Duntsch joined Baylor Regional Medical Center at Plano (now Baylor Scott & White Medical Center – Plano) as a minimally invasive spine surgeon with a salary of $600,000 per year, plus bonuses.
Baylor Plano
Early in his tenure at Baylor Plano, Duntsch made a poor impression on his fellow surgeons. Veteran vascular surgeon Randall Kirby recalled that Duntsch's skills in the operating room left much to be desired: as Kirby put it, "he could not wield a scalpel".
Several of Duntsch's surgeries at Baylor Plano resulted in severely maimed patients:
- Lee Passmore, a Collin County medical investigator, experienced chronic pain and limited mobility after Duntsch cut a ligament which was not normally touched during that particular procedure, misplaced hardware in his spine, placed a screw which kept the hardware in place in an incorrect location in his spine and also stripped the screw's threads so it could not be moved. Vascular surgeon Mark Hoyle, who assisted with the operation, became so disturbed by Duntsch's actions that at one point he physically restrained him.
- Barry Mongoloff, the owner of a pool service company, was left with bone fragments in his spinal canal after Duntsch tried to pull a damaged disc out of his back with a grabbing tool. Mongoloff eventually lost most of the function on his left side and required a wheelchair.
- Jerry Summers, a longtime friend of Duntsch's, came to Plano to have two neck vertebrae fused. During the operation, Duntsch removed large amounts of muscle tissue, rendering Summers a quadriplegic. Summers later claimed that he and Duntsch had used cocaine the night before his surgery. Despite passing a drug test, Duntsch was asked by Baylor Plano officials after Summers' operation to limit himself to minor surgeries. Summers remained a quadriplegic for the rest of his life; he died of an infection related to complications from the botched operation in 2021.
- During his next surgery, Duntsch severed a major artery in patient Kelli Martin's spine during a minor back operation. Duntsch continued operating despite clear signs, and the warning of a trauma surgeon colleague, that Martin was losing massive amounts of blood. Martin ultimately bled to death.
Baylor Plano officials found that Duntsch failed to meet their standards of care, and he resigned rather than face certain termination. Had Duntsch been fired, Baylor Plano would have been required to report him to the National Practitioner Data Bank (NPDB), which is intended to flag problematic doctors.
Dallas Medical Center
Duntsch moved to Dallas Medical Center in Farmers Branch, where he was granted temporary privileges until hospital officials could obtain his records from Baylor Plano. However, red flags surfaced early on, as nurses wondered if Duntsch was under the influence while on duty. He lasted for less than a week before administrators pulled his privileges after the death of a patient, Floella Brown, and the maiming of another, Mary Efurd.
Duntsch had severed Brown's vertebral artery, then packed it with too much of a substance intended to stop the bleeding. She suffered a stroke as a result. Duntsch did not respond to messages from the hospital for a few hours, then the next day postponed caring for Brown to perform an elective surgery on Efurd. Hospital officials were exasperated while Duntsch was in Efurd's surgery, and asked him multiple times to care for Brown or transfer her out of his care. Duntsch suggested drilling a hole in Brown's head to relieve the pressure, but was refused permission as he was not qualified for and held no privileges to perform brain surgery, and the hospital did not have the proper equipment or personnel for such an operation. Brown was left in a coma for hours before Duntsch finally acquiesed to her transfer. Brown ultimately died.
While operating on Efurd, Duntsch severed one of her nerve roots during spinal fusion surgery while operating on the wrong portion of her back, twisted a screw into another nerve, left screw holes on the opposite side of her spine, and left surgical hardware in her soft muscle tissue so loose that it moved when touched. Efurd was left paralyzed. She later recalled waking up feeling "excruciating pain", a "ten-plus" on a scale of 1 to 10. Several people who were in the operating room for Efurd's surgery suspected that Duntsch might have been intoxicated, recalling that his pupils were dilated.
Longtime spine surgeon Robert Henderson performed the salvage surgery on Efurd, and likened Duntsch's work on her to a child playing with tinker toys or an erector set. Henderson later recalled that he wondered if Duntsch was an impostor, as he could not believe that a real surgeon would botch Efurd's surgery so badly. He felt that anyone with a basic knowledge of human anatomy would know that he was operating in the wrong area of Efurd's back. Henderson sent Duntsch's picture to the University of Tennessee to determine whether he had actually graduated from the institution, and received confirmation that Duntsch in fact had a medical degree from the university.
Despite both of his surgeries at Dallas Medical Center going catastrophically awry, hospital officials were not required to report him to the NPDB. At the time, hospitals were not required to report doctors who only had temporary privileges.
Other hospitals
After leaving Dallas Medical Center, Duntsch received a job at an outpatient clinic named Legacy Surgery Center (now Frisco Ambulatory Surgery Center) in Frisco. While there, he damaged patient Philip Mayfield's spinal cord whilst drilling into it, leaving him temporarily paralyzed from the neck down. Mayfield was left with permanent damage in one of his legs and frequently suffered "blinding" headaches along with severe nerve pain. He died on February 21, 2021, of COVID-19. While operating on Jacqueline Troy, Duntsch cut all but one of her vocal cords and one of her arteries and poked holes through her trachea. Troy was left barely able to speak above a whisper, had to be sedated for weeks, and had to be fed through a feeding tube for some time as food was getting into her lungs.
When Duntsch applied for a job at Methodist Hospital in Dallas, the hospital reported him to the NPDB. Even after this report, Duntsch was hired by University General Hospital in Dallas in the spring of 2013. Soon afterward, he severely maimed Jeff Glidewell after mistaking part of his neck muscle for a tumor during a routine cervical fusion, severing one of his vocal cords, cutting a hole in his esophagus, slicing an artery and leaving a surgical sponge embedded in his throat. Vascular surgeon Randall Kirby was rushed in to repair the damage, and later described what he found after opening Glidewell back up as the work of a "crazed maniac". He later told Glidewell that it was clear Duntsch had tried to kill him. Glidewell was left with only one vocal cord and was partially paralyzed on his left side. Kirby claimed that it looked as if Duntsch had tried to decapitate him. As of 2018, Glidewell was reportedly still suffering the effects of Duntsch's botched operation and was only able to eat small bites of food at a time. He proved to be Duntsch's last surgery.
Medical license revoked
Kirby wrote a detailed complaint to the Texas Medical Board, calling Duntsch a "sociopath" who was "a clear and present danger to the citizens of Texas." Under heavy lobbying from Kirby and Henderson, the Texas Medical Board suspended Duntsch's license on June 26, 2013. The lead investigator on the case later revealed that she wanted Duntsch's license suspended while the ten-month probe was underway, but board attorneys were not willing to go along. Board chairman Irwin Zeitzler later said that complications in neurosurgery were more common than most laymen believe, and it took until June 2013 to find the "pattern of patient injury" required to justify suspending Duntsch's license. He added that many board members found it hard to believe that a trained surgeon could be as incompetent as Duntsch appeared.
The board called in veteran neurosurgeon Martin Lazar to review the case. Lazar was scathingly critical of Duntsch's work. For instance, he upbraided him for missing the signs that Martin was bleeding out, saying that, "You can't not know [that] and be a neurosurgeon." The Texas Medical Board revoked Duntsch's license on December 6, 2013.
