Patients Kept Nearly Dying at a Texas Hospital. No One Suspected an Inside Job.

ON AUGUST 24, 2022, an 18-year-old named Jack Adlerstein checked into the Baylor Scott & White North Dallas Surgicare center. He had come in to have an injury repaired—a deviated septum—following a dirt-bike accident. It’s a common procedure. While he was under anesthesia, the teen’s blood pressure soared to 200/150, a dangerously high figure. The local news reported the dramatic details: Fluid filled his lungs and then his heart stopped. He was transferred to an ICU. Hours later, he awoke without the ability to speak or move, and doctors worried about lasting neurological damage. During all of this, Ashley Burks, the facility administrator, called the surgery center’s governing chair. “It’s happening again,” she said.

The North Dallas Surgicare center occupies a handsome, modernist building near the North Central Expressway. It is partly owned by physicians, which means that trained medical professionals rather than corporate bureaucrats decide how it operates. (Proponents of this model say it can result in better care.) The rest belongs to Baylor Scott & White, a health-care conglomerate that manages 48 hospitals and more than 900 patient-care sites in Texas. It employs some 7,300 doctors and 49,000 health-care workers across the state, making it the largest not-for-profit health-care entity there and one of the biggest in the country.

Mistakes happen at the center. Mistakes happen at hospitals everywhere, because medicine is not an exact science. Unexpected events occur, especially at large hospitals, given the sheer number of procedures that are done there. But what had been taking place at the North Dallas surgery center was frighteningly abnormal. At least 11 unexplained emergencies occurred with OR patients in the summer of 2022. In August alone, when Adlerstein had his near-fatal incident, the center had the same number of “transfers”—when problems require moving a patient to an emergency medical facility—as the number recorded in all of 2021. It was as if some awful curse had befallen it.

“We couldn’t find similarities in all the cases. There wasn’t the same nurse in the room or wasn’t the same doctor and it wasn’t in the same operating room. We looked at all of the things and were extremely perplexed,” Burks later testified in court. “We were desperately trying to figure out what was wrong.”

The surgery center’s unsettling emergencies extended beyond its patients. In late June of 2022, Melanie Kaspar, M.D., a 55-year-old anesthesiologist there, had begun to feel unwell. She tried to work through it. One day, she brought an IV bag home, intending to self-medicate by rehydrating with it. Some renovations were being done in the house, so her husband, John, helped connect her IV bag and she left to rehydrate in the apartment above their garage.

Some minutes later, John received a call from Melanie. She was shrieking into her phone. When he reached her, John asked if the IV bag, still connected to her arm, was the cause of her agony. “No, it’s my arm and my chest!” she screamed. While John was on the phone with 911, Melanie collapsed, spoke incoherently for a few seconds, then fell silent. In a panic, John began CPR. By the time the paramedics arrived, Melanie’s heart had stopped.

Initially, her sudden death was thought to be due to a heart attack. But even in his immense grief, John found this difficult to comprehend. An avid cyclist and an adventurous traveler, his wife had been in excellent health. Two months later, an autopsy vindicated his doubts. Coroners found high levels of bupivacaine, a nerve-block medication commonly used for local anesthesia and pain management, in her bloodstream. They determined that the cause of death was a fatal dose of that drug, though it was unclear how she’d received it. It appeared that her death had not been a mere misfortune after all.

Around the time that Melanie’s autopsy report was completed, another anesthesiologist at the North Dallas center, Chad Marsden, M.D., came into the facility. His plan was to comb over patient files, looking for a connection among all the unexplained events—one of which had happened while he was working in the OR the week before. Inexplicably, the patient’s heart rate continued to climb up and up during follow-up surgery after a tummy tuck. That situation had been “confusing and frankly very scary,” he later testified in court. As with all of the similar incidents at the Surgicare center that summer, the patient survived after receiving emergency care.

When Dr. Marsden got to the center to go through the patient files, he learned another emergency was under way. It was Jack Adlerstein, and the doctor rushed to the operating room. There, he recounted something that had occurred during the incident in his OR: A tech had swapped out an IV bag minutes before he noticed the patient’s blood pressure escalating. His theory sounded outlandish, he admitted, but “I think there might be a problem with the IV bags,” he said. He convinced Burks, the administrator, to exchange Adlerstein’s IV bag for a fresh one.

It worked. After the teen was transferred to the ICU and stabilized, Dr. Marsden inspected all of the IV bags and wrappers in the OR. He spotted a tiny puncture hole in the plastic wrapper of the bag that had been changed out. The bag was eventually tested for contamination. Bupivacaine, the same drug found in Melanie Kaspar’s system, was present in the saline, alongside two other powerful drugs, lidocaine and epinephrine. When the surgery center learned about Melanie’s autopsy results, it was ruled too similar to be a coincidence.

