Surgical Roulette – Times Publications, January 2008

Alone and soaking wet, Jeanann Schwark awakes in an operating room. It’s dark. As her eyes begin adjusting to the darkness, she sees a clock on the wall. It’s 9:45 p.m.

More than 12 hours earlier, Schwark had laid on the operating table at this Anthem clinic for a liposuction session on her stomach and waist, something she hoped would help her look better in a swimsuit for an upcoming Hawaiian vacation to celebrate her 45th birthday.

It was supposed to be a simple operation. The charismatic, blue-eyed doctor performing the procedure told her she would remain conscious throughout the session. The magazine advertisement that attracted her to the clinic said she could “return to work the next day.”

Following the surgery, a medical assistant wrapped her in bandages and helped her dress. “Lie down on the operating table and relax,” he told her.

The last thing Schwark remembers is the assistant injecting her with what was purported to be a painkiller.

Now after nearly nine hours, disoriented and confused, Schwark stumbles off the operating table and into the front office where she encounters an elderly woman sitting at the reception desk, busy doing paperwork.

After giving Schwark a strange look, the woman asks in a thick German accent, “Are you okay? Do you want me to call the doctor?”

Schwark, now fearful of the doctor who left her alone and unconscious for hours, says she is fine and struggles desperately to regain her senses.

Before she can gather herself, she is overtaken by nausea and begins vomiting. The elderly lady helps steer her into a nearby bathroom.

Horror fills Schwark’s eyes as she looks into the bathroom mirror and realizes the dampness she has been feeling is from her own blood. “I thought, ‘What’s happened to me? What is happening to me?’” she says. “I was scared, but in a way I’ve never been scared before.”

Months after the hellish experience, Schwark is left with deep scars on her back and sides, but says she is grateful to be alive.

Later, Schwark says she became even more aware of how lucky she was after seeing news reports featuring the same charismatic, blue-eyed doctor, Peter Normann, and learning that three patients had died in his office during liposuction procedures in a period of less than seven months.

“I feel extremely lucky,” she says, more than a year after her surgery. “I lived to tell about it.”

On October 10 of last year, three months after a third patient died while in his care, Peter Normann’s license and privilege to practice medicine was revoked. An investigation revealed he had used untrained, unqualified medical assistants, dispensed narcotic medications without a license and had left patients unmonitored and unsupervised while they were sedated.

In the administrative hearing that resulted in the ruling, former staff members described his practice as a “surgical nightmare.”

While the cosmetic horror stories described by the patients of Peter Normann represent some of the most egregious in the state’s history, research shows they are part of a larger and growing danger of ill-equipped and inadequately trained plastic surgeons performing invasive cosmetic procedures.

Normann, an emergency room and internal medical physician, was never certified as a plastic surgeon. In other cases, some Valley physicians certified to practice as gynecologists or even ear, nose and throat doctors have been found to be practicing cosmetic surgery, many with little more experience than a weekend training course.

The results are patients being left scarred, disfigured, and in three of Peter Normann’s cases, dead.

PETER J. NORMANN, COSMETIC SURGEON

Before moving to Arizona in 2004, Peter Normann, 46, had an unblemished career as an internal and emergency room physician.

In 1994, he graduated from St. George’s University, a small medical school in the Caribbean Islands. After completing a three-year residency at a hospital in Rhode Island, he began practicing in New York.

During that time, he met Sandra, a pediatrician and native of Germany. The two later married and had four children.

In March 2004, the family purchased a spacious home in an upscale community in Anthem. According to friends and neighbors, they appeared to be the picture of success.

But sometime between 2004 and 2006, something changed for Normann. He quit his practice of internal medicine and moved into the more lucrative and growing field of cosmetic surgery.

Rather than become certified as a plastic surgeon, according to unsealed exhibits from the Arizona Medical Board, Normann learned about liposuction procedures at a course consisting of seven sessions. Despite the minimal amount of experience, Normann was able to begin practicing cosmetic surgery, and he did so without bothering to purchase malpractice insurance.

