Dr. Death revisited

There was no way Glidewell could have known from Duntsch's carefully curated internet presence or from any other information then publicly available that to be Duntsch's patient was to be in mortal danger.

In the roughly two years that Duntsch — a blue-eyed, smooth-talking former college football player — had practiced medicine in Dallas, he had operated on 37 patients. Almost all, 33 to be exact, had been injured during or after these procedures, suffering almost unheard-of complications. Some had permanent nerve damage. Several woke up from surgery unable to move from the neck down or feel one side of their bodies. Two died in the hospital, including a 55-year-old schoolteacher undergoing what was supposed to be a straightforward day surgery.

Multiple layers of safeguards are supposed to protect patients from doctors who are incompetent or dangerous, or to provide them with redress if they are harmed. Duntsch illustrates how easily these defenses can fail, even in egregious cases.

At least two facilities that quietly dumped Duntsch failed to report him to a database run by the U.S. Department of Health and Human Services that's supposed to act as a clearinghouse for information on problem practitioners, warning potential employers about their histories…

It took more than six months and multiple catastrophic surgeries before anyone reported Duntsch to the state medical board, which can suspend or revoke a doctor's license. Then it took almost another year for the board to investigate, with Duntsch operating all the while…

Glidewell was the last patient Duntsch operated on before being stripped of his license to practice medicine.

According to doctors who reviewed the case, Duntsch mistook part of his neck muscle for a tumor and abandoned the operation midway through — after cutting into Glidewell's vocal cords, puncturing an artery, slicing a hole in his esophagus, stuffing a sponge into the wound and then sewing Glidewell up, sponge and all…

In sworn testimony from 2014, an ex-girlfriend of one of his closest friends described a drug-fueled, all-night birthday celebration for Duntsch about midway through his residency. Revelers drank and used cocaine and pills, she said. At dawn, Duntsch slipped on his white coat and headed for rounds at the hospital…

fter his arrest, the Dallas district attorney's office subpoenaed every hospital on Duntsch's CV for records of his surgeries, including those during his residency and subsequent one-year fellowship.

According to the Accreditation Council for Graduate Medical Education, a neurosurgery resident does about 1,000 operations during training. But according to records gathered by the DA, by the time Duntsch finished his residency and fellowship, he had operated fewer than 100 times…

"We were told Duntsch was one of the best and smartest neurosurgeons they ever trained, as they went on at length about his strengths," they said in the email. "When asked about Dr. Duntsch's weaknesses or areas for improvement, the supervising physician communicated that the only weakness Duntsch had was that he took on too many tasks for one person."…

One weekend in September 2011, Kirby said, Duntsch was supposed to be taking care of a patient. He went to Las Vegas instead. One of the partners, Dr. Michael Rimlawi, "was notified by the administration that the patient wasn't getting rounded on, and Dr. Rimlawi then dismissed Dr. Duntsch after that," Kirby said. (Rimlawi declined to comment for this story…

Vascular surgeon Mark Hoyle assisted with the operation. In later testimony, he said he watched in alarm as Duntsch began to cut out a ligament around the spinal cord not typically disturbed in such procedures. Passmore started bleeding profusely, so much so that the operating field was submerged in a lake of red. Duntsch not only misplaced hardware in Passmore's spine, but he stripped the screw so it could not be moved, Hoyle testified. At one point, Hoyle said, he either grabbed Duntsch's scalpel or blocked the incision — he could not remember which — to keep Duntsch from continuing the procedure. Then Hoyle said he left the operating room and vowed never to work with Duntsch again…

But Duntsch quickly got into trouble. Instead of using a scalpel, he tried to pull Morguloff's problem disk out with a grabbing instrument that could damage the spine. Kirby said he argued with Duntsch, even offering to take over, but Duntsch insisted he knew what he was doing. Kirby left the room…

His previous surgeon testified at Duntsch's trial that the procedure had left bone fragments in Morguloff's spinal canal. The surgeon said he repaired what damage he could, but Morguloff still walks with a cane. As scar tissue builds up, his pain will worsen and his range of motion will decrease. One day, he will likely be in a wheelchair…

In a deposition he gave later to the district attorney, Summers said he asked Duntsch to operate on him because he had chronic pain from a high school football injury that had gotten worse after a car accident. After the February 2012 surgery, however, Summers couldn't move from the neck down. 

According to doctors who later reviewed the case, Duntsch had damaged Summers' vertebral artery, causing it to bleed almost uncontrollably. To stop the bleeding, Duntsch packed the space with so much anticoagulant that it squeezed Summers' spine…

During the surgery, records show, Martin's blood pressure inexplicably plummeted.

As she regained consciousness after the surgery, the nurses tending to Martin testified that she began to slap and claw at her legs, which had turned a splotchy, mottled color. She became so agitated the staff had to sedate her. She never reawakened. An autopsy would later find that Duntsch had cut a major vessel in her spinal cord, and within hours, Martin bled to death…

But — importantly — they did not fire him outright. Instead, he resigned, leaving on April 20, 2012, with a lawyer-negotiated letter saying, "All areas of concern with regard to Christopher D. Duntsch have been closed. As of this date, there have been no summary or administrative restrictions or suspension of Duntsch's medical staff membership or clinical privileges during the time he has practiced at Baylor Regional Medical Center at Plano."

Since Duntsch's departure was technically voluntary and his leave had been for less than 31 days, Baylor-Plano was under no obligation to report him to the National Practitioner Data Bank…

Despite his string of problems at Baylor-Plano, Duntsch also wasn't reported to the Texas Medical Board, the state's main purveyor of doctor discipline. Such boards often move slowly, but if hospital officials submit material they've gathered to justify letting a doctor go, boards can act to protect patients from imminent harm…

On July 24, 2012, Duntsch operated on Floella Brown, 64, a banker about to retire after a long career. She had come to Duntsch for cervical spine surgery to ease her worsening neck and shoulder pain.

