ON THE COVER North Coast Journal Weekly

In their hands -- Humboldt heart patients say Redding doctors betrayed their trust [graphic of a pair of hands holding human heart]


They all heard the same message, the same terrifying ultimatum, as they lay in a hospital bed at Redding Medical Center, anxious for some information from the man rumored to be one of the best heart doctors anywhere.

[Dr. Chae Hyun Moon]"You can go home and die," Dr. Chae Hyun Moon [photo at right] reportedly told three Humboldt residents, as well as other heart patients, "or you can stay and have the surgery."

This is the story of those three Humboldt County men who stayed -- how many would not have? -- for the coronary bypass operation Moon said they could not live without. These men, and hundreds of others, put their trust in the two doctors who would later be the subject of investigations and lawsuits alleging that they performed unnecessary procedures for profit. Now, these patients, and others, have been given another diagnosis by a Redding law firm that is even more startling: They had a $200,000 operation they never needed.

"I worked all my damn life," said Roscoe Littlefield of Weitchpec, who had a triple bypass last year and is now suing Redding Medical and the doctors involved. "Now I really can't do much of anything."

Moon, 56, former director of cardiology at Redding Medical Center, and Dr. Fidel Realyvasquez Jr., 54, [photo below left] former chief of cardiac surgery there, have since left the hospital. They have yet to be charged with any crime, and there's no indication that Humboldt physicians were complicit in any way in the alleged wrongdoing.

[Dr. Fidel Realyvasquez]But local doctors had their suspicions. "Nobody really wanted to go up against that system," said one North Coast physician, referring to not just the medical center but to its owner, the Santa Barbara-based Tenet Healthcare Corp.

Next month, just over a year after the offices of Moon and Realyvasquez were raided by the FBI, the Redding law firm of Reiner, Simpson, Timmons and Slaughter is scheduled to begin discovery in the suit it filed against the 238-bed Redding Medical Center and the doctors on behalf of hundreds of heart patients. Lead counsel Bob Simpson said a team of physicians hired by the firm has reviewed the records of 560 patients. The reviewers determined that 230 of them had "invasive heart procedures" -- stents, angioplasties, catheterizations, valve replacements and bypasses -- that were unnecessary. Some of the patients died, including Zena Mary Afdahl, a Eureka resident, who was operated on by Dr. Moon in 1994. Afdahl's family was not interviewed in detail for this story.

The number of people who may have had unnecessary surgeries could grow larger.

"We're still reviewing another 300," Simpson said, "and that is about half of the cases that are out there."

Expecting vindication

The story continues to unfold. In August, Tenet paid $54 million to the U.S. Justice Department to settle charges that it conducted unnecessary cardiac surgery and other procedures at Redding that were paid for by Medicare. Blue Cross canceled a contract with Tenet's Doctors Medical Center in Modesto last month after an independent review found that 13 of 23 coronary bypass operations performed there had not been medically necessary. The civil suit, one of several that have been filed, charges Moon and Realyvasquez with fraud, battery and negligence, among other charges. It also names as defendants Redding Medical Center, Tenet, and other doctors: cardiologists Thomas Russ, Walter Fletscher, B.V. Chandramouli, and their medical group, Cardiology Associates of Northern California; and cardiac surgeons Ricardo Moreno-Cabral, Kent Brusett and Kevin Miller of the Cardiac, Thoracic and Vascular Surgery Medical Group in Redding. The FBI investigation, which began Oct. 30, 2002, continues.

Tenet has disputed the charges. Moon's attorney, Matthew Jacobs of Sacramento, said Moon is living in Redding but not practicing medicine. "There are a lot of plaintiffs' lawyers running around trying to generate business. They found a lot of people who were perfectly happy with Dr. Moon's results and procedures before all this broke, and suddenly decided they have a bone to pick with him." Jacobs said Moon is "looking forward to vindicating himself in whatever proceeding anybody happens to bring."

Realyvasquez' attorney, Malcolm Segal of Sacramento, said he could not comment on the events surrounding his client, who is on a leave of absence from Redding Medical Center but maintains his own office practice. He said only that Realyvasquez "awaits the outcome of the inquiry with great anticipation, and needless to say, expects to be vindicated."

