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When Moises Garcia got his first doses of radiation late in 1995, he felt immediate relief from the wrenching pain in his shoulder. Diagnosed with prostate cancer two years earlier, Garcia had endured surgery and chemotherapy, but the cancer had already taken hold and spread. Eventually the pain, which throbbed throughout his body but was most concentrated in his shoulder, wore Garcia down, and his doctor decided that more intensive treatment was in order.
Garcia was referred to Carlos Fernandez, a radiation oncologist who practiced at the Bellaire Cancer Treatment Center. Fernandez prescribed a course of therapy using the center's showpiece linear accelerator, a $1.25 million piece of equipment that zaps tumors with radioactive beams. Within days, Garcia was better able to function: gardening, cooking and taking care of his wife, who has Alzheimer's. "My dad was fine," says Rosa Carbajal, his stepdaughter. "He could do his work."
But the pain recurred, and on April 2, 1996, the doctor injected Garcia with 4 millicuries of strontium-89, a powerful radioactive agent that is effective in easing pain from bone cancer. On May 22, he repeated the strontium treatment. After each shot, Garcia experienced temporary relief.
In between doses, Fernandez started his patient on another round with the accelerator. That still wasn't enough juice, apparently, because the doctor decided to perform a gold seed implant, a procedure in which tiny radioactive bits of gold are surgically placed around a tumor. Fernandez operated on June 25.
Garcia never recovered. Three days after the surgery, he slipped into a coma. Two weeks and various complications later, he contracted pneumonia and died.
Carbajal and her mother are suing Fernandez for malpractice, claiming that the combined treatments constituted a serious overdose of radiation that led directly to Garcia's death. When the case comes to trial, they'll have several grenades to lob. Among the more explosive: The manufacturer's instructions warn that strontium-89 injections should not be administered less than 90 days apart. The reason? Too much of the stuff can send blood counts plunging to lethally low levels. Indeed, after Garcia's second injection, his blood counts dropped precipitously, which made it difficult if not impossible for him to fight off infection or other trouble.
Equally damaging is the fact that, if pain relief was the primary objective, less dangerous alternatives to a second hit of strontium-89, such as morphine, were readily available. Yet Carbajal says Fernandez never informed her of any such options or told her of any risks associated with the strontium. "He didn't say, 'We can do this or this or this,' " Carbajal recalls. "He just said, 'We'll give him another injection, make him feel better.' "
Fernandez says that since Garcia had done so well with the first shot of strontium-89, he went with what had already worked. "If the patient has a response to the treatment, and his pain comes back in four or five weeks, why deny that patient the treatment?"
Besides, he argues, it wasn't the radiation that killed Garcia, but the cancer, which had affected many of his vital organs. "His blood count might have dropped off a little bit," Fernandez concedes, "but he died because of massive liver problems."
As for alternatives, Fernandez says, a patient can experience unpleasant side effects with any medication. "He can also die with the morphine," the doctor says. "He can also have constipation."
Proving just what caused Garcia's demise or how much time he had left may be tough for either side, but Fernandez has more pressing problems to worry about: On April 7, the State Board of Medical Examiners temporarily suspended his medical license. The action came after an investigation that lasted 18 months and included seven cases of questionable patient treatment, including Garcia's. "Available evidence and information indicate that [Fernandez's] continuation in the practice of medicine would constitute a continuing threat to the public welfare," the board's order read.
Harold Ward, a radiation oncologist who practiced with Fernandez at the Bellaire Cancer Treatment Center and testified against his colleague before the board, takes the criticism one step further. "He's a disgrace to our profession," says Ward.
In his defense, Fernandez says he's the victim of a vendetta by treatment center owner Bill Kubricht, with whom he's feuded since the two decided to form the business together in 1992. Kubricht and the center staff, he says, funneled information to the State Board of Medical Examiners to make him look bad, and most of the testimony against him has come from people connected to the center. "My accusers are not my patients," he told the board panel that heard his case. "They are guided by a nonmedical person trying to hurt me, my family and my reputation."
That explanation didn't satisfy the board, but it may be enough to sway a jury. Fernandez plans to fight the suspension, which will eventually end up in court if the board holds its ground. And if that happens, more people than Fernandez are likely to be dodging bullets on the witness stand. State regulators will have to explain, for example, why it took so long to act if the evidence against the doctor was so damning, especially since the board had reprimanded Fernandez only a few months before the investigation began. And a number of hospital administrators with connections to Fernandez may find themselves squirming when asked why he left their institutions -- or why he's still there.
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