James Harold Bischoff was admitted to Largo Medical Center the day after Christmas with acute kidney failure.
As the 70-year-old's condition deteriorated, a kidney specialist ordered dialysis, saying it was critical Bischoff get excess potassium and fluid filtered out of his blood quickly.
The dialysis never took place.
The doctor ordered Bischoff's dialysis to begin no later than 6 a.m. on Dec. 28. The order was called in to Fresenius Medical Care — the outside vendor that performs dialysis at the hospital — at 2:30 a.m.
At 9:40 a.m., the dialysis nurse called to say he would be late.
He arrived at 11 a.m., as doctors and nurses were trying to revive the patient, whose heart had stopped.
By 11:18 a.m., Bischoff, a loner who lived in a trailer park in Largo, was dead.
His specialist, Dr. Abraham Awwad, got a voice mail about noon from the Fresenius nurse. "He said, 'I came to dialyze your patient but they were running code and he expired. Call me if you have any questions,' " Awwad said. "If dialysis had even been started by 8 a.m., Mr. Bischoff would still be with us today."
The December death at Largo, an HCA hospital, opens a window into the practice of outsourcing critical inpatient services like kidney dialysis. Though lots of local hospitals do it, the death at Largo shows how high the stakes can be for a seemingly routine procedure.
Dialysis can be postponed for some patients, Awwad said, but timely treatment is a life-and-death matter for people who have fluid overload in their lungs, congestive heart failure or, like Bischoff, dangerously high potassium levels.
State inspectors found serious deficiencies in Largo's dialysis program. But the whole episode would have remained buried in official records — with even Bischoff's closest relatives unaware — if his specialist hadn't decided to speak out.
Awwad, who has a reputation among colleagues for being both passionate and a pain in the neck, says there still are problems with contracted dialysis services at local HCA hospitals.
"I'm not walking away from this,'' he said. "I anticipated something like Mr. Bischoff's death could happen if doctors have no say in dialysis. But nothing was done."
Limiting cost, control
The state's investigation at Largo came less than a year after regulators suspended dialysis services at Northside Hospital, another Pinellas HCA facility. The forced closure followed months of physicians' complaints about the outside dialysis provider. HCA responded by promising improvements, including hiring a new dialysis company: Fresenius.
HCA says all is well at both Northside and Largo. "At the present time, there are no issues with Fresenius," said spokeswoman Tammy Robiconti.
Fresenius, which also operates an extensive network of outpatient dialysis clinics, did not respond to the Times' calls concerning Bischoff's death or its hospital contracts.
Contractors such as Fresenius provide everything from dialysis machines to tubing to fluids to personnel, saving hospitals money. But they also limit doctors' control over the procedure.
Dr. Jacques Durr, head of nephrology at the University of South Florida's College of Medicine, converted the dialysis program at Bay Pines VA from an outsourced to an in-house program, a move he said proved cost-efficient, while improving care. He currently sees patients at Moffitt Cancer Center, which contracts with Fresenius, and Tampa General Hospital, which has an in-house dialysis unit.
"If a hospital does cardiac surgery or intensive care, it would be better to have dialysis done in-house," Durr said. "But we also have to live with the reality of the world and what a hospital can afford."
Awwad, who did his nephrology fellowship at USF, said HCA has refused to discuss creating an in-house dialysis program for its five Pinellas hospitals. He also disputes HCA's statement that it involved doctors in the selection of Fresenius as its contractor.
"The administrators just told us they'd brought in a new 'vendor,' like Burger King selecting someone to supply the ketchup," he said. "The experts were kept out of it. We never even saw the contracts."
How long of a wait?
Sitting in the lunch room of his St. Petersburg office recently, Awwad shuffled through a stack of patient files. Each one, he said, contained an incident of dialysis care gone wrong.
In February, less than two months after Bischoff's death, Awwad ordered a stat or emergency dialysis at 1:40 a.m. for a Largo patient. When a Fresenius worker had not arrived by 3:30 a.m., the Largo supervisor made a follow-up call. Fresenius' response was that, according to its contract with Largo, its staff has four hours to respond to a "stat" dialysis order. The Fresenius nurse arrived at 4:45 a.m.
Though the patient was successfully dialyzed, Awwad said the delay was potentially dangerous. Dr. Gerald Schulman, head of nephrology at Vanderbilt University Medical Center in Nashville, agreed.