A disturbing reality was beginning to take shape: Someone at the North Dallas Surgicare center was tampering with those bags.

CLINICIDE REFERS TO doctors who intentionally cause a patient’s death during treatment. It was coined in 2007 by Robert M. Kaplan, a forensic psychiatrist in Sydney, Australia. Though the term is relatively new, the phenomenon is old. One of the first documented cases was that of William Palmer, who poisoned several patients in mid-19th-century England.

Other grim notables include Harold Shipman, a British general practitioner who is thought to have murdered as many as 450 patients in the late 20th century, and Michael Swango, M.D., an American who killed 60 patients in several U. S. states, Zambia, and Zimbabwe between 1983 and 1996.

Nurses have also been prolific killers. In fact, one 2006 study of serial murder by health-care professionals, published in the Journal of Forensic Sciences, found that nurses accounted for 86 percent of the prosecutions of these cases.

The personality types and profiles of perpetrators are myriad, but these people all do harm under the cover of care. The authors of a 2020 paper in the British Medical Journal were blunt: “Arguably, medicine has thrown up more serial killers than all the other professions put together.”

Varied as the psychological motivations behind clinicide may be, “the critical issue is the power doctors hold over life and death,” says Kaplan. Psychopaths, like Shipman and Swango, use the thrill of killing to overcome their inner emotional numbing, and there is also “a gray zone for those with massive hubris who will not accept criticism of their work and see themselves above the issues affecting their patients,” he adds. All of this raises the question: How can we, as patients, trust that our doctor is not one of the bad ones?

In America, there are systems that are supposed to weed out the rotten apples. In 1986, Ronald Reagan signed into law the Health Care Quality Improvement Act. This enabled the formation of the National Practitioners Data Bank (NPDB), a federal database of physician disciplinary, malpractice, judgment, and conviction reports. It was intended to prevent dangerous doctors from jumping from state to state and to provide legal protection for those reporting negligent colleagues.

How is it, then, that nearly four decades later, the problem of lethal health-care professionals persists? That they can rampage through reputable facilities like the Baylor Scott & White North Dallas Surgicare center? One reason is that the average health-care professional is simply not on the lookout for malicious colleagues. “Medicine is messy, and you don’t always get the results you hope for or your patient hopes for,” says Kaplan. “So there’s a great degree of tolerance for adverse events. That takes you a long way before somebody starts thinking, Damn, is he deliberately killing these people?”

RAYNALDO ORTIZ JR., M.D., a 61-year-old anesthesiologist, received his Texas medical license in 1991. Domineering and full of swagger, he eventually started his own business, Garland Anesthesia Consultants. It contracted out anesthesiologists—including himself—to health-care facilities.

Ortiz’s pudgy, forlorn face belied his reputation for being quick-witted and an effective charmer in professional settings. He was known as a lavish spender, according to David Billman, M.D., who is part of an anesthesiology group that competed with Ortiz’s for decades. The Dallas anesthesiology market was highly competitive, and Ortiz would woo surgeons with expensive dinners and event tickets. By 2017, it was estimated that his company was raking in up to $9 million in revenue annually. Ortiz was able to purchase a Corvette, a Lexus, and three Mercedes. He bought a mansion with a large pool in Murphy, a wealthy Dallas suburb, that was valued at $1.3 million.

But he also had a tendency toward rage. During the height of the pandemic, Ortiz became irate when a surgery administrator ordered him to wear a mask. In an angry fit, he shouted into the other man’s face. He made such a scene that security had to be called in. The administrator he threatened, Jeremy Johnson, recalled that Ortiz could be rough with patients while they were intubated if he became frustrated, according to the local news outlet D Magazine. Johnson also said that he feared Ortiz might retaliate against him or his family for speaking out. Dr. Billman remembers a similar vibe: “Everyone gave Ray a wide berth because there was a perception that he wasn’t a guy you’d mess with.”

Ortiz had been that way for a long time. In 1995, he was arrested for assaulting his wife, who then divorced him. The two eventually entered a settlement for an undisclosed sum. A decade later, another woman filed for an emergency protective order against Ortiz, also alleging assault. In 2014, he was arrested for assaulting a third woman, who thereafter filed for an emergency protective order. (With that victim, yet another settlement was reached for an undisclosed sum.) Ortiz’s neighbor Roxanne Bogdan witnessed that assault and testified on behalf of the victim during the protective-order hearing. A few months afterward, Ortiz shot Bogdan’s dog with a pellet gun. He was charged with a Class A misdemeanor (which the Texas Medical Board referred to as “a crime of moral turpitude”). He was fined $4,000, ordered to pay the dog’s veterinary bills, and given two years of community service.

