A surgeon so bad it was criminal

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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.

Duntsch seemed impressive, at least on the surface. His CV boasted that he’d earned an M.D. and a Ph.D. 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 U.S. 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.

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.”

Glidewell was the last patient Duntsch operated on before being stripped of his license to practice medicine.

Jeff Glidewell had surgery with Dr. Christopher Duntsch in 2013. He was Duntsch’s last patient, and his call to a judge in early 2015 helped bring the case back to the DA’s attention. (Dylan Hollingsworth for ProPublica)

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.

Before Duntsch became a doctor, he doggedly pursued a football career. One teammate remembers Duntsch struggling with basic drills and attributed Duntsch’s success to “sweat equity.” (Via Facebook)

“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 wound up at Millsaps College in Mississippi, which offered him financial aid. But 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 M.D. and a Ph.D.

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.

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 1000 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 Dec. 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 Jan. 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.

Barry Morguloff had what was supposed to be routine surgery with Duntsch. The lasting damage has affected his ability to walk, and as time passes he gradually loses function on the left side of his body. (Dylan Hollingsworth for ProPublica)

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.

Despite his string of problems at Baylor-Plano, Duntsch also wasn’t reported to the Texas Medical Board, the state’s main purveyor of doctor discipline. Such boards often move slowly, but if hospital officials submit material they’ve gathered to justify letting a doctor go, boards can act to protect patients from imminent harm.

“Had Baylor’s action been reported appropriately, I would anticipate the board would have met within days to have an immediate suspension,” said Dr. Allan Shulkin, a Dallas pulmonologist who was on the medical board in 2012.

The board would still have conducted an investigation, but Duntsch would not have been allowed to operate while it was going on, Shulkin said. He was visibly angered by Baylor-Plano’s failure to report. “What’s the worst that can happen, a lawsuit?” he said. “Come on. These are people dying, and we’re stopping because you’re afraid of a lawsuit?”

Two years after Duntsch left Baylor-Plano, the hospital’s decision not to report its review of his work or its results prompted an investigation by state health authorities. The hospital was hit with a violation and fined $100,000 in December 2014, but a year later, the citation and penalty were withdrawn. The Texas Health and Human Services Commission would not explain why, saying the records were confidential.

Hospital officials declined to be interviewed for this story, submitting a written statement instead.

“Our primary concern, as always, is with patients,” it said. “Out of respect for the patients and families involved, and the privileged nature of a number of details, we must continue to limit our comments. There is nothing more important to us than serving our community through high-quality, trusted healthcare.”

Duntsch’s next stop was Dallas Medical Center, which sits outside Dallas’ northern edge in the city of Farmers Branch. Baylor-Plano officials might have thought any future employer would contact them before hiring him and they could share information confidentially, but Dallas Medical Center granted Duntsch temporary privileges while its reference checks were still going on.

On July 24, 2012, Duntsch operated on Floella Brown, 64, a banker about to retire after a long career. She had come to Duntsch for cervical spine surgery to ease her worsening neck and shoulder pain.

About a half hour into Brown’s surgery, Duntsch started to complain that he was having trouble seeing her spine.

“He was saying: ‘There’s so much blood I can’t see. I can’t see this,’” said Kyle Kissinger, an operating room nurse. He kept telling the scrub tech “’suck more, suck more. Get that blood out of there. I can’t see.’ That’s really concerning to me because, not only that he can’t do it correctly when he can’t see that but, why is it still bleeding?”

Brown bled so much that blood was saturating the blue draping around her body and dripping onto the floor. The nursing staff put down towels to soak it up.

After the operation, Brown woke up and seemed fine, but early the next morning she lost consciousness. Pressure was building inside her brain for reasons that were unclear at the time.

That same morning — with Brown still in the ICU — Duntsch took another patient into surgery.

The patient’s name was Mary Efurd. She was an active 71-year-old who’d sought Duntsch’s help because back pain was keeping her off her treadmill.

Duntsch arrived at the hospital about 45 minutes after Efurd’s surgery had been set to start, Kissinger said. He spotted a hole in Duntsch’s scrubs. “It’s on the butt cheek of his scrubs. He didn’t wear underwear. That’s why it really shined down to me,” Kissinger said. The nurse realized he’d seen that hole for three straight days — Duntsch apparently hadn’t changed his scrubs all week. Kissinger also noticed that Duntsch had pinpoint pupils and hardly seemed to blink.

When Duntsch arrived, the staff told him that Brown, his patient from the day before, was in critical condition.

