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Education Report

Rotary Club of Fresno
March 1st 2004
...As a frequent lecturer on
health care, Dr. Pearl is an
advocate for
power of physicianled,
integrated medical delivery
He believes that
organizations like Kaiser
Permanente in which
collaborate rather than
compete, and in which a
multi-specialty medical
works in partnership with a
not-for-profit health plan
and hospital system, are
able to provide superior
quality care over

...Before the strike started,
CNA Chief Nurse
Representative Melanie
Alvarado said she tried to
speak to the nurses on the
night shift, to see that all
patients were handed over
to other certified nurses
called in to relieve the
Kaiser nurses.
prevented me from
speaking to my nurses,"
she said. "They're not
allowed to do that."  
Alvarado, who is a Kaiser
charge nurse for adult
and family medicine, said
the union will likely file a
complaint against Kaiser
because of that action.
"In December of that year, Moran had his meeting with Dr.
Robbie Pearl,
Permanente’s top physician for Northern
and Central California, to discuss
Moran’s concerns about
According to his notes made at the time,
Moran said he warned Pearl about Safari, and Pearl said he
was “well aware” of the situation, including Safari’s threats
to harm himself."

Below, the Los Angeles Times details Kaiser
Permanente's cover-up of the warning signs that Dr.
Hamid Safari was eventually going to harm a patient.  He
ended up killing three of them.
Kaiser doctor, accused of negligence, remains on the job
By Tracy Weber and Charles Ornstein
Los Angeles Times

Late one April night, the first of Sarah Valenzuela’s twins arrived with little trouble, but the
second stayed put.

Though the baby was not in distress, Kaiser Permanente perinatologist Hamid
Safari attached a vacuum extractor to the boy’s head to draw him out. Again and
again he tugged, but still the baby would not come.

He vigorously shook the vacuum, up and down, side to side,
according to government documents and hospital incident

It took 90 minutes and six tries — the last with Safari on his
knees, pulling. Horrified staffers — and the boy’s father —
looked on as baby Devin finally emerged. His skin was a
bloodless white, his neck elongated and floppy.

His spinal cord had been severed.

Safari lashed out at a nurse. “What did you do to that baby? I gave you a good baby,” he
said, according to a complaint letter the nurse sent to her union representative.

Staffers at the Fresno birthing center were devastated and angry — and not just because
of the twin lost that night in 2005.

Over the years, doctors and nurses repeatedly had complained to higher-ups — including
Kaiser’s top medical officer in Northern and Central California — about problems they saw
in Safari’s skills and behavior, according to interviews and documents.

This is a story not just of tragic medical outcomes, but of a health plan that did not
prevent them.

A year before Devin’s death, the doctor had waited more than three hours to do a
Caesarean section even though the baby girl was in distress and her family said they had
been pleading for the procedure, according to interviews and government records. She
was severely deprived of oxygen and died months later.

As far back as 2002, a physician review committee at the hospital concluded that Safari
provided “inappropriate” care and that his “conduct needed significant improvement,”
according to a lawsuit later filed by two of his peers.

Still, the doctor continues to work at Kaiser Fresno, practicing under restrictions that
staffers say have not been explained to patients.

Regulators acted only recently. This July, the state Department of Managed Health Care
fined Kaiser a record $3 million for its haphazard handling of complaints and physician
errors throughout the state. Officials said in an interview that the Safari matter played a
significant role in their decision to investigate the HMO’s practices.

Late last month, the state medical board accused Safari of gross negligence, seeking to
revoke or suspend his license.

The board also has faulted Kaiser, the nation’s largest HMO with 6.5 million members in
California. The health plan made the board’s investigation of Safari “protracted and
difficult” by providing incomplete medical records, a spokeswoman said.

Kaiser did not allow senior officials to be interviewed for this story — and warned staffers
at Kaiser Fresno not to talk, several said. In a statement, hospital administrator Susan
Ryan said the HMO has cooperated with the medical board and is “committed to ensuring
the safety of our patients.”

In July 2005 — three months after Devin’s death — Kaiser imposed its restrictions on
Safari, barring him from performing vaginal deliveries and requiring him to be monitored
by another physician or an advanced-practice nurse, Ryan said. The restrictions became
permanent in April 2007. Kaiser and other hospitals typically do not notify patients of such
actions, officials said.

Safari, 49, declined to comment. His lawyer, Stephen D. Schear, said the accusations are
“completely unwarranted” and that Safari intends to challenge the medical board’s action
in a hearing. Safari, he said, has the support of many at the hospital and in his

“If you’re doing thousands of high-risk deliveries over the years, it’s almost inevitable that
there’s going to be some unfortunate cases where children die, where things don’t go
right,” Schear said.