Months later, he received a public reprimand and a $2,000 fine from the Texas Medical Board for failing to notify all hospitals of the charge. One board record also referred to Ortiz’s “history of violence against women.” Despite the arrests, he was allowed to continue practicing after a 14-day suspension.

This was not so surprising: State medical boards rarely draw a straight line between personal misbehavior and professional misconduct. A doctor’s personal and professional realms are routinely viewed as unconnected. Any medically related or felony criminal judgments or convictions are required to be reported to the NPDB, but strictly personal or minor offenses are not. This is a norm that runs deep through the culture of physicians.

“I know surgeons that do a wonderful job, but their personal lives, on many levels, are wheels off,” says Dr. Billman, the Dallas anesthesiologist. “But I’d let them operate on me because they’re great surgeons. When you get into pure criminal behavior, there is a limit, but I’m setting that bar pretty high.”

Kelsey McKay, a patient advocate and former prosecutor in Texas, says that medical boards, which are composed mostly of doctors, often argue that even an extreme case of personal misbehavior by a physician “is not a patient issue” and therefore not relevant. That’s a standard she’s trying to change. “Sexual assault and domestic violence are public-health issues,” she says. “If the medical community is not going to do anything about this, then who is?”

By 2020, Ortiz was working at a Baylor Scott & White Surgicare center in Garland, Texas. In November, a patient he was overseeing there had to be resuscitated and transferred to an ICU after Ortiz failed to notice that the patient was having difficulty breathing. Whether it was an oversight or something sinister isn’t clear. But not long after, he relinquished his privileges to practice at the Garland surgery center and continued working for other facilities.

Dangerous doctors frequently change locations after incidents, says Robert E. Oshel, Ph.D., a retired associate director at the NPDB who now advocates for patient safety. Hospitals, fearful of being sued by vengeful physicians, might pressure them to leave quietly before an investigation is initiated-. Hospitals can then avoid having to report anything to the NPDB. They also avoid potential legal battles and embarrassing public scrutiny.

Leaving the Garland center didn’t allow Ortiz to escape notice forever, however. The Texas Medical Board weighed in on the near suffocation there in a report issued two years later. For a short period, he’d be monitored by another physician who would review at least 30 of his patient records and prepare written reports “documenting any perceived deficiencies.” He also had to complete medical training classes and pay a $3,000 penalty. Citing Ortiz’s “rehabilitative potential and present value to the community,” the Texas Medical Board did not revoke his license.

In its report, the medical board acknowledged Ortiz’s past reprimand over failing to disclose the dog-shooting incident to all health-care entities and the board. But this savage act of animal cruelty, it determined, was “not based upon any activity related to the practice of medicine.”

ON THE EVENING of August 24, 2022, the same day as Adlerstein’s emergency and Dr. Marsden’s IV-bag inspection, the FDA was notified by Tenet Healthcare—the company that operates the Baylor Scott & White North Dallas Surgicare center—about the potential tampering Dr. Marsden had discovered. The center was temporarily closed, and an investigation was immediately opened.

The FDA investigators reviewed the surgery center’s security footage. The cameras had only recently been installed. One camera watched over the area where the IV bags were stored, a stainless-steel repository known as a warmer. When investigators went over this footage, they noticed an unsettling pattern.

Just prior to several of the adverse OR incidents, Ortiz could be seen setting IV bags into the warmer. This was unusual: IV bags are typically handled by techs, not doctors. In the footage, Ortiz often glanced around from side to side, as if scanning for witnesses. In one instance, he left the operating room with an IV bag concealed in what appeared to be a paper folder, then swapped the bag with another from the warmer.

Adjacent to the warmer was a medical cabinet containing lidocaine, bupivacaine, and epinephrine. These were the same drugs found in Adlerstein’s IV bag, and the one found in Melanie Kaspar’s system in her autopsy. In one recording, Ortiz was seen filling syringes with drugs. A number of the OR events happened soon after video surveillance showed Ortiz placing bags in the warmer. He became an immediate suspect.

On September 9, just over two weeks after the FDA got involved, the Texas Medical Board suspended Ortiz’s license. In its ruling, it cited the suspicious surveillance footage. Ortiz didn’t know his license was suspended until a local reporter called him for comment. She quotes Ortiz as saying, “I’m just devastated. I didn’t do it, ma’am” and insisting that the only thing he would ever add to an IV bag was antibiotics. When the reporter asked if he was concerned about the patients who had suffered emergencies, he told her, “Am I concerned? I didn’t do anything.”

