Dr. Sean Cao, the lone transplant surgeon employed by UCI Medical Center, was typing at his computer around midnight.
In the subject line of an e-mail message, he wrote: "confidential memo for transplant team members only."
"LET ME CLARIFY ONE ISSUE," he wrote, leading off the April 9, 2004, message with emphatic capitals.
There was no truth to "rumors floating around the hospital and beyond" that he had been turning down offers of donor organs that could have been used to save his patients.
He had refused livers, he said, but only with good reason: if they were from a "marginal donor" or were offered for patients so sick they would never recover. He cited the 2003 case of an extremely ill 40-year-old cirrhosis patient who died six weeks after surgery.
Cao warned the staff against questioning his medical opinion and integrity.
"Anyone who spreads the rumors," he wrote, would be subject to discipline for "professional misconduct" and held "liable, especially if the patients ... find out something and decide to take legal action."
He signed only his last name: "CAO."
The e-mail serves as one strong clue to the meltdown at the liver transplant program, which UCI finally was forced to shut last month.
The hospital was performing so few transplants -- with such poor results -- that it failed to meet federal requirements. The main problem was that the program had been turning down the vast majority of donated livers, many of which were then successfully transplanted into patients at other centers.
Cao's memo -- and the story of his 4 1/2-year stint at UCI -- suggest that the pattern of organ refusals was, in part, a response to the travails of being a small transplant center.
With so much riding on each operation and so few people to bear the responsibility, the program was driven to dysfunction by a paralyzing fear of failure and an obsession for keeping up appearances.
So intense was its aversion to openness that many patients, whose lives swayed in the balance, never suspected anything was wrong until the program was closed, according to interviews and documents.
Cao, who declined to be interviewed for this article, did not create the problems, nor did they disappear when he left -- three months after firing off the April 2004 e-mail.
But his tenure marked a time when all the elements of dysfunction began to coalesce.
"Somebody should have intervened," said Magdi Hanna, a onetime patient of Cao's who waited several months for a liver before giving up on UCI.
"As a patient you are defenseless," he said. "You rely entirely on the integrity of the doctors."
Hiring Cao was a coup for UCI.
He arrived in January 2000, joining two other surgeons on the team. UCI's was a tiny program compared with the powerhouses at UCLA and USC. But it brought business to many parts of the hospital and gave it the distinction of providing the only liver transplants in Orange County.
Hopes were high that Cao could improve the program's record and eventually provide the next generation of leadership.
Young and driven, Cao had arrived in the United States in 1975 as a 14-year-old Vietnamese refugee.
"I quickly learned to speak English and graduated from high school in three years, receiving awards for outstanding senior in math and sciences," Cao wrote in a letter to the New York Times Magazine in 1986, responding to a story titled "The Victorious Personality."
At the time, he had just been accepted to medical school at the State University of New York at Buffalo. He went on to do a surgical residency at UC Davis, then a fellowship in transplantation at Stanford University.
"He wanted to be famous," said Tracy Tran, his wife at the time.
He joined an elite corps of medicine. There are fewer than 1,500 transplant surgeons in the nation. In California, he was the only one from Vietnam.
Tran remembered him as willing to sacrifice almost anything for his patients.
Cao rarely attended church, Tran said, but at Loma Linda Medical Center, where he started in 1998, he sometimes prayed in the chapel to calm his nerves before difficult cases.
"Before he'd do a case, he'd call me and say, 'Tracy, can you pray for me?' " Tran said.
Some of his other beliefs were less typical. For example, every Friday the 13th, he insisted that his wife not leave the house, Tran said.
He spent most of his time at the hospital. More than anything, she said, his schedule led her to file for divorce in 2000.
Cao had just joined UCI. "That was his dream," Tran said. "He wanted to work with Vietnamese people."
Orange County has the largest Vietnamese community in the United States. Cao quickly became one of its stars. He participated in medical missions to train surgeons in Vietnam, discussed health on Vietnamese talk radio, officiated at cultural events.
He served as a grand marshal in the 2004 Tet Parade, a celebration of the Vietnamese New Year. Wearing traditional garb, he waved to the crowds lining the streets of Westminster's Little Saigon.
Cao's first two years at UCI were rough for the liver transplant program.
The one-year survival rate for transplant patients hovered around 70% -- below the federal minimum of 77%. And in 2001, 35 people died on the waiting list, up from 15 the previous year.
These problems would soon be Cao's alone.
Ten months after he was hired, one surgeon left for a new job. A year later, Dr. David Imagawa, who had founded the program, suffered a heart attack and stopped doing transplants.
Now the only surgeon, Cao was responsible not only for transplanting livers, but also kidneys and pancreases -- in addition to performing other types of surgeries involving those organs.
Such isolation is a huge detriment for a transplant surgeon, said Dr. Carlos Esquivel, who started the liver transplant program at Stanford and helped train Cao. "If you are the only person, it is difficult to carry that responsibility, especially if you are young and just out of training," he said.
Among the first cases Cao handled as lead surgeon was that of John Hotiu, a 60-year-old Romanian immigrant who had hepatitis C and had been Imagawa's patient for four years.
His condition had been failing rapidly, and on Jan. 17, 2002, the hospital accepted a liver for him.
Hotiu became very upset, transplant staff said, when he learned that Imagawa would not be performing the operation. Hotiu had never met Cao.
The operation started that night and lasted into the morning. But Hotiu's body rejected the new organ, and he died in the intensive care unit shortly after 11 a.m.
Hoitu's sister, Silvia Bor, said she was glad that UCI had tried.
"For years, I saw him dying, every single minute, every single day," she said.
But to members of his team, Cao seemed spooked.
