Simple surgeries. Tragic results
How a push to cut costs and boost profits at surgery centers led to a trail of death
The surgery went fine. Her doctors left for the day. Four hours later, Paulina Tam started gasping for air.
Internal bleeding was cutting off her windpipe, a well-known complication of the spine surgery she had undergone.
But a Medicare inspection report says nobody who remained on duty that evening at the Northern California surgery center knew what to do.
In desperation, a nurse did something that would not happen in a hospital.
She dialed 911.
By the time an ambulance delivered Tam to the emergency room, the 58-year-old mother of three was lifeless.
If Tam had been operated on at a hospital, a few simple steps could have saved her life.
But like hundreds of thousands of other patients each year, Tam went to one of the nation’s more than 5,600 surgery centers.
Such centers started nearly 50 years ago as low-cost alternatives for minor surgeries. They now outnumber hospitals as federal regulators have signed off on an ever-widening array of outpatient procedures in an effort to cut federal health care costs.
Thousands of times a year, these centers call 911 as patients have complications ranging from minor to fatal. Yet no one knows how many people die as a result, because no national authority tracks the tragic outcomes. An investigation by Kaiser Health News and the USA TODAY NETWORK has discovered that more than 260 patients have died since 2013 after in-and-out procedures at surgery centers across the country. Dozens — some as young as 2 — have perished after routine operations, such as colonoscopies and tonsillectomies.
Reporters examined autopsy records, legal filings and more than 12,000 state and Medicare inspection records, and interviewed dozens of doctors, health policy experts and patients throughout the industry, in the most extensive examination of these records to date. The investigation revealed:
Surgery centers have steadily expanded their business by taking on increasingly risky surgeries. At least 14 patients have died after complex spinal surgeries such as those that federal regulators at Medicare recently approved for surgery centers. Even as the risks of doing such surgeries off a hospital campus can be great, so is the reward. Doctors who own a share of the center can earn their own fee and a cut of the facility’s fee, a meaningful sum for operations that can cost $100,000 or more.
Medicare requires surgery centers to line up a local hospital to take their patients when emergencies arise. In rural areas, centers can be 15 or more miles away. Even when the hospital is close, 20 to 30 minutes can pass between a 911 call and arrival at an ER.
Some centers are accused of overlooking high-risk health problems and treat patients who experts say should be operated on only in hospitals, if at all. At least 25 people with underlying medical conditions have left surgery centers and died within minutes or days, including an Ohio woman with out-of-control blood pressure, a 49-year-old West Virginia man awaiting a heart transplant and several children with sleep apnea.
Some centers risk lives by skimping on training or lifesaving equipment. Others have sent patients home before they were fully recovered. On their drives home, shocked family members in Arkansas, Oklahoma and Georgia discovered their loved ones were not asleep but on the verge of death. Surgery centers have been criticized in cases where staff didn’t have the tools to open a difficult airway or skills to save a patient from bleeding to death.
Most operations in surgery centers go off without a hitch. And surgery carries risk, no matter where it’s done.
But Kaiser Health News and the USA TODAY NETWORK found more than a dozen cases where the absence of trained staff or emergency equipment appears to have put patients in peril.
And in cases similar to Tam’s, patients who had surgery in the upper spine have been sent home too soon, with the risk of suffocation looming.
In 2008, a 35-year-old Oregon father of three struggled for air, pounding the car roof in frustration while his wife sped him to a hospital. A Dallas man collapsed in his father’s arms waiting for an ambulance in 2011. Another Oregon man began to suffocate in his living room the night of his upper-spine surgery in 2014. A San Diego man gasped “like a fish,” his wife recalled, as they waited for an ambulance on April 28, 2016.
None survived.
Many in the health care field — from doctors to private insurance companies to Medicare — have dismissed the mounting deaths as medical anomalies beyond the control of physicians.
Responding to lawsuits around the nation, surgery centers have argued that fatal complications were among the known outcomes of such surgeries. Two centers blamed patients for negligence in their own deaths.
“There is nothing distinct or different about the surgery center model that makes the provision of health care any more dangerous than anywhere else,” said Bill Prentice, chief executive of the Ambulatory Surgery Center Association.