Normann rented a modest office in the Anthem area and called it the Normann Medical Center. He began running magazine ads claiming he was “cost competitive” and put up a website falsely listing himself as a member of at least two professional cosmetic surgery organizations. His efforts quickly began attracting cost-conscious patients, and his practice grew.

Out of an operating room in the back of the office, Normann performed a variety of elective procedures, including hair restoration, breast implants, liposuction, tummy tucks and fat injections. While several patients complained of botched results, research shows Normann was often able to satisfy them with significant discounts on future procedures.

UNWITTING VICTIM

In March 2006, Phoenix resident Ralph Gonzalez had his first appointment at Normann’s office. A 33-year-old owner of a Valley electrical engineering business, Gonzales had met Normann while doing some electrical work for him.

Gonzalez made an appointment with Normann for a consultation on liposuction for fat on his stomach and waist.

On May 16, Normann performed liposuction on Gonzalez, and though he experienced significant pain during the procedure, Gonzalez’s recovery went well.

Seven months later, Gonzalez returned for a repeat liposuction on those same areas.

Thirty-five minutes into the procedure, Gonzalez stopped breathing. A member of Normann’s staff called 911, and an emergency medical technician arrived to find Normann attempting to revive Gonzalez. According to the medical report, his heart wasn’t beating and his chest was “severely distended.” Normann inserted a tube into Gonzalez’s throat in an attempt to re-establish breathing and insisted on riding with him to the hospital.

In the ambulance, the emergency medical technician told Normann he couldn’t hear breathing sounds, but Normann persisted, saying, “the tube was good.”

When Gonzalez arrived at the hospital, he had no pulse. His pupils were dilated; his skin was blue and blotchy. Hospital staff discovered the breathing tube was placed incorrectly and reinserted it. But it was too late. Gonzalez was dead.

The Medical Examiner ruled Gonzalez’s death was a result of an adverse reaction to medication. No charges were filed against Normann, and no complaints were filed with the medical board.

On the following day, it was business as usual at the Normann Medical Center.

GROWING DANGER

There were nearly 11 million cosmetic procedures performed in the United States last year, 48 percent more than in 2000, according to the American Society of Plastic Surgeons.

Growing with the demand is an influx of opportunistic doctors, not certified as plastic surgeons, aiming to cash in on this lucrative business, says Steven Miller, vice president of the American Board of Plastic Surgery.

“It’s a growing problem,” he said in a recent Times interview.

Any person who is licensed to practice medicine in the state of Arizona can legally perform any type of cosmetic procedure without specific training or certification. No state licenses medical specialties.

According to Miller, board certification provides one level of assurance that a doctor is trained and skilled in their specialty.

To be certified, a doctor must graduate from an accredited medical school, complete a combination of at least five years residency in general and plastic surgery and pass both written and oral exams.

One in every 51,459 cosmetic procedures ends in death, according to a 2004 study by the American Society of Plastic Surgeons.

Improper surgical training is contributing to the increased risk of patient harm, according to Miller.

In the past year, the Arizona Medical Board has taken action against three doctors, all practicing cosmetic surgery but not board certified in this area.

These include a doctor of internal medicine who was performing liposuction procedures and a gynecologist who conducted aesthetic facial treatments, including Botox injections and laser procedures.

During research for this story, one Valley doctor, Paul Blumberg, an ear, nose and throat physician who has been performing facial plastic surgery and breast implants for over a decade, had what appeared to be an inordinate number of infractions.

Over the course of his career, Dr. Blumberg has been sued 15 times for malpractice, and in the most recent board action against him, six former patients alleged various problems, from unnecessary scarring after a tummy tuck to a woman who, according to court records, says she nearly died of a massive infection following a breast implant procedure.

“He has an unusually high infection rate,” says Chris Zachar, an attorney representing five malpractice suits against Blumberg. “And he seems to make the same mistakes over and over.”

