Xavier Soto has been desperately looking for answers since his 23-year-old partner, Jeimily Morales, died in June at a hospital in Puerto Rico, nine days after the pair returned from a vacation to the Dominican Republic.
Soto, 27, believes Morales, the mother of a 4-year-old boy, was in good health during their trip to the neighboring Caribbean island. She had a thyroid condition which was under control, he said. He says he would later tell four hospitals that she had a rough landing during a zip line ride, but didn't notice her back hurting until shortly after landing back in Puerto Rico, two days later. Her condition worsened from there.
Morales' death on June 26, which followed the string of hospital visits in Puerto Rico, was the result of a pulmonary embolism, Soto was told by doctors at the Mayagüez Medical Center in the western part of the island.
She died at a time when the Dominican Republic's image had been under scrutiny after the recent deaths of U.S. tourists in different hotels and resorts. But Soto is not pointing fingers and is not ready to do so. What caused the pulmonary embolism that took Morales’ life? Was it something that happened on the trip to Punta Cana with effects that went unnoticed when she was treated in Puerto Rico?
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Perhaps, according to a doctor not involved in her care who is an expert on pulmonary embolisms, and who says that immobility during air travel can put certain travelers at risk for blood clots.
Doctor Umesh Gidwani, chief of cardiac critical care at Mount Sinai Hospital in New York City, told NBC he finds it strange that doctors in the hospitals visited by Morales didn’t suspect the possibility of an embolism, given that Soto says she reported that her back hurt. She then complained about chest pain, had trouble breathing and had traveled on an airplane a few days before, Soto said.
A pulmonary embolism, Gidwani explained, is when “a blood clot forms somewhere in the vein, typically in the legs or pelvic area.” The clot grows as it accumulates blood until it is expelled, then travels through the artery that goes up to the lungs, where the clot lodges. The consequences can be fatal.
A patient with a pulmonary embolism typically meets at least one of three criteria known as the Virchow’s triad, named after the German physician Rudolf Virchow, who studied embolisms about 200 years ago. The factors are “damage to the lining of the blood vessels (veins and arteries), reduced mobility or immobility and a tendency to form clots” depending on a person’s coagulation, according to Gidwani.
Sometimes someone at risk of suffering a pulmonary embolism shows no symptoms, but in Morales’ case, two of the three factors appeared to be present and they didn’t seem to be silent, according to Gidwani.
“She probably had a blood vessel injury [...] But the other thing here is that she took a flight, and that is immobility. So, the combination of the damage to the endothelium (blood vessel) along with the immobility (in the flight), caused the clot to form,” he said.
The blood vessel injury may have been the result of Morales' mishap on the zipline in Punta Cana.
“She let herself go off the rope like a second earlier than she was supposed to and had a kind of a rough landing on the water,” Soto said.
“It’s entirely possible that the small blood clot formed during this flight and then went undetected,” Gidwani said.
Gidwani admitted the diagnosis is challenging but it’s possible through a CT scan or an ultrasound machine, if there’s any suspicion of a clot, as he believes there should have been in Morales’ case. If detected, doctors administer the patient a blood thinner or perform a procedure to remove the clot with a catheter, ultrasound waves or use of a clot busting drug, Gidwani said.
Morales wasn’t given any of these treatments until her last hospital visit. Medical records provided by Soto showed she was prescribed muscle relaxants and pain relievers like tramadol, meloxicam, amoxicillin, among others. She was also given shots of toradol, morphine and decadron.
“She was treated for spasms [...] I was surprised they didn’t even run any blood tests,” Soto said.
For doctor Andrew J. Einstein, associate professor and director of cardiac CT research at Columbia University Irving Medical Center, a CT scan is performed “if it’s a patient who has a high pretest probability of having a pulmonary embolism.” Einstein understands that a pulmonary embolism on a relatively healthy young woman complaining about musculoskeletal pain is not at the top of the list of a diagnosis.
