Evil in a Lab Coat: Anatomy of a Tragedy

Dr Robert J Henderson

Dr Robert J Henderson

I said, “You don’t seem to understand. This guy already killed somebody, made another a quadriplegic, made a partial paraplegic out of my patient. He needs to be stopped. Not only shouldn’t he be operating, he shouldn’t be making any decisions about treatment or pathology.” 

My statement had no effect whatsoever. (Doctor Robert Henderson, neurosurgeon, Dallas Medical Center, speaking to the Texas Medical Board)

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In late 2010, Doctor Christopher Duntsch came to Dallas to start a neurosurgery practice. By the time the Texas Medical Board revoked his license in June 2013, Duntsch had left two patients dead and four paralyzed in a series of botched surgeries.

Dr Christopher Duntsch

Dr Christopher Duntsch

Physicians who complained about Duntsch described his practice in superlative terms. They used phrases like “the worst surgeon I’ve ever seen.” One doctor, brought in to repair one of Duntsch’s spinal fusion cases, remarked that it seemed Duntsch had learned everything perfectly just so he could do the opposite. Another doctor compared Duntsch to Hannibal Lecter three times in eight minutes.

When the Medical Board suspended Duntsch’s license, the agency’s spokespeople too, seemed shocked.

“It’s a completely egregious case,” said Leigh Hopper, then head of communications for the Texas Medical Board. “We’ve seen neurosurgeons get in trouble, but not one such as this, in terms of the number of medical errors in such a short time.”

But the real tragedy of the Christopher Duntsch story is how preventable it was. Over the course of 2012 and 2013, even as the Board and the hospitals he worked with received repeated complaints from a half-dozen doctors and lawyers begging them to take action, Duntsch continued to practice medicine. Doctors brought in to clean up his surgeries decried his “surgical misadventures.” His mistakes were obvious and well-documented. And still it took the Board more than a year to stop Duntsch – a year in which he kept bringing into the operating room patients who ended up seriously injured or dead.

In Duntsch’s case, we see the weakness of unregulated system of health care, a system built to protect doctors and hospitals. And a system in which there’s no way to know for sure if your doctor is dangerous.

Up until 2003, medical care in Texas was regulated by a system of checks. Hospital management, the court system and the Texas Medical Board formed a web of regulation that penalized and prevented bad care.

But in the past 10 years a series of conservative reforms have severely limited patients’ options for holding doctors and hospitals accountable for bad care. In 2003, the Texas Legislature capped pain-and-suffering damages in  malpractice lawsuits at $250,000. Even if a plaintiff wins the maximum award, after you pay your lawyer and your experts and go through, potentially, years of trial, not much is left.

The Legislature also made suing hospitals difficult. Texas law states­ that hospitals are liable for damages caused by doctors in their facilities only if the plaintiff can prove that the hospital acted with “malice” – that is, the hospital knew of extreme risk and ignored it – in credentialing a doctor. But the Legislature hindered plaintiffs’ cases even more by allowing hospitals to, in most cases, keep credentialing information confidential. In effect, plaintiffs have to prove a very tough case without access to the necessary hospital records. This is an almost impossible standard to meet, and it has left hospitals immune to the actions of whatever doctors they bring on. Hospitals can get all of the benefit of an expensive surgeon practicing in their facility and little of the exposure. This has freed hospitals from the fear of litigation, but it’s also removed the financial motivation for policing their own physicians.

The medical malpractice cap and the near-immunity for hospitals snapped two threads from the regulatory web. What remained was the Texas Medical Board.

But the Board wasn’t designed to be an aggressive enforcer. It was mostly designed to monitor doctors’ licenses and make sure the state’s medical practitioners are keeping up with professional standards. The board’s mandate, spelled out in the Medical Practice Act, recognizes a doctor’s license as a hard-won, valuable credential. Doctors’ rights are to be protected at every step of the process. The Board can’t revoke a license without overwhelming evidence, and investigations can take months, with months or years of costly hearings dragging on afterward. The protections make some sense. The Legislature doesn’t want the Medical Board taking a doctor’s license – and livelihood – unnecessarily or based on flimsy or frivolous claims. But the result is that unless a doctor is caught dealing drugs or sexually assaulting patients – or is convicted of a felony – it is difficult to get his or her license revoked.

