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Crantz v. United States

United States District Court, D. Montana, Great Falls Division

January 13, 2017

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,
v.
UNITED STATES OF AMERICA, Defendant.

          FINDINGS OF FACT, CONCLUSIONS OF LAW AND ORDER

          Brian Morris United States District Court Judge.

         This 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.

         Witnesses were sworn and testified, and certain exhibits were offered and received into evidence. From the evidence presented, the Court makes the following:

         I. FINDINGS OF FACT:

         A. JURISDICTION AND VENUE

         1. This 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).

         2. At 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.

         3. The 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.

         B. BACKGROUND

         4. 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.

         5. 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.

         6. 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.

         C. MEDICAL HISTORY

         7. 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.

         8. 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.

         D. DECEMBER 9, 2013 ASTHMA ATTACK

         9. 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.

         10. 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.

         11. 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 any specialty.

         13. 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.

         14. 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.

         15. 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%.

         16. 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 8:22 p.m.

         17. Dr. 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.

         18. 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 pulse.

         19. Dr. 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.

         20. A 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.

         21. Dr. 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.

         22. One 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 safely.

         23. Dr. 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 intubation attempt.

         24. 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.

         25. Dr. 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.

         26. Dr. 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.

         27. 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.

         E. STANDARD OF CARE

         28. 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.

         29. The 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 ...


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