“You’re talking about one minute maybe where he pulled too hard to try to extract this
baby. . . . Just look at his whole record, 10 years.”

But doctors and other staffers allege that Devin’s death was the culmination of Safari’s
troubles, not a fluke.

“We do not feel that our perinatologist is competent,” reads an August 2005 petition
signed by eight of Safari’s peers, about half of the ob-gyn department. “Over and over
again he put our patients at risks and most recently with the undeniably terrible outcome.”

Kaiser was “misleading our patients and the public” by advertising that it had a
perinatalogist on staff even though his practice was restricted, said the petition, which was
addressed to the hospital’s medical director.

The petition, complaint letters, depositions and other documents used in preparation of
this story are part of the ongoing lawsuit by the two doctors and arbitration cases against
Kaiser, or have been provided to state regulators investigating Kaiser and Safari.

Dr. Gilbert Moran, one of the doctors who sued Kaiser and its affiliated Permanente
Medical Group, alleges that they punished him and others who complained, rather than
address their legitimate concerns.

“I’ve been telling these guys for years that he was going to kill someone,” said Moran, the
former ob-gyn chief. “And no one would listen.”
Misjudgments, mistakes

In 1997, Kaiser’s Fresno hospital needed more obstetricians but was having difficulty
finding specialists willing to live and work in the Central Valley.

A staff physician recommended Safari, a former classmate from the Tehran University
Faculty of Medicine in Iran, who had just completed a fellowship in perinatology at Los
Angeles County-USC Medical Center. That training qualified him to treat high-risk
pregnant women.

Without its own perinatologist, Kaiser had been forced to send such women to
outside doctors and hospitals, often at enormous cost.

Safari arrived that August. Within months, staff members began to file
complaints to Moran, alleging that Safari was rude and inappropriate.

“Dr. Safari let everybody know in no uncertain terms that since he was hired as
the perinatologist that his intelligence level exceeded everybody’s,” said a
nurse who, like several other staffers, insisted on anonymity because she
feared for her job.

As time went by, staffers allege, they began to notice that the specialist also was making
misjudgments and mistakes.

But Safari resisted criticism, they said. After the ob-gyn department’s quality
committee ordered him to work on his deficiencies in 2002, Safari “adamantly
refused to follow the committee’s plan, stating that general OBGYN’s cannot tell
a specialist, perinatologist, what to do,” according to a pending lawsuit filed in
May by Moran and a colleague, Dr. Robert Rusche.

The suit does not name Safari as a defendant but seeks damages from Kaiser and the
Permanente Medical Group, alleging the HMO retaliated against them for drawing
attention to Safari. In court papers, the defendants have denied the allegations.

The hospital called in Kaiser’s regional chief of perinatology, who reviewed
Safari’s charts and sided with the committee, the suit said.

One of the cases involved a woman with possible pre-eclampsia — characterized by high
blood pressure and swelling that can lead to serious complications, according to Schear,
Safari’s attorney. A review by physician peers found that she should have been
hospitalized, he said. In a second case, they cited Safari’s failure to detect a potentially
risky condition in which twins had markedly different weights, he said.

The review process was driven by Safari’s enemies, principally Moran, and the cases
cited did not involve harm to patients, Schear said. Even so, Safari followed the committee’
s instructions, he said.

“Peer review can be used in an unfair way to go after a doctor that people want to go
after,” he said. “No doctor is perfect.”

Some of Safari’s colleagues agreed.

“Dr. Safari has been scrutinized way beyond what a person in similar circumstances would
have happen to them,” said Dr. Thomas Kulterman, a Safari supporter.

Moran said Safari’s performance made him a target, and it did not improve with time or

Repeatedly during 2002 and 2003, Moran and Rusche complained to Dr. Varoujan
Altebarmakian, the hospital’s chief physician, and others that Safari’s “unsafe”
treatment of patients “clearly fell below any accepted standard of care,”
according to the doctors’ lawsuit.

Altebarmakian told them the situation “would be taken care of,” the suit said.

Little need to question

Tanella Bessard knew nothing about Safari when she first saw him in October 2003.

She had grown up under the HMO’s care. Her children were born at Kaiser hospitals, the
second with a congenital heart defect. So when Bessard became pregnant with her third
child, she heeded her Kaiser doctor’sadvice to consult Safari, the hospital’s sole

In mid-January, when she was about 32 weeks pregnant, Bessard was hospitalized for
early contractions. Safari ordered shots to halt the labor and other steroid injections to
develop her baby’s lungs, then allowed her to return to work, she said.

