By Craig Malisow
By Jeff Balke
By Angelica Leicht
By Jeff Balke
By Sean Pendergast
By Sean Pendergast
By Jeff Balke
By Ben DuBose
Kaye Parsley had always been overweight.
When she was 16, her family sent her to what she calls fat camp in Kerrville, where she and her hefty sisters spent long days waging war on their waistlines. It worked. She lost 30 pounds at camp and 20 more when she went home to Magnolia.
She spent the rest of her life gaining it back.
At her peak, Kaye, just shy of five foot eight, weighed 300 pounds. If the bathroom scale wasn't enough to make her shudder, there was also the calendar. Kaye was closing in on 40. She could handle one or the other, but she knew she didn't want to be fat and40.
After everything else failed -- Weight Watchers, Jenny Craig, diet pills, Slim-Fast -- Kaye looked into bariatric surgery. Commonly known as stomach stapling, the procedure has been widely recognized for years as an extreme but effective solution for many who suffer from life-threatening weight disorders.
But last July, after Kaye checked into a Lubbock hospital for what should have been a safe, routine procedure, it looked like she was going to die.
From her stomach, which had been cut in two, stapled shut, then cut open again, an infectious fluid was leaking into her intestines. She spent the first 24 hours after her surgery in a fugue state, not really knowing where she was or how many times her surgeon, Ramesh Srungaram, had opened her stomach. When she came out of the second surgery, she could barely breathe. Lubbock's Highland Medical Center didn't have a ventilator for her, so Srungaram, a surgeon with malpractice and personal injury lawsuits in his past, had to have one delivered.
Soon afterward, Kaye blacked out. She was transferred to nearby University Medical Center, where doctors gave her parents a startling update: Her insides were so infected that she had only a 20 percent chance of survival. She needed surgery immediately.
Three more operations couldn't totally clear the infection. Faced with the prospect of losing a young mother of a four-year-old boy, doctors asked Kaye's parents to allow them to attempt to flush the infection with an experimental antibiotic. It was $10,000 a bag, and it wasn't FDA-approved. But it was possibly her only chance.
Her parents signed a waiver to allow the antibiotic that saved Kaye's life.
She was one of the lucky ones.
On July 29 and 30, Srungaram sent Kaye and three other women to UMC with similar complications. One of them, 49-year-old Eva Marie McNew, died.
In August, the Houston-based law firm of Richard Mithoff and Tommy Jacks sued Srungaram and Community Health Systems, the corporate giant that owns Highland Medical Center and owns or oversees 60 other U.S. hospitals. In addition to the four women who suffered in the July surgeries, the attorneys have rounded up more of Srungaram's patients for the suit. They're alleging that CHS lured the obese patients to rural, underequipped hospitals through an Internet marketing scheme that paired desperate people with sometimes negligent surgeons who cared more about the bottom line than patient care.
It turns out that some doctors at a CHS-owned hospital in Cleveland, Texas, also have complained about the corporation's money-versus-medicine mentality for years. What they and other CHS critics say is that what happened to those four patients was not just an accident. It was inevitable.
Weight loss is a big industry aimed at big people, and bariatric surgery is growing bigger every year.
A surgical alternative to late-night infomercials hawking a plethora of pills, snake oil shakes and medieval muscle stimulators, modern bariatric surgery offers the morbidly obese a true way out.
In 2001, 47,200 people had the surgery -- about 10,000 more than in the previous year, according to the American Society for Bariatric Surgery. The group estimated that 63,100 more would undergo the procedure in 2002.
Some surgeons attribute the increase to improved, less invasive methods and the fact that more insurance companies are covering the operation. The death rate is about three out of 1,000 patients, according to the ASBS.
Celebrity success stories also drive the popularity of this type of surgery. When NBC broadcaster and former Fat Albert doppelgänger Al Roker had the operation and lost more than 100 pounds, his familiar smile and streamlined gut soon graced the cover of People magazine. Three years earlier, 300-pound singer Carnie Wilson broadcast her bariatric surgery online.