A few days later, the police pulled over Ortiz in his white two-door Mercedes with expired plates and arrested him. “A single incident of seemingly intentional patient harm would be disconcerting,” announced Chad E. Meacham, the U. S. attorney for the Northern District of Texas at the time. “Multiple incidents are truly disturbing.” Ortiz was denied bail.

His arrest reverberated throughout Dallas. The city was still reeling from 2017’s much-publicized “Dr. Death” trial, involving the local surgeon Christopher Duntsch, who had a drug habit; his 38 career surgeries resulted in 33 injured patients and two deaths. People questioned, again, how a man with such a sordid history could have been allowed to continue administering care at all.

“Why was someone with such a violent past given so many slaps on the wrist?” wondered prominent medical YouTuber Dr. Michael Cellini soon after Ortiz’s indictment. “Like, what does it take to lose your license? The guy actually shot a dog because he was angry. Isn’t that a red flag for being a physician?”

According to the Texas Medical Board, Ortiz’s prior history was not, in fact, pertinent to his practicing medicine. “While Dr. Ortiz had previous encounters with law enforcement and prior disciplinary history with the Board, specifically a prior conviction for animal cruelty, that is not necessarily grounds for license revocation,” a representative for the board told Men’s Health. “Furthermore, an arrest itself, with certain exceptions, is also not necessarily actionable by the agency.”

Patient advocates routinely criticize state medical boards for inaction. But some boards are more proactive or responsive to patient complaints than others. Public Citizen, a watchdog group, analyzes state boards for how often they take serious disciplinary actions against a physician, such as suspensions or license revocations. In its latest analysis, from 2019 to 2021, Michigan topped the list for the highest rate of serious disciplinary actions, with 1.74 per 1,000 physicians annually. Ohio and North Dakota were next. California, the state with the most licensed doctors, ranked 27th.

These differences among states may stem from differences such as staffing and funding—many boards lack the resources to investigate all or even most complaints. There are also varied laws pertaining to patient safety and medical malpractice in every state. For instance, not all states allow boards to conduct investigations without an outside complaint. In any case, activists do not consider the legal system protective enough of patient safety.

“Most of the laws are written to protect the livelihood of the physician over the welfare of the patient,” adds Michelle Monserratt-Ramos, a patient-safety advocate with the nonprofit Consumer Watchdog who lost her fiancé to a negligent doctor. If only we had a system that also watched out for the person on the table.

IN APRIL OF THIS YEAR, after Ortiz had been in detention for more than a year and a half, his federal criminal trial began in Dallas. During the trial, prosecutors played the suspicious surveillance footage for the jury, alongside a slow drip of anecdotes and context. Dr. Marsden recalled that on the day of the scary incident with his patient, an IV bag had arrived in the OR cold. An FDA criminal investigator’s testimony pointed out that no incidents had occurred while Ortiz was on vacation.

Prosecutors also revealed that Ortiz had been operating under considerable personal stress. Despite his flashy lifestyle, he was in immense debt, investigators found. In court, he was assigned a public defender, being “financially unable” to afford his own attorney. He owed several million dollars to the IRS. Back in 2022, he told staff members that he felt he was being “crucified” by Baylor Scott & White over a situation that happened at the North Dallas center prior to the Jack Adlerstein incident—one that was eerily similar to his failure to notice the patient’s respiratory distress in Garland. The North Dallas center launched a disciplinary inquiry five days after the incident. (Baylor Scott & White did not respond by press time to a request for comment.) Ortiz said that losing his privileges at that facility would be “devastating financially.” Prosecutors argued that the inquiry made Ortiz angry and caused him to retaliate.

“When I was watching the trial, it looks like he was trying to sabotage his colleagues to make it look like, ‘Hey, I’m not the only one having adverse events during my surgeries,’ ” says Stacey Hail, M.D., a Dallas toxicologist who was an expert witness for the prosecution. “So there appears to be some kind of underlying antisocial disorder that, coupled with some of the disciplinary measures, may have caused him to act like that.” Such disorders, says Kaplan, the forensic psychiatrist, are common in perpetrators of clinicide.

Ortiz’s defense tried to muddy the waters, casting doubt on the idea that the victims had been poisoned and emphasizing some of their underlying health issues. The lawyers suggested that colleagues had the same opportunity to pull off the alleged sabotage.

The jury didn’t buy it.

