Patient Care Fueled Bitter Hospital Fight

By Bill McKelway; Contact Bill McKelway at (804) 649-6601\ or bmckelway@timesdispatch.com\

By this time in his life, Dr. John Raviotta figured he’d be slipping into retirement. He would be bringing to a close a medical career that spanned 30 years and saw the delivery of thousands of babies.

“Bringing babies into the world, giving care to their moms — that was my calling in life. That is what I was here for.”

Instead, Raviotta is hanging on by his fingernails.

He lost his home in South Hill to foreclosure and lost much of his beloved native city, New Orleans, to Katrina.

His privileges to practice medicine at South Hill’s Community Memorial Healthcenter have been terminated. He has sought bankruptcy protection. Shunned by the medical community across Virginia and beyond, he has been turned down for positions at hospitals throughout the state, across the country and as far off as New Zealand.

Desperate for income, he even applied for a teaching job at a prison. Prison officials said no.

Thanks to a friend’s kindness, Raviotta shares a ramshackle country home rent-free with his greatest champion, his wife, Judy, his sweetheart since their teenage years. She was diagnosed in recent weeks with cancer and is undergoing post-mastectomy chemotherapy.

The couple raised three boys who are now on their own. Judy is an award-winning high school teacher but fears for her job because of her health. Raviotta, who is 60, works part time teaching anatomy to nursing students at a community college. He has even worked as a substitute teacher in home economics and car repair at the local high school.

“There is so much more I could be doing,” Raviotta laments.

How a sometimes tempestuous medical career blew up in Raviotta’s face is a long story.

But at its heart, it is a tale of suspect patient care and damaged lives, of secret proceedings within the hospital and of an embittered doctor whose career the proceedings helped bring to a shattering close.

Along the way Raviotta’s work history includes a series of soured business relationships.

A brief partnership in South Hill ended, according to lawsuits against Raviotta and the hospital, amid allegations of patient interference and claims that he and the hospital conspired to drive his former partner out of town. Raviotta denied the allegations and was dropped from the suit. The hospital settled privately out of court, according to court records.

Preceding his arrival in South Hill, his practice in Fairfax also ended in a business dispute.

Conditions became so hostile in South Hill that one patient of Raviotta’s would testify in revocation proceedings that she was called at home by someone at the hospital whom she couldn’t identify and told she should sue Raviotta. Days earlier, Raviotta had saved the woman’s life in an emergency operation.

Over the past three years, Raviotta has shared with a Times- Dispatch reporter details of his medical career and of his ongoing fight against doctors and hospital executives at Community Memorial.

The years-long battle includes allegations against Raviotta of malpractice and insubordination and Raviotta’s counter-accusations of hospital mismanagement and patient harm.

Much of the information detailing the controversy comes from confidential proceedings within the hospital that cost Raviotta his job there. The proceedings — obscurely titled “In the Matter of Physician No. 272″ and by state law hidden from public access — reveal a sour, unrelenting war of wills.

If Raviotta is accurate, Virginia has lost a good doctor to what he calls a twisted, secret system of privilege and cronyism. Left hanging, he says, are his allegations of patient harm and failed hospital policies.

If he is wrong, why does John Raviotta — accused by hospital officials and some colleagues of incompetence and patient harm — still hold a medical license in Virginia? And why was he allowed to keep practicing at Community Memorial for five years as allegations against him multiplied?

This much is clear: In one of Virginia’s most rural areas where access to patient care is crumbling and hospitals have shut obstetrical wards, veteran obstetrician John Raviotta cannot find work as a physician.

“I have checked every hospital in Virginia,” he said. “They are not interested.”

*****

A city boy raised in his dad’s New Orleans restaurant, which until Hurricane Katrina was a hangout for medical students from nearby Charity Hospital, Raviotta can’t help feeling like a displaced person. At times, he seems almost lost.

“This tree here drops these big green things,” he said one day strolling back to the house, whacking a golf ball-size object out of his path. It was a walnut still wrapped in its immature husk.

Raviotta wonders why no one seems to listen, why it has all come to this.

He and Judy traveled last year to statewide public forums about medical care that were attended by high-ranking government officials, including Jane H. Woods, Virginia secretary of health and human resources. Each time, Raviotta or his wife boldly summarized their allegations of substandard medical care at Community Memorial.

Panel members barely raised their heads from their notes. Not one of them has asked Raviotta for more details, he said.