What all this means is that the Texas Legislature has committed the state to a policy of medical deregulation – a free market system in which doctors can practice as they please with limited government interference. Only their consciences, and those of their fellow doctors, limit them.

Into this milieu rolled Christopher Duntsch MD like a 100-year storm.

When he moved to Dallas in late 2010, Duntsch was 41 years old, fresh out of a residency program at the University of Tennessee Health Science Center’s Department of Neurosurgery in Memphis. He founded a neurosurgery practice, Texas Neurosurgical Institute. He hired a marketing team and nurses. In November 2011 he was granted surgical privileges at Baylor Regional Medical Center of Plano. He put together a website and began bringing in patients.

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“The TMB [Texas Medical Board] must stop this sociopath Duntsch immediately or he will continue to maim and kill innocent patients. Dr. Duntsch is a clear and present danger to the citizens of Texas.” (Dr. Randall Kirby, Neurosurgeon, Baylor Plano)

Dr Randall Kirby

Dr Randall Kirby helped stop a medical madman

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Dr. Randall Kirby was another surgeon at Baylor Plano. In January 2012, he assisted on one of Duntsch’s surgeries. Kirby had spent 16 years performing general surgery in the Dallas area, in which time he’d assisted on more than 2,000 spine operations. Duntsch, he said, was the worst.

The operation was a spinal fusion in which two vertebrae are joined; surgeons use a metal plate to help hold the vertebrae together. Among neurosurgeons, the procedure isn’t considered terribly difficult. Kirby said Duntsch had problems at nearly every step of the operation. He seemed to have a hard time moving organs and blood vessels out of the way, according to Kirby. He nicked the patient’s vertebral artery, causing the space he was working in to fill with blood. He then had trouble moving the plate into place.

“His performance,” Kirby wrote, “was pathetic . . . He was functioning at a first- or second-year neurosurgical resident level but had no apparent insight into how bad his technique was.”

After surgery the patient, Barry Morguloff, woke up in more back pain than he’d started with and had no feeling in his left leg. For the next several months, he was in constant pain, according to Mike Lyons, his attorney. Scans later revealed bone fragments lodged in the nerves of his back.

Three weeks later, Duntsch performed a spinal fusion on Jerry Summers, a childhood friend. During the surgery, Duntsch sliced into one of the arteries running down Summers’ spine, causing massive bleeding, which he tried to staunch by packing coagulants around the wound. When Summers woke up he couldn’t move his arms or legs. Rather than immediately ordering scans to find out what was wrong, Duntsch moved on to other patients.

Baylor brought in a senior surgeon to fix the damage to Summers’ spine. His report was damning. He blamed Summers’ paralysis on Duntsch’s “surgical misadventures,” which had led to the artery being cut. The final straw, he wrote in his report, had been the packing of coagulants around the cut, which had seriously damaged Summers’ spinal cord. Topping it all off had been Duntsch’s failure to order tests and re-operate on Summers in a timely manner – a delay that likely cost his childhood friend the use of his arms and legs. Summers remains paralyzed.

Following Summers’ surgery, Baylor Plano suspended Duntsch for 30 days. After that, he was supposed to be supervised on every surgery he performed, according to Kirby.

But Baylor didn’t hold him to that. Soon after Summers woke up paralyzed, a woman named Kellie Martin came to see Duntsch at Texas Neurosurgical Institute. She was 55 and had been experiencing persistent back pain after a fall at home. When physical therapy didn’t relieve the pain, her family doctor suggested she see Duntsch.

Kellie Martin and her husband, Don, went to see Duntsch. “He sounded impressive,” Don said. “He was very eloquent in stating the causes and the need for the procedure. He felt confident. We felt confident too.”

Kellie Martin went into surgery on March 12, 2012. It was supposed to be a simple procedure. Don Martin, who was waiting outside, was told the operation wouldn’t take more than 45 minutes. Forty-five minutes passed, then an hour, two hours, with no word.

Don was a lieutenant with the Garland Police Department and had spent enough time in hospitals to know this delay wasn’t a good sign. He went to the operating room and asked to speak to the doctor. When Duntsch came out, he told Don there had been “some complications,” and that Kellie would have to stay the night, but that the operation had gone fine.

