. They breached standards of medical care, and no one held them accountable.

In cases of emergency C-sections, the expected length of time is thirty minutes. Kira Johnson had no emergency conditions, and her C-section was an elective procedure. Naim had two medical practices in Hollywood and Beverly Hills and was probably multi-tasking.

Johnson’s procedure began at 2:31 p.m. and ended at 2:48 p.m., 17 minutes, including her delivery. Unfortunately, in Naim’s haste, he failed to close the bladder flap. Shortly after that, he left the hospital, leaving Johnson’s care to the resident physicians who were in training.

At 4:40 p.m., Johnson developed abnormal bleeding in the bag that collects urine (known as the Foley catheter). Then, at 5:45 p.m., a massive blood clot could be felt through her skin incision. Her pulse then increased dramatically, and is a classic sign of impending shock.

Johnson received multiple blood transfusions and exhibited signs of a dangerous condition called DIC (disseminated intravascular clotting) which meant her blood was not clotting properly. Naim did not arrive at Johnson’s bedside until 8:47 p.m. Despite Johnson’s unstable condition, he wrote orders, including a CT scan and then LEFT THE HOSPITAL.

Johnson’s condition deteriorated further, and the resident physicians called Naim again. He arrived at the hospital at 11:45 p.m. but only wanted to continue to merely observe. However, the resident physicians convinced him to return to the operating room to determine the site of her bleeding.

At 12:25 a.m., Johnson was taken back to the operating room, and at 1:15 a.m., the resident physicians scrambled to find a general surgeon to assist Naim with the procedure. Unfortunately, Kira Johnson’s heart stopped beating.

Further evidence from the California Board of Medicine reported that Johnson was not the only patient who experienced medical neglect.

  1. On August 21, 2015, a patient had a ruptured tubal pregnancy. Naim performed her surgery but failed to achieve any follow-up hospital care for three days despite her requiring a blood transfusion
  2. On March 14, 2016, a patient had a ruptured uterus after experiencing a 16-week pregnancy loss. The uterus was repaired, the patient required a blood transfusion, and Naim did not see the patient during her entire hospital stay.
  3. On May 31, 2016 (approximately one month after Kira Johnson expired), Naim performed a C-section on his patient with a placenta previa (placenta covering the baby). Unfortunately, the placenta could not be removed, and the patient required a hysterectomy performed by Naim and a GYN oncologist. Although it was Naim’s patient, he failed to see her daily during her hospital course.

The California Board of Medicine placed Naim on probation in 2018 for two years, but he is practicing medicine again, including delivering

Would you want him to be your physician?

Soulmates Left Behind on Mothers’ Day

Charles Spurgeon Johnson, Anthony Wallace, Juwan Lopez, and Bruce McIntyre III.

On this Mother’s Day, I honor the soulmates of mothers who left before their time on earth based on clinical incompetence, arrogance, and, yes, that dreaded word no one wants to discuss but is ever apparent racism.

Here are some examples of why Sha-Asia Washington, Amber Rose Isaac, Kira Johnson, and Dr. Chaniece Wallace are no longer with us:

Dr. Dmitry A. Shelchkov, a foreign medical school graduate, failed to provide adequate oxygen or monitor three previous patients before finally killing Sha-Asia Washington. He did not give her oxygen when she became short of breath and placed her epidural catheter incorrectly. His mistakes had been known for years, but it took the death of a 26-year-old first-time mother before the New York Medical Board suspended his medical license.

The obstetrician who performed a 17-minute elective C-Section led to a postpartum hemorrhage and the preventable death probably of Kira Johnson. Unfortunately, he probably still has privileges at the infamous Cedar Sinai Hospital.

The ob-gyn residents and their attending physicians at Montefiore Hospital who missed Amber Rose Isaac’s dropping platelets are probably still practicing without any accountability except providing a pathetic apology that will not bring her back to life.

And then there’s the case that keeps me up at night involving my fellow physician colleague and sorority sister, Dr. Chaniece Wallace. The horrific two-hour delay of starting an intravenous line in the setting of her hypertensive crisis is chilling. Yet, St. Vincent’s Hospital in Indiana purports to have given her the best care.

Yet, amid this madness, four remarkable men have turned their pain into action on behalf of their departed soulmates. Their comments and posts on social media platforms demonstrate a palpable love. They speak about their beloved in the present tense. They not only continue to love these women but remain IN love with them despite their physical absence of 6 years for Charles Spurgeon Johnson IV and two years for Anthony Wallace, Juwan Lopez, and Bruce McIntyre III.

These brothers teach us that love continues to win, even in death, and has created beautiful children that represent their legacy.

Today, I salute the soulmates of Kira, Sha-Asia, Amber, and Chaniece, who continue to teach all of us that death has no real power over love, just as it had no power over Jesus, the Christ.

May my sisters continue to rest in Power, and may their memory continue to be a blessing.