After nine days of jury trial and seven hours of deliberation, Ortiz was convicted on ten charges: four counts of tampering with consumer products resulting in serious bodily injury, one count of tampering with a consumer product, and five counts of intentional adulteration of a drug. He was not charged with Melanie Kaspar’s death, for reasons that are not fully clear. (“The DOJ does not discuss its charging decisions publicly,” a representative from the DOJ told Men’s Health.) On November 20, he was sentenced to 190 years in prison. During the course of the trial, which featured forensic experts and tearful witnesses, he betrayed no emotion. He was the only person in the courtroom wearing a face mask.

Melanie’s widower, John, testified. (Even though Ortiz was not charged with her death, the rules of evidence in federal criminal trials allow all the harms allegedly caused by a defendant to be considered by the jury.) He sat through each day of the trial, and at the reading of the verdict, he sobbed.

“There’s no closure. My best friend is gone,” he said shortly after. “I’ll have regrets forever for not yanking the IV bag out of her arm.” Speaking to reporters after the verdict, one juror said, “It kind of makes you question if you even want to go to a doctor yourself.”

PATIENT ADVOCATES AND lawmakers are trying to increase transparency and accountability in the medical system to make it easier to identify and dislodge dangerous doctors. One major result: California passed a law in 2018 that requires doctors to notify patients if they are on probation for certain offenses that have directly resulted in patient harm. Another one: Texas’s H. B. 1998, which was signed into law last year. It increases the obligations of Texas hospitals to report any disciplinary actions regarding a physician to the NPDB, takes into account criminal activity as part of their professional profile, and effectively bars a physician whose license has been suspended or revoked in other states from practicing there.

The Ortiz case was cited by lawmakers as a motivating factor behind the bill. Its Democratic coauthor, State Representative Julie Johnson, whose wife is a physician, actually had surgery at the North Dallas center when the incidents connected to Ortiz were taking place. This, of course, made the issue “very personal,” she says.

“Everybody wants the medical board to do its job, but they were not doing their job,” says Johnson. “What we realized when I met with them is that they didn’t have enough of the tools and the teeth to do their job. We tried to address a lot of those issues in 1998.” She just won a congressional seat in Washington, and hopes to pursue these issues on the national level.

While hospitals are beginning to be held accountable for reporting issues to boards, transparency to the consumer is still obscured. Robert Painter, a Texas attorney focused on medical malpractice cases, points out that hospitals and physicians have been granted massive amounts of confidentiality in legal proceedings that are not afforded to other professions. Even in the event of medical malpractice, victims or would-be patients are not allowed access to important hospital records pertaining to the physician in question.

“With engineers, if there’s a question about air-conditioner maintenance or fire sprinkler systems and there’s a legal claim, then in the legal process, you can subpoena that information and review it forensically,” says Painter. “But not in the medical profession. You just have a black hole.”

When hospitals are forced to reckon with the damage caused by dangerous doctors, they may try to do so as quietly as possible, further obscuring them from public view. Often this takes the form of cash settlements, or what some call “go-away payments.” In the fallout from the Ortiz case, Baylor Scott & White reached confidential settlements with at least two of his 11 victims.

Patients aren’t completely helpless when it comes to identifying ill-intentioned doctors. One resource is DocInfo.org, which is managed by the Federation of State Medical Boards, a nonprofit representing all medical licensing boards in the U. S. On the site, you can search the educational and professional backgrounds of more than a million U. S. doctors, as well as see any action taken against them by state medical boards. “Before you schedule your next checkup, make sure your doctor checks out,” the website reads. Still, with how ineffective many state boards can be, that may not be enough to fully sniff out such doctors.

The only comprehensive source for license sanctions, clinical-privileges sanctions, and malpractice payments is the NPDB, but by law its information is not public. Oshel, formerly of the NPDB, recommends petitioning your local political representative to change this. After all, if hospitals are not going to do their due diligence, patients must be allowed to do theirs.

JACK ADLERSTEIN, the teenager whose near-death emergency led to Ortiz’s downfall, has recovered from his ordeal. (As a result of the settlement agreement with Baylor Scott & White, the Adlersteins declined a request to be interviewed.)

One might think the family would find it hard to trust the medical profession after what happened. After all, Ortiz’s actions were not only criminal but also a monumental betrayal of the trust that is at the heart of the doctor-patient relationship. But speaking to a local news station after Jack’s recovery, his father, Dovi, was more sanguine. He expressed his gratitude to Dr. Marsden for his life-saving intervention.

“He’s the reason we have this guy around,” Dovi said, sitting next to his son. “We’re forever in his debt. All of his doctors, really.” As for Ortiz, he added, “I hope that he can comprehend the magnitude of what he did and spend the rest of his life marinating in it.”