Longform

Missed Diagnosis

Page 8 of 10

Some of the board's most visible cases do scream from the headlines--like when it stripped the license of anesthesiologist Joseph Verbrugge Jr., who was accused of falling asleep during routine surgery on an eight-year-old boy, causing the boy's death. (Recently the boy's family lost its lawsuit against Verbrugge on appeal.) In January the board suspended the license of Gupta Kuna, a Pueblo pediatrician accused of unprofessional conduct in the cases of seven patients, including two children who died. But the following month the board reversed its suspension order, sharply dividing the Pueblo community. Kuna has since agreed to forfeit his Colorado license upon his retirement next year.

And now the board is a legal target itself: Colorado Springs physician Dr. Faisal Amanatullah has filed suit against the board, which revoked his Colorado license because of accusations that he ordered needless tests and X-rays to make more money while practicing medicine in Nevada.

"The board has no business in protecting careers," Miller insists. "I do think they have an obligation to be fair to the licensees, the physicians, but their primary concern has to be the public. And I do believe that is their first concern."

Sixty-eight-year-old Elizabeth Liechti had immigrated to the U.S. from Switzerland in her twenties and spent much of her life working in Denver-area bakeries and as a store clerk. Solid, healthy, an avid mystery-movie fan, "she was a very happy person, very religious," recalls Woodard, a Littleton house painter and father of four.

But Liechti suffered back pain and went to see Dr. George Frey, who suggested an operation that would correct the line of her spine and alleviate the pain. Liechti took to the orthopedic surgeon because both of Frey's parents were Swiss; she even brought the physician a gift of Swiss chocolate and cookies, Woodard says. On February 21, 1996, Liechti underwent nine hours of surgery at Centura Health-Porter Adventist Hospital.

Liechti never recovered. Instead, for the next three weeks she suffered debilitating pain--which didn't respond to even the most potent painkillers, such as morphine or Percocet. She lost sensation below the waist; her wounds oozed, her white-blood-cell count skyrocketed and she ran a fever. But after Liechti repeatedly called for help from her ICU nurses and screamed in pain, she was labeled as a complainer, according to her medical records. On the night of March 9, Woodard contacted Liechti's on-call physician--who answered his phone at a noisy Denver Nuggets basketball game--and asked if something couldn't be done. The doctor called the hospital and ordered more morphine.

In Woodard's view, no one took Liechti's pain seriously until the next morning, when she suffered myocardial ischemia, a form of heart attack where the heart is deprived of blood. Woodard received a call at around 3:30 a.m. but was assured his mother was stable and there was no need for him to rush in.

That morning, doctors appeared at Liechti's bedside, and lab tests revealed her wound was full of clostridium--an uncommon postoperative infection that Liechti probably acquired in the hospital. Later that day, she died.

Woodard was furious that during his panic over his mother's quickly declining condition, nurses pulled him out of her hospital room. He and his fiancee, Dea Wilhelm, were trying to convince the ICU staff to honor Liechti's request for a toilet; the nurses countered that she probably didn't need one and it would cost extra to bring up a portable toilet, which was on another floor. "That was the last time I saw my mother alive," says Woodard. "When we were pulled out of the room to argue about a toilet."

Later, Woodard and Wilhelm would send a twenty-page handwritten complaint to the Board of Medical Examiners, detailing everything from Liechti's symptoms to their outrage at the doctors' and hospital's behavior. Within a short time, Woodard says, they received a one-paragraph response stating that the board had dismissed the case. Wilhelm was so disgusted she crumpled up the letter and threw it in the trash.

In the three and a half years since, Woodard has lived with bitterness and regret. But the hospital denies it did anything wrong. "The nursing care at all our hospitals is outstanding," says Centura Health spokesperson Chuck Reyman. "I have no reason to believe Mrs. Liechti would've been treated with anything but the highest-quality care."

Under law, most medical-malpractice victims can only bring a lawsuit within two years of their injury. But patients and their families can often spend more than a year recovering, grieving--or being so angry they can't see straight or figure out what to do. Woodard did contact a lawyer and expert witnesses to pursue a case against Frey, but the lawyer dropped his client just before the statute of limitations was about to expire. Attorney Jerry Katz, who specializes in medical-malpractice litigation, concluded that Liechti's was not "an open-and-shut case."

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Gayle Worland