Death of Patient at 44 After Surgery Raises Questions

When Karen Halmhofer dropped off her husband, Rudy Ruiz, at an Oxnard hospital one weekend in March, she thought he would be back home in a day or two.

“You wouldn’t believe how completely casual it was,” she said. “I went out with friends, and I told them, ‘Oh, yeah, he’ll be home Monday.’ ”

But Rudolf Anthony Ruiz, a sweet-tempered Ventura musician and concert promoter, never really came home again.

He died 17 days later, on March 30, a day after his 44th birthday, of a gangrenous infection caused by complications from what seemed to be a routine hernia operation.

Ruiz’s death at an early age was tragic enough. But what frustrates and angers his wife is that he was discharged briefly from the hospital by his HMO-contract doctor just two days before his surgery and only 12 days before he died.

“Why was he let out of the hospital in the first place?” Halmhofer, 39, asks. “In the hospital, my husband says this, and he says that, and they don’t listen to him. He just falls through the cracks.

“Why was I allowed to pick him up? There should have been bells and whistles that told them not to let him go. But I only spoke to a discharge nurse. She said, ‘Sign here.’ And I signed the discharge papers, and then I was in the truck driving him away. It’s a nightmare.”

Word of Ruiz’s death spread rapidly through the local medical community as an HMO cautionary tale. HMOs encourage shorter hospital stays, arguing that such costly care has traditionally been overused.

Dr. Robert A. Reed, medical director at Cottage hospitals in Santa Barbara, said he heard about the Ruiz case in early April, within days of the death, when it was mentioned at a staff meeting.

“It was a utilization review,” Reed said. “And word had gotten out about this case. There’s a grapevine when these bad things occur that is pretty rapid. We’re always concerned about [hospital] readmissions within 30 days.”

Administrators at the Buenaventura Medical Group, which oversaw Ruiz’s care, have promised a complete internal inquiry after queries from The Times.

“I think this case raises enough questions to warrant a more thorough investigation, and we will do it,” said Dr. John Keats, medical director at Buenaventura, after reviewing hospital records and speaking with Ruiz’s primary doctor. “I still have questions, too.”

Keats said he is particularly troubled by news that one of Ruiz’s doctors--an out-of-office kidney specialist--opposed the discharge, thinking the patient’s condition was unstable.

Ruiz had a basic HMO insurance plan. His care was managed by Buenaventura, where a part of doctors’ salaries is based on how much they spend on hospitalization each year.

But Keats said that financial considerations never entered the picture.

“To prematurely discharge patients is false economy,” he said. “Invariably you end up spending more taking care of sicker patients than if you had taken care of them at the first opportunity. We go to great lengths trying to have our physicians understand that.”

And despite lingering questions about Ruiz’s care, Keats said, there were good reasons to send the patient home.

Although only two days separated the hospital discharge and the hernia operation, the illnesses that put Ruiz in the hospital in the first place--a failed kidney and a urinary infection--were apparently not related to his hernia operation, Keats said.

In addition, the two doctors most involved in treating Ruiz agreed he should be discharged, Keats said, and Ruiz was eager to go home.

Ruiz’s primary physician, Dr. Ernest Pillado, discharged the patient from St. John’s Regional Medical Center on March 18 because he seemed to have recovered from the urinary infection that had made him feverish and kept him hospitalized for five days, Keats said.

Doctors had also inserted a shunt into Ruiz’s arm to allow him to receive dialysis for his failed kidney, which had been diagnosed a month earlier. And Ruiz reported none of the abdominal pain and nausea that were two symptoms of his hernia two days later, Keats said.

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“In the opinion of the physician caring for him, he was well,” Keats said. “There was nothing to indicate that Mr. Ruiz--at the time of his discharge--had the condition that he developed over two days after his release.”

A surgeon’s note on March 20, the day of the hernia operation at Ventura’s Community Memorial Hospital, indicates that Ruiz told the doctor the swelling in his groin developed over “the last couple of days,” Keats said.

In fact, Ruiz’s white blood cell count the same day was normal, indicating that he was not yet infected, Keats said.

“I’m certainly sympathetic to his wife’s perspective--that this was going on and someone should have known about it,” Keats said. “But it was a different problem.”

Still, after a review of hospital records, Keats acknowledged that Dr. Aron Swerdlin, who specializes in kidney problems, opposed Ruiz’s discharge and ordered nurses to inform Pillado of his position.

“In Dr. Swerdlin’s opinion, the patient shouldn’t have been discharged because of a fever and the need for continued daily hemodialysis,” Keats said. Swerdlin’s examination was at 11:30 a.m. March 18, just a few hours before the discharge.

But when Pillado double-checked that afternoon, he found that Ruiz had experienced no fever for at least 24 hours, Keats said. Then Pillado spoke with Swerdlin’s partner, Dr. John Stevenson, who during his own rounds early that morning had found Ruiz suitable for release and in need of dialysis only three times a week, Keats said.

“So he called Dr. Stevenson and said, ‘Gee, have you changed your opinion? Are you still OK with the patient being discharged?’ And he told Dr. Pillado that he was.”

Why hadn’t Pillado called Swerdlin, the nephrologist on duty that day and the one who had seen Ruiz most recently?

Keats said Pillado cleared the discharge with Stevenson because Stevenson had taken care of Ruiz during hospitalization and was the patient’s primary kidney specialist.

Swerdlin and Stevenson declined comment on the case.

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Although the cause of Ruiz’s death is listed as blood poisoning caused by overwhelming infection around the repaired hernia, Keats said Ruiz’s collapse was influenced by his kidney failure.

The death certificate lists renal failure as a contributing factor in the death.

Ruiz was kept in the hospital for several days after the hernia operation because doctors thought his kidney condition put him at much greater risk of infection, Keats said. And widespread infection--not just at the point of the surgeon’s incision--was detected four or five days after the surgery.

“Patients with renal failure are compromised,” Keats said. “They do not fight infection in the usual way. If he did not have renal disease, it is unlikely that he would have had the rapid downhill course that he had.”

To friends of Rudy Ruiz, his tragic case is not so much a lesson on medical care as a sad warning of how quickly a community can lose a fine man.

Ruiz was well-known locally as the coordinator of concerts at the California Strawberry Festival in Oxnard, Ventura’s California Beach Party and other big shows around the state--including last summer’s Los Angeles Salsa Music Festival.

An Oxnard native, he performed with several local jazz, blues and rock bands over the years. He was also a former president of American Federation of Musicians Local 1581, and consistently helped colleagues find work, friends said.

“Rudy was one of the greatest guys that you’d ever want to know,” said Todd Terres, a strawberry festival executive board member. “I never saw him mad, and I never heard him say anything bad about anybody. And you can’t say that about many people.”

Terres said Ruiz was in such bad medical shape a couple of months before his death that he could not recognize all the people in a room for a meeting. His kidney failure was diagnosed about that time.

“But he got better, and nobody expected him to die as long as he was on dialysis,” Terres said.

Least of all his wife.

Karen and Rudy were optimistic about his chances, she said.

“Our whole life was rotating around a kidney transplant,” she said. “But we didn’t even get to find out if I could be a donor.”