Duntsch went back into the operating room and left Don waiting. He waited until they told him his wife had been sent to the ICU. Then he waited several more hours until the nurses came out to tell him and his daughters that Kellie Martin was dead.

The Collin County medical examiner was astounded by what had happened to Kellie Martin. He listed the cause of death as “therapeutic misadventure.” During surgery Duntsch had sliced through one of the arteries alongside Martin’s spine, as he had with Summers. Unlike with Summers, though, he hadn’t noticed in time and Martin bled to death.

Kelly Martin before her surgery

Kelly Martin before her surgery

Martin’s surgery was Duntsch’s last at Baylor. He resigned soon after, with full clinical privileges. By all appearances, he had simply decided to leave.

After his wife died Don Martin found himself at a loss. “My whole world crashed,” he said. “I thought, this couldn’t have happened. It was supposed to be such a simple procedure. It was horrible. When I think about it, it’s just devastating.”

When I spoke to him, a year after his wife’s death, he told me that they had trusted Duntsch, and that there had been no sign suggesting they do otherwise. “Maybe,” he sighed, “we should have gotten a second opinion.”

But a second opinion wouldn’t have helped. Kellie Martin was in good health; a laminectomy is considered a minor procedure. There’s no reason to assume another doctor would have advised her differently. But no one bothered to tell the Martins – and there was no way for them to know – that their doctor had left a man paralyzed a month before in a case in which the hospital’s own surgeons found him at fault.

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One might think that if a doctor had paralyzed one patient and had another die in the course of a month, it would be someone’s job to figure out why. But as in many other areas of medicine, Martin’s death and Summers’ paralysis fell into a regulatory no man’s land. Once Duntsch left Baylor, he was no longer the hospital’s problem. The only entity that could stop Duntsch from seeing more patients was the Texas Medical Board.

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But the Board is limited in its ability to investigate malpractice. For one thing, it can open a case only if it receives a written complaint. With the exception of pain management clinics and anesthesiologists, the board doesn’t have the authority to inspect a doctor, or to start an investigation on its own.

During the summer of 2012, as Duntsch was searching for a new hospital, another doctor who had witnessed Duntsch’s errors at Baylor sent a complaint about Duntsch to the Board.

That complaint was filed – along with the 6,000-8,000 other complaints the Medical Board receives each year. The process for resolving complaints is slow, set up to guarantee doctors the maximum legal protection. First, the Board staff has to screen every complaint and has 45 days to decide whether to act on it. If the board decides to act on a complaint – and only one in four complaints makes it that far – investigators subpoena hospital records, which the board will eventually send to a pair of volunteer doctors in the same specialty, who will review the case (if they disagree, a third doctor has to be found to break the tie). These doctors are busy – they have practices of their own that pay a lot better than volunteering for the Medical Board – and there aren’t many of them. In a specialized field like neurosurgery, that means months of delay.

Once the case has been put together investigators make a recommendation to the Board itself, a group of 12 physicians and seven laypeople appointed by the governor. They know if they try to discipline a doctor, the burden of proof will be on them. A poorly put-together case can mean months or years of expensive litigation. So the Board members tend to act conservatively. They move slowly and only take action they’re reasonably sure will be effective. It takes the Texas Medical Board an average of nine months to resolve complaints. Some drag on for years.

And all the while, until their cases are resolved, doctors – even those accused of the most heinous malpractice – can continue to practice. Even the fact that the board is conducting an investigation remains confidential until the investigation is over. It’s left to hospitals to police their doctors.

In July 2012, four months after Kellie Martin’s death, Duntsch applied for surgical privileges at Dallas Medical Center. The hospital conducted an initial background check on Duntsch, and he came up clean. So while hospital administrators did a deeper background examination, they granted Duntsch temporary privileges.

