Lessons learned while tracking a UCSD anesthesiologist’s drug abuse and diversion case Date: 03/04/20
By Cheryl Clark
When patients undergo surgery, the anesthesiologist usually administers more than one type of drug. Some tackle pain, so you don’t feel the incisions. Some tackle memory, so you don’t recall the experience.
What any patient wants is for there to be no pain. But also, patients shouldn’t be able to remember what was being said or any noises, smells or other scary sensations during the operation that could haunt them later, like very bad dreams.
But what if someone stole some of your pain meds? Would you have felt pain during the operation, but not remember it? Or what if someone stole the drugs that induce amnesia and substituted saline for some of your medications? Would you remember whirring noises from drills or surgical team conversations after you woke up? Would they haunt your subconscious?
What if they substituted some of the drugs in the syringe with saline?
Those are some of the spooky questions that emerged as I worked on a story for MedPage Today about Dr. Bradley Glenn Hay, an attending anesthesiologist at the University of California San Diego Medical Center who admitted an addiction to sedative drugs he took from UCSD and its patients since his anesthesiology residency in 2003. KPBS, San Diego’s NPR affiliate, interviewed me about the case last month.
In April 2018, the Medical Board of California took away his license to practice after he was found unconscious on the floor of a bathroom at UCSD Medical Center on Jan. 27, 2017, pants down, covered in vomit and lying next to several syringes containing the sedative sufentanil that he had withdrawn for a patient.
Now there are lawsuits against Hay and UCSD in federal and state courts. And that means there are depositions. According to those documents, one of the plaintiffs, the one he had withdrawn the sufentanil for, is Randy Dalo, who underwent surgery on that day, Jan. 27, just before Hay collapsed in the bathroom. According to his lawsuit, Dalo thinks he was aware of what went on during his operation that day. He believes he suffered because Hay did not administer the amount of anesthetics he was supposed to receive.
Hay admitted that he falsified Dalo’s medical records to indicate that Dalo received more anesthetic than he actually did, according to Hay’s deposition.
Dalo testified during his deposition that he complained to his wife shortly after his surgery that he kept having weird dreams or nightmares, had trouble falling asleep and couldn’t sleep lying down, or in his bed. He had panic attacks some nights and that during those dreams, he would find himself ripping at his arms, which now show wounds and scars.
“It was the same thing every single time,” he said. “I’m – I am assuming I’m lying down, and I’m looking up. All I see is just really hazy shadows. I can count one, two, three people over me and one person in the back looking over them. And then it’s just this giant, round with a fuzzy bright light.” he testified.
“I tried – I – I try and say something, and nothing is coming out … I’m saying, ‘Hey, I’m awake.’ That’s what I’m trying to say. When I couldn’t talk, it was so frustrating … I couldn’t even make a grunting sound or anything. Then I would start screaming, trying to get – get something out. And then I’d – I’d wake up.”
Dalo’s wife Karen, who was employed as UCSD’s operating room coordinator, kept trying to reassure him that everything was fine, that it was his imagination or bad dreams.
They said they discovered that their anesthesiologist, Hay, had a problem when they read a report on a TV channel website in late 2017 that the Medical Board of California had filed an accusation against Hay because of an incident on Jan. 27.
The full story wouldn’t come out until recently, when the parties involved sat for depositions.
On Nov. 14, 2019, Hay — who is said by his attorney to be extremely remorseful, in recovery and sober — sat for a 4-1/2 hour deposition.
Bradley Glenn Hay gave a deposition in November 2019. (Photo: Still from deposition video provided by plaintiff’s attorney Eugene Iredale.)
During that time, Hay confessed that he had been stealing anesthesia medications from patients and UCSD and using them himself off and on for years, since his first year of anesthesiology residency in 2003, sometimes as much as five to eight times a day. He often administered anesthesia to patients while under the influence, he admitted.
In the 10 months before getting caught, he ordered more drugs than he believed the patient would need, he said. Then, he would “waste” what was leftover, according to hospital policy, which requires that another health provider witness the disposal of the drug.
He described in his deposition that he had taken some of the drugs for himself and substituted saline some 800 times.
Those drugs included morphine, ketamine, fentanyl, sufentanil, midazolam, Dilaudid and dexmedetomidine, all of which he obtained from UCSD in the name of patients he was caring for during surgeries.
It is not known how many patients may have been affected overall, but according to the exhibits filed by the plaintiff’s attorney, Hay was the anesthesiologist in 800 patient cases between April 2016 and January 2017.