Soon after beginning Efurd’s surgery, Duntsch turned to Kissinger and told him to let the front desk know he would be performing a procedure on Brown called a craniotomy, cutting a hole in her skull to relieve the pressure in her brain. Problem was, Dallas Medical Center did not perform those, or even have the proper equipment to do them.

As he operated on Efurd, Duntsch quarreled first with Kissinger and later with his supervisors, insisting on a craniotomy for Brown, according to court testimony. All the while, the operating room staff questioned whether Duntsch was putting hardware into Efurd in the right places and noticed he kept drilling and removing screws.

In the end, Duntsch did not perform a craniotomy on Brown. She was moved to another hospital but never regained consciousness. In court, her family said they withdrew life support a few days later. A neurosurgeon hired to review her case would later determine that Duntsch had both pierced and blocked her vertebral artery with a misplaced screw. The review also found that Duntsch misdiagnosed the source of her pain and was operating in the wrong place.

The day after her surgery, Efurd awoke in agony. She couldn’t turn over or wiggle her toes. Hospital administrators called Dr. Robert Henderson, a Dallas spine surgeon, to try to repair the damage.

Shortly after he arrived at the hospital, Henderson pulled up Efurd’s post-operative X-rays. When he saw them, he said, “I’m really thinking that some kind of travesty occurred.” That impression only grew when Henderson reopened Efurd’s freshly made incisions the next day. “It was as if he knew everything to do,” Henderson said of Duntsch, “and then he’d done virtually everything wrong.”

There were three holes poked into Efurd’s spinal column where Duntsch had tried and failed to insert screws. One screw was jabbed directly into her spinal canal. That same screw had also skewered the nerves that control one leg and the bladder. Henderson cleaned out bone fragments. Then he discovered that one of Efurd’s nerve roots — the bundle of nerves coming out of the spine — was completely gone. For some inexplicable reason, Duntsch had amputated it.

The operation was so botched, Henderson recalled thinking Duntsch had to be an impostor passing himself off as a surgeon. Even after Henderson’s repairs, Efurd never regained her mobility and now uses a wheelchair. (In an email, Efurd said that discussing what happened to her again would take a toll on her health.)

By the end of the week, hospitals administrators told Duntsch he would no longer operate at Dallas Medical Center. But, as had happened at Baylor-Plano, Duntsch was allowed to resign and the hospital didn’t notify the National Practitioner Data Bank. Dallas Medical Center officials said the hospital had different managers when Duntsch worked there and that current administrators could not comment on his work or the circumstances under which he left.

Duntsch would continue to operate. In fact, his career in Dallas was only about half over.

After Duntsch’s disastrous run at Dallas Medical Center, he was finally reported to the state medical board. The first report came from Shulkin, the Dallas physician who served on the board, who had been told of the surgeries on Efurd and Brown. Other doctors started complaining, too.

“Once I heard about those cases, I called the medical board,” said Kirby, the vascular surgeon who had been present for Morguloff’s surgery. “I said: ‘Listen, we’ve had egregious results at Baylor-Plano. He was not reported to the databank. We’ve had egregious results at Dallas Medical Center. He’s got to be stopped.’”

After being called in to help Efurd, Henderson, too, made it his personal mission to stop Duntsch from operating. He called Boop at the University of Tennessee to ask about Duntsch’s training and spoke to officials at Baylor-Plano hospital. He also called the state medical board.

When a couple of months passed and they didn’t hear about more bad outcomes, Henderson and Kirby said they assumed perhaps Duntsch’s mistakes had finally caught up with him.

Then, in December 2012, Kirby was asked to help Jacqueline Troy, a patient suffering from a severe infection. (The Troy family would not comment for this story.) Troy was being transferred to a Dallas hospital from a surgery center in the suburb of Frisco. She’d had neck surgery, but the surgeon had cut her vocal cords and one of her arteries. When Kirby learned the details, he asked the doctor who referred the case to him about the surgeon: “Is it a guy named Christopher Duntsch?”

It was.

Duntsch had managed to get a job at Legacy Surgery Center, an outpatient clinic. (The ownership of the clinic has changed and the new owners declined to comment for this story.)

Soon after Troy’s surgery, Duntsch was finally reported to the National Practitioner Data Bank, though not by any of his previous employers. A report dated Jan. 15, 2013, obtained by an attorney representing one of Duntsch’s patients, shows that Methodist Hospital in the Dallas suburb of McKinney had reported Duntsch after denying him privileges six months earlier. Their rejection was based on Duntsch’s “substandard or inadequate care” at Baylor-Plano. (Methodist McKinney declined to comment for this story.)