But Kenneth Rothfield, a physician and board member of the Physician-Patient Alliance for Health & Safety, said many surgery centers and physicians push the envelope on how much can be done in outpatient centers. “It’s important to realize that surgery centers are not hospitals,” he said. “They have different resources, different equipment.”
The first surgery center in the U.S. opened in Phoenix in 1970, a place where, for $90, a child could receive an incision to relieve pressure on the inner ear, The Arizona Republic reported at the time. Taking such minor procedures out of hospitals reduced the cost for patients and insurers because surgery centers don’t require the same level of staffing or lifesaving equipment.
Today, surgery centers outnumber hospitals and perform scores of procedures with approval from Medicare.
The expansion came despite lingering safety concerns. In 2007, Medicare noted that surgery centers “have neither patient safety standards consistent with those in place for hospitals, nor are they required to have the trained staff and equipment needed to provide the breadth of intensity of care.” Some procedures are “unsafe” to be handled at surgery centers, the report concluded.
The explosive growth of surgery centers — which receive $4.1 billion a year from Medicare — has taken place under circumstances some medical experts consider unseemly. Federal law allows surgery center doctors — unlike others — to steer patients to facilities they own rather than the full-service hospital down the street. In some cases, doing so could increase the risk to a patient but double a physician’s profits.
Medicare advised centers to transfer patients to hospitals when emergencies arise. Only a third of surgery centers participate in a voluntary effort to report how often that happens. They sent at least 7,000 patients to the hospital in the year that ended in September 2017, a KHN analysis of surgery center industry data shows. Not all survive the trip.
James Long, 56, died after surgery in a Colorado center in 2014. His family was shocked that the center called 911.
“In the 21st century in the USA, a doctor doing a surgery on a patient has to call 911?” said Robin Long, his ex-wife, who did not sue the center. “Give me a break. … It’s just absolutely ignorant.”
Not always prepared
Patients enter hospitals with heart attacks, gunshot wounds and traumatic injuries. The doctors and nurses become skilled at saving lives in emergencies.
Doctors in surgery centers may excel at the procedures they perform most often. But the centers aren’t always prepared and sometimes struggle in a crisis, according to a review of Medicare records and more than 70 lawsuits.
Health inspectors working on behalf of Medicare have discovered 230 lapses in rescue equipment or training regulations at surgery centers since 2015.
A center in California had empty oxygen tanks. One operating on children in Arkansas didn’t have a pediatric tracheotomy set to restore breathing. Another lacked pediatric defibrillator pads to shock hearts back into rhythm.
When emergency crews arrive, surgery centers are not always prepared to receive them.
In Florida, paramedics who rushed to a surgery center after its usual operating hours found a locked door while a patient inside gasped for breath. The 55year-old remains in a vegetative state.
In 2016, paramedics arrived at West Lakes Surgery Center in Iowa as staff tried to revive 12-year-old Reuben Van Veldhuizen after he experienced complications during a tonsillectomy, according to a Medicare inspection report.
One paramedic told state inspectors she had to ask who was in charge of the resuscitation efforts. No one replied, the report says. The boy made it to the hospital 37 minutes after the surgery center called 911. He was pronounced dead.
In court records responding to a lawsuit filed by the family, the surgery center and anesthesiologist said Reuben’s death was a result of “pre-existing conditions, acts of others, or conditions over which (Defendants) had no control or responsibility.”
‘She never woke up’
While the thrum of a hospital continues through the night, some surgery center doctors keep bankers’ hours. That means patients whose surgeries end later in the day are sometimes left in the care of one or two nurses for up to 23 hours. Some patients have been sent home to grapple with complications on their own.
Spinal surgery patient McArthur Roberson, 60, lost more than a quart of blood during the operation and struggled to breathe after surgery, his family said in a lawsuit. He died on the way home.
If he “had been observed in a hospital overnight,” said Daniel Silcox, a spine surgeon in Atlanta and expert for the family in their lawsuit, “his death would not have occurred.”
The surgery center denied wrongdoing in the case, which reached a confidential settlement in 2017.