Meanwhile, Redding Medical has suspended its heart surgery program and finds itself on the brink of collapse, according to a story last month in the Sacramento Bee.

It's a stark change. The hospital was often rated among the most successful heart centers in the country in terms of patient outcomes. For years, it wooed patients from throughout Northern California and southern Oregon. It ran ads in the newspapers (including this one) and on TV. It put up billboards along Highway 101 and sent mailers. The word began to spread.

Dr. David Ploss, a cardiologist in Eureka, estimated that there are about 150 to 200 cardiac bypass patients each year from Humboldt, parts of Trinity and Del Norte counties, and parts of southern Oregon. Before St. Joseph Hospital opened its Heart Institute in 1997, "The majority of those cases went to Redding Medical Center," he said. "After we opened our program, Redding still received 60 a year."

Some were referred by their local Humboldt County doctors, including family physicians. Others went to Redding because of its reputation.

Weakened health

[Roscoe Littlefield]Roscoe Littlefield, 74, [photo at right] was one of those. He said he had never had any pain, shortness of breath or other symptoms of heart problems, but he went to Redding Medical Center last year after one Humboldt heart doctor told him he needed a pacemaker and another said he didn't. "I was all mixed up," Littlefield said. "I didn't know who to believe. That's why I decided to go over to Redding."

Feeling good, Littlefield expected to get a checkup and a final verdict on the pacemaker issue. Instead, after an angiogram, Moon came into Littlefield's room to say he needed a triple bypass. "He said I was going to die if I didn't get it done." Littlefield had no doubt it was true. "Doctor tells you you're gonna die, you're gonna die. I was happy he was going to save my life."

The news "freaked me out," said one of Littlefield's four sons, Tim. "Dr. Moon said if he left, he was gonna die. He said, `We have to operate on you immediately,' but he was 13th on the list." By the next morning, the list had somehow opened up. Littlefield had the surgery.

When he went back for his checkup some weeks later, he and his wife saw FBI agents carting out boxes of files from Moon's office.

Littlefield remained confident in his doctor. But as the months went by and the news about the investigation unfolded, his family started wondering. Roscoe Littlefield was not the same. The man who had operated cranes and other construction equipment for most of his working life now walked with a cane and felt like hell. The surgery had left him weak. "We kept waiting for him to jump up and say, `I feel great, I want to go for a walk,'" said his wife, Sylvia. But that didn't happen. After they saw an ad in the paper about the lawsuit, family members pressed him, for weeks, to call the law firm and get his case checked out.

"I don't believe in suing people. I never sued nobody in my life," Littlefield said. Now, he doesn't regret joining the suit. "Goddam right I'm glad I did it," he said. "I'd castrate that son of a bitch."

`Little heart attacks'

[Patrick Williams]Like Littlefield, Patrick Williams of Eureka [photo at right] never expected he would return from Redding with a long, vertical scar down his chest, the characteristic "zipper" of open-heart surgery.

Williams, 53, a social services eligibility worker, went to see Moon for a treadmill test at the urging of his Willow Creek family physician, after he mentioned he sometimes felt short of breath when shooting baskets. Get it checked out, just to be safe, his doctor said. At the time, it was not among his greatest worries. Williams had wrestled with serious health problems: He had been diagnosed some years earlier with diabetes, which he'd kept under control, and multiple sclerosis, which has yet to cripple him. But he also had a family history of heart disease.

When he got to Redding, Moon asked him whether he'd had any pain. Williams told him about the stabbing sensation he occasionally felt in his left jaw, a pain he described as akin to "biting down on an electrical cord."

"He just kept saying, `That's angina,' Williams said. "He said, `You've been having little heart attacks.'"

Williams urged Moon to call his neurologist, who had diagnosed the pain as trigeminal neuralgia, a nerve disorder, and linked it to his multiple sclerosis. But Moon was convinced it was heart-related, and predicted that Williams had 90 percent blockages in his arteries. He never called the neurologist.

After the angiogram, Moon was blunt. If Williams left, he could have a heart attack at any moment. Initially told he was 15th on the list, he was moved up later that day and told the surgery was scheduled for the next morning.