“I didn’t have a lot of reason to question him,” said Bessard, now 33. “He
seemed to stay in tune with me and what my concerns were.”

On Jan. 28, when the baby was several weeks shy of full term, Bessard’s contractions
became unstoppable, according to interviews and deposition transcripts. She was
admitted to the hospital, and by 10 p.m. Safari noted drops in the baby’s heart rate after
the contractions peaked. Such “late decelerations” can signal a reduced oxygen supply to
the baby and, if prolonged, can cause critical harm.

Bessard’s mother, Lanell Brown, said she was watching the fluctuating lines on the fetal
monitor with growing concern. She and Bessard pushed Safari to do a Caesarean
section, but he resisted, they alleged.

Bessard’s baby, Paris, ultimately was delivered by C-section just past 1 a.m. —
more than three hours after the late decelerations began. By that time, the pH of
Paris’ umbilical cord — an indicator of a baby’s oxygen level before birth — was

This level is “almost incompatible with life, it is so bad,” said Dr. Khalil Tabsh,
chief of obstetrics at UCLA’s medical school, who spoke generally and did not
review Bessard’s records. “Babies that are born with 6.8, they either are dead or
they are in deep trouble.”

In her first months, Paris required oxygen and had seizures. “She didn’t do the
normal things that children would do at her age,” Brown said. Paris died that
November, not yet 10 months old.

The county coroner attributed her death to chronic bronchitis
and bronchiolitis — respiratory diseases — but did not address
whether it was related to birth trauma.

Bessard filed an arbitration claim, which Kaiser settled for an undisclosed amount. The
HMO requires arbitration in legal disputes, a mandate that keeps all legal filings and their
resolution confidential and out of public view.

In a deposition reviewed by The Times, Safari testified that it was Bessard who
resisted his recommendation for a C-section.

“He changed everything around,” she said in an interview, “which really blew
me out of the water.”

A financial settlement with Kaiser, reached in October 2005, gave Bessard little solace,
she said. That’s why she asked her lawyer to refer her allegations to the state medical

Nearly two years later, when the board accused Safari of gross negligence, it
cited his failure to do an “immediate Caesarean section.” Instead, officials said,
he waited more than two hours to call for one and then took “some 50 minutes to
deliver the infant.”

Another warning

About the time of the Bessard birth, tensions within the birthing center were escalating,
according to memos and interviews.

In early 2004, Safari’s “behavior became irrational and included threatening to
starve himself, light himself on fire, and to call CNN to witness his plight,” said
Moran’s suit, which refers to Safari as “Dr. X.”

Schear, Safari’s attorney, said his client never said he would burn himself, but did
threaten to go on a hunger strike to protest harassment by his boss, Moran. Other
physicians complained that Moran played favorites, he said.

In May 2004, medical director Altebarmakian removed Moran as ob-gyn chief,
citing his arrogance and his department’s dysfunction in a follow-up letter. At
the time of his removal, Moran contends in his suit,
he warned
Altebarmakian that if something wasn’t done, Safari “would
again permanently harm one of Kaiser’s patients.”

In December of that year, Moran had his meeting with Dr. Robbie Pearl,
Permanente’s top physician for Northern and Central California, to discuss

Moran’s concerns about Altebarmakian.
According to his notes made at the time,
Moran said he warned Pearl about Safari, and Pearl said he was “well aware” of
the situation, including Safari’s threats to harm himself.

Devin, the twin boy, died in the delivery room four months later, and the case is
now key to the medical board’s complaint against Safari.

Tabsh, UCLA’s obstetric chief, said that in his 35 years of practice he’d never
heard of a full-term baby’s spinal cord being severed during a vacuum

“Everybody that was involved in it was literally sick,” said one nurse, who also spoke on
condition of anonymity. “She was begging for a C-section.”

Another nurse, the one allegedly blamed by Safari for Devin’s death, questioned
why no one had investigated whether Safari was threatening his colleagues. In
her July 2005 letter of concern given to her union representative, she described
him as repeatedly “harassing” her about the event.

“Those of us who did the right thing and came forward to speak up against Dr. Safari
when he was in the wrong feel very threatened,” the veteran nurse wrote.

Schear said Safari threatened no one and had safely performed about 200 vacuum

“It stinks. It just stinks. You’re looking at one minute of this guy’s career and you’re going
to cream him. It’s very dramatic-sounding, ‘Oh, the poor baby broke his neck.’ It’s not
something where you want to destroy a good and excellent perinatalogist’s reputation.”

Today, Valenzuela and her husband, Randy Ramirez, both 37, decline to say much about
what happened. Valenzuela said she can’t discuss her arbitration settlement, and that
they are afraid talking about Devin will make life unbearable again.

