United States District Court, D. Montana, Great Falls Division
RHETT CRANTZ, Individually, as Personal Representative of the Estate of Venus Crantz/ and as Guardian of Marina Crantz, Marley Crantz, McKenzy Crantz, and Maisen Crantz, Plaintiff,
UNITED STATES OF AMERICA, Defendant.
FINDINGS OF FACT, CONCLUSIONS OF LAW AND
Morris United States District Court Judge.
matter came before the Court for trial without a jury, the
Honorable Brian Morris presiding, on October 11 and 12, 2016.
The plaintiff, Rhett Crantz, was represented by Timothy M.
Bechtold and Kristine M. Akland. The defendant, United States
of America, was represented by Assistant United States
Attorney, Timothy J. Cavan.
were sworn and testified, and certain exhibits were offered
and received into evidence. From the evidence presented, the
Court makes the following:
FINDINGS OF FACT:
JURISDICTION AND VENUE
is a negligence action brought by the plaintiff pursuant to
the Federal Tort Claims Act (FTCA), 28 U.S.C. § 2671,
et seq. The plaintiff seeks to recover damages from
the United States based on medical care provided to Venus
Crantz (Venus) by health care providers employed by the
Department of Health and Human Services, Indian Health
Service (IHS). The plaintiff alleges that IHS providers
negligently treated Venus when she presented to the emergency
department of the Fort Belknap Hospital, resulting in her
death. (Doc. 1).
the time this action was filed, the plaintiff was a resident
of the State of Montana, and lived in Blaine County, Montana.
The alleged acts and omissions which gave rise to this claim
also occurred in Blaine County, Montana.
plaintiff submitted administrative tort claims with the IHS
on or about January 31, 2014. The plaintiff filed the present
action on August 18, 2014, more than six months after
submitting his administrative claim, without a final
determination by the agency.
Venus was born in 1979 in Harlem, Montana, and died on
December 9, 2013. She was an enrolled member of the
Assiniboine and Gros Ventre Tribes, and lived in Harlem on
the Fort Belknap Indian Reservation. She received the
majority of her medical care during her life through the IHS
Fort Belknap medical facility in Harlem.
Venus married Rhett Crantz in 2004, and they had four
children together: Marina Crantz, born in 1996; Marley
Crantz, born in 2002; Mackenzy Crantz, born in 2006; and
Maisen Crantz, born in 2013.
Venus attended high school, and later obtained her
certification as a certified nursing assistant. She was
employed part-time as a nursing assistant by Sweet Memorial
Nursing Home in Chinook, Montana at the time of her death.
(Deposition of Joni Myhre). She had been employed by Sweet
Memorial since May 7, 2013.
Venus's medical history is significant for ongoing bouts
of asthma. Venus was first diagnosed with asthma in 2008.
Venus presented to the emergency department (ED) for acute
asthma attacks at least 10 times in the years that followed.
Her difficulties with asthma accelerated sharply in the last
1.5 years of her life, with approximately 13 contacts with
physicians and emergency visits occurring in 2013 alone.
Venus's asthma also progressively limited her personal
and work activities. A walk around the block with her young
child could lead to coughing spells that would require Venus
to return home. She also missed several days of work because
of her asthma.
DECEMBER 9, 2013 ASTHMA ATTACK
Venus was driving with her husband in Harlem on December 9,
2013, when she began to experience respiratory difficulties.
She returned home for a nebulizer treatment at approximately
7:00 p.m. Venus had three home nebulizer treatments, but they
were not effective.
Venus remained at home for approximately 1 to 1.5 hours
before William Abieta, her adopted brother, took her to the
hospital for treatment. It took approximately 3.5 to 4
minutes to travel from Venus's residence to the hospital.
Abieta dropped Venus off at the ED entrance.
Venus barely could breathe by the time that she arrived at
the ED. She walked up to the nurse's station window in
the emergency room and mouthed “I can't
breathe.” 12. Two nurses, Kathleen Olver and Shauna
Gilbert-Azure, and an IHS physician, Amy Kroeger, M.D,
staffed the Fort Belknap Hospital Emergency Department that
night. Dr. Kroeger is a licensed physician. She also attended
a residency program in emergency medicine at Washington
University from 2008 to 2011. She did not complete the
residency program, however, and lacks board certification in
Nurse Olver staffed the nurse's station window in the ED
when Venus arrived. Dr. Kroeger also observed Venus approach.
