A death underscores unsettling surgical truth

CAMBRIDGE -- The surgeon didn't feel sick.

In fact, Dr. Thorkild Norregaard didn't know he had a staph infection when he operated on Jean Cantwell at Mount Auburn Hospital in October 2004. But, as tests later showed, the bacteria had invaded his nose. The germs somehow got past his mask and into the surgical opening in the 75-year-old woman's lower back, infection-control specialists at the hospital later concluded.

Over the next two weeks, Cantwell's initial relief at being able to walk on her own again gave way to a fever and vomiting as the infection spread. Eventually, the bacteria shut down her kidneys and other organs, leaving Cantwell's family standing at her hospital bedside, stunned, while a doctor disconnected the tubes that kept her alive.

The family's shock turned to anger when hospital officials told them that Cantwell was the fifth patient of Norregaard to return with a staph infection after surgery in less than three months, far more than normal. The surgeon did not know he was infected, hospital officials said. The hospital traced two of the infections to Norregaard, and state investigators concluded the hospital did nothing wrong in Cantwell's death

But her husband and daughter said they should have been warned about the unusual number of recent infections.

Norregaard disagrees that he caused Cantwell's infection, suggesting it could have happened while she was at home, according to his lawyer, Frank Reardon, whom Norregaard asked to speak on his behalf.

Cantwell's death underscores an unsettling truth about American hospitals: Surgical wounds often become infected, sometimes leaving patients sicker than they were. Each year, about 500,000 surgical wounds become infected with staph or other germs, killing tens of thousands, according to the Centers for Disease Control and Prevention. Usually, post-surgical infections happen when pathogens on the patient's body get into the wound, but germs also can come from contamination in the operating room or from the surgeon.

''There is no such thing as a sterile operating room environment," said Dr. Dale Bratzler of the Oklahoma Foundation for Medical Quality, who helped write national guidelines for reducing infection after surgery. ''We make things as clean as possible," but most hospital surfaces still contain bacteria, he said.

Nonetheless, the Cantwell case has sent shockwaves through Mount Auburn, a hospital with a national reputation for aggressive infection control. Dr. Susan Abookire, the hospital's chairwoman of quality and patient safety, has met more than 20 times with Cantwell's family to answer questions. Abookire also told them the hospital had no reason to suspect Norregaard was carrying staph before Cantwell got sick.

Norregaard, who had been a surgeon for 17 years, resigned in a dispute with Mount Auburn over the steps he should take before he would be allowed to perform surgery again. And Beth Israel Deaconess Medical Center, where he also practiced, revoked his admitting privileges after learning about the problems at Mount Auburn. Last month, with a state investigation of his safety procedures underway, Norregaard closed his private office, too.

Norregaard, his lawyer said, believes Mount Auburn's requirement that he undergo three rounds of antibiotic treatment before performing surgery again was excessive.

The fallout hasn't placated Cantwell's husband and daughter, who believe she would have skipped the elective back surgery if she had known that other Norregaard patients were getting sick.

''We just can't get past the fact that my mother didn't have to die," Jean Cantwell Doherty, Cantwell's daughter, said in an interview.

Staph is the leading cause of infections after surgery, and the CDC estimates that 20 percent of operating room workers carry staph and have no symptoms. The infection is rarely fatal except among people weakened by other conditions, and it is so widespread that hospitals don't routinely test employees for it. Instead, surgeons and other operating room workers are expected to wear masks and gloves and wash their hands. In addition, patients are supposed to be given antibiotics right before surgery, and the incision area is shaved and disinfected.

Compliance with these precautions has been uneven at some hospitals, but prodded by federal health officials, hospitals are doing better, Bratzler said. For instance, surgeons administer antibiotics to patients right before their operations 69.7 percent of the time -- up from 55.7 percent of the time in 2001. Antibiotics can kill bacteria that enter an open wound before they spread through the bloodstream. However, Bratzler said hospital personnel still have to be more rigorous about infection control procedures.