Williams' reaction was mixed. "He made it so scary," he said. At the same time, he offered hope: Moon would save his life and get rid of that terrible pain, all at once. "He had dangled out this carrot. He said, `Here, we can fix this. You don't have to live with this pain." The alternative was to leave the hospital and risk death with his next step -- as well as lose his place in line, Moon reportedly told him.

Williams took the carrot.

In hindsight, Williams said, he should have had more suspicions. His brother, who had had a bypass earlier, described feeling like a new man after the surgery. "I didn't feel any of that," Williams said. "I didn't feel that sudden parting of the skies. I felt about the same as I'd always felt."

Still, it took a long time for him to question what his Redding doctors had done. "`You're in good hands.' That's what I was told before I went there. It took a lot to make me doubt, and the thing that makes me angry about all this is, these are people who you're putting your life in their hands." Seven weeks later, Williams was seized with another attack of the jaw pain. He quickly took a nitroglycerin pill, which is designed to ease angina. It did nothing.

Physical damage?

For those who had unneeded surgery, the psychological effects -- the sense of betrayal, the loss of trust, the fear -- are devastating. The physical results, for those who survived, may be more difficult to assess.

All surgeries involve risk, said Ploss, the Eureka cardiologist. A few patients have adverse reactions to the anesthesia or the blood transfusion; there is a small risk of stroke; some have chronic edema, or swelling, in the part of the leg where a vein was removed for a cardiac bypass. And the bypass does not last indefinitely, because the vein that is used to bypass a clogged artery is not accustomed to the high-pressure flows of an artery that supplies blood to the heart.

On the other hand, Ploss said, if the bypass was unnecessary -- meaning the arteries were not obstructed in the first place -- then those healthy arteries would just take over again when the bypass veins gave out. Unless, of course, the intervening years had made the healthy arteries clogged.

[Robert Robinson]Robert Robinson of Blue Lake, [photo at left] another plaintiff in the lawsuit, said he feels great after his two bypass operations at Redding Medical. (No different, he said, from how he always felt.) But the hospital bills and long recovery time crippled him financially. The surgeries, one in 1996, the other in 1998, made him lose a job he loved; the boss thought he was a bad risk. And the financial strain contributed to the breakup of his marriage.

"I said, man, that guy [Moon] ruined me," Robinson, 69, said. "I could have worked up until 70 years old. I lost 10 years or more." The Laytonville native spent most of his life servicing truck tires -- a job that gave him good health insurance, vacation benefits and a chance to shoot the breeze with truckers. Now, he works the graveyard shift as a security guard for a lumber company. He talks to virtually no one and makes $7.75 an hour, no benefits.

"We had to go bankrupt because of the medical bills," he said. He and his ex-wife lost their McKinleyville mobile home; he now rents a one-bedroom apartment for $400 a month.

Still, even though the law firm's review panel said that both of his bypass operations were unnecessary, Robinson said he has no hard feelings toward Moon and Realyvasquez.

"You can't curse `em or anything like that," he said. "The Lord says love your enemy like you love yourself. If you can't do that, there's no sense in doing anything." In fact, he feels blessed, he said. "I could've died right there on the operating table. I believe the good Lord spared me."

Heart procedures primer

[model of human heart]Angiogram -- An X-ray test that takes pictures of the blood flow within an artery or vein. The test is performed by threading a catheter from the patient's thigh to the heart area, where a dye is injected into the vessel to make it more visible.

Angioplasty -- A procedure in which a catheter is inserted through the groin area or arm and guided to the blocked artery in the heart, where a small, expandable wire tube called a stent is often inserted. A balloon placed inside the stent opens it and pushes it in place against the wall of the artery, where it remains permanently.

Cardiac catheterization -- A test to measure various heart functions. Once inside the heart, the catheter can measure pumping and valve pressure, take blood samples, inject dye into the heart chambers and assess valve problems.

Coronary bypass -- Open-heart surgery in which clogged coronary arteries are bypassed with veins from elsewhere in the body in order to increase blood flow to the heart.

Stent -- A small, coiled, wire-mesh tube inserted into a blood vessel to expand its flow.

Valve replacement -- Open-heart surgery in which a damaged heart valve is replaced with an artificial valve.