“Words can’t even describe it,” Ramirez said.

Sarah’s sister, Helen Valenzuela, recalled that Sarah “cried for a year” after Devin’s death.

Helen still remembers a nurse emerging from the delivery room, crying.
Later, she said,
she confronted Safari in the hallway: “You murdered my nephew!”

“He told me to ‘Calm down, or we’re going to have you removed,’ ” she said.

Near dawn, hours after Devin’s death, Helen said she was in the room when Safari sat on
the side of Sarah’s bed and unburdened himself.

” ‘Nothing like this has ever happened to me before,’ ” she recalled him saying.

Futile to complain

As staffers traded details about the case, Moran and Rusche recall wondering
why it hadn’t been promptly discussed by the hospital’s ob-gyn quality review
committee — a practice they called routine in serious cases.

The doctors separately looked at Valenzuela’s medical records and Rusche brought his
concerns to his supervisors.

In July, hospital officials took action by limiting Safari’s scope of practice. But they also
took aim at the messengers, Moran and Rusche, for violating patient privacy restrictions
by reviewing the records.

Moran was suspended for two weeks without pay, had his salary cut by $20,000 a year
and was denied a year-end bonus, while Rusche was suspended for one week without
pay and denied a bonus, according to their disciplinary letters.

Both men challenged the discipline but got nowhere, their suit alleges. It was their right to
view the records, they contend, as quality committee members. And Moran said he had
treated Valenzuela after her delivery.

In the months that followed, the hospital administration chastised the eight
obstetricians who submitted the petition warning administrators about Safari in
August 2005.In a staff memo, Altebarmakian wrote that a petition “targeting an
individual practitioner is counterproductive and discourages the cooperative,
harmonious and respectful work environment that the medical group expects
and encourages.”

Several staffers began to sense that it was futile — not to
mention risky — to complain.

“It looks like nothing changes,” said one veteran nurse. “I don’t know who
protected him. I don’t know who came to bat for him. But he’s still there.”

Rusche recalls the moment he decided he’d had enough. A new patient had
come in, and Rusche deemed her high-risk — a decision that ensured she would
be sent to Safari.

“To me, I had crossed the line there,” he said. “It all of a sudden hit me what the heck I
had just done.”

In January 2006, he and Moran gave up on resolving matters internally. They took their
complaints to the medical board, just as Bessard’s lawyer had done earlier.

Rusche retired last year and has traveled the country in a motor home.

Moran now works for Kaiser in Bakersfield, 100 miles from his home, and sees
his family on his days off.

Safari is a “really good physician” with a lengthy track record of doing “very difficult
deliveries,” said Dr. Daryoush Razi, a fellow student from the Tehran medical school who
now heads the ob-gyn department’s quality committee. “I trust him with treating my family.”

Earlier this year, he and 10 other doctors signed a letter of support for Safari. Several
were new to the department, but three had apparently changed their minds after signing
the protest petition in 2005.

He is “an asset to our department,” the letter said.
TPMG Awards

Altebarmakian, MD
2003 Everyday Hero
Urology | Physician-in-Chief Fresno

“I do everything out of love and passion,”
says Varoujan Altebarmakian, MD,
Physician-in-Chief and Urologist at
Kaiser Permanente Fresno.
“With passion, results are always good.”

Dr. Altebarmakian–lovingly nicknamed
Dr. Alte by his co-workers–considers
serving people his life’s mission.
“I feel it is my duty to give to others in need.” Whether conferring with a patient or colleague, Dr. Alte
shows genuine concern for their well-being. Along with his welcoming bear hugs, Dr. Alte is known for
his availability; he invites staff to call him– no matter the hour–because ‘no question or need is too

“I love people unconditionally,” he says. “If our members receive good care and are happy, we’ve
achieved our goal.”

“He’s the hardest working man I know,” says Corwin Harper, Director of Hospital Operations and
Medical Group Administrator at the Fresno facility. “He’s caring, compassionate, and committed. He
drives for success and excellence–for the greater good of all, not just for himself.”

Dr. Altebarmakian volunteers tirelessly in the community. His strong spiritual beliefs have led the
Armenian Apostolic Church to name him Chairman of the Western Diocese–the highest honor it
bestows. “When you do something for your community or church, you understand yourself as well as
others better.” Dr. Altebarmakian elaborates, “Those who give their time and resources are happiest in

[Maura Larkins comment:  Perhaps it also requires blindness to the harm you do to others, Dr.
See also Kaiser
kidney transplant
See story about father's death used by CEO Dr. Robert Pearl