At Mount Auburn, officials said they followed all the guidelines, including pre-operative antibiotics, but that wasn't enough to protect Cantwell and the other four patients, who all recovered.

The hospital's infection control manager spotted a trend when the first three Norregaard patients had to be readmitted with Staphylococcus aureus infections from Aug. 10 to Sept. 10, 2004, but initial lab tests showed each patient had a different strain of bacteria, suggesting no single person could be the source. The manager watched Norregaard's team at work repeatedly, but observed no failures to follow safety precautions, according to a Department of Public Health report on the case.

By early October, with no new infections reported, Mount Auburn officials concluded that the infections were a coincidence, although they couldn't be sure.

Unfortunately, state officials said, uncertainty is a common outcome of these types of investigations.

''Whenever this happens, you review all your procedures. . . . You start looking at very subtle things. Frequently, you do all those things and you don't find anything," said Dr. Alfred DeMaria Jr., director of communicable disease control at the state Department of Public Health.

When Cantwell went to Mount Auburn for her operation on Oct. 15, 2004, Norregaard told her that he had an excellent record of success in the surgery, called a laminectomy, her husband, William Cantwell, said. Norregaard warned them of the general risk of infection after surgery, but said nothing about the infections his other three patients had contracted.

In a statement, hospital officials said Norregaard's briefing was appropriate, and that he had no reason to mention the past infections because they were unrelated and ''there was no increased risk of infection" for Jean Cantwell. In a letter to state regulators, Norregaard wrote that he didn't know about the first three infections at the time he briefed the Cantwells. However, Mount Auburn officials said he would have known about the patients because he was responsible for their admission.

Nine days after Cantwell's surgery, she became feverish and the surgical wound oozed blood and fluid. The next morning, she was vomiting and light-headed, and she went to the hospital. By then, the staph infection had spread through her body. A week later, on Oct. 31, 2004, Jean Cantwell's husband, convinced that his wife could not recover, agreed to disconnect her life support.

This time, lab tests showed that the strain of bacteria that infected Cantwell was identical to one found in another Norregaard patient admitted with a staph infection four days earlier. At the request of infection control officials at the hospital, Norregaard suspended surgery while they investigated whether he was the source. A culture taken from Norregaard's nasal passage found staph that matched the strain in Cantwell and the other patient, according to the state report. The bacteria taken from the surgeon also was similar to a strain found in one of the three earlier patients, but by then, hospital officials said, they had destroyed that patient's sample so that a more detailed comparison couldn't be made.

While awaiting clearance to work at Mount Auburn, Norregaard began performing surgery at Beth Israel Deaconess, where he also had admitting privileges. But after Beth Israel officials learned that he had been restricted from operating at Mount Auburn, they revoked his admitting privileges, according to the Board of Registration in Medicine. He also resigned from Mount Auburn last January, citing ''professional disagreement" with the hospital.

The hospitals reported their actions to the Board of Registration, and Cantwell's daughter filed a complaint for what she felt was inferior medical care. For instance, Norregaard had a physician assistant see Jean Cantwell on the day she was discharged because he had flown to California for a conference.

As a result, Cantwell's daughter believes, he missed a chance to detect early signs of infection.

In August, Norregaard sent a letter to the state board, promising to pay closer attention to patients.

But a month later, Norregaard announced that he would close his private practice on Oct. 14, writing to patients that he needs to ''reflect on how best I can serve fellow human beings."

Officials at Mount Auburn, especially sensitive to safety issues since a 2002 episode when Dr. David Arndt left a patient mid-operation to go to the bank, named a lecture series after Jean Cantwell. ''Although we do not share Ms. Doherty's opinion that her mother's death could have been avoided, our hearts go out to her and to her father," the hospital said in its statement.

That's not enough for William Cantwell, who is considering a lawsuit against Norregaard and the hospital. ''I can't even think of my wife now without visualizing her as she lay in the bed in the critical care ward," he said.

Scott Allen can be reached at allen@globe.com.