The Deadly Doctor
For years Dr. Deborah Spiva made bizarre diagnoses, ordered strange treatments, and prescribed massive doses of powerful drugs. Patients died because of her. And for years no one tried to stop her.
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Garcia’s hemophilia was a Factor IX deficiency; his blood contained only 1.5 per cent of the amount of the factor found in normal blood. When Garcia checked in for his wrist repair, Dr. Spiva was responsible for the administration of this missing factor (the brand name is Konyne) to prevent bleeding problems during surgery. To provide adequate protection, hematologists testified before the board, it is recommended that the amount of Factor IX be brought up to about 50 per cent of normal, a level that provides sufficient clotting action. Increasing the amount of Factor IX much beyond that level is unnecessary and potentially dangerous. Excessive doses of Konyne can lead to disseminated intravascular coagulation (DIC), the dangerous condition that Spiva had glossed over in her presentation while a resident in Rochester.
To prepare Garcia for surgery, Spiva ordered an infusion of 6000 units of Konyne, approximately twice the recommended dose, according to physicians’ testimony. In tests taken two hours after the infusion, Garcia’s level of Factor IX was 148 per cent. Garcia’s surgery on April 24 went well. The wrist was repaired, and there was no undue bleeding during or immediately after surgery. It is recommended that Konyne dosages be reduced following surgery, and doses are usually repeated at 12- to 24-hour intervals. On April 25 Spiva ordered that Garcia’s dosage of Konyne be brought down to 3000 units every six hours—an amount approximately three times the recommended postsurgical dose, according to testimony.
On April 27 Juan Garcia developed a troubling complication. The nurse on duty noticed that his right calf was swollen and hard to the touch; it looked like a hematoma, the result of bleeding into a closed site. Garcia told the nurse that he had had some bleeding in that calf when he had injured it about a week before surgery.
Any hematoma in a hemophiliac is cause for concern. What made this one particularly so was that it happened in spite of Garcia’s being on such high doses of coagulant. The drug circular that accompanies Konyne warns physicians to stop its administration in cases of unusual bleeding or evidence of DIC. There are several simple blood tests that are routinely done to check for DIC, hematologists testified, none of which were performed at the time. In response to the problem in Garcia’s leg, Dr. Spiva on April 29 ordered the dose of Konyne be increased to 5000 units every six hours.
She hoped, as she later testified before the board, that the increased dosage would stop the bleeding problem. It did not. The leg continued to be swollen and tender, and Garcia was in increasing pain. On May 4 Dr. Evans brought Juan Garcia back into the operating room to drain the hematoma. After the surgery a suction device was attached to the wound; it was later changed to a simple drainage bag. Under Spiva’s orders Juan Garcia continued to receive high doses of Konyne.
The night of May 5 was bad for Garcia. He bled continuously, so much that by morning he had lost about half of his blood through the drain in his leg, according to testimony. At seven-thirty in the morning the nurse on duty called Spiva to voice her concern. Spiva’s home in King William was about a five-minute drive from the Nix, but she told the nurse she was not feeling well; she had some kind of stomach upset and would not be able to come to the hospital soon. She did order over the phone that Garcia’s dosage of Konyne be increased to 12,000 units every six hours. According to a hematologist who reviewed the case for the Board of Medical Examiners, it was the largest dosage he had ever seen ordered. By nine-fifteen Garcia’s measured level of Factor IX was raised to 296 per cent.
To replace the blood Garcia had lost during the night, Spiva also ordered that he receive four units of washed, warmed red blood cells. Spiva later told the Board of Medical Examiners that washing and warming the blood was needed to avoid an allergic reaction to the transfusion. Hematologists testifying before the board said the procedure, which can take several hours to perform, was completely unnecessary. Garcia did not receive the first unit of this blood until the middle of the afternoon.
Around mid-morning, Spiva arrived at the hospital. Because no blood replacement had yet been given to Garcia, she ordered that he be transfused with three units of red blood cells. There is no evidence in the record that Spiva performed a physical on her patient that day.
That afternoon Garcia’s parents arrived for a visit. His mother, Rosa Garcia, said in an interview that she was surprised at her son’s obvious deterioration. At 5:35 the nurses moved Garcia into a chair in the room so his sheets could be changed and he could be given a sponge bath. Mrs. Garcia recalls what happened: “I noticed my son was real quiet. I started to talk to him, but he didn’t respond.” Juan Garcia’s parents were told to leave the room. A code—a situation requiring emergency assistance—was called. Doctors and nurses rushed in, and cardiopulmonary resuscitation was performed. It was unsuccessful; Juan Jose Garcia was dead. Dr. Spiva broke the news to the parents. “Dr. Spiva told us our son had passed away,” Mrs. Garcia says. “She said it had nothing to do with his hemophilia.”
