This Texas surgeon injured so many of patients that he was sentenced to life in prison

Christopher Duntsch (not pictured) conducted surgeries so badly that Texas prosecuted him for harming patients and sentenced him to life in prison.

Christopher Furlong/Getty Images

Christopher Duntsch was a neurosurgeon

who practiced medicine in Dallas, Texas

.

Duntsch’s surgeries

severely injured 33 of his patients and killed two. 

Almost all had been injured during or after these procedures, suffering almost unheard-of complications like permanent nerve damage and paralysis

.

The pain from the pinched nerve in the back of Jeff Glidewell’s neck had become unbearable.

Every time he’d turn his head a certain way, or drive over bumps in the road, he felt as if jolts of electricity were running through his body. Glidewell, now 54, had been living on disability because of an accident a decade earlier.

As the pain grew worse, it became clear his only choice was neurosurgery. He searched Google to find a doctor near his home in suburban Dallas who would accept his Medicare Advantage insurance.

That’s how he came across Dr. Christopher Duntsch in the spring of 2013.

Christopher Duntsch.

Dallas County Jail via AP

Duntsch seemed impressive, at least on the surface. His CV boasted that he’d earned an MD and a PhD from a top spinal surgery program. Glidewell found four- and five-star reviews of Duntsch on 

Healthgrades

 

and more praise seemingly from patients on Duntsch’s Facebook page.

On a link for something called „Best Docs Network

,“ Glidewell found a slickly produced video showing Duntsch in his white coat, talking to a happy patient, and wearing a surgical mask in an operating room.

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.

Neurosurgeons are worth 

millions in revenue for hospitals

, so Duntsch was able to get operating privileges at a 

string of Dallas-area institutions

. Once his ineptitude became clear, most chose to spare themselves the hassle and legal exposure of firing him outright and instead let him resign, reputation intact.

At least two facilities that quietly dumped Duntsch failed to report him to a database run by the US 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 seems to be the custom and practice,“ said Kay Van Wey, a Dallas plaintiff’s attorney who came to represent 14 of Duntsch’s patients. „Kick the can down the road and protect yourself first, and protect the doctor second and make it be somebody else’s problem.“

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.

When Duntsch’s patients tried to sue him for malpractice, many found it almost impossible to find attorneys. Since Texas enacted tort reform in 2003, reducing the amount of damages plaintiffs could win, the number of malpractice payouts per year has dropped by more than half.

Jeff Glidewell was one of Duntsch’s patients — Duntsch cut 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.

Inside Edition/YouTube

Duntsch’s attorney did not allow him to be interviewed for this story. Representatives from one hospital where he worked also would not respond to questions. Two more facilities said they could not comment on Duntsch because their management has changed since he was there, and a fourth has closed.

In the end, it fell to the criminal justice system, not the medical system, to wring out a measure of accountability for Duntsch’s malpractice.

In July 2015, Duntsch was arrested and Dallas prosecutors charged him with 

one count of injury to an elderly person and five counts of assault

, all stemming from his work on patients.

The case was covered intensely by local and state media outlets. D Magazine, Dallas‘ monthly glossy, published a cover story in 2016 with the headline „Dr. Death;

“ the nickname stuck.

Last year, Duntsch was convicted and sentenced to life in prison, becoming the first doctor in the nation to meet such a fate for his practice of medicine.

„The medical community system has a problem,“ Assistant District Attorney Stephanie Martin said in a press conference after the verdict. „But we were able to solve it in the criminal courthouse.“

Christopher Duntsch (right) during surgery.

WFAA/YouTube

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.

Glidewell spent four days in intensive care and endured months of rehabilitation for the wound to his esophagus. To this day, he can only eat food in small bites and has nerve damage. „He still has numbness in his hand and in his arm,“ said his wife, Robin. „He basically can’t really feel things when he’s holding them in his fingers.“

Neither Glidewell, nor the prosecutors, nor even Duntsch’s own attorneys said they thought his outlandish case had been a wake-up call for the system that polices doctors, however.