"I wouldn't want to wait four hours to treat somebody in an extreme situation," said Schulman, a member of the American Society of Nephrology's Dialysis Advisory Committee. "If they had very high potassium levels, difficulty breathing or fluid overload, a four-hour wait is not acceptable."
Awwad said he also has had patients who received treatments without a doctor's orders or had their session cut short.
Dialysis treatments usually take three-and-a-half to four hours. Awwad said if fluid is taken too quickly from patients, their blood pressure can drop, causing dizziness or an irregular heart rhythm. If the session is terminated earlier than ordered, the blood won't be adequately cleansed and excess fluid will remain in their system.
"These outside contractors want a dialysis treatment that's 'one size fits all,' but it has to be fine-tuned to the needs of the patient," Awwad said.
Last month at Northside, Awwad learned a Fresenius nurse ended dialysis 30 minutes earlier than ordered, though it appeared in the patient's chart as if the full treatment had been received. The doctor, who had quality issues with the same nurse in the past, complained to Northside's management.
Awwad also noted in the chart that the patient, her mother and her 17-year-old daughter said dialysis had been abbreviated and a formal incident report was required.
In response, Awwad received a letter from Northside's chief medical officer, Dr. Charles Nutinsky, who said Fresenius had investigated the incident and fired the nurse. But Nutinsky suggested Awwad shouldn't leave a paper trail of complaints in the patient's record.
"I want to thank you for bringing your concern to our attention while at the same time request that a phone call or communication other than on the hospital chart be considered in the future," he wrote.
Nutinsky did not respond to calls or an e-mail from the Times.
Pushing for change
Awwad believes Northside already retaliated against him once, granting him staff privileges for just one year rather than the standard two after he complained about the former dialysis company. But Awwad, 49, does not give up easily. He lost his right eye in a motorcycle accident six years ago yet just bought a new Harley-Davidson, Being an outsider is part of his upbringing as a Palestinian Christian who was born in Jerusalem and moved to Miami at 14.
"I want to pressure them to make a change," said Awwad, whose practice is largely dependent on local hospitals.
While Awwad said colleagues share his concerns, none of his fellow nephrologists at HCA returned calls for comment.
The internist who cared for Bischoff, however, supports Awwad. Dr. Michael Saccente agreed that his patient would have lived if dialysis had been received. "There was no care from a dialysis standpoint," he said.
Saccente, who shares office space with Awwad in Largo, was also present at a meeting of the hospital's medical staff in February to discuss Bischoff's death. Before the meeting started, Largo's chief of staff "verbally assaulted" Awwad, the internist said, for having called in the middle of the night after yet another patient's dialysis was delayed.
"Dr. Awwad simply wished to speak with a physician in a position of power and then he gets that response,'' Saccente said.
Chief of staff Dr. Larry Feinman said recently he didn't know about continuing complaints about dialysis. "I did not expect to get in the middle of this," said Feinman, a vascular surgeon.
New chain of command
Durr, the director of USF's nephrology fellowship, is not surprised to hear that his former student is making waves.
"Dr. Awwad was very caring of his patients and always put them ahead of hospital politics," Durr said. "I'd rather have a physician speaking out, even if he becomes a pain in the neck, than have someone who does nothing when they see something that endangers a patient."
Awwad's complaints about Bischoff's care resulted in a state investigation, discipline of the night nurses in the case and a new "chain of command" when dialysis is delayed.
But no one told Bischoff's closest relative, second cousin Nanci Bender, about the controversy surrounding his death. Bender, who lives in Odessa, said she wasn't close to Bischoff, a bachelor and alcoholic. "I'd see him on holidays, but Jimmy didn't really associate with the rest of the family," she said.
Bischoff was taken by ambulance to Largo after a neighbor found him unconscious in his mobile home. Bender didn't know Bischoff had been hospitalized until the day he died.
"I called Largo hospital sometime between 10 and 11 a.m. and they said they'd call back," she said. "That night about 10 p.m. they said he was deceased." She still has his ashes in the back seat of her car.
Bender only recently read the state's investigation into Bischoff's death. "He should have had decent care," she said.
Times researcher Shirl Kennedy contributed to this report. Kris Hundley can be reached at firstname.lastname@example.org or (727)892-2996.