Doctor dozed during surgery, report says

Beth Israel faulted in case

When Dr. Loren J. Borud began his first case at about 8 a.m., an operating room nurse noticed he looked tired and wobbly. She was so concerned, according to one account of the Friday last June, that she suggested Borud postpone his next patient.

Borud said he had been up all night working on a book, but he kept operating, starting a second case, during which he briefly fell asleep, according to a report from state investigators. The nurse again called him aside and suggested "maybe he should take a break," according to her interviews with investigators, but he continued the surgery.

These findings are part of a report in which state Department of Public Health investigators found that Beth Israel Deaconess Medical Center provided poor care to Borud's second patient that day. They also faulted the hospital's response to Bo rud's apparent impairment.

The patient, Michael K. Hicks of Quincy, has said he suffered complications after liposuction surgery and repair of a scar on his chest, and in July he sued the hospital, six doctors including Borud, and two nurses. He has settled his case; the terms are confidential.

Dr. Kenneth Sands, senior vice president of healthcare quality at the hospital, said in an interview yesterday that, in retrospect "we wish [staff] had acted more quickly." He said he would not comment on the details of the state's report because the hospital had not fully reviewed it.

The state report, which the hospital must respond to by next week, said that while staff members gave different accounts of Borud's behavior on June 27, "signs and symptoms of impairment were not immediately called out."

The operating room nurse called the plastic surgery department twice to report Borud's behavior that morning and early afternoon, the report said, and the office nurse told her to "keep an eye on him." But no senior surgeon or administrator ordered Borud to stop operating - even though there was widespread awareness of his history of drug and alcohol abuse, according to investigators.

He didn't stop working until 1:30 p.m., when a resident - a doctor in training - who was assisting him had to leave to see patients. The resident called another plastic surgeon for help because Borud wasn't on his "A game," the resident told investigators. The plastic surgeon sent a fellow, a more senior doctor in training, to assist Borud. About 10 minutes after the fellow, Dr. Eran Bar-Meir, arrived, Borud left for unexplained reasons.

The state also faulted the hospital for allowing Bar-Meir to take over Hicks's operation by himself; hospital policy requires an attending surgeon be present with a fellow.

State investigators said the hospital did not treat the patient appropriately after his surgery, either. Hicks was not assessed by a physician before he was discharged that night, and hospital administrators did not tell Hicks that Borud had to abandon his operation, and why, until 10 days after the surgery. The operation lasted seven hours, rather than the 90 minutes Hicks said Borud had estimated it would take.

Last summer, the hospital fired Borud and the state temporarily suspended his license.

In an initial investigation completed in September, the public health department found that Hicks's complaints were invalid. But after Hicks objected to the findings, staff reopened the investigation and interviewed additional staff as well as Hicks.

In the initial report, the state said the hospital had not properly trained staff on recognizing and reporting impaired physicians. Sands said yesterday that since then, all nurse managers have completed education sessions on dealing with staff who aren't performing adequately.

"Patient safety is a priority, and staff will never be thought of unfavorably for intervening, calling out and stopping the line," Sands said. "If a person doesn't feel they are getting an immediate resolution, they are supposed to call the supervisors of that area to get resolution."

Borud's attorney, Bruce Singal of Boston, said he could not comment on the state findings. The Boston Herald first reported the conclusions of the state's second investigation yesterday.

A patient safety specialist said the case reveals broader issues about the culture of operating rooms and how difficult it can be to get nurses, technicians, and residents to challenge surgeons - even when they have problematic histories.

"How common is it that nurses and other personnel don't speak up? I can't think of any [hospital] in the world where this isn't an issue," said Dr. Allan Frankel, former director of patient safety at Partners HealthCare and founder of a patient safety consulting company based in Washington, D.C. Frankel said that even in cases such as the one at Beth Israel Deaconess, where a nurse apparently did try to confront Borud, too often hospitals haven't designated a specific manager who will come in and make the final decision.

Max Borten, Hicks's attorney, said his client now believes "justice has been done." He said Hicks, 40, will need more plastic surgery because of damage done during the operation.

Kowalczyk can be reached at kowalczyk@globe.com.