It’s not clear how much Dallas Medical Center officials knew about Duntsch’s past or how much Baylor told them. Neither hospital would talk about Duntsch for this story. The answer in both cases seems to be very little. According to Baylor, Duntsch had clinical privileges when he resigned. As for what Baylor told Dallas Medical Center, a Baylor spokesperson said in a statement that, “It has been the longstanding policy of Baylor to respond with comprehensive information when it receives a proper inquiry from another hospital. Because the credentialing process is deemed confidential under Texas Law, we are not permitted to discuss specific physicians or specific requests other than to say all policies were followed.”

Dallas Medical Center also declined to comment, citing privacy concerns. But according to Dr. Robert Henderson, another neurosurgeon at Dallas Medical Center, the “comprehensive information” Baylor sent when Duntsch applied consisted of an email saying that there were no issues,, that he’d been on staff and had voluntarily resigned.

Henderson says that Duntsch told the Dallas Medical Center administration about the Martin and Summers cases, but explained that the outcomes hadn’t been his fault: Summers, he said, had been paralyzed by a bad drug interaction, and Martin had died because of complications from anesthesia. He didn’t tell them about internal reports that faulted him in both cases. Duntsch’s explanation, along with the email, was enough to get him a trial run of five surgeries at Dallas Medical Center.

“I think their rationale was, he’s a trained neurosurgeon, a combined MD-PhD.,” Henderson said. “How much risk can there be?”

The first three surgeries of Duntsch’s took place on three consecutive days in July 2012, a month after the first complaint against him with the Texas Medical Board. The first surgery went fine. In the second, while doing a cervical fusion on a woman named Floella Brown, Duntsch “removed a bone from an area that was not required by any clinical or anatomical standards, resulting in injury to the vertebral artery,” according to Board records. Brown was later found unresponsive in her hospital room and staff couldn’t contact Duntsch for 90 minutes, according to those records. Brown had suffered excessive blood loss and a stroke, according to the agency. By the time she was transferred to UT Southwestern Medical Center later that day, she was brain dead. As she lay dying, Duntsch performed his third surgery, on a woman named Mary Efurd. Another spinal fusion; another routine procedure. Efurd woke up after surgery in horrible pain, barely able to move her legs.

Two days later, once Efurd was stable, Henderson was assigned to do the repair surgery. A CT scan found that the metal spinal fusion hardware, meant to be placed on the patient’s spine to keep the vertebrae from moving, was sunk into the muscles of her lower back, inches from her spine.

Henderson went in to remove it. He had been a neurosurgeon for 40 years and what he saw inside Efurd’s back shocked him.

“He had amputated a nerve root,” Henderson said. “It was just gone. And in its place is where he had placed the fusion. He’d made multiple screw holes on the left everywhere but where he had needed to be. On the right side, there was a screw through a portion of the S1 nerve root.”

At first, Henderson thought Duntsch might be an impostor. He faxed over a picture of Duntsch to the residency program at the University of Tennessee Health Science Center to see if Duntsch had graduated.

“I couldn’t believe a trained surgeon could do this,” Henderson told me. “He just had no recognition of the proper anatomy. He had no idea what he was doing. At every step of the way, you would have to know the right thing to do so you could do the wrong thing, because he did all the wrong things.”

But the school told Henderson that Duntsch had completed the residency program. He was horrified to realize that Duntsch was going to keep practicing. After a few calls to various Dallas-area medical societies, someone suggested he call the Medical Board.

“So I called them up, and they said, ‘Will you fill out a complaint, and we’ll probably read the complaint in about 30 days, and we’ll start an investigation after that.’

“I said, ‘You don’t seem to understand. This guy already killed somebody, made another a quad, made a partial paraplegic out of my patient.’ I said, ‘He needs to be stopped. Not only shouldn’t he be operating, he shouldn’t be making any decisions about treatment or pathology.’ It had no effect whatsoever.”

After the Brown and Efurd debacles in July 2012, Dallas Medical Center fired Duntsch and reported him to the Medical Board.

Over the next year, the Board would receive six more complaints from doctors who had seen Duntsch’s work up close. Doctors, and later lawyers, would call, begging them to do something. They all received the same response Henderson had: Send us what you have, and we’ll get back to you.

