A Surgeon on the Loose: Duntsch made surgical mistakes that one doctor called “never events,” meaning they shouldn’t ever happen in a career.

Physicians

A Witness to Dr. Death: ‘In the Presence of a Sociopath’

A surgery tech shares his experience on working with Dr. Christopher Duntsch and surgery that led to the death of Kellie Martin.

Anson Fulton was only two weeks into his new job as a surgery tech at Baylor Scott & White – Plano when he was scheduled to assist on a surgery with Dr. Christopher Duntsch. Because Fulton was experienced, his preceptor felt comfortable letting him work alone with the surgeon. Fulton scrubbed in for the surgery, unaware of any issues that were already cropping up around the now infamous former surgeon.

“When he walked in the room, I don’t know if you’ve ever been in the presence of a sociopath, but it’s a very ominous feeling,” Fulton says. “I tend to be an empath and pick up on different things, and the vibe he gave me was just not good. It was very dark, and it just wasn’t a good feeling.”

Fulton had been a surgery tech since 2007 and had mostly worked on heart surgeries. He always wanted to be in a profession where he could help others and was excited about a change of pace while working on spine surgeries with Baylor in 2012. In his brief time working there, he witnessed how Duntsch worked, and recalling the memory nine years later still traumatizes him. His first and only surgery with Duntsch was a consequential and horrific one: He was present for the surgery that resulted in the death of Garland school teacher and mother of two, 54-year-old Kellie Martin. The full story of Duntsch’s actions can be read in Matt Goodman’s D Magazine feature from 2016, when the magazine first coined him “Dr. Death.”

Duntsch had been suspended from operations for two weeks before Martin’s surgery after his friend Jerry Summers woke up from a surgery paralyzed. 

As a surgery technician, it was Fulton’s job to prepare the operating room for surgery, stabilize and prepare all equipment, ensure adequate supplies, and prepare the patients by disinfecting incision sites. In addition, they pass instruments and other sterile supplies during the surgery while keeping track of what goes into the patient to make sure everything comes out.

He didn’t receive a warm welcome from Duntsch. Being new to the program, Fulton introduced himself, but Duntsch didn’t return the favor. “The first thing he said to me was, ‘Why is my patient not draped?’” Fulton says. Surgeons often have preferences about how they want their patients draped or covered to keep the area sterile during surgery. “He just keeps repeating himself three or four times, and then I stopped answering because I knew where it was going, which was nowhere.”

Martin’s procedure was supposed to be a 45-minute, minimally invasive discectomy. Fulton says it quickly became apparent that Duntsch was struggling, having difficulty with the simple parts of the procedure. “Throughout the case, the way he was grabbing tissue and manipulating tissue showed that he was not sure about himself,” Fulton says. He tried to offer the surgeon some advice but was rebuffed. “I know what I’m doing; I don’t need your help,” Duntsch told Fulton, the same type of messaging the surgeon would often tell his colleagues. 

About 25 minutes into the surgery, Fulton says there was a lot of blood – rare for this type of surgery with a small inch-long incision. Fulton suggested using equipment called a cell saver that could make sure the patient didn’t lose too much blood by pumping it back into the body. But, again, he was told to mind his own business. “At that point, I know what I’m talking about because my heart experience kicks in, and I could see there was a lot of blood loss happening,” Fulton says. 

Eventually, the cell saver was used, but Martin had lost 400, then 500 ccs of blood. Soon, it climbed to 800 ccs of blood loss in 15 minutes. The patient had lost nearly a liter of blood, almost halfway to being in danger of dying from blood loss. Again, Fulton tried to make a suggestion. “Verbatim, he looked at me and said, ‘Shut up, you don’t know what you’re talking about.’ I do know what I’m talking about because I can see it happening,” Fulton said at the time.

Eventually, Duntsch realized there was a problem; Martin’s blood pressure began to drop quickly. Duntsch held pressure on the incision, and the anesthesiologist also noted the blood loss even though Fulton had been noting it for nearly half an hour. Finally, Fulton says the patient began to go into cardiac arrest and was moved onto her back on another hospital bed. Less than a minute later, the team brought her heart back. 

At this point, Fulton says Martin woke up but couldn’t speak because she was still intubated. She was clearly in pain. She began slapping her legs, which had become patchy and full of purple streaks and spots. This often occurs when the heart hasn’t been strong enough to pump blood to that part of the body. As she panicked, the anesthesiologist put her back to sleep. It would be the last time she would be conscious. 

The chest compressions continued, and she was moved to the ICU, where they continued to try and save her life. “I kept walking back and forth from the ICU because I was honestly concerned about her. I knew there was a major issue.” Although surgeons would usually accompany the team in the ICU to make sure their patient was going to be okay, Fulton says Duntsch remained outside the room, watching through a window. 

After a couple of hours in the ICU, Martin died. Worse yet, Fulton says no one went out to notify her family during this process. Finally, the family called the operating room to see what was happening, as Martin had been in surgery for more than three hours for what was supposed to be a 45-minute surgery. That’s when they learned she had died, Fulton says.

Not only was the experience heartbreaking for Fulton, but he says it was also bizarre. “I’ve never seen a surgeon or even a doctor so disconnected from his patient and what was going on,” he says. A few weeks after the surgery, Fulton left his position at the hospital and now works as a surgery tech in Oregon. 

Fulton was approached to testify in court against Duntsch in one of the civil cases against him but ultimately opted out as he was unsure how it would impact his future as a healthcare worker. The district attorney’s office says it knew that Fulton was in on one of Duntsch’s surgeries but decided not to depose him or call him to the stand. Recalling the memory is still painful for him today, and he was unable to watch the latest TV series without shutting down. After years of counseling, he is able to talk about it now, but not without consequences. “Anytime I talk about it, I’m depressed for a couple days afterwards,” he says. “It never gets old. It’s like it’s just happened yesterday. Because I watched someone get murdered in front of my eyes, basically. That doesn’t go away.”

Duntsch, of course, would go on to be the only physician ever to be convicted in a criminal court for something they did in an operating room, and he is now serving life in prison following a host of charges, including injury to an elderly person. 

As a veteran of numerous surgeries, Fulton is no stranger to death on the operating table, but this experience stands out. “I have never been in another room where a patient has died because of negligence. It’s always been things that we can’t fix,” he says. “I have not experienced that Dr. Duntsch experience ever again in my career.”

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