Like Normann, Zachar says, Blumberg also carries no malpractice insurance.

In October, the Arizona Board of Osteopathic Medical Examiners suspended Blumberg’s license for a period of six months, after finding his actions had caused harm and endangered patient health.

Calls to Blumberg’s office were not returned.

LOSING MOM

On the morning of April 25, Alicia Santizo kissed her 13-year-old daughter goodbye and went to work at her job as a hotel maid. That night, on the operating table of Normann’s Anthem office, her heart stopped.

Alicia Santizo was a 41-year-old single mother who had raised three kids in Guatemala before moving to Gilbert three years ago.

“She was such a hard worker. A lot of times she worked two jobs,” says her son Fray Santizo, 26. “She provided a good life for her children.”

Somehow Alicia Santizo scraped together enough cash to treat herself to some cosmetic procedures.

On her first visit to Normann’s office in September 2006, she met with Joey Lopez, a licensed massage therapist employed by Normann. Lopez had no medical training, but during Alicia Santizo’s consultation he presented her with a business card that read, “Joey Lopez, Cosmetic Surgery.” He would later be present and assist during Santizo’s cosmetic procedures.

Over the next several months, Alicia Santizo saw Normann for two liposuctions and breast implants.

After the third procedure, Alicia’s family says she told them she was mistreated by Normann’s medical staff. Fray Santizo says his mother complained of sexual and demeaning slurs and that they had sprayed water in her face.

Alicia Santizo complained to Normann, and he offered to discount her next procedure.

On April 25, Alicia went in for a liposuction procedure on her hips and a fat injection on her buttocks, her fourth procedure in seven months.

Twenty-five minutes into the surgery, she stopped breathing and went into cardiac arrest. Normann attempted to resuscitate her.

Minutes later, Normann’s staff called 911, and an ambulance took her to John C. Lincoln hospital, where she died at around 6 p.m.

Coincidentally, the same emergency medical technician who was on call when Gonzalez had stopped breathing also arrived on the scene of the Alicia Santizo call. The technician reported Normann to the Arizona Medical Board, which later resulted in the revocation of Normann’s license.

The following day, Fray Santizo went to Normann’s office to confront him and to collect his mother’s paperwork. Six patients were seated in the waiting room.

Fray says he waited patiently for two hours, while the doctor saw each patient. Once the waiting room cleared, Normann finally spoke to Fray.

“I asked him, ‘Did you know what you were doing?’” Fray says. “He had no words. He just said he was sorry.”

After his mother’s death, Fray Santizo left his home in California to raise his teenage sister, Lala. Currently residing in Gilbert, he works over 60 hours a week to support her.

DISREGARDING THE RULES

Eight days after Alicia Santizo’s death, Normann signed an agreement with the medical board promising not to perform procedures until the investigation was complete. Shortly afterward, Normann made a deal with Gary Page, 42, a homeopathic physician with a questionable past.

Page was to perform cosmetic procedures in Normann’s office and give Normann a cut of the profits.

In Arizona, homeopathic physicians are not permitted to perform major surgeries like liposuction. No stranger to breaking the rules, Page disregarded the policy.

According to court records, in 1993, while attending Brigham Young University, Page was arrested for using a fraudulent credit card and placed on probation.

Later, while working as a cosmetic surgeon in Utah, he was investigated by the Drug Enforcement Administration for prescribing medicine over the Internet, an illegal practice in every state. Page voluntarily surrendered his license for a period of one year for the violation.

After leaving Utah, Page tried to apply for medical licenses in Nevada and Arizona. His applications were denied due to his past suspension in Utah.

In July 2005, Page applied and received an Arizona homeopathic license, and began practicing in Gilbert.

For the month and a half Page worked for Normann, he performed procedures on at least nine patients, according to unsealed exhibits from the Arizona Medical Board. The last of those procedures resulted in the death of a 53-year-old woman.

