Ep 44-Moose, Murder, And Medicine: The Attack of a Nightmare Patient

A quiet clinic. A calm voice in the hall. Then the shots that shattered a July morning in Petaluma, California. We follow the life and death stakes behind headlines: a breast cancer survivor seeking reconstruction, a competent surgeon navigating a fraught era of silicone implant fear, and the slow, chilling arc from anxious follow-ups to a fixed narrative of betrayal.

We also step back to consider what safety looks like now. AI-assisted mammography is catching more interval cancers, reducing recalls, and freeing radiologists to spend time where it matters—conversation, judgment, and care. The contrast is stark: technology advancing early detection while human systems still learn to spot behavioral red flags—anger, fixation, refusal of evidence—before harm erupts. 

If this story moved you, share it with someone who cares about safer healthcare. Follow the show, leave a rating or review, and tell us: what warning signs would you act on earlier?

Chapters

• 0:00 Snowstorm Banter And Night Noises
• 4:12 The Moose Or Cow Mystery
• 6:52 Sponsor: Kensho Non‑Alcoholic Cocktails
• 9:42 July 1997: The Petaluma Clinic Shooting
• 15:22 Teresa Ramirez: Diagnosis And Reconstruction
• 20:02 From Anxiety To Obsession
• 24:42 Silicone Implant Fears And Lawsuit
• 29:12 Settlement Fallout And Escalation
• 33:02 Chart Note: AI And Cancer Detection
• 38:42 Fixation, Red Flags, And Premeditation
• 43:42 The Hit List And Second Intended Target
• 48:02 Arrest, Trial, And Verdict
• 52:42 Aftermath For Staff And Healthcare Safety
• 57:02 Sponsor: Molly Bz Gourmet Cookies
• 59:22 Listener Medical Mishap: The Fruit Fly Cast
• 1:03:42 Wrap‑Up, Tease, And Listener CTAs

Transcript

SPEAKER_04: 1:25

And uh Jenna. Hey yo, how you doing? Oh, thriving. How are you? Good. Got a little taste of what do you call that?

SPEAKER_02: 1:37

Polar vortex. Got sent home. Oh, they had to close the clinic today. Tons of snow and lots of wind and whatever.

SPEAKER_03: 1:46

So it's a cozy evening in. How about you? What better way to spend your cozy evening than to record a podcast? Right.

SPEAKER_04: 1:56

Oh man, did it snow much where you are?

SPEAKER_03: 1:59

No, we haven't gotten any more snow. Excuse me. Um since that was it last weekend it snowed? I can't even remember. All the days are starting to blend.

SPEAKER_01: 2:12

Right.

SPEAKER_03: 2:13

We did have like a big snow system come through at some point. I don't remember when it was. It was recent. And we haven't gotten any more zen that's accumulated to anything meaningful.

SPEAKER_02: 2:25

So I sent you basically what should have been a sound clip, although it was a video, but it was a video of black nightness and some sound last night. Did you oh my gosh?

SPEAKER_03: 2:37

Yeah, I know I saw it in the middle of the night because you know I'm up every hour to go to the bathroom. And I forgot that I saw that until you just mentioned, and so I need to watch that. It