About 127 million American adults are overweight, and approximately nine million are morbidly obese -- at least 100 pounds overweight, according to the American Obesity Association. Obesity is related to more than 30 medical conditions, including diabetes, heart disease and, among postmenopausal women, breast cancer.
In addition to the problems for adults, the AOA research found an earlier onset of obesity-related diseases in children. And a commentary in the November 2002 issue of the medical journal Pediatricsstated that childhood obesity borders on a "national crisis." The article wondered if the time had come to "establish bariatric pediatrics as a legitimate subspecialty."
Pioneered by an Iowa surgeon in the early 1960s, modern bariatric surgery was recognized by the National Institutes of Health in 1991 as the only safe and effective treatment for morbid obesity. Candidates must have a body mass index of at least 35, which means a person of Kaye's height would weigh 230 pounds.
A common form of bariatric surgery is the Roux-en-Y gastric bypass, which separates the stomach into two parts. The upper half is restricted to form a pouch that can hold about one fluid ounce. The larger portion at the bottom is stapled shut. The small intestine is then cut and reconnected to the newly created pouch.
With a smaller stomach, bariatric patients don't eat as much as they did before. The procedure also has a built-in safety mechanism called the dumping syndrome, which makes patients sick if they eat fatty and sweet foods. And because food bypasses part of the small intestine, patients absorb fewer calories.
These three factors, along with continued psychological counseling and help from support groups, can help patients lose weight safely.
When Kaye had exhausted all other options, she contacted a bariatric referral service and got the names of two local doctors. After finding out her first choice had an extra-long waiting list, she called Srungaram. A nurse invited Kaye to the doctor's monthly seminar, held in a Cypress-Fairbanks Medical Center Hospital meeting room.
Along with about 100 others, Kaye attended the seminar and heard from Srungaram and some of his patients. During the Q&A session, Kaye, never one to hold her tongue, stood up and asked Srungaram point-blank if he had ever lost a patient.
Yes, he said, he had lost one. That was because the person opted for herbal medicine rather than the recommended regimen.
Fair enough, Kaye thought.
She and other audience members spent a few minutes with Srungaram before the seminar ended. She decided he was her man and scheduled an operation.
Born in 1985 to relatively humble Houston roots, Community Health Systems has become one of the largest hospital groups in the country. Now based in the Nashville suburb of Brentwood, CHS's holdings soared in the last six years.
The chain encountered controversy when a whistle-blower at one CHS hospital accused it of filing fraudulent pneumonia claims for years. That triggered a U.S. Justice Department investigation of alleged "upcoding" -- submitting fabricated bills to Medicare, Medicaid and TRICARE, a federal employee insurance program. CHS hired an independent accounting firm to check the billing records of the 36 hospitals it owned between 1994 and 1997.
Three months before its second public stock offering in 2000, CHS reached a $31 million settlement with the justice department, which put CHS on a three-year corporate compliance agreement, a sort of financial-ethical to-do list.
CHS, which admitted no wrongdoing, released a self-congratulatory statement in March 2000.
"We were very pleased that through our company's initiative and effort, and with the government's cooperation, we were able to reach a final and satisfactory conclusion," CEO Wayne Smith said in the news release. He attributed the upcoding to a complicated reimbursement system, which he said "can sometimes be susceptible to misinterpretation."
Around this time, CHS started a company called Images, an Internet-based bariatric surgery referral program that purported to screen potential candidates, offer them psychological counseling and process their insurance claims. As part of the package, they'd receive airfare, ground transportation and lodging. Patients could go through Images for surgery at four rural hospitals in Texas and Louisiana. Images, now called COMPASS, offered surgeons' profiles and literary descriptions of the hospitals' locales.
Highland Medical Center, for example, is located "in the heart of the vast southern plains of West Texas and eastern New Mexico." Patients there can enjoy Lubbock's "warm days and cool nights."
One worker involved in Images/ COMPASS marketing told of being pressured to process as many patients as possible through those programs. Patient fees, the staffer said, were geared toward how many clients had already been processed each month. Those who paid through insurance reportedly would be charged as much as $15,000 more than those who paid cash for the surgery, which could cost up to $50,000 per patient.