Hay revealed that UCSD officials on the hospital’s Physician Well-Being Committee became concerned about his behavior and ordered him into treatment at a Betty Ford clinic in 2008, and so were aware of his substance abuse problem.
The latest lawsuit, filed in federal court on Jan. 24, asks UCSD to inform all of the patients who had Hay as an anesthesiologist, so they can have an opportunity to determine if something like what Dalo experienced had happened to them.
UCSD officials declined to comment on pending litigation, although in testimony, the chairman of the anesthesiology department said UCSD had determined Hay’s patients weren’t affected. But the issue unearths a horrifying potential effect that drug diversion in health care settings might have on patients, whether they consciously remember it or not.
What happened to Hay’s patients is far from unique.
In 2008, for example, the California Department of Public Health fined Pomerado Hospital in Poway, a San Diego suburb, after three patients who underwent gynecologic procedures reported frightening descriptions of their surgical awareness.
One of the patients told investigators that she could hear and feel the procedure. “Remembered hearing ‘cut this side’ … could feel the cutting, like it was pressure ... could hear the ‘click, click, click’ of the speculum being inserted ... tried to tell my body to wake up, but I could not move. I could not open my eyes ... remembered gagging feeling.”
She told the anesthesiologist, “I felt every ... [expletive deleted] ... thing you did. I was awake the whole time.”
The state agency classified the event as an immediate jeopardy, or an event in which a health care provider’s “noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death” to a patient or resident.
In dozens of other cases over the last decade, health professionals such as technicians, registered nurses and nurse practitioners have been caught taking for themselves sedation drugs or opioids that were prepared in syringes for patients. A famous case involved former cath lab tech David Kwiatkowski, who took fentanyl in syringes and replaced it with saline in many of the hospitals where he worked in some nine states across the country, from Arizona to Maryland, until he was finally caught in New Hampshire.
That happened when an observant physician noticed that several older catheterization patients at small Exeter Hospital were presenting with unusual acute hepatitis C. The common element: they had all undergone cath lab procedures involving Kwiatkowski. Their viral strain turned out to be the same as Kwiatkowski’s. Some of his contaminated blood had entered the syringes he had filled with saline. He now is serving a 39-year prison term.
Did any of those patients lack sufficient sedation? Did they feel pain, but had enough medication so that they didn’t remember the experience? Anesthesiologists can tell if a patient is experiencing awareness if their blood pressure and heart rate rise while they are undergoing their procedures, even if they are not conscious enough to scream.
The Centers for Disease Control and Prevention has been tracking this issue, with a paper published in February by Mayo Clinic Proceedings. It noted that since 2001, some 200,000 U.S. patients were notified about “potential exposure to blood-contaminated medications or injection equipment.”
And since 2012, 66,748 patients were notified in 38 separate events, and 11 of these “involved drug tampering by a health care provider.”
It added, “facility leadership has an obligation to ensure adherence to safe injection practices and to respond properly if unsafe injection practices are identified.”
Many questions emerged during my reporting on this story:
First, Hay’s was an old case that didn’t get much media attention in 2017, yet following up with the legal proceedings and paperwork revealed a much more worrisome issue. Why did UCSD let an anesthesiologist that it knew had a drug problem continue to practice? Did they believe that he had licked his addiction and did not need to be monitored?
Should the facility have more carefully tracked the number and kinds of medications Hay withdrew from the pharmacy? The pharmacist in charge at UCSD testified in depositions that Hay had withdrawn more anesthetic medications than other attending anesthesiologists.
Another question lawyers are asking, probably with a potential class-action lawsuit in mind: Does UCSD have an obligation to track down any patient whose anesthesia was administered by Hay to determine whether they are suffering any post-traumatic stress pressures from inadequate anesthesia and surgical awareness?
Advice to fellow journalists:
After a disciplinary action is filed by a state licensing agency, especially one in which a physician’s license eventually is taken away, track any lawsuits filed against the doctor or the health system. Ask the plaintiffs’ attorneys for copies of the depositions and read them carefully. They often unveil substantial lapses in patient safety efforts.
See other papers published on this topic:
- Mayo Clinic Proceedings: Bloodstream Infection Outbreaks related to Opioid-Diverting Health Care Workers: A Cost-Benefit Analysis of Prevention and Detection Programs.
- Mayo Clinic Proceedings: Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection and Prevention
- PubMed: BIS Monitoring to Prevent Awareness During General Anesthesia
- Cochrane Library: Anaesthetic Interventions for Prevention of Awareness during Surgery