But even after the report to the databank, Kirby was stunned to discover another hospital had given privileges to Duntsch. In May 2013, he was invited to a “Meet Our New Specialist” dinner thrown by University General hospital at a Dallas restaurant. The event was to celebrate the arrival of a new neurosurgeon: Christopher Duntsch.

“I called down there and raised holy hell,” Kirby said.

University General, formerly known as South Hampton Community Hospital, had a troubled history: two bankruptcies and a former CEO sentenced to prison for health care fraud. Purchased for $30 million in 2012 by a Houston-based company, University General was one of only three hospitals serving Dallas’ southern half, an area that spans 200 square miles and includes more than 560,000 people. The surrounding community was hoping for a turnaround.

The hospital is now closed, and its administrators from that time did not respond to questions about why they hired Duntsch.

It likely came down to simple economics. According to the health care analysis firm Merritt Hawkins, the average neurosurgeon is worth $2.4 million a year in revenue to a hospital.

“That’s a dream for a hospital administrator,” Kirby said.

It’s also a virtual employment guarantee for a doctor with Duntsch’s credentials, Dallas neurosurgeon Dr. Martin Lazar said.

“I don’t think it’s because of our charm,” Lazar added dryly. “We are like a cash cow.”

It was at University General that Glidewell had his neck surgery, knowing none of Duntsch’s by then two-year history of botching operations.

Glidewell’s back problems had begun almost a decade earlier, in 2004, when he broke his back in two places in a motorcycle accident. After a year of rehab, he tried to go back to his job working on air conditioning systems but lasted only months before the pain stopped him. He left his first meeting with Duntsch elated and filled with hope.

“I was actually so happy with the way it went that I called my wife and my mother and said, ‘I think I found somebody on my insurance that’s gonna fix my neck,’” he said.

The day of the surgery began ominously. That morning, “We pulled out of the driveway, and soon as we started going forward down the street, a black cat ran across the front of the car,” Glidewell said. “I said, ‘Oh, Lord, this is not good.’ We turned the corner, and when we got on the first county road, and another one. Turning into the hospital, another one.”

Three black cats on the way to the hospital. “I said, ‘We need to just turn around and go home.’”

Once at the hospital, Glidewell and his wife waited. And waited. Three hours late, they said, Duntsch finally arrived in a cab. “He had on jeans that were frayed at the bottom,” Glidewell said. “He didn’t look like he was ready for a surgery.”

Reluctantly, Glidewell went ahead. But hours later, Duntsch came out and told Glidewell’s wife that he had found a tumor in Glidewell’s neck and aborted the procedure.

“I was devastated, crying,” Robin Glidewell recalled. She went to see her husband in the recovery room. “Immediately, Jeff was: ‘Where is the doctor? I can’t move my arm or my leg.’ He was having trouble even talking and said, ‘Something’s wrong, something’s wrong.’”

There was no tumor, but Duntsch had made a series of errors after mistaking a portion of Glidewell’s neck muscle for a growth, according to a review of the case.

The owner of University General heard about what happened to Glidewell and called Kirby to try to mitigate the damage.

“I, with reluctance, went down there and met the Glidewell family and took care of him,” Kirby said. Glidewell was spiking fevers and was transferred to another hospital for care. He would remain there for months.

“This was not an operation that was performed,” Kirby said. “This was attempted murder.”

By the time Duntsch operated on Glidewell, the state medical board had been investigating him for about 10 months.

Frustrated by the board’s inaction, Henderson had called the lead investigator six months earlier to beg for faster intervention. In a recording Henderson made of the call, he says, “This is a bad, bad guy, and he needs to be put on the fast track if there’s such a thing.” She tells him she wishes they could suspend his license while they investigate, but the board’s attorneys wouldn’t go for that.

Kirby sent the board a five-page letter on June 23, 2013, spurred by what had happened to Glidewell. “Let me be blunt,” it said. “Christopher Duntsch, Texas Medical Board license number N8183, is an impaired physician, a sociopath, and must be stopped from practicing medicine.” Robin Glidewell also sent a letter, describing what happened to her husband.

By then, Brett Shipp, a reporter from Dallas’ ABC affiliate, had gotten tips about the board’s slow-moving investigation of Duntsch from a friend of one of Duntsch’s patients and a plaintiff’s attorney. “Very shortly after I contacted them,” Shipp said, “they suspended his license.”

On June 26, Duntsch was ordered to stop operating. The head of the medical board at the time, San Angelo family physician Dr. Irvin Zeitler, said the investigation took a while because “it’s not uncommon for there to be complications in neurosurgery.”