„Nothing has changed from when I picked Duntsch to do my surgery,“ Glidewell said. „The public is still limited to the research they can do on a doctor.“

For Duntsch, the path into medicine was unconventional and, perhaps, a reflection of his tendency to fixate on unlikely goals.

The first of these had been college football. Duntsch’s father had been a gridiron standout in Montana and Duntsch, though not a particularly talented athlete, was determined to follow in those footsteps. He trained hour after hour on his own and played linebacker on his high school team in Memphis, Tennessee. Classmates remember him as a turbine of sheer determination.

„He had his goal, his sight on a goal and whatever it took to get there,“ said one classmate, who did not want to be named. „He wanted to go to college and play, and I can recall he was like 180 pounds and said, ‚I need to get to 220‘ in order to be a linebacker at Colorado or Colorado State.“

He did get a football scholarship, but it was to Millsaps College in Mississippi. He yearned to transfer and play linebacker for a Division I team. He set his sights on the Colorado State Rams his sophomore year and made it as one of the few walk-on players. Chris Dozois, a fellow linebacker with the Rams, recalled Duntsch struggling, even with basic drills, but begging to run them over and over.

„He’d be, ‚Coach, I promise I can get this, let me do it again.‘ He’d go through; he’d screw it up again,“ Dozois said. „I gathered very quickly that everything that he had accomplished in sports had come with the sweat equity. When people said, ‚You weren’t going to be good enough,‘ he outworked that and he made it happen.“

Homesick, Duntsch left Colorado after a year and transferred again to what was then Memphis State University, now the University of Memphis. He had hoped to play football, but he tearfully told Dozois his multiple transfers had taken away his eligibility.

It was then, Dozois recalled, that Duntsch set his sights on his next goal: to be a doctor. And not just any doctor — a neurosurgeon, operating on injured backs and necks.

After getting his undergraduate degree in 1995, Duntsch enrolled at the University of Tennessee at Memphis College of Medicine, in an ambitious program to earn both an MD and a PhD

As part of the program, he worked in a 

research lab

, studying the origins of brain cancer and the various uses of stem cells. For a time, after he earned his dual degrees in 2001 and 2002, it seemed he might make a career in biotechnology rather than treating patients.

As he did his surgical residency, Duntsch teamed up with two Russian scientists, recruited by the University of Tennessee, to explore the commercial potential of stem cells to revitalize ailing backs. They patented technology to 

obtain and grow disk stem cells

, and in 2008, they launched a company, 

DiscGenics

, to develop and sell such products. Two of Duntsch’s supervisors from the university were among the first investors.

Christopher Duntsch in his „Best Docs Network“ video.

Inside Edition/YouTube

While Duntsch appeared to be thriving during these years, more unsavory aspects of his life simmered below the surface.

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.

„Most people, when they go binge all night long, they don’t function the next day to go to work,“ she said in her deposition. „After you’ve spent a night using cocaine, most people become paranoid and want to stay in the house. He was totally fine going to work.“

One of the early investors in DiscGenics, Rand Page, said he was initially impressed with how Duntsch presented himself and the company, but as time passed, Page became wary of his new business partner.

„We would meet in the mornings, and he would be mixing a vodka orange juice to start off the day,“ Page said. Once, he stopped by Duntsch’s house to pick up some paperwork. He opened a desk drawer to find a mirror with cocaine and a rolled-up dollar bill sitting on top of it.

Ultimately, Duntsch was forced out of DiscGenics and his partners and investors sued him over money and stock. (Representatives of DiscGenics declined to be interviewed for this story.)

The University of Tennessee said it could not comment on Duntsch, citing the confidentiality and privacy of medical students‘ records, but Dr. Frederick Boop, chief of neurosurgery at the hospital where Duntsch did his residency, appears to have known about Duntsch’s substance abuse.