In her testimony before the board, Spiva said the immediate cause of death had been aspiration—that is, Garcia had choked on vomit that was found in his windpipe after the attempt at resuscitation. She also said that his death was a result of shock due to loss of blood and that in his condition, Garcia never should have been allowed out of bed. Dr. George and Dr. Richard Parmley, the director of the South Texas Hemophiliac Treatment Center, who both reviewed the case for the board, testified that Juan Garcia had died from a hemorrhage in his brain. It was, they said, the final consequence of DIC induced by massive overdoses of Konyne ordered by Deborah Spiva. George said it was clear from reading the chart that Spiva had failed, until the last day of Juan Garcia’s life, to even recognize the signs of DIC. The hearing officer for the Board of Medical Examiners agreed with that conclusion.
In 1984 Dr. Stewart Johnson, a surgeon, began a year’s term as chairman of the Nix’s executive committee. Though he had been a fan of Spiva’s—they had frequently referred patients to each other—he later wrote to the state board, “The Transfusion Committee continually had problems with Doctor Spiva, however, she was able to convince us that she was doing the right thing. She told us that none of us are hematologists and could not totally understand the rational [sic] behind her thinking.”
By the end of the year many people at the hospital were baffled by the rationale behind her thinking. On September 26, according to a letter written by Dr. Johnson to the Board of Medical Examiners, a special meeting of the hospital’s executive committee was called; the charts of two patients of Spiva’s were reviewed. One was a patient who fit the description of Juan Garcia. The other was that of a middle-aged woman who was also a patient of Johnson’s. Johnson had performed what he later concluded, according to testimony, was an unnecessary splenectomy. The surgery had been done at the recommendation of Dr. Spiva, who had diagnosed a rare hereditary blood disease. The diagnosis, Johnson later testified before the Board of Medical Examiners, was not supported by the patient’s laboratory data.
After reviewing the records, the Nix executive committee unanimously voted to revoke Spiva’s privileges to practice at the hospital. According to his letter, Johnson telephoned her with the news; he told her of her right to appeal. She said she would not. Instead, she resigned.
Today Spiva says that following her departure from SAMA, she voluntarily resigned from the Nix. “That’s a closed club,” she says. “So that didn’t bother me. It’s like a men’s locker room.”
Leaving the Nix did not make a big dent in her practice. She was still seeing patients in her office, and she retained privileges at other San Antonio hospitals. In testimony before the Board of Medical Examiners, Dr. Hempel explained why Spiva’s former SAMA colleagues did not alert these other hospitals that she could not be trusted: “We have been very careful not to say anything bad about her to other physician members, so we have kept our talk to other physicians at a minimum. I have not been involved in any other actions against her at any other hospitals because she always thinks—she will tell you that there is a conspiracy against her, that people are out to get her. So we very carefully avoided pursuing her to another hospital.” Today some malpractice suits against Spiva also name the Nix and SAMA, accusing them of negligence for not warning patients about her.
But by the time Spiva left the Nix, Hempel had also found out about the unnecessary splenectomy and yet another porphyria patient of hers whose lab data showed that she did not have the disease. It was too much. In early November 1984 he notified the Texas State Board of Medical Examiners and told them they should investigate Dr. Deborah Spiva.
The Registered Letter
By the summer of 1984 Spiva had moved most of her hospital practice to Humana Hospital Metropolitan, another downtown facility. To treat her porphyria patients and others who she felt needed regular pheresis treatment, she persuaded the hospital administration to buy a cell separator, the approximately $10,000 machine used in the procedure. The decision was made without consulting Dr. John P. Whitecar, Jr., then the hospital’s chief of staff. Because pheresis was a new procedure at Humana Metropolitan, a committee was formed to oversee its use, and Whitecar sat on the committee. Although other doctors used the new machine, no one came close to the frequency of Dr. Spiva.
Whitecar, a hematologist and oncologist, had heard the rumors that Spiva had had some problems at the Nix. But the Nix was closemouthed about what had happened, and Whitecar says he could never pin anything down. “She already had privileges at the Metropolitan, and we hadn’t heard anything upfront from the Nix, so we decided to grandfather her in,” he says.
Unlike most of the doctors Spiva dealt with in San Antonio, Dr. Whitecar actually had some experience with porphyria; while doing a fellowship in hematology at the University of Minnesota, he had treated some victims of the disease.
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