Later that summer, Community Memorial’s chief executive, W. Scott Burnette, was appointed by the governor to the Health Department’s board of directors. Burnette, Raviotta says, was his principal adversary.

“It was like getting punched in the stomach,” when he read the news in the local paper, Raviotta said.

Meanwhile, Raviotta’s complaints to the state Board of Medicine and other oversight agencies about physician conduct and patient care at Community Memorial are still under review years after he raised them or have been found to be without merit, Raviotta said.

Burnette, who said he is barred by state law from discussing the proceedings, strongly defended the hospital in an interview. He said the facility is constantly under review by state and federal regulators and that it has repeatedly sought and received high ratings from independent quality-care organizations.

Community Memorial Healthcenter, which celebrated its 50th anniversary last year, remains a bulwark of medical care along the North Carolina border with Virginia. Its mission statement reads: “To provide excellence in the delivery of healthcare.”

The hospital, the community’s largest employer, is so cramped for space that Burnette operates from a modular building; his original office has been converted for patient use. The hospital is embarking on a multimillion-dollar expansion that must be accomplished if it is to remain a locally owned nonprofit operation.

“It is crucial,” said former board of trustees Chairman Wayne Parrish, a local businessman who retired from the board after 17 years. “I still have copies of checks from people here 50 years ago who helped make this hospital a reality.

“We can’t fail them,” he said, referring to those early sacrifices and to services that could be lost in a sale to outside interests.

But to Raviotta, who left Fairfax County for South Hill in early 1996 and then became chief of obstetrics at the hospital, the differences between medical care were stunning.

“Things were going on that you would expect to see in a Third World country,” he said.

*****

Within a few months of arriving at Community Memorial, Raviotta was knee-deep in hot water and the realities of practicing medicine in a rural hospital. He had split from his partner there and would later be accused in a suit of breaching his contract.

“There was no contract,” said Raviotta, who was dismissed as a defendant in the case.

Complaints had been filed against him to the state medical board, which were investigated and found to be unsubstantiated.

He also complained to hospital officials at length about what he saw as lax procedures involving sponge counts during surgery. Counting sponges, which soak up blood, is crucial but tedious. A missing sponge raises the possibility it was accidentally left inside a patient’s body.

In a sworn affidavit he would give years later, Raviotta described “sponges (being) placed in a bucket and counted in a haphazard manner.” Sometimes different personnel made the counts before and after surgery, and there was no count board.

Shortly before his arrival, a sponge had been left inside a patient’s stomach cavity and wasn’t diagnosed for three months, “requiring a small bowel resection.”

Then, in May 1997, Raviotta lost a sponge inside a patient. His complaint had come back to haunt him.

The dangerous foreign object turned up in an X-ray when the patient began experiencing extreme discomfort. An emergency operation was required to remove it.

In November 1998, Raviotta’s patient filed suit, accusing him and the hospital of negligence.

As the trial approached, Raviotta exposed details of his previous concerns about sponge counts. He also said that a nurse had picked up a loose sponge from the floor after the operation, thus correcting the count. It had been one sponge short.

Raviotta told lawyers that no one had cleaned up from the previous operation and that the sponge on the floor likely had been left behind.

The plaintiff in the case dropped Raviotta as a defendant and the hospital admitted liability. A jury only had to determine damages, but Raviotta’s pre-trial details about hospital shortcomings were never made public.

Badly scarred from her operation and kept in the hospital for more than a week because of infections and other complications, the patient offered moving testimony to a seven-person jury: “The fear of not knowing whether I was going to live or die was there in those first three days.”

Her lawyer brushed back any notion that the ordeal had been an incidental consequence of a simple medical error. “The only infraction that she might have made was trusting in this hospital. . . . It turned overnight into a nightmare.”

The jury returned with a verdict in 40 minutes against the hospital: $175,000.

“I think I was a marked man from that point on,” Raviotta said in an interview.

There were other things at play before the November 1999 decision in the sponge case.

A month earlier, Burnette, the hospital CEO, and Dr. Wallace Horne, head of risk management, called Raviotta in for a talk. Burnette warned Raviotta that he faced possible disciplinary action if his conduct didn’t improve.

Raviotta said in an affidavit that Burnette suggested my “behavior was out of control in the OR.”

Burnette mentioned staff complaints about Raviotta’s outspoken criticisms of equipment malfunctions and availability, according to Raviotta, who said he never saw copies of the actual complaints.

In a letter, Burnette warned that Raviotta’s conduct had “potentially compromised the staff’s ability to work with [Raviotta] in an effective manner.”