"He became much more cautious," said Lorrie Gibson, then a transplant coordinator.
Every transplant surgeon plays the odds.
Using a subpar liver in a very ill patient dramatically lowers the chances for survival. But holding out for a better offer is also risky, since there is no guarantee that it will come in time.
Every liver transplant candidate has a score calculated from three blood serum measurements. The higher the score, the sicker the patient and the greater the chance of receiving a liver. When an organ becomes available in the Los Angeles area, OneLegacy, the local organ procurement agency, moves down a list of the region's sickest patients until a hospital accepts it.
More and more, Cao was passing up livers.
Patients had little idea that anything was wrong. To many, the surgeon radiated confidence.
"Look at what my doctor is doing," Jorge Gomez recalls his wife, Maria, saying, as he guided her wheelchair through the hospital lobby three years ago.
On the wall was a photograph of Cao in a green surgical cap -- in honor of him performing the first liver-pancreas transplant at UCI.
Soon after joining the waiting list in 2002, Maria instructed her daughter's fiance to repair the doorbell -- just in case somebody from the hospital came while she was asleep.
Hepatitis C was destroying her liver, and Cao seemed moved by her plight.
On one occasion he appeared to be holding back tears, Jorge remembered. She had forgotten where she was because the toxins accumulating in her body were clouding her thoughts.
"We're looking for a liver, Mrs. Gomez," Jorge remembers Cao telling her during a hospital stay. "Hang on, hang on."
She slipped into a coma and died Feb. 21, 2003. She was 48.
It is unclear whether any livers were ever offered for her -- at the time, it never occurred to her family to ask.
The transplant staff had always explained that waits for livers were long because of a shortage of organ donors.
Maria Gomez's faith in the surgeon never wavered. Two days before her death, she gave her husband a message to pass on:
"Tell Dr. Cao thanks for all the help."
Outward appearances were a sharp contrast to strange battles playing out inside the liver transplant program.
Staff members had become worried that Cao was turning down too many livers. As the rumors circulated, he retreated, sometimes ignoring certain employees for days at a time.
In October 2002, transplant coordinators raised many of their concerns in a meeting with Dr. Samuel Wilson, the chairman of the surgery department, who promised improvements, according to correspondence between Wilson and the coordinators.
But there was little sign of improvement, staff members said. Tensions grew.
There was an overwhelming sense that the liver transplant program was crumbling -- and it was clear from the numbers.
Transplantation is one of the most closely monitored areas of medicine. Each donated organ is tracked, each surgery recorded, each death tallied.
Regulators pay closest attention to two statistics: the number of transplants and the percentage of patients who survive a year or more after surgery.
The hospital, which had performed 15 transplants in 2001, did just eight in 2002 and eight more in 2003.
That was far fewer than the 18 per year required by the state or the 12 mandated by the federal government -- rules aimed at ensuring that hospitals maintain expertise.
UCI had one of the lowest transplant rates in the country.
Of the scores of patients who joined the waiting list between July 1998 and June 2001, just 16.2% had received a transplant within three years. The nationwide figure was 42%.
Improving the statistics became the mission of the program, according to Gibson, the former staffer.
But with so few surgeries, a single death in the operating room could drastically skew the survival rate -- a mathematical misfortune of small transplant programs.
"It was sort of a Catch-22," Gibson said.
Cao was not taking any chances.
Former team members said he began demanding that transplants be conducted in his favorite operating room -- No. 1, the largest at UCI -- and became upset when it was not available.
Still, the survival rate did not improve.
Magdi Hanna called the transplant center almost daily to ask when a liver would become available.
It was the spring of 2003, and Hanna, a retired engineer battling liver cancer and hepatitis C, had begun to wonder whether he would survive long enough for his name to come up.
Then one day a transplant coordinator told him a transplant could be imminent, he recalled. Six livers had been offered for him recently -- and turned down, Hanna was told.
Distressed, he confronted Cao in a hospital corridor.
"I stood before him and said, 'Dr. Cao, what the hell are you doing? Do you want to kill me?' " Hanna recounted.
The surgeon told him that most of the livers were of inferior quality, Hanna said. Cao reminded Hanna, as well, of his concern about a partially clogged heart artery.
"I am afraid you will die on the operating table," Cao said, according to Hanna, then 60.
Fed up, Hanna went to UCLA, where he received a transplant in a matter of months, on Jan. 15, 2004. In February, he returned to UCI to see Cao one more time.
"I said, 'Look at me. You were concerned I would die on the table. Here I am, alive and kicking. And I feel great.' "
A few months later, the state stopped sending Medi-Cal patients to UCI for transplants, citing its failure to perform a minimum number of transplants.
Cao instructed his team to start helping the sickest patients transfer to other hospitals.
He had called at least one patient himself.
"The hospital here does not give me any help," Mark Forster recalled Cao telling him. "I'm working 24 hours a day. I haven't seen my family. Here's the deal: I'm leaving."
After Cao left in July 2004, the program survived through the summer and into this year, relying on two part-time surgeons based 90 miles away, at UC San Diego.
But the statistics did not improve, and in November, after a Times report, Medicare decided it would no longer pay for liver transplants at UCI. The program had little choice but to close.
From 2002 through 2005, 58 people died on the waiting list. It is unclear how many livers had been offered on their behalf.
While the university conducts an investigation, the hospital CEO, Dr. Ralph Cygan, has been placed on paid leave.
He said last month that UCI probably held on to Cao too long.
Now in private practice, Cao shares an office with three vascular surgeons at the Orange Coast Memorial Medical Center in Fountain Valley. His business card features a color drawing of the hepatobiliary system, and he still performs liver and pancreas surgeries.
He no longer does transplants.