Source: WebMD, mywebmd.com

Local MDs had doubts

While their North Coast patients regularly traveled to Redding, sometimes returning after major surgeries or other heart procedures that they had not anticipated, Humboldt area doctors began to wonder whether something was amiss.

"They did very good work. There was absolutely nothing wrong with the quality of their surgery," Ploss said. "It was all basically patient selection. As long as we controlled who went [to Redding Medical] and who didn't, there was never an issue."

Another local cardiologist, Dr. Robert Lock, said he too had doubts about what Moon and Realyvasquez were doing. "There was a lot that went on there that I didn't agree with," he said.

Dr. Janet Wright, director of cardiology at Enloe Medical Center in Chico, said it was clear to cardiologists everywhere that Redding was doing an enormous number of heart procedures for their market size. The data were mapped in the Dartmouth Atlas, a research project of the Dartmouth Medical School.

"Everybody knew for a number of years that the number of surgeries [in Redding] far outstripped the population area," Wright said. But that wasn't necessarily damning. There was a movement in cardiology that basically said, more is better. "The message going out to cardiologists is, in order to be well-qualified, you have to do a lot of these procedures," Wright said. "Like most pieces of wisdom, it can be twisted. It doesn't mean, go out and do them at the sake of doing them for less than perfect indications."

Without looking at the individual cases, she said she herself does not know whether or not there was any wrongdoing.

But if they had doubts, why didn't local doctors blow the whistle?

One North Coast physician, who asked that his name not be used, said doctors had nothing to gain and everything to lose by challenging the Redding doctors and the giant Tenet corporation. To make accusations, without having all of a patient's records, was risky -- especially when patients came back from Redding convinced that their lives had been saved.

"You didn't really have all of the goods, you didn't have all of the story, and you had everybody telling you it was great. Nobody was complaining. All you could get was hammered."

He pointed out that the people responsible for dealing with suspected improprieties were the medical staff at Redding Medical Center. "That didn't happen," he said. "Their internal quality review process didn't function."

A damaged relationship

In fact, the civil suit alleges that Redding area doctors contacted the hospital's CEO on several occasions, beginning at least as early as 1997, to say they believed unnecessary heart procedures were occurring there. The outsiders asked for an independent review of the cases, which, according to the lawsuit, never happened. (The FBI was tipped off to the alleged problems by a friend of one of Redding Medical's patients.)

Ploss predicted that it would not be difficult for investigators to conclude whether or not unnecessary procedures were done.

"You can't rely on symptoms to decide in retrospect whether a procedure was appropriate or not," he said. "But in cardiology, we've got hard data, because we have the angiograms. And anybody can go back and look at the pictures and say, were there really blockages here or were there not?"

Regardless of the outcome of the federal investigation or the lawsuits, the damage has already been done, said Wright, the Chico cardiologist.

The doctor-patient relationship is "a sacred trust," she said. "The fact that that could be violated is devastating."

Before the Redding investigation, patients she had never met before would put their life in her hands without question. "Now I suggest a procedure that is clearly in their best interest, and they have this doubt, a lack of trust. Now I see this fear in their eyes, and I can see they've heard these horror stories. It's a tragedy."

 The local option

Since 1997, when St. Joseph Hospital opened its own Heart Institute, many patients from Humboldt County and elsewhere on the North Coast have eschewed going out of the area for their coronary bypass operations, stents, angioplasties and other heart procedures.

The institute had something of a rocky start. Just three months after it opened in April of 1997, the hospital shut down the program pending a review by its own staff, the state and, at the request of the hospital, the American Society of Thoracic Surgeons.

"They had a higher mortality rate than they felt was reasonable," said Dr. David Ploss, a Eureka cardiologist who is on staff at the institute.

Since it reopened in August 1998, that's all changed, Ploss said. "The results have been fabulous, better than the national average." Of 190 patients who had coronary bypass surgery at St. Joseph from July 2000 to the end of 2002, for instance, three of them, or 1.6 percent, died. The average death rate is 3 percent, based on a Society of Thoracic Surgeons national database.

That's important for Humboldt residents, particularly those who come to the hospital in immediate need of a procedure, Ploss said. "The ability to do things locally makes a huge difference."




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