Nurse Olver and Dr. Kroeger promptly escorted Venus to a
critical care patient room. Dr. Kroeger also leaned into
another patient room, and told a second IHS nurse, Shauna
Gilbert-Azure, that her assistance would be needed. When
Gilbert-Azure responded, Dr. Kroeger sent her to retrieve
additional respiratory medications, and to summon additional
assistance from EMTs.
Nurse Olver attempted to record the timing of events She
testified that she looked at a clock in the critical care
room when she started an IV for Venus and recorded the time
at 8:20 p.m. She estimated the timing of events for the
medical record, before and after 8:20 p.m., based upon the
time each intervention typically takes to accomplish.
According to Nurse Olver's tracking, Venus presented to
the nurses' station window at approximately 8:16 p.m.
Within one minute, medical staff escorted Venus back to the
critical care room and started an Albuterol nebulizer.
Venus's oxygen saturation level increased after the
treatment from 87% to 95%.
Medical staff started a second nebulizer treatment with
racemic epinephrine at 8:19 p.m. Medical staff started an IV
line by 8:20 p.m., and they administered magnesium sulfate at
Kroeger continued to monitor and assess Venus's
respirations, breath sounds, and pulse. Dr. Kroeger detected
that Venus began to deteriorate rapidly as the administration
of magnesium sulfate was completed. Venus's pulse became
“thready, ” her heart rate increased, and her
breath sounds became less audible.
Venus collapsed at approximately 8:23 p.m. Dr. Kroeger
continued to assess her cardiac and respiratory status. Dr.
Kroeger determined that Venus was in respiratory arrest. She
was also unable to detect a pulse, and determined that Venus
had gone into cardiac arrest almost simultaneously with her
respiratory arrest. Venus continued to display pulseless
electric activity (“PEA”). PEA describes cardiac
electric activity that is too unordered to be considered a
Kroeger initiated cardiopulmonary resuscitation (CPR) after
Venus's collapse. Medical staff immediately started
ventilation with the use of a bag valve mask. They also
initiated chest compressions.
bag valve mask is a breathing device. A padded mask fits over
the patient's mouth and provides a seal around the mouth.
Pressurized oxygen connects to the device. The medical
provider forces oxygen into the patient's lungs by
squeezing a self-inflating bag.
Kroeger and Nurses Olver and Gilbert-Azure continued
resuscitation efforts for the next six minutes. Nurse
Gilbert-Azure ventilated Venus with the bag valve mask and
managed the airway.
EMT arrived at approximately 8:29 p.m., and began assisting
with chest compressions. The arrival of the EMT prompted Dr.
Kroeger to attempt for the first time an endotracheal
intubation of Venus. Intubation involves the placement of an
endotracheal tube through the vocal cords and into the
trachea. A provider must be able to visualize the
patient's vocal cords in order to perform the procedure
Kroeger attempted to perform an intubation at 8:29 p.m., but
she could not adequately visualize Venus's vocal cords.
She aborted the attempt. Medical staff restarted the bag
valve mask in an attempt to provide ventilation. The medical
team also continued CPR after withdrawing from the first
Venus's IV became dislodged at approximately 8:33 p.m.
The IV had to be restarted in order to administer
medications. Medical staff restarted the IV by 8:36 p.m., and
began to administer Epinephrine at 8:38 p.m. Additional EMT
assistance also arrived at this time.
Kroeger waited 9 minutes after the first failed intubation
attempt before making a second intubation attempt. Vomitus in
Venus's airway obscured Dr. Kroeger's ability to
visualize the vocal cords on the second attempt. Medical
staff suctioned this area. Dr. Kroeger remained unable to
visualize Venus's vocal cords.
Kroeger abandoned the second intubation attempt and chose
instead to start an alternative airway at 8:39 p.m., with the
insertion of a combitube. The combitube is a “blind
insertion” airway device intended to be placed at the
top of a patient's throat, above the glottis, or
supraglottis. The combitube does not require that the
provider visualize the vocal cords.
Medical staff administered several additional medications.
Medical staff also continued to administer CPR protocol for
45 minutes. The medical team proved unable to reestablish
spontaneous circulation or respiration. Dr. Kroeger called
the code at 9:08 p.m.
STANDARD OF CARE
Both parties presented doctors qualified to testify regarding
the appropriate standard of care in this case. The competing
conclusions by these witnesses reflect a difference in their
view regarding the appropriate standard of care to be applied
in this case in light of the training and experience
possessed by Dr. Kroeger.
plaintiff called Gregory Kazemi, M.D. as a standard of care
expert. Dr. Kazemi is a board certified emergency medicine
physician. He has practiced at St. Patrick's hospital in