Cecilia Aldridge said she also felt as if the surgery center staff was rushing her out the door after her 2-year-old daughter’s tonsil surgery in Arkansas in 2015.
A lawsuit filed by the parents said the surgery center “discharged Abbygail too early because a snow storm was moving into the area.”
Abbygail turned blue in the car on the way home. Her mother said she raced into an emergency room, shouting for help, her toddler in her arms.
“She never woke up,” Aldridge said tearfully in an interview.
At-risk patients
Because surgery centers have less safety equipment and staffing than hospitals, industry leaders stress the importance of selecting patients healthy enough to fare well. Their predictions, though, are not always correct.
Abbygail had sleep apnea, an irregular heartbeat and was very heavy for her age, according to the lawsuit.
The lawsuit says Abbygail’s risk factors “were documented and known by the Defendants,” including the doctor. It said the toddler should have been operated on “in an inpatient setting under hospital care and monitored overnight.”
Michael Marsh performed Abbygail’s tonsillectomy at Executive Park Surgery Center in Fort Smith, Ark.
The surgery center’s lawyer declined to comment. The doctor’s lawyer did not return email and voice messages. In court documents responding to the lawsuit, Marsh and the center denied wrongdoing.
In the court filing, Marsh said the toddler’s injuries were “the natural progression” of her illness. Executive Park Surgery Center said in a court filing that “no action on their part ... was a proximate cause of any damages or injury” The case was settled.
In at least 25 cases, surgery centers opened their doors to ailing and fragile patients who died after simple procedures such as tonsillectomies, retinal repairs or colonoscopies, KHN and the USA TODAY NETWORK found.
Robin Long Ex-husband James Long, 56, died after surgery in a Colorado center in 2014
“In the 21st century in the USA, a doctor doing a surgery on a patient has to call 911?”
A widening niche
Such tragedies rarely find their way into the discussion when Medicare decides whether to approve new procedures at surgery centers.
Take spinal surgery. Until 2015, Medicare wouldn’t pay for it at surgery centers. Then, the industry’s trade association encouraged a letter-writing campaign from surgery centers across the nation.
In an email, a Medicare spokeswoman said the agency opened the spine proposal to the public and received no comments suggesting the procedures would pose a threat to Medicare patients. Medicare approved 10 spine-surgery codes to be billed at surgery centers starting in 2015 and added more spinal procedures for 2017.
By 2017, at least 14 patients had died after such surgeries.
Paulina Tam’s death at Fremont Surgery Center is documented in court and EMS records and in a Medicare report that concluded the center “failed to provide a safe environment for surgery.”
Upper-spine surgeries like Tam’s on April 7, 2014, come with a risk of suffocation for at least 24 hours, according to the Medicare inspection report. Yet, when Tam stopped breathing, the only doctor present was a digestive health specialist, the inspection report shows.
Medical experts say the first step in helping such patients is removing the surgical staples so pooled blood can disperse. In Tam’s case, staff tried and failed to insert a breathing tube through her mouth and into her airway, the inspection report shows. A last-ditch remedy would have been to punch a hole through the front of her throat, but the gastroenterologist later told an inspector that he “was not prepared” to do so.
The inability to perform the suffocation-rescue maneuver, the inspection report says, amounted to the center’s “failure to ensure patient safety.”
From the time a nurse called 911, it took 24 minutes to get Tam to the nearest hospital, EMS records show. She arrived without a pulse.
The center did not return calls and denied wrongdoing in a legal filing. Tam’s surgeon declined to discuss the case but filed records in court saying Tam’s “carelessness and negligence” caused her death. The case reached a confidential settlement.
After Tam’s death, the center told Medicare inspectors that a qualified doctor would stay on-site after all upper-spine cases.
Nancy Epstein, chief of neurosurgical and spine care at New York University Winthrop Hospital, said surgery centers doing delicate work near the spinal cord in a same-day procedure is “pretty revolting.” But she said the centers are making so much money — “reeling it in hand over fist” — that the dangers are being ignored.
“Medically, it should not be tolerated,” she said. “But it is.”