In a 2012 phone call recorded by a Texas doctor who contacted Boop because he was alarmed by Duntsch’s surgical errors, Boop acknowledged that an anonymous woman had filed a complaint against Duntsch, saying he was using drugs before seeing patients.

In the phone conversation, Boop said university officials had asked Duntsch to take a drug test, but he had avoided it, disappearing for several days. When he returned, he was sent to a program for impaired physicians and closely supervised for the remainder of his surgical training, Boop told the Texas doctor. (An attorney for the University of Tennessee said Boop would not respond to questions for this story.)

It’s not clear how much training Duntsch actually received, however.

After 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.

Despite what Duntsch had told friends when he headed off to medical school, Page said Duntsch had staked his fortune on being a businessman, not a doctor.

„I don’t think his plan was ever to become a surgeon,“ he said. When Duntsch was kicked out of DiscGenics, „I think the decision was made for him that he was going to have to enter into the medical community to support himself.“

Duntsch’s first job as a practicing physician was at the Minimally Invasive Spine Institute in the affluent Dallas suburb of Plano, which hired him in the summer of 2011, when he also received privileges to operate at Baylor Regional Medical Center.

The hospital welcomed Duntsch with a 

$600,000 advance

. While no one from the practice agreed to be interviewed, they sent an email describing the recommendations they had gotten from Duntsch’s supervisors at the University of Tennessee medical school in Memphis.

„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.“

In 2010, Boop faxed a 

recommendation for Duntsch

 

to Baylor-Plano, checking off „good“ or „excellent“ in boxes asking about his skills and noting, „Chris is extremely bright and possibly the hardest working person I have ever met.“ Another supervisor, Dr. Jon Robertson, who was an old family friend of the Duntsches and an investor in DiscGenics, noted on his recommendation that Duntsch had an „excellent work ethic.“ (A University of Tennessee attorney said Robertson could not respond to questions.)

A vascular surgeon who operated at Baylor-Plano, Dr. Randall Kirby, said he met Duntsch soon after he started and found him to be an arrogant know-it-all.

„I would see him maybe once a week at the scrub sinks or in the doctor’s lounge,“ Kirby said. „He is among giants up there, and he was trying to tell me over and over again how most of the spine surgery here in Dallas was being done inappropriately and that he was going to clean this town up.“

Duntsch lasted only a few months at the spine institute, not because his patients had complications, but because of a falling out with the other doctors over whether he was fulfilling his obligations.

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.)

Nonetheless, Duntsch still had privileges at Baylor-Plano, and on December 30, 2011, he operated on a man named Lee Passmore.

At the time, Passmore was an investigator in the Collin County Medical Examiner’s office, just north of Dallas. He had undergone successful back surgery once before, but the pain had returned.

Passmore’s pain specialist told him he didn’t have a back surgeon to whom he routinely referred patients, but that he’d gone to lunch recently with one who „seemed like a guy that knew what he was talking about,“ Passmore recalled in court testimony.

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. (In response to a request for comment, Hoyle sent a note saying he was through talking about Duntsch.)

Passmore did not respond to requests for comment for this story. Passmore has testified that he lives with chronic pain and has trouble walking as a result of Duntsch’s errors.

The next patient Duntsch operated on was Barry Morguloff.

Morguloff ran a pool service company. He had worn out his back working in his father’s import business, helping to unload trucks. „It took a toll on my back even with back supports and exercise and a strong core,“ Morguloff said. His pain returned after an earlier back surgery, but the surgeon recommended exercise and weight loss, not another procedure.

A pain specialist gave Morguloff Duntsch’s card.

„Everything that I read when we first got his card — outstanding reviews, people loved him. I read everything I could about this guy,“ Morguloff said. He set up an appointment and found himself impressed by Duntsch’s easy confidence.