It also struck the board as highly improbable that a surgeon fresh out of training could be so lacking in surgical skill.

“So none of us rushed to judgment,” Zeitler said. “That’s not fair, and in the long run, it can come back to be incorrect. To suspend a physician’s license, there has to be a pattern of patient injury. So that was, ultimately that’s what happened. But it took until June of 2013 to get that established.”

Henderson was called in to repair the damage to one patient following her surgery with Duntsch. After he saw the damage to her spine, he made it his personal mission to keep him from operating on anyone else. (Dylan Hollingsworth for ProPublica)

Even after the board acted, those most involved in trying to keep Duntsch from operating were afraid it would not be the end of his career.

“I was terrified of that term, ‘suspended,’” Henderson said. “I mean, that indicates that he might get it back at some point in time, and I was already aware of the fact of how glib Dr. Duntsch was, and how disarming he was, and how friendly and intelligent he appeared whenever he introduced himself to people that he wanted to impress. I was concerned that he would do the same thing in getting his license back whether it was six months later, a year later, two years later.”

Kirby, Henderson and another doctor decided to contact the district attorney, convinced that Duntsch’s malpractice was so egregious it was criminal. They met with an assistant DA but got little traction.

On Dec. 6, 2013, the medical board permanently revoked Duntsch’s license.

He left Texas, moving in with his parents in Colorado and filing for bankruptcy, claiming debts of around $1 million. His life seemed to go into a free fall. In January 2014, he was pulled over by police in southern Denver around 3:30 a.m. Officers said he was driving on the left side of the road with two flat tires. When he opened the window, they smelled the sour tang of alcohol and spotted an empty bottle of Mike’s Hard Lemonade on the floor of the car. A full one was sitting in the console. After a breath test, Duntsch was arrested for DUI and sent to a detox facility.

Even though he was living in Colorado, he continued to return to Dallas to see his two sons. His older son had been born back when he at Baylor-Plano. His girlfriend, Wendy Young, had a second son in September of 2014.

The following spring, in March, police were called to a bank in Northeast Dallas after passers-by noticed a man with blood on his hands and face beating on the doors. It was Duntsch, babbling about his family being in danger. He was wearing the shirt of his black scrubs. It was covered in blood. Officers took him to a nearby psychiatric hospital.

In April, Duntsch went to a Dallas Walmart because his father had wired him money. According to a police report, he filled a shopping cart with $887 worth of merchandise, including watches, sunglasses, silk neckties, computer equipment, a walkie-talkie and bottle of Drakkar Noir cologne. He put them in bags he swiped from a register. He then picked out a pair of trousers and put them on in a dressing room. He put his own pants into the cart and rolled the cart out the front door without paying for the pants he was wearing. Moments later, he was arrested for shoplifting.

By then, reporters were following every twist in the Duntsch saga. In May 2015, the Texas Observer published an article with the headline, “‘Sociopath’ Surgeon Duntsch Arrested for Shoplifting Pants.” In the comment section underneath the article, Duntsch responded with a series of diatribes against everyone he thought had conspired against him. His cybermanifesto ran to more than 80 pages when printed out.

In one comment directed at Kirby, he wrote, “You use the word without explanation impaired physician and sociopath. Since I am going to sue you or [sic] libel and slander of a criminal nature, this might be a good point to defend this comment.” He called Morguloff’s surgery “a perfect success.”

Kirby took the comments to the district attorney’s office. By then, a judge who knew Glidewell had also brought the case to the DA’s attention.

Prosecutors began discussing the case anew and one assistant district attorney, Michelle Shughart, found it particularly interesting. In 13 years with the Dallas DA’s office, she’d prosecuted drug dealers, robbers, but never a doctor. “I went and started doing my own research,” she said. “I just ended up taking over the case.”

One of the biggest challenges was that there hadn’t been a case like it before.

“We did a lot of research to see if we could find anyone else who had done any cases like this, any other doctors who had been prosecuted for what they had actually done during the surgery,” Shughart said. “We couldn’t find anyone.”

As she and other prosecutors contacted every person Duntsch had ever operated on or their survivors, they struggled to figure what crimes he could be charged with. They settled on five counts of aggravated assault arising from his treatment of four patients, including Brown and Glidewell, and one count of injury to an elderly person, because Efurd was over 65.

In Texas, this charge carried a potential life sentence, but prosecutors had to race to file the case.

“We had about four months left before we were going to run out on the statute of limitations” on Efurd’s case, Shughart said. “I spent those four months just digging as hard as I possibly could, trying to gather as much information as I could. And by the time we got down to that July, I had overwhelming evidence to indict him.”