It became clear later that staffers accused Raviotta of berating them over procedures that they thought were in line with Raviotta’s written instructions and preferences. Some mentioned Raviotta’s loud voice and glaring looks, which can seem severe because of a congenital trait that gives Raviotta’s eyes a narrowed, piercing look.

“He was screaming at me in the hall in front of employees and anyone else who was in listening range,” one OB nurse complained, recalling an incident from 1997. “I was literally scared to death of what Dr. Raviotta would do to me, he was so angry.”

But the same nurse described Raviotta this way: “I never saw a patient that was too old, too dirty, too poor or too ignorant to receive the very best care that Dr. Raviotta had to offer.”

Some co-workers said they had never heard Raviotta utter a curse word.

As far back as May 1998, Raviotta fired off a blistering memo alleging failed equipment and delays in beginning emergency operations.

During one delayed case, a patient lost excessive amounts of blood, a nurse was secretly taping him hoping to record his outbursts, and an anesthetist left the operating room, leaving the patient unattended, Raviotta alleged. Testimony during the revocation proceeding four years later substantiated his claims.

“This is another example of what can only be described as belligerence, obstruction, and insubordination,” he wrote in a memo of the events that day in 1998. “It is outrageous to have this much difficulty attempting to get a patient to surgery and through a surgical procedure for managing a condition recognized by everyone as an unquestionable emergency.”

His “legally binding orders” were not followed, he wrote. “I am fatigued at having to justify my actions to those who have not my credentials, experience or legal responsibility for the life and well-being of my patients.”

He suggested the problems were serious enough that some staffers could lose their licenses and “the hospital may have serious accreditation problems.”

A week later, Raviotta apologized in a letter for any conduct that may have been upsetting. “It is my intention to make a greater effort to avoid what has been construed by many of the staff to be intimidating behavior. I apologize if in dangerous and difficult situations, that I have been intense. Intensity when used appropriately saves lives and prevents disasters.”

*****

There was more at stake for the hospital and Raviotta than the consequences of the so-called lost sponge case and Raviotta’s building concerns and outbursts.

In June 1999, five months before the sponge verdict, a multimillion-dollar suit was filed by the family of a woman treated at Community Memorial.

The suit alleged widespread negligence in her care. Her preterm labor led to a deluge of complex emergency medical conditions including extreme blood loss and organ failure. Raviotta, the hospital and five others were named defendants.

Raviotta successfully delivered the infant during emergency surgery in November 1997, but the mother had to be rushed to Virginia Commonwealth University Medical Center after losing her vital signs. She died from multiple complications at VCU three weeks after Raviotta operated on her.

The case stalked Raviotta’s increasingly difficult tenure at Community Memorial for years.

The case file fills a half-dozen cardboard crates on a high shelf in the Mecklenburg County clerk’s office. Formally dropped this month, eight years after the operation, the case had gone to trial and produced a verdict in Raviotta’s and the hospital’s favor. The state Supreme Court found reversible error and sent the case back for possible retrial. After settlement terms were refused, the case was dismissed.

“It was a terrible outcome, but I never lost my confidence that I was not at fault. I was able to save the baby under very difficult circumstances,” Raviotta said in an interview.

In July 1999, a month after the wrongful-death suit was filed, Raviotta got more worrisome news.

“Your dedication and service are commendable,” CEO Burnette wrote, noting that Raviotta had been responsible for obstetrically related emergency room calls seven days a week, 24 hours a day for a full year.

“I am concerned that the continued stress of remaining on call could create an unhealthy and potentially unsafe situation for you and for the patients.”

Burnette said two new obstetricians would be coming to town, which would allow him more time off.

But South Hill cannot support three obstetricians, Raviotta said. “There isn’t that much business.”

Then in December 1999, Raviotta underwent another trial of nerves.

A policy change shifted responsibility for women more than 20- weeks pregnant from the emergency department to the obstetrical department. Raviotta was incensed that at a small, rural hospital, pregnant women could be denied immediate attention until the on- duty obstetrician appeared.

“It is mind-boggling to me that contract [ER] physicians have been able, through this policy change, to shun their responsibilities,” Raviotta wrote the hospital’s chief of staff on Dec. 5.

“I can only imagine the public relations problems when the community becomes aware that our ER physicians ‘do not feel comfortable’ and ‘refuse to care for’ pregnant patients after a certain stage of their pregnancy,” Raviotta wrote, using his own words to characterize the ER department’s posture.

