This is the second part of my discussion of the system failures that allowed Dr. Christopher Duntsch to become a Dallas area neurosurgeon and to damage patient after patient.
Having resigned his staff privileges with his first hospital after negotiating an agreement for that hospital to say nothing negative about him, Dr. Duntsch was ready to begin again at a new Dallas hospital. He was given temporary surgical privileges at his new hospital while it reviewed his references and processed his application for full surgical privileges. It did not take long, however, for his incredible incompetence and huge ego to cause operating room disasters at the new hospital too.
One of the first patients he operated on at his new hospital bled heavily during the surgery, so much so that Dr. Duntsch complained to the nurses that he could not see what he was doing. In a properly conducted surgery of the type being performed by Dr. Duntsch, there should never be that much blood. The patient was taken to the ICU the next morning after she became unconscious. In the ICU, it was discovered that pressure was building inside her brain. She was transferred to another hospital, but never regained consciousness and died. A neurosurgeon examining her case for the family concluded she became brain dead because Dr. Duntsch had blocked an artery to her brain with a screw and had been operating in the wrong area from the start.
While that patient was deteriorating in the ICU, Dr. Duntsch began another surgery. The patient woke up after the surgery in tremendous pain and could not turn over or wiggle her toes. The hospital brought in another spine surgeon to examine her. He could not believe what he saw. Dr. Duntsch had punctured the patient’s spinal canal in three places, had put a screw into nerves that controlled the legs and the bladder, and had cut away other important nerves. The mistakes were so egregious that the surgeon wondered if perhaps Dr. Duntsch was an imposter only pretending to be a doctor.
By the end of the week, the new hospital informed Dr. Duntsch that his temporary privileges were revoked and that he would never operate there again. As with the first hospital, no report of this was made to the Data Bank. Dr. Duntsch was allowed to resign and move on to another hospital with no stain on his record. He would injure more patients before he was stopped.
Things were beginning to happen, however. Dr. Duntsch was reported to the Texas Medical Board, which, even though it had the power to summarily suspend his license, only opened a routine investigation. It would be ten months before a summary suspension order was made and that was only after news of Dr. Duntsch’s surgical disasters was all over the Dallas news. As is often the case, the medical board cared more about the “rights” of the Dr. Duntsch than it did about the safety of the public.
Without hospital privileges, Dr. Duntsch began operating on patients at a Dallas surgery center, a place where the surgeries are usually less complex than those performed at hospitals. That didn’t save his patients, however. One of the patients upon whom he operated at the surgery center had to be transferred to a full-service hospital after Dr. Duntsch severed an artery in her neck and cut her vocal cords.
Remarkably, Dr. Duntsch was able to obtain surgical privileges at another Dallas hospital, one which, surprise, surprise, was in a poorer section of town. He only stopped operating when the Texas Medical Board temporarily suspended his license. It was another six months before the suspension was made permanent.
In the meantime, some of the surgeons who had been trying to clean up Dr. Duntsch’s surgical disasters were able to persuade the Dallas District Attorney’s office to consider the possibility of criminal charges, something which almost never happens to a doctor. It took over two years before Dr. Duntsch was arrested. It was another two years before his trial began. He was tried on a single count of elder abuse involving one of his patients, but the judge allowed the prosecutors to bring up all of the other patients he had injured. He was convicted and is now serving a life sentence.
During his surgical career in Dallas, Dr. Duntsch had operated on 37 patients. 33 of them were injured by errors he made during their surgeries. That is almost a 90% failure rate. Many of these patients did what I routinely advocate before letting a surgeon touch you. They looked up Dr. Duntsch’s credentials on the internet. They looked to see if he had been disciplined by the Texas Medical Board. What they found was a surgeon with excellent training, a clean record at the medical board, and many glowing reviews by people who claimed to have been his patients. As you can see from the figures concerning his surgical failures, the patients who might be complimentary of Dr. Duntsch would have a hard time filling a phone booth. Many of the reviews on line were fake.
While Dr. Duntsch is the one in prison, he is not the only one who is responsible for the damage he caused. The doctors and hospital administrators, who had both the opportunity and the duty to report him and to stop him, put their own self-interest above that of the public. Many of them made money off the surgeries performed by Dr. Duntsch. These people absolutely failed in their duty to protect the public by keeping bad doctors off the street and out of the operating room. Not one of them has ever been punished for this breach of trust. And the worst of it is that nothing has changed.
If another Dr. Duntsch came along tomorrow, there is no reason to believe that the people who allowed Duntsch to go on his way to the next hospital would act any differently. There is no reason to believe that the members of the public would have the ability to identify and protect themselves from a mistake prone doctor. Fortunately, there are not many doctors as incompetent as Dr. Duntsch. There are, however, a lot of incompetent doctors out there injuring patients and getting away with it. That is the real shame of this whole tawdry episode.
Next week: The final insult to the patients injured by Dr. Death.