Duntsch was taken into custody on July 21, 2015.

For some of his patients, the criminal case offered a last chance at justice they couldn’t get through the civil courts.

Since Texas capped damages in medical malpractice lawsuits, limiting the amount plaintiffs can be awarded for pain and suffering in most cases to $250,000, the number of suits filed and amounts paid out have plummeted.

The suits that go forward often ride on economic damages, such as lost earning power, which the law does not limit in non-death cases. But many of Duntsch’s patients were disabled when they came to him, or older, or had lower incomes. Some had pain that was hard to economically quantify. Despite having clear-cut claims and serious, irreversible injuries, three patients I talked to said they had trouble finding attorneys to take their cases.

“It is not worth an attorney’s time and energy to take on a malpractice case in the state of Texas,” Morguloff said.

Ultimately, at least 19 of Duntsch’s patients or their survivors obtained settlements, but 14 of them were represented by Van Wey, who said she’s taken them on more out of a sense of outrage than out of any financial upside.

Morguloff was told no so often, he was surprised when attorney Mike Lyons finally took his case. He received a confidential settlement but said, “It wasn’t much.” He took more solace from the criminal case.

“To get this guy off the streets so nobody else got hurt again was important,” he said. “The public needed to know that there was a monster out there.”

Duntsch’s trial began on Feb. 2, 2017, and focused on the charge related to Efurd, injuring an elderly person.

She testified, but first, to show that her botched surgery was part of pattern, prosecutors — over objections from Duntsch’s attorneys — put a long line of his other patients and their relatives on the stand.

“You had people in walkers. You had people on crutches. You had people that could barely move. You had people that had lost loved ones,” Robbie McClung, Duntsch’s lead defense attorney, said. “You had all sorts of things that had gone wrong. Before we even get to Mary Efurd, you can see that it’s just … it’s going downhill. I mean, it’s going downhill fast.”

A screenshot shows Duntsch during a deposition. (District attorney’s office)

Duntsch held up remarkably well, seeming calm in the certainty that he really was a good surgeon.

“I always thought when I looked at him, even when he was in his jail clothes, he exuded a confidence,” Richard Franklin, another member of the defense team, said. “And I could certainly understand why patients would trust him.”

Then Lazar and other experts walked the jury through a litany of Duntsch’s surgical missteps. Duntsch’s attorneys noticed a change come over him. He deflated before their eyes.

“I think that he thought he was doing pretty good,” Franklin said. “Really and truly, in his own mind. Until he actually heard from those experts up there.”

A key prosecution witness was Kimberly Morgan, who had been Duntsch’s surgical assistant from August 2011 through March 2012 and was also his ex-girlfriend. Morgan described Duntsch’s mercurial nature, vacillating from being kind and caring to patients to being angry and confrontational behind closed doors.

The prosecutors had Morgan read parts of an email Duntsch had sent to her in the early morning hours of Dec. 11, 2011, three weeks before he operated on Passmore at Baylor-Plano, the first of his surgical disasters.

The subject line of the email was “Occam’s Razor.” Occam’s razor is the idea that the simplest explanation for anything is most likely the right one. The email rambled on for five profanity-laced pages, but Morgan delivered the most startling passage.

“Unfortunately, you cannot understand that I am building an empire and I am so far outside the box that the Earth is small and the sun is bright,” Duntsch had written. “I am ready to leave the love and kindness and goodness and patience that I mix with everything else that I am and become a cold blooded killer.”

It took the jurors just hours to find Duntsch guilty of knowingly injuring Efurd. He was sentenced to life in prison. He’s currently incarcerated in Huntsville, about an hour outside Houston. On Sept. 18, his attorney filed an appeal in a Dallas court, arguing that the testimony on cases other than Efurd’s and the email read by Morgan unfairly influenced the jury.

In February, I visited Summers, Duntsch’s old football buddy-turned-patient, in his small apartment in downtown Memphis.

He remains in much the same condition as he awoke in after Duntsch operated on him, unable to move from the neck down. He requires 24-hour caregivers and sat, tipped back, in his power wheelchair, as I talked to him about Duntsch.

Summers seemed resigned to his injuries, to his friend’s role in them and to the systemic weaknesses that allow problem doctors to keep practicing. He said he tries not to think about Dallas anymore.

I asked him why he’d trusted Duntsch to be his doctor. He couldn’t say. He looked out the window.

He knew his friend could barely drive a car without getting lost, he said. He just assumed he had been better trained for neurosurgery.

This article was first published on ProPublica.