We now know that the Texas Medical Board was working behind the scenes trying to find grounds to temporarily suspend Duntsch’s license. The temporary suspension was a power the Legislature gave the board in 2003. For the first time, the board could suspend without a hearing doctors who “constituted a continuing threat to the public welfare,” i.e., cases where the public couldn’t afford to wait for the full board proceedings. For a temporary suspension, the standard is even higher than other enforcement actions. It isn’t enough to prove that a doctor did something awful. To suspend a license there has to be enough evidence to prove a pattern.

And while the Medical Board investigated, the pattern continued. If you were a patient in the Dallas area around this time looking for a spine surgeon, there would have been nothing to suggest that Duntsch was a risky choice. Because investigations are confidential, Duntsch’s public record with the Texas Medical Board remained clean. On the online doctor-rating site Healthgrades.com, he had 4.5 stars out of five. He had a slick marketing team in Best Docs Network, a physician PR company that pumps out infomercials to local TV stations.

In December 2012, he performed a cervical fusion at Legacy Surgery Center of Frisco that left his patient with paralyzed vocal cords – an unheard-of complication. In January, one of his patients at University General Hospital Dallas woke up paralyzed from the waist down, according to the patient’s lawyer.

None of this hurt his career. At the end of May 2013, Kirby and Henderson received invitations to a celebratory dinner, courtesy of University General Hospital, to meet their new neurosurgeon, Dr. Christopher Duntsch, at an expensive uptown restaurant.

Kirby called the owner of University General. “He’s bad news, multiple members have reported him to the Med Board.”

According to Kirby, the hospital owner told him that Duntsch had privileges to do only minimally invasive surgeries.

It was a minimally invasive surgery, Kirby said, that killed Kellie Martin.

Two weeks later Kirby got a call to come to University General to do a recovery surgery on one of Duntsch’s patients. The surgery had gone so badly that the OR team had to physically restrain Duntsch from continuing. For two days the patient, Jeffrey Glidewell, lay unattended in the ICU while Duntsch made excuses to the family. Finally the family fired him. When Kirby saw Glidewell, he later wrote the Medical Board, he was “horrified.” The incision was cut into Glidewell’s throat “two or three inches lower and an inch midline from where it should have been oriented … saliva and pus were coming out of the wound.”

Duntsch, it turned out, had, as with other patients, cut into Glidewell’s vertebral artery; an MRI found that he had also left a sponge festering in the soft tissue of Glidewell’s throat.

Later in June 2013 Kirby sent a sworn statement to the Board in which he laid out all of Duntsch’s patients he knew about and included reports from many surgeons who had worked on them. Near the end of his report, Kirby wrote, “The [Medical Board] must stop this sociopath Duntsch immediately or he will continue [to] maim and kill innocent patients.” Perhaps it was the completeness and forcefulness of his presentation; perhaps it was the fact that another neurosurgeon had just joined the board, and he understood the severity of what Duntsch had done. Whatever the reason, this time they acted. On June 26, the board held an emergency meeting and suspended Duntsch’s license.

More than a year had passed since Kellie Martin’s death and the complaint that started it all. In the time between the first complaint to the board, and when Duntsch was finally stopped, five patients were seriously injured and one died.

Until the day of the suspension, if you had looked Duntsch up on the Texas Medical Board website, you would have found him a physician in good standing.

In 2012, the public interest group Public Citizen commissioned a research project to cross-reference doctors sanctioned by the Texas Medical Board with those listed in the National Practitioner Databank. When a doctor loses clinical privileges at a hospital, hospitals are required by law to notify the National Practitioner Databank. Public Citizen found that 793 Texas doctors had lost clinical privileges between 1990 and 2011. But Public Citizen found that of those 793 doctors, the Texas Medical Board had taken serious action in less than half the cases.

But the National Practitioner Databank doesn’t make doctors’ names public, so we don’t know who they are.

Here’s another look at this American embarrassment:

http://crimeblog.dallasnews.com/2015/08/7-chilling-thoughts-of-jailed-neurosurgeon-christopher-duntsch.html/

(We are indebted to investigative reporter Saul Elbein for this remarkable story )

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2 thoughts on “Evil in a Lab Coat: Anatomy of a Tragedy

  1. Ione says:

    Unbelievable . . . and he continued to kill and maim for a whole year more.

    Patrick, you have made me very paranoid of doctors and hospitals . . . lol.

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