About a half hour into Brown's surgery, Duntsch started to complain that he was having trouble seeing her spine.

"He was saying: ‘There's so much blood I can't see. I can't see this,'" said Kyle Kissinger, an operating room nurse. He kept telling the scrub tech "'suck more, suck more. Get that blood out of there. I can't see.' That's really concerning to me because, not only that he can't do it correctly when he can't see that but, why is it still bleeding?"

Brown bled so much that blood was saturating the blue draping around her body and dripping onto the floor. The nursing staff put down towels to soak it up. 

After the operation, Brown woke up and seemed fine, but early the next morning she lost consciousness. Pressure was building inside her brain for reasons that were unclear at the time.

That same morning — with Brown still in the ICU — Duntsch took another patient into surgery…

Soon after beginning Efurd's surgery, Duntsch turned to Kissinger and told him to let the front desk know he would be performing a procedure on Brown called a craniotomy, cutting a hole in her skull to relieve the pressure in her brain. Problem was, Dallas Medical Center did not perform those, or even have the proper equipment to do them. 

As he operated on Efurd, Duntsch quarreled first with Kissinger and later with his supervisors, insisting on a craniotomy for Brown, according to court testimony. All the while, the operating room staff questioned whether Duntsch was putting hardware into Efurd in the right places and noticed he kept drilling and removing screws.

In the end, Duntsch did not perform a craniotomy on Brown. She was moved to another hospital but never regained consciousness.  In court, her family said they withdrew life support a few days later. A neurosurgeon hired to review her case would later determine that Duntsch had both pierced and blocked her vertebral artery with a misplaced screw. The review also found that Duntsch misdiagnosed the source of her pain and was operating in the wrong place.

The day after her surgery, Efurd awoke in agony. She couldn't turn over or wiggle her toes. Hospital administrators called Dr. Robert Henderson, a Dallas spine surgeon, to try to repair the damage.

Shortly after he arrived at the hospital, Henderson pulled up Efurd's post-operative X-rays. When he saw them, he said, "I'm really thinking that some kind of travesty occurred." That impression only grew when Henderson reopened Efurd's freshly made incisions the next day. "It was as if he knew everything to do," Henderson said of Duntsch, "and then he'd done virtually everything wrong." There were three holes poked into Efurd's spinal column where Duntsch had tried and failed to insert screws. One screw was jabbed directly into her spinal canal. That same screw had also skewered the nerves that control one leg and the bladder. Henderson cleaned out bone fragments. Then he discovered that one of Efurd's nerve roots — the bundle of nerves coming out of the spine — was completely gone. For some inexplicable reason, Duntsch had amputated it.

The operation was so botched, Henderson recalled thinking Duntsch had to be an impostor passing himself off as a surgeon. Even after Henderson's repairs, Efurd never regained her mobility and now uses a wheelchair. …

By the end of the week, hospitals administrators told Duntsch he would no longer operate at Dallas Medical Center. But, as had happened at Baylor-Plano, Duntsch was allowed to resign and the hospital didn't notify the National Practitioner Data Bank…

Duntsch would continue to operate. In fact, his career in Dallas was only about half over…

Troy was being transferred to a Dallas hospital from a surgery center in the suburb of Frisco. She'd had neck surgery, but the surgeon had cut her vocal cords and one of her arteries. When Kirby learned the details, he asked the doctor who referred the case to him about the surgeon: "Is it a guy named Christopher Duntsch?"

It was.

Duntsch had managed to get a job at Legacy Surgery Center, an outpatient clinic…

Reluctantly, Glidewell went ahead. But hours later, Duntsch came out and told Glidewell's wife that he had found a tumor in Glidewell's neck and aborted the procedure.

"I was devastated, crying," Robin Glidewell recalled. She went to see her husband in the recovery room. "Immediately, Jeff was: ‘Where is the doctor? I can't move my arm or my leg.' He was having trouble even talking and said, ‘Something's wrong, something's wrong.'"

There was no tumor, but Duntsch had made a series of errors after mistaking a portion of Glidewell's neck muscle for a growth, according to a review of the case…

"This was not an operation that was performed," Kirby said. "This was attempted murder."

By the time Duntsch operated on Glidewell, the state medical board had been investigating him for about 10 months…

Kirby sent the board a five-page letter on June 23, 2013, spurred by what had happened to Glidewell. "Let me be blunt," it said. "Christopher Duntsch, Texas Medical Board license number N8183, is an impaired physician, a sociopath, and must be stopped from practicing medicine." Robin Glidewell also sent a letter, describing what happened to her husband…

Kirby, Henderson and another doctor decided to contact the district attorney, convinced that Duntsch's malpractice was so egregious it was criminal. They met with an assistant DA but got little traction.

On Dec. 6, 2013, the medical board permanently revoked Duntsch's license…

As she and other prosecutors contacted every person Duntsch had ever operated on or their survivors, they struggled to figure what crimes he could be charged with. They settled on five counts of aggravated assault arising from his treatment of four patients, including Brown and Glidewell, and one count of injury to an elderly person, because Efurd was over 65. 

In Texas, this charge carried a potential life sentence, but prosecutors had to race to file the case…

It took the jurors just hours to find Duntsch guilty of knowingly injuring Efurd. He was sentenced to life in prison. He's currently incarcerated in Huntsville, about an hour outside Houston.

https://www.medscape.com/viewarticle/902981

See:  http://childnervoussystem.blogspot.com/2016/12/dr-death.html
 http://childnervoussystem.blogspot.com/2015/08/medical-mayhem.html