Cary Spivak

Milwaukee Journal Sentinel

In a new HBO documentary, a retired surgeon blasts Aurora West Allis Medical Center for "plain goddamn sloppy medicine" in its care for one of his patients.

Those comments were secretly recorded seven years ago by the documentarian, but on Monday evening Mark Bauer, who retired in 2015, stood behind his comments in an interview with the Journal Sentinel, criticizing the hospital's practice of monitoring intensive care patients with doctors and nurses who are not on site.

"That really isn’t appropriate," Bauer told the Journal Sentinel. "That’s just not good medicine."

Bauer's initial comments came in a 2011 conversation with Steve Burrows, a Greendale native and Hollywood director whose mother suffered brain damage and physical injuries following a routine hip surgery by Bauer. His mother's case is the basis for "Bleed Out," a 90-minute documentary that began airing Monday.

Bauer performed two relatively routine hip surgeries in 2009 on Judith Burrows, who was 69 at the time.

The aftermath of the second surgery, which included Burrows going into a coma for nearly two weeks, sparked a painful and frustrating journey through the medical and legal systems for the Burrows family.

In addition to the brain damage, the retired but active teacher was unable to walk without assistance and incapable of living on her own after the surgery, according to her son and court records.

“I didn’t know if my mom was going to survive," said Burrows, a comic actor turned director. ”When she came out of that coma nothing was the same."

Documenting his mother's case

Burrows said in an interview that he began recording his mother to document her case for possible litigation but that effort eventually grew into a full documentary. The documentary includes numerous conversations that were secretly recorded using a spy pen.

"It was just personal. I was trying to take care of my mother and trying to get her accountability," Burrows said. "I kind of got obsessed with it."

Burrows said he was intrigued when he learned about statistics showing that medical errors were the third leading cause of death in the U.S. and that patients who bring medical malpractice suits to trial lose nine out of 10 cases.

When Bauer met with Burrows in a Panera restaurant, the physician did not know that a cameraman in a nearby booth was secretly recording his conversation using a spy pen.

Aurora's eICU system

During the recorded conversation, Bauer blasts Aurora for using the eICU system, in which a doctor in an office near Mitchell International Airport monitors up to about 150 patients in various intensive care units.

"You know, that's just not intensive care," Bauer told Burrows. "She didn't get any care."

Mary Beth Kingston, the chief nursing officer for Advocate Aurora Health, defended the eICU system in an interview with the Journal Sentinel Tuesday. Forms of that system are used today in 24 Advocate Aurora hospitals in Wisconsin and Illinois that have intensive care units.

Aurora and the Advocate Health Care systems merged earlier this year.

"The eICU is an additive layer … it is not there to replace other people," Kingston said. "It improves outcomes for our patients … we've got many examples of that."

The off-site nurses and doctors "are receiving vital signs that would alert them when something is happening," she said, explaining that on-site staff could then react. There are also cameras that allow the off-site doctor to view the patient, though Burrows said it appears the cameras in his mother's room were not turned on that night.

Burrows also noted that neither the off-site doctor nor nurses contacted the nurse in the ICU about his mother's vital signs. Rather, he said, records show the on-site nurse contacted the eICU staff when his mother's blood pressure fell to a dangerously low level.

Kingston declined to speak specifically about Bauer's case, except to twice note that the hospital and caregivers prevailed in the medical malpractice suit Burrows filed.

'I'd like an accounting'

When Burrows asked the physician what he would do if he was in Burrows' situation, Bauer responded, "I'd like an accounting, just like you, for why in the hell no doctor was there. Their intensive care unit is where this problem occurred."

In his interview Monday with the Journal Sentinel, Bauer said that after doing a six-hour surgery, he asked for a physician to be on the ICU floor and checking in on Judith Burrows. He said he was upset when he learned later there was no doctor in the unit that evening.

"I expected someone to be there," said Bauer, who retired in 2015 and said he was not critiquing the practices in place at the health care company today. "The only person who was there was a nurse, a young nurse."

Judith Burrows was on the blood thinner Plavix when she went into the surgery and "she was bleeding heavily" during the surgery, Bauer said. "It was a very difficult operation."

Steve Burrows said his mother lost about half her blood during the surgery. Her systolic blood pressure — the top number on a blood pressure reading — dropped below50 during the night after surgery, but she was not seen in person by a physicianduring the night, Burrows said.

"That is a really low blood pressure," said Michael End, Burrows' attorney. "She was a suffering a brain injury, which was very evident the next morning."

Burrows said he made the documentary because he knew many families had gone through similar complicated situations involving doctors and lawyers

Throughout the documentary and in interviews, he complained about the lack of information he received from the hospital and medical providers.

"I'm just a comedy guy in L.A.," said Burrows, best known for writing, directing and starring in the 2000 comedy "Chump Change." "It just didn’t make any sense to me."

To this day, Burrows said: "I still don’t know who was in charge of my mom's care,"

Aurora message to employees

In a message sent to employees Friday in anticipation of the broadcasting of "Bleed Out," Jim Skogsbergh and Nick Turkal, the co-presidents and CEOs of Advocate Aurora Health, said: "Patient safety is our top priority. While the court found no malpractice in this 2009 case, we deeply regret this negative patient outcome can't be reversed and we are committed to learning from it."

The CEOs also noted that "our hearts go out to the patient and their family for what they've endured and for having to contend with the complexities of the national health care delivery system."

The family's courthouse ordeal was just as frustrating as the medical ordeal.

The first attorney they planned on using to file a medical malpractice lawsuit opted out because he stopped handling medical malpractice cases.

"There are just so many hurdles in those cases," said Lynn Laufenberg, the attorney.

Malpractice plaintiffs rarely prevail

The Journal Sentinel in 2014 reported on the hurdles faced by patients who bring medical malpractice cases. Nine out of 10 cases that go to trial are won by the defense. In Wisconsin, the medical community is backed by a nearly $1.4 billion state-managed insurance fund that helps provide an aggressive defense against lawsuits.

In addition, state law caps noneconomic damages, such as pain and suffering, at $750,000, a cap that lowers potential payments to lawyers and their clients.

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Plaintiffs' attorneys frequently pay the upfront costs of bringing a suit, funds that are generally not recouped if the case is lost. In most cases, the plaintiff lawyers are paid a percentage of the winnings in a malpractice suit but receive nothing if they lose.

The Burrows family paid about $100,000 of the expenses, Steve Burrows said. Their attorney, End, said he put in at least 700 hours of work on the case and that the firm also paid some of the expenses.

Following a six-day trial in June 2016, the jury concluded there was no negligence by the hospital or medical professionals who were sued.

End said the case may have been lost because of the complexity of the medical testimony.

"We may have lost the case because the numbers shown in the records are alarming numbers to a physician, but not necessarily so to a lay juror," End said in an email.

The verdict came just one hour and 12 minutes after the jury began deliberations, court records show.

"My heart sank" when he was told the jury had returned so quickly, Steve Burrows said. "It's depressing to think that after all these years they wouldn't take a little bit more time to maybe hash it out."

Journal Sentinel reporter James B. Nelson contributed to this report.