Meanwhile, hospitals are urged to report "sentinel events," unexpected occurrences resulting in death or serious injury, to the Joint Commission on Accreditation of Healthcare Organizations. Despite the allegedly botched bariatric surgeries of July 29 and 30, Highland never reported them as sentinel events.
According to the employee, Images and COMPASS worked with strict sales quotas that put a priority on numbers.
Four sentinel events. Two days. One doctor. Zero reports.
CHS's numbers didn't seem to be adding up.
Among the surgeons to whom CHS referred patients via COMPASS were Srungaram, a general surgeon with a private practice on FM 1960, and David Syn. Syn, who is licensed in New York, lives in Lubbock. He applied to the Texas State Board of Medical Examiners in June, but was not licensed to practice medicine in Texas at the time he was on the Web site. Neither Syn nor Srungaram would answer questions for this story.
A brief profile of Srungaram can be found in public information from the Texas medical examiners' board, in civil district court lawsuits and on his Web site, www.obesenomore.com.
After graduating from medical school in India in 1975, Ramesh K. Srungaram spent a six-year general surgery residency at Cabrini Medical Center in Manhattan. He followed that with cardiovascular surgery fellowships in Brooklyn and Houston. In 1987, he won the Denton A. Cooley Cardiovascular Surgical Society Outstanding Fellow Award.
He is certified by the American Board of Surgery, which gives him the credentials to perform bariatric procedures. He also belongs to the 20-year-old American Society of Bariatric Surgery, which means he's had at least 25 successful bariatric surgeries and passed two peer-committee reviews. That membership is not listed on the state medical board's Web site, however. Board spokeswoman Jill Wiggins says her board lists only American Board of Medical Specialities-recognized affiliations because that signifies a meaningful certification.
"Some of the [non-ABMS] boards are almost like mail-order-certificate type of things," she says. It is impossible, she says, to tell if some board certifications mean anything more than showing up for a golf weekend and leaving with a certificate.
Srungaram holds monthly seminars for prospective bariatric patients and has told reporters he's performed more than 500 bariatric procedures. He's also faced five medical malpractice and personal injury lawsuits since 1989. (Srungaram has also filed at least one lawsuit himself -- against Kmart, for a slip and fall.)
One suit, filed two years ago, is nearly identical to the case involving Kaye Parsley. Srungaram is accused of malpractice in Janice Jo Urbantke's bariatric surgery. Urbantke died, but this never came up when Kaye asked about patient deaths at Srungaram's seminar.
The 2000 lawsuit says that Srungaram operated on Urbantke in 2000 and she complained of abdominal pain seven days later. He sent her to the Memorial Hermann emergency room, where doctors discovered she was leaking abdominal fluid into her chest and lungs. Urbantke underwent two more surgeries before dying of a heart attack about three weeks after the original procedure.
Urbantke's relatives sued Srungaram for failing to properly evaluate her, failing to adequately close her wounds and failing to sufficiently monitor her after surgery.
Srungaram responded to the allegations the same way he responded to his other suits, by stating that the patient's death was "unavoidable" and "an act of God" and that the problems were caused by her "pre-existing medical or psychological conditions or disabilities."
But Srungaram also has patients who laud him, and their testimonials can be found on the Association for Morbid Obesity Support Web site. There are dozens of postings saying that patients found that what he lacked in bedside manner he made up for with certain skill.
One former patient of Srungaram's even railed against the local media for allegedly trashing Srungaram when Eva Marie McNew died after the surgeries last July. The former patient, who lives in Houston, failed to respond to e-mails from the Houston Press. So did three other former patients who posted positive reviews.
Because of the life-changing ramifications of bariatric surgery, responsible surgeons put their patients through extensive testing and counseling before the operation.
According to Neil Hutcher, a bariatric surgeon from Richmond, Virginia, who sits on the American Obesity Association's advisory council, bariatric candidates should enter into a long- term relationship with their doctors.
The 60-year-old Hutcher, who says he's performed about 3,000 bariatric surgeries in 30 years, spends a great deal of time with his candidates prior to the procedure.
