by Judy Hodgson
Dr. Dietl rendering by Rose Welsh
In the December edition, The Journal reported that the St. Joseph Heart Institute had been in operation just three months -- May through July 1997 -- when the hospital voluntarily suspended operations in order "to review an unusually high death rate."
That statement was incorrect. As previously reported, the reason for the suspension was to conduct a program review to determine if the death rate was high -- or within expected limits -- and that has yet to be determined.
The article further reported that after a review of the program the state Department of Health Services found that "six deaths out of 40 (procedures) represents a 15 percent mortality rate. The acceptable national rate is 3 to 5 percent."
That information is incomplete. In fact, there were four deaths out of 34 coronary bypass surgeries (and two following valve surgery) for an 11.8 percent mortality rate. The national rate cited in the state report -- 2 to 3 percent -- was for large heart programs that perform 200 to 300 and more bypass surgeries per year. And even those numbers don't tell the whole story.
So what do the statistics really mean and how damning was the state report released in December?
In an exclusive interview last month, Dr. Charles Dietl, who was "terminated without cause" in December as the Heart Institute's medical director, attempts to answer some lingering questions.
"At the Heart Institute we had problems but they were not in the operating room," said heart surgeon Dr. Charles Dietl.
"First of all, not a single death can be traced back to improper manpower or technical errors in the operating room. Not a single one. That needs to be published," he said.
"Ask yourself, how is it possible for a surgeon with a 2.6 percent mortality rate to have a 15 percent rate here in Eureka? What's wrong in Eureka?"
Dietl was sitting in his chilly office on a gray January day. The furnace had been shut off. Diplomas and other medical certificates had already been removed from the walls and packed for the trip to Buffalo, N.Y., where he will enter private practice once his contract with St. Joseph Hospital expires Feb. 1. On his desk was a 45-page curriculum vitae detailing his medical training and experience, list of publications, letters of recommendation and a three-year summary of his operating history at the Geisinger Medical Center in Pennsylvania -- all documentation that led St. Joseph to select him nearly a year ago to head the Heart Institute.
"I took the most difficult cases (at Geisinger), cases other surgeons didn't want, and I still had a 2.6 percent mortality rate," he said.
There is little doubt that Dietl's comments were defensive. On the advice of his attorneys, Dietl has kept silent for the last six months during the hospital's internal investigation, the state investigation and the case review by the Society of Thoracic Surgeons which Dietl said he personally requested as early as June.
Dietl said he believes when all the reviews are complete and analyzed, they will show that the deaths that occurred were within predicted mortality rates for small heart programs nationwide, those with less than 100 patients per year. That rate -- 1.7 times that of the larger programs -- was "elevated, but not statistically significant."
Dietl also said he believes the community, which contributed $1.7 million toward establishing the Heart Institute, needs more complete information in order to decide what type of heart program it really wants and is willing to support.
When Dietl came to the North Coast, St. Joseph administrators assured him Eureka alone was sending 150-200 patients per year out of the county for heart surgery and another 100 were leaving from other nearby communities.
"You need to have at least 200 cases per year for a strong heart program," Dietl said. "In my opinion, if a heart program cannot sustain two heart surgeons and at least five cardiologists, forget it.
"It is well known that heart surgery programs doing less than 100 cases per year have the worst results, because all the personnel working with these patients need constant exposure to be alert, to prevent problems and to solve problems in a timely manner if they occur."
Dietl said he was promised a 200-patient volume, but after the first few deaths he was told by former Chief
Executive Officer Paul Chodkowski to accept only "low-risk" patients, those with a predicted mortality rate of less than 5 percent.
The hospital "changed the rules" and the result was a Catch-22 situation: low-risk patients constitute only about 60 cases per year -- not enough volume, according to Dietl. In addition, low-risk patients usually have the option and time to travel to more established heart programs out of the area.
It was often the immediate, most difficult cases that were ending up in the new Heart Institute operating room early last summer.
"Most of the cases we were doing here were diagnosed one day and done the next. They were bedridden, very unstable," he said.
In the January edition of the Humboldt-Del Norte medical bulletin, Willard Foote, interim CEO of St. Joseph, agreed with many of Dietl's conclusions.
"Our patients were very ill," he said. "The Society of Thoracic Surgeons database will help us 'risk adjust' the cases" to determine whether the mortality rate was within an acceptable national range.
Regardless, Dietl said he was disappointed that the hospital did not more aggressively defend the program and staff and, by terminating his contract, cast a doubt on his personal competency.
For instance, the state report criticized a nurse for performing the surgical task of harvesting a vein from a patient's leg during bypass surgery, saying she was not authorized to act as a first surgical assistant.
"But she was -- she was well qualified and she was authorized by both the head nurse and the head operating room nurse," Dietl said. "The hospital just hadn't done the paperwork."
And, Dietl claims, the hospital brought in a medical statistician after the program was suspended who basically agreed with Dietl that the mortality numbers were not "statistically significant."
"Why didn't they announce that? And why didn't (hospital administrators) tell about all the good things we did?" Dietl asked rhetorically.
"We saved a young woman, mother of three, who was stabbed by her husband. She lost 1.5 times her blood volume and she went home on the fifth day. She would not be alive today. Nobody knows about it."
What the state report did find was that the hospital was deficient in developing written policies and procedures and did not have proper supervisory committees that it should have had during the three-month tenure of the heart program.
But "there is no evidence," acting CEO Foote wrote to the medical community, that those deficiencies in any way contributed to the deaths.
At press time, Dietl and his wife were making travel arrangements. At the same time a few blocks away, St. Joseph officials were preparing to announce the hospital's affiliation with an established heart program out of the county and their intentions to reopen the Heart Institute this spring. (Dietl said he recommended just such an affiliation when he first came to Eureka.)
Dietl had one parting comment to the community: "Tell people this interview is for the guy who buys his groceries in Safeway, picks up a Journal and takes it home to read -- the guy who works in the lumber company. They might not understand statistics and analyses and percentages.
"They need to know that they can't expect a small program to have the same mortality as the Cleveland Clinic or places like that. But to have 1.7 times the national average, that's OK for a small program."
Editor's note: St. Joseph spokeswoman Laurie Watson-Stone said she has been directed by hospital attorneys not to comment on any specific issues raised in this interview.
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