“My concerns at this hospital are genuine and I am unwilling to accept responsibility for the consequences which inevitably will occur with this change in policy,” he concluded in a four-page letter that incorporated several emergency scenarios that would leave the hospital vulnerable to suit and possible loss of life.

Within the next two days, two of Raviotta’s nightmare predictions became a reality.

On Dec. 7, 1999, a high-risk patient arrived at the emergency room 27 weeks pregnant with the baby in a breech position, its feet dangling from the mother’s vagina.

The mother was sent to the obstetrical ward by the ER, Raviotta wrote the chief of staff that night. No one from the ER contacted him and he discovered the emergency only because he was on the way to do another operation, he wrote.

An emergency delivery produced a limp, almost lifeless infant who was rushed to VCU Medical Center by a transport team summoned from Richmond. The baby died the next morning.

Raviotta accused the ER department of showing “a reckless disregard for the patient and the baby” in a letter to the chief of staff. The baby’s condition wasn’t checked, a transport team wasn’t notified promptly and the patient was sent out of the ER without an attending physician, Raviotta wrote.

Raviotta predicted that “other disastrous episodes will occur.” One came the next morning, Dec. 8.

*****

Another woman in preterm labor arrived at the hospital bleeding vaginally. She was rushed to labor and delivery with no notification to Raviotta until he was called by an obstetric nurse. “No doctor attended this patient prior to my arrival,” he wrote in his third letter in as many days.

Raviotta rushed to the hospital, administered drugs to delay delivery and had the woman transported to the VCU medical center.

As the year 2000 started, Raviotta was clear of one trial, awaiting developments in another and battling the administration over emergency department procedures.

Especially dangerous, Raviotta alleged, was the hospital’s repeated inability to surgically deliver infants within 30 minutes, the so-called “decision-to-incision” window that is a nationally recognized standard of care. The hospital consistently argued that its policy was in line with other rural hospitals and that state and federal regulators found the hospital was in compliance with accepted standards of care.

The hospital was contemplating more than responses to Raviotta’s barrage of complaints and alarms about patient safety.

On Jan. 14, 2000, a committee of CMH doctors wrote Raviotta that it was investigating a series of complaints — against Raviotta.

Raviotta may have engaged in conduct detrimental to patients and the hospital that disrupted hospital operations and impaired community confidence in the facility, the committee wrote.

The letter listed a half-dozen incidents ranging from allegedly abusive comments to staff, to questionable emergency deliveries that “bumped” other scheduled operations, to poor documentation, to his failure to promptly respond to a call from the emergency department.

Raviotta, in other words, was being accused of the very failures that he had alleged against the hospital.

He put together a three-page letter listing more than three dozen examples of hospital and staff shortcomings — from a burned-out microscope light and a shortage of appropriately sized scrub suits to delays of up to three hours for emergency procedures.

“I hope we can find some solutions to these problems and resolve the adversarial relationship which I feel has developed between the medical staff and administration in my efforts to meet quality medical standards,” Raviotta wrote hospital officials. “Finding solutions to these problems will greatly reduce stress levels for everyone.”

“Respectfully, John,” the letter concluded.

Almost two years later, in October 2001, on probation and subject to a future revocation hearing for his past conduct, Raviotta had his privileges at the hospital summarily suspended.

The sudden action came when administrators learned Raviotta was copying medical records of two people who were not his patients, something that Raviotta still claims he was entitled to do as a department head.

“It’s not like I was hiding anything. I walked in front of everyone and made copies,” Raviotta recalled in an interview. The records were intended to illustrate continuing problems.

The suspension remained in place. It took until February 2003 for the hospital’s board to uphold revocation of Raviotta’s already suspended privileges.

At the end of a 110-page report to the board that was prepared by a special hearing committee, two sentences spoke to a behind-the- scenes struggle.

“It is clear that CMH and Dr. Raviotta cannot coexist, and that it is the staff and, ultimately, patient care that suffers. The irony is that Dr. Raviotta’s unbridled patient advocacy is what has led, and would continue to lead, to interference with CMH’s ability to deliver quality patient care.”

Asked in an interview about that conflict, Raviotta was unremitting: “What they fail to acknowledge is what CMH considers `quality patient care.’ “

Coming tomorrow: Unanswered questions, unending fight.

ON THE INTERNET

For a video interview with Dr. John Raviotta, and to view earlier stories in the Medicine on Trial series, click on this story on TimesDispatch.com