His first step is to hold a two-hour seminar with up to 20 candidates at a time, then to visit one-on-one with them for about 40 to 60 minutes. Each candidate then meets with a nurse-practitioner for 30 to 60 minutes. The potential patients then must complete five hours of classes at the hospital, where they are tested on a 100-page manual written by Hutcher and his colleagues. Candidates are also encouraged to enroll in pre-op support groups. Throughout the process, Hutcher advises each candidate to be accompanied by a family member or significant other.
And because the morbidly obese face a host of illnesses, from diabetes to sleep apnea, he likes to take a team approach to the surgery, having lung, heart and other specialists examine the patients.
He has never heard of COMPASS and says an Internet-based form of preparation conflicts with his methodology.
"We're old-fashioned dinosaurs," he says. "Patients are living, breathing, touching things. And that's the way we treat them."
Kaye saw Srungaram professionally only one more time after his seminar, stopping by his office to get a prescription for the B12 shots that bariatric patients have to take after surgery. She says her physical examination consisted of her lying down while he pressed on her stomach in three places. No X-rays, no request for medical records, no blood work -- nothing.
He told her he'd take care of everything else at the hospital. She was good to go.
Although Kaye was scheduled to undergo surgery at Cy-Fair, she received a letter in June from COMPASS, explaining that it was now handling Srungaram's bariatric affairs. The letter said that Cy-Fair was no longer allowing bariatric surgery there, so Srungaram would perform the operation at a hospital in Lubbock. Kaye was puzzled -- she had never heard of COMPASS -- but since they would be paying the airfare, she wasn't too worried.
What the letter didn't say was that Cy-Fair still allowed bariatric procedures. According to Cy-Fair spokeswoman Lisa Anderson, Srungaram voluntarily withdrew his privileges in June after less than one year with the hospital. Two weeks before he "voluntarily" quit, Srungaram performed bariatric surgery on Steven Burr, another COMPASS client who would later file suit against Srungaram for allegedly shredding his stomach, intestine and surrounding tissue.
So now Kaye was heading to a hospital owned by CHS, which some doctors have accused of instituting bariatric programs without the right equipment, and without peer review.
This was among the complaints doctors at the CHS-owned Cleveland Regional Medical Center presented to the Texas Medical Association's advocacy committee in June, one month before Eva Marie McNew died. The committee's mission, as described by chairperson Susan Strate, is to promote quality care for patients.
In their presentation, hospital chief of staff Philip Wisiackas and former chief of staff Mark Kreit complained about CHS's "continuing policy of imposing cuts and ignoring major deficiencies that jeopardize patients' safety." Except for one member, the hospital board of trustees resigned in protest in 1999 for CHS's reckless policies, Wisiackas and Kreit claim.
According to the doctors, CHS hastily approved credentials for underqualified anesthesia nurses and violated hospital bylaws by referring all unassigned ER patients to a physician hired by the hospital. The hospital did this to have more control over cost of care and length of stay, according to Kreit.
Wisiackas and Kreit also objected to CHS's system of rating doctors' effectiveness by their patients' length of stay and cost per case. This was the way CHS distinguished its "top 20" doctors from the "bottom 20" in Cleveland, Kreit says.
Kreit, who was rated in the bottom category, says he and other doctors were threatened with losing their privileges when they spoke out against the new policies.
"They called it disruptive behavior, when you're trying to protect the best interest of your patients," he says.
The surgical department didn't even get a chance to protest when CHS said it was starting a bariatric program, Kreit says. CHS just decided there would be a program, and that was that.
But Kreit, who also sits on the hospital's credentialing committee, says Cleveland was not equipped for bariatric surgery. So when Srungaram applied for bariatric privileges, the committee was a bit perplexed -- there wasn't even a bariatric department. The hospital didn't have the facilities necessary for the extensive post-op care bariatric patients required, Kreit explains.
"Our point was, we don't have a program you can't just do bariatric surgery because you know how to do it, you have to have support," he says. But ultimately CHS squeezed the surgery department hard enough to get Srungaram his privileges, Kreit says.