According to medical records, the woman, who has not been publicly identified, saw Page on July 3, for liposuction on her thighs. The procedure was completed at 5:50 p.m. At 7 p.m., she woke up vomiting. Ten minutes later, Page left the unconscious woman in Normann’s care.

At 10 p.m., the woman remained unconscious. Normann checked and discovered she wasn’t breathing. He called 911, and the ambulance took her to the hospital, where she later died.

After her death, Page’s license was suspended. He is currently awaiting a hearing with the Arizona Board of Homeopathic Medical Examiners on his future as a homeopathic physician.

DOCTOR’S DISAPPEARANCE

Today all that remains of the Normann Medical Center are boxes packed with abandoned items and paperwork strewn about the waiting room. The home where Normann lived with his wife and four children is vacant with a lock box on the front door.

Neighbors say moving trucks came in the middle of the night, shortly after the media first reported the story.

Norman’s whereabouts remain unknown. The day his license was revoked, he did not appear at the hearing, and several legal notices have been returned undeliverable.

One neighbor says Normann has returned several times in the past few months to remove paperwork from his home, the last time in mid-November. Others say they suspect he’s fled to Germany, his wife’s native country.

The Maricopa County Sheriff’s Office is currently investigating the case to determine whether Normann will face criminal prosecution.

The families of both Ralph Gonzalez and Alicia Santizo have filed malpractice suits against both Normann and Lopez, but with no malpractice insurance and little equity in Normann’s Anthem residence, it is unlikely the families will ever be compensated.

Kevin Keenan, a Tempe attorney representing the Santizo family, says this is one of the most exceptional cosmetic surgery malpractice cases he’s ever represented.

“You’re not supposed to be dying from something like this. It’s not supposed to happen,” he says. “There have been only three deaths I know of, but I think there are a lot of people who have been hurt by him.”

PREYING ON IMMIGRANTS

In Arizona, some unskilled cosmetic surgeons are growing their practices by performing procedures on immigrants, says Dr. Mwata Dyson, a Phoenix anesthesiologist.

Working in the emergency room, Dyson says he’s personally seen cases of immigrant patients who have nearly died from shoddy cosmetic procedures.

It is a common occurrence in cities with large immigrant populations, like Florida and California, where strong community networks easily circulate the names of practitioners catering to the immigrant population.

“If they’re here illegally, they don’t have any insurance coverage. They don’t want to risk being deported, but yet they still want to live the American lifestyle,” Dyson says. “So they’re going to these unqualified doctors who offer cheaper prices and don’t ask questions.”

Brochures and literature in Normann’s office were predominately written in Spanish, a former patient of Normann’s told The Times. And at least three patients who came forward following Normann’s suspension spoke no English.

RECOVERY AND REGRET

Following Jeanann Schwark’s nightmarish experience in Normann’s operating room, she made it across the street to a hotel, where she spent the night. Her wounds later became severely infected.

Ten days after her procedure, she returned to Normann’s office to confront the doctor.

“I got into the room and I said, ‘I need to know what happened to me,’” Schwark says.

Normann blamed her prolonged unconsciousness on an extreme reaction to the medication.

Schwark decided not to return to Normann and found another doctor to treat her infected wounds.

Looking back, Schwark, a nurse practitioner, says she should have known better. But Normann convinced her she would be in good hands, and though she did review his medical practice history, his record was clean at the time.

Schwark says she always intended to file a complaint with the medical board against Normann, but time passed and the memory of her horrifying experience faded. That is, until the day she turned on the news and saw Normann’s picture.

Schwark says her heart sank when she heard the stories of the victims and learned how closely their stories paralleled hers.

“I have tremendous regret. I don’t regret for my own self. I feel blessed to be alive and well. But I feel very regretful that I didn’t complain,” she says. “People lost their lives. My heart is broken for them.”

Following the deaths at Peter Normann’s office, the Arizona Medical Board released a guide for choosing a cosmetic or plastic surgeon. That guide can be found at www.azmd.gov under the consumer section.