Doubts about a transplant team

“Do you think this goes against God?”

Jennifer Endsley, a nurse at Sierra Vista Medical Center in San Luis Obispo, told investigators that she spoke up because she was troubled by the behavior of a visiting transplant team as they prepared to harvest the organs of a 25-year-old disabled man last year.

“I don’t think this is right,” Endsley, one of several staffers in the operating room that February night, recalled saying.

What happened in Sierra Vista’s Operating Room 3 is now the subject of an unprecedented criminal case.

San Luis Obispo County prosecutors filed three felony charges last week against San Francisco transplant surgeon Hootan Roozrokh, 33, alleging he tried to hasten the death of Ruben Navarro in order to harvest his organs.

Endsley’s statements to police, along with those of other Sierra Vista nurses and staffers, were contained in court records made public Monday. The Tribune of San Luis Obispo reported on their contents Saturday.

The documents paint a picture of disarray in the operating room, with some staffers concerned that Navarro was being mistreated and overmedicated by Roozrokh, one of two surgeons dispatched by the regional group that procures organs for much of Northern and Central California.

Nurses said the hospital had never before performed the type of organ donation attempted in this case.

For the most part, organs are not retrieved from patients until they are declared brain-dead. But that night at Sierra Vista, surgeons were attempting a different type of harvesting, known as “donation after cardiac death.”

In such situations, patients with irreversible brain damage are removed from life support. Their death is declared when their heart stops beating -- clearing the way for organ removal.

Staffers said that they believed that a Sierra Vista doctor, Laura Lubarsky, was supposed to be in charge of removing Navarro from life support and declaring that his heart had stopped.

According to state law and national standards, transplant physicians cannot direct the treatment of potential organ donors before they are declared dead.

But it was clear that Roozrokh was in charge, witnesses told police.

As time passed, some staffers recalled Roozrokh becoming increasingly anxious. Once life support was removed, Navarro’s organs would remain viable for only about 30 minutes.

Scrub technician Celeste Tracy told police that at one point Roozrokh asked Lubarsky if the patient’s heart was coming to a stop. Lubarsky said no.

“Dr. Hootan was ready to get started to harvest,” police said she told them.

Navarro’s main treating physician in the hospital, Dr. Eric Schultz, told investigators that he believed large quantities of the narcotic morphine and sedative Ativan given to Navarro were an attempt to “speed up” his death.

Schultz told police that he had written in Navarro’s chart that he would not die quickly once he was removed from life support -- which would render his organs unusable.

Indeed, Navarro remained alive for more than seven hours after being removed from life support. His organs were not viable and were never removed.

Roozrokh’s lawyer, M. Gerald Schwartzbach, said Monday he had not seen the documents and would not comment. In a statement released last week, the lawyer said his client had been “the subject of an 18-month witch hunt” and had committed no crime.

Navarro had been found unresponsive at a long-term care facility on Jan. 29, 2006, and was taken to nearby Sierra Vista, where he was put on life support and admitted to the intensive care unit.

On Feb. 1, hospital staff contacted the California Transplant Donor Network, the regional group that procures organs.

Navarro’s mother, Rosa, gave her consent to donation, although she now says she was not given complete information about his condition or what would take place.

About 11:20 p.m. on Feb. 3, the two transplant surgeons dispatched by the regional network entered the operating room with Navarro, before Lubarsky even arrived.

Endsley said that at one point, when she asked why the surgeons were in the operating room, she was “stared at and ignored,” according to her interview summary.

Around midnight, after Lubarsky arrived, respiratory therapist Mark Winekoff said Roozrokh instructed him to remove the breathing tube. Winekoff told police he “looked at Dr. Lubarsky and without saying anything, Dr. Lubarsky motioned to [him] to go ahead and remove the tube.”

Minutes later, Roozrokh asked nurse Diana Dean Stevens, “Do you have the stuff to give him?” according to a police report. Stevens then gave Navarro medication, witnesses said.

About 20 minutes after life support was removed, Roozrokh “was heard to say they needed more ‘candy’ ” and placed an order for another 100 milligrams of morphine and 40 milligrams of Ativan -- the same doses that had been given to Navarro earlier, the police report said.

Nurse Susan McDougall said she had to hunt around the hospital to find enough morphine and Ativan to fill the second order. She told investigators she was “very uncomfortable with the amount of medication she had,” according to police records.

When Navarro didn’t die, Roozrokh began making outside calls to ask for advice, the hospital staffers recalled.

Tracy told investigators that once Navarro “was no longer of any use to the harvest team, they disregarded him and disappeared.”

At that point, Endsley told police, Navarro was “frothing from the mouth and shivering.”

Navarro was brought back to the intensive care unit, where he died at about 8 a.m. on Feb. 4.

Lubarsky’s attorney, Mark Connely, defended his client, saying that by the time she arrived, the transplant team already appeared to be in charge.

He said Lubarsky never had participated in an organ retrieval process of this sort, but Roozrokh, who had been involved with one before, should have known better.

“What the hell is he doing?” Connely said.

“Not only should he not have been in the room, there’s nothing about their protocol that suggests he should be anywhere near this kid.”

Connely said Lubarsky’s conduct was reviewed by the Medical Board and she was cleared of any wrongdoing last year. Roozrokh’s conduct is still under review, medical board spokeswoman Candis Cohen said.

Schwartzbach, Roozrokh’s lawyer, said in his statement last week that nothing his client did hastened the death of Navarro.

The surgeon turned himself in to authorities last week and is free on $10,000 bond. He is set to be arraigned next week.

In the wake of the incident, the United Network for Organ Sharing, which oversees the national transplant system, reprimanded the California Transplant Donor Network for its handling of the case.

Kevin Chaffin, a lawyer for Navarro’s mother, said the documents clearly show that what happened in the operating room was “so horrifying and gruesome” that he does not want to show them to his client.

charles.ornstein@latimes.com

tracy.weber@latimes.com