According to COMPASS's old Web site, which was revised soon after the lawsuit against Srungaram and CHS, Srungaram and Syn performed bariatric surgery at Cleveland Regional Medical Center. However, CHS spokesperson Rosemary Walsh says she cannot confirm that Srungaram ever performed bariatric surgery there, because she doesn't even know if there ever was a bariatric program there. The Cleveland hospital doesn't appear on COMPASS's new Web site. Walsh declined to answer other questions because of the pending litigation.
CHS's attorney, Gail Friend, did not return phone calls. Kreit and Wisiackas also claim that the physicians on Highland's board of directors were appointed by the administration, not elected.
"They do not represent the desire and the views of the medical staff and repeatedly had objected [to] the medical staff decisions in favor of the administration, in such obvious trend to suggest malice," they stated in their presentation.
While the doctors urgently described a dire, life-threatening situation at Cleveland, the TMA's advocacy committee remained a rather impotent bunch.
Chairwoman Strate says all committee discussions are privileged and that the committee takes no significant action regarding complaints.
"We try to mediate and resolve differences between parties" was all Strate could tell the Houston Press."We don't take stands one way or the other."
On July 28, one month after the advocacy committee decided not to take a stand, Kaye Parsley and Srungaram were on a commuter flight to Lubbock. They stayed at the Ashemore Inn, COMPASS's hotel of choice for clients and visiting surgeons. Kaye was scheduled for surgery Tuesday, with Monday reserved for the testing that Srungaram never did in Houston. But Kaye says someone from COMPASS called her Sunday night and said the surgery had been bumped up to first thing Monday morning.
Kaye says the next morning was a blur of X-rays, blood work and gallbladder tests whose results weren't even ready by the time she was wheeled into the OR.
"It was just hurry, hurry, hurry," she says. "They never explained to me why it was important for me to be first."
Over the next 48 hours, Kaye underwent the bariatric surgery -- then more emergency operations at two hospitals, with experimental antibiotics flowing through her stomach's infected wounds.
Long before the first operation, Srungaram had told her not to bother bringing any relatives because she'd be home in no time. After the surgical problems, Kaye managed a weary call to her parents. They flew in and made the decision to approve the experimental drugs for their daughter.
As for Kaye, being thin and 40 didn't matter anymore. She just wanted to survive.
Strangely enough, Srungaram would be the first to publicly criticize Highland's bariatric inadequacy. While he and his attorney, Larry Thompson, declined to talk to the Press, Srungaram complained about the hospital in an August interview with the San Angelo Standard-Times.
Because Highland "did not have the proper facilities to take care of the patients post-operatively, I was forced to transfer them to the University Medical Center," he said. "After the patients were transported I was cut off from their post-operative care, which I really wanted to be involved with, and I was kept in the blind as far as their treatment and recovery."
Kaye got her wish to live. And for all the wrong reasons, she even lost weight. She was so sick after her surgeries that she couldn't keep food down, so she shed 75 pounds in the first 30 days and is now down to around 220 pounds.
She still has a hole in her stomach that will take about a year to heal, according to her new doctor. She changes the gauze around the hole every day.
She's no longer in pain and eats three small meals a day. But her job future is uncertain. Since she had to take off so much time from work, the office she returned to no longer needed her. Kaye says her boss told her she is going to be transferred to a small branch office in a border town. She doesn't know if she wants to move her son hundreds of miles away from his grandparents. Meanwhile, she faces $300,000 in medical bills.
Kaye says COMPASS never offered her the counseling, pre- or post-op, which its Web site says is so important.
In the meantime, CHS has dropped Srungaram from its COMPASS program. He still practices privately, holds monthly seminars for bariatric candidates and maintains his Web site. It shows his smiling picture below photographs of a woman before and after bariatric surgery, holding a gigantic pair of pants in front of her now-slim frame.
And the revamped COMPASS Web site is still a destination for many desperate people turning to bariatric surgery as their last hope.
"More than likely you are on this site because you are searching for something, a weight loss solution," the site states. But Kaye, and many others, are beyond that now. They're just searching for the truth.
Her attorney, Richard Mithoff, believes the truth points to one simple, painful fact -- something that Kaye has to live with.
"It's clear that CHS was playing a numbers game," he says. "It appeared to be all about money."