However, “every patient who comes to the emergency department on multiple visits and keeps coming back and they report to the physician that they have chest pain and shortness of breath has to be taken seriously and they need more than just a treatment for back spasms.”
In a scenario of constant visits to the hospital with Morales showing chest pain and shortness of breath on top of musculoskeletal pain, Einstein said a D-dimer blood test should’ve been ran to detect the blood clot that ultimately took her life.
“Almost every patient who shows up to the emergency department gets blood work. Certainly, patients who show up multiple times,” Einstein said.
A D-dimer blood test helps detect blood clots in a patient and in Morales’ case, if performed, the results “would’ve been positive,” according to Einstein.
Morales, who was recently promoted to manager at the Church's Chicken fast food restaurant in her hometown, had lost her Medicaid health insurance about a month before because her new income exceeded the limit for eligibility. Soto said they were in the process of acquiring a private medical insurance plan for her and her son.
From 'An Amazing Week' to the 'Unthinkable'
Soto recalled having “an amazing week” in the Dominican Republic. They met another Puerto Rican couple and spent time at beaches, the hotel pool, nightclubs and an adventure park.
On June 16, the evening of Father's Day when they landed in Puerto Rico, Morales mentioned “her back hurt really bad.” So they decided to go to a pharmacy. She took a pain reliever and lay down in bed to rest, but it didn’t help, he said.
The following morning, as her pain persisted, Soto took Morales to the Aguadilla Medical Services Center where they gave her a shot of decadron -- a steroid to treat inflammation -- and a pain medication prescription after X-ray images didn’t reveal anything abnormal except a severe spasm, records show.
The scene repeated five other times in three other hospitals in the following week. The four hospitals visited by Morales declined to comment on her case regardless of a HIPAA waiver form the family signed allowing them to talk to NBC about Morales’ case. The hospitals said it's their policy not to comment about specific cases even if authorized by families.
The three times Morales visited the emergency room at Aguadilla Medical Services, on June 17, 18 and 19, she was given shots and higher doses of pain medication each time, until a doctor referred her to a physical therapist, according to Soto.
“We went to the therapist who massaged her and she felt slightly better so we didn’t go to the hospital” the following day, Soto said.
But on Friday, June 21, the pain worsened. They visited the Buen Samaritano Hospital, also in Aguadilla, after she noticed a rash on her chest and complained about having trouble breathing. “The doctor said that was a normal reaction to the severe spasm she had,” Soto said.
As her pain intensified, Soto said he became desperate. He took Morales to a different hospital, San Carlos Borromeo, in the nearby city of Moca on June 22 and 24, where a doctor referred her to a chiropractor thinking she might have had a pinched nerve, records show.
That day, June 24, the chiropractor gave her a referral to have an MRI, according to documents. The problem was that “she didn’t have medical insurance,” Soto said. The San Carlos Borromeo Hospital told Soto they don't perform MRIs and that the procedure would cost them at least $800. Instead, they gave her a shot and more muscle relaxants, according to Soto.
However, “an MRI is not the standard way for detecting a pulmonary thrombosis (blood clot) or embolism,” Gidwani said. Instead, he would have ordered a CT scan or an ultrasound image -- that could have given them time to tackle the clot, he said.
Soto took Morales back to the Aguadilla Medical Services Center on Tuesday, June 25. As Soto ran out of patience, he said a nurse at the medical center told him to take his partner to another hospital that was better equipped and staffed in Mayagüez.
Both Soto and Morales' family criticized the Aguadilla Medical Services Center for allegedly not providing Morales an ambulance to transfer her to Mayagüez, roughly a 30-minute drive. She had shortness of breath, they said, and Soto had to drive.
They arrived at the Mayagüez Medical Center at 7 p.m. The staff there ran a CT scan, detected the blood clot and provided Morales a blood thinner, according to Soto. But it was too late. She was intubated and sent to the ICU at around 4 a.m., where she was conscious but struggling to breathe, Soto said. Since she was going to stay there he went home at around 5 a.m. to grab clothes, documents from the previous hospital visits and other personal documents in case they asked him for more information. But the “unthinkable” happened.