„Phenomenal, great guy, loved him,“ Morguloff recalled. Most importantly, he added, „I was in pain and somebody, a neurosurgeon, said, ‚I can fix you.'“

His surgery, an anterior lumbar spinal fusion, took place on January 11, 2012. At the request of a head-and-neck surgeon also on the case, the vascular surgeon assisting Duntsch was Kirby. Kirby said it should have been a routine case.

„In the spectrum of what a neurosurgeon does for a living, doing an anterior lumbar fusion procedure’s probably the easiest thing that they do on a daily basis,“ he said.

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.

Morguloff awoke in excruciating pain.

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.

„As time goes on, the scar tissue and everything builds up, and I lose more and more function of that left side,“ he said. „I do my best to stay active. But some days I just can’t get moving. The pain is continuous.“

Soon after the Morguloff surgery, Duntsch took on a patient who was also an old friend.

Jerry Summers had played football with Duntsch in high school and helped with logistics at the research lab during his residency. When Duntsch took the job in Dallas, he asked Summers to move with him and help set up his practice. They lived in a downtown luxury high-rise while Duntsch shopped for a house.

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.

For days after the operation, Summers lay in the ICU, descending into a deep depression. „Jerry was calm with Chris,“ said Jennifer Miller, then Summers‘ girlfriend, „but all Jerry would say to me is: ‚I want to die. Kill me. Kill me. I want to die.'“

One morning, Summers began screaming and told several nurses that he and Duntsch had stayed up the night before the surgery doing eight-balls of cocaine. In truth, the night before the surgery Summers and Miller had dinner at a local restaurant and watched the University of Memphis basketball team play Southern Mississippi on the bar TV.

In his 2017 deposition, Summers acknowledged he made up the pre-surgery cocaine binge because he felt Duntsch had abandoned him, as both his surgeon and his friend.

„I was just really mad and hollering and wanting him to be there,“ Summers said. „And so I made a statement that was not something that was necessarily true… The statement was only made so that he might hear it and go, ‚Let me get my ass down there.'“

Baylor officials took Summers‘ accusation seriously and ordered Duntsch to take a drug test. As at the University of Tennessee, he stalled at first, telling administrators he got lost on the way to the lab.

He passed a separate psychological evaluation and, after three weeks, was allowed to operate again, but he was told to stick to relatively minor procedures.

His first patient after his return was elementary school teacher Kellie Martin, who had a compressed nerve from falling off a ladder as she fetched Christmas decorations from her attic. 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.

Baylor-Plano again ordered Duntsch to take a drug test. The first screening came back diluted with tap water, but a second, taken a few days later, came up clean. Hospital administrators also organized a comprehensive review of Duntsch’s cases, after which they determined that his days at the facility were over.

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

.

The databank, which was established in 1990, tracks malpractice payouts and adverse actions taken against doctors, such as being fired, barred from Medicare, handed a long suspension, or having a license suspended or revoked.

The information isn’t available to the public or other doctors, but hospital administrators have access to the databank and are supposed to use it to make sure problem doctors can’t shed their pasts by moving from state to state or hospital to hospital. Robert Oshel, a patient safety advocate and former associate director of the databank, says that hospitals are required to check all applicants for clinical privileges and once every two years for everyone who has clinical privileges.

Many hospitals, however, hesitate to submit reports to the databank, worrying that doing so may hurt doctors‘ job prospects or even prompt lawsuits.

„What happens sometimes is that doctors are allowed to resign in lieu of discipline so that the hospital can protect its perceived legal liability from the doctor,“ said Van Wey, the Dallas trial lawyer. „If Dr. Duntsch was unable to get privileges at other hospitals, theoretically Dr. Duntsch could have sued Baylor and said: ‚Look, I could be making $2 million a year here… You owe me $2 million for the rest of my life.'“

According to a report by Public Citizen, a consumer watchdog group, about half the hospitals in the country had never reported a doctor to the databank by 2009. A more recent analysis didn’t find much change, said Dr. Sid Wolfe, a founder of Public Citizen’s Health Research Group.

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