“At 8 a.m. of Wednesday, June 26, they called me to tell me she passed away,” he said.
That’s when Soto was told by doctors that she died from a pulmonary embolism and that it was possible she had an undiagnosed condition. “They didn’t say it had something to do with our trip to the Dominican Republic,” he said.
Her body was sent to the Forensic Sciences Bureau in San Juan, the only forensic laboratory on the island, which is short-staffed with five pathologists working only on weekdays with about 300 bodies to examine, according to Carlos Vélez, a forensic investigator at the bureau. Violent deaths and car accidents are the priority.
An autopsy was performed and a toxicological analysis was done, the results of which will be available in “not less than 90 days,” Vélez told NBC.
Morales' body was returned to her family on July 10, after two weeks at forensics. They held the funeral and burial on July 11 in her hometown.
“I’m not thinking about lawsuits or any of that," Soto said. "I’ll wait for the results, for answers. I lost my partner and we were always together. I don’t know how things are going to be from now on.”
'Impossible Not to Love Her'
The pair met seven years ago behind the counter of a Church's Chicken. As co-workers their relationship grew over time. In a short time they became friends. Then, they found themselves in love.
"It was impossible not to love her. She gave herself to everyone around her [...] She was joyful, very charismatic," he said.
Morales' aunt, Yolanda Salas Guzmán, told NBC that the days following her niece's death have been "painful and devastating" for the whole family.
Salas, 52, will remember Morales as the light of the party, with her "sparkling smile" while dancing to Romeo Santos' bachata. "She loved to dance, and she danced good," she said.
Salas also highlighted her niece's generous spirit, saying that she lived for others. "She liked to stand up for people that couldn't, and help them," she said.
Morales was close to her grandmother. As the youngest of nine grandchildren, she was the favorite, according to Salas. She'd show up randomly during the week with gifts for her grandmother, even if there was no holiday.
Her grandmother, Morales' favorite cook, lives on the top of a high hill. The only way to get there is by walking up a set of stairs, a total of 102 steps, that she very often walked with her stylish stilettos to enjoy her favorite dish, "arroz con habichuelas y bistec encebollado con tostones," or rice and beans with steak, onions and green fried plantains.
That close tie between Morales and her grandmother made it difficult for Salas to tell her about the death of their "dear Jeimily."
"It was devastating [...] She fainted and couldn't stop crying," Salas said. "A cold shiver ran down our spines. It's been very difficult."
Like Soto, Salas is worried about the 4-year-old who'll have to live without his mother.
"I'd tell him that mamá is up in heaven, but while she was here on Earth she was the best mom in the world," she said.
For Soto, Morales was "the best person" in his life.
"We felt in good company. We were always together," he said.
Soto was recently promoted and "that would've been something to celebrate together. Now, it doesn't mean much. It's not the same," he said.
The family's grieving has been made worse due to inaccurate local media coverage, he said.
Soto referred to outlets in Puerto Rico that seemed to tie her death with their visit to the Dominican Republican without providing other details.
“I don’t know where were they getting that information,” he said.
He said he felt "harassed" by reporters showing up at his home, her workplace and her grandmother's house.
For Carmen Guzmán, Morales’ cousin, the young woman was a “loving and caring mother and daughter.” She hopes authorities “investigate and shed light on what happened to her.”
As for Soto and Salas, nothing can be ruled out, but the possibility that Morales' may have been a victim of an inadequate medical intervention “is present in our minds.”
"I think the protocol failed. They (hospitals) didn't dig deeper, because she didn't have a spasm," Salas said.
For now, Soto says he has to somehow carry on because of his two kids and Morales' 4-year-old boy.
“I told her everything I felt for her. We expressed our feelings all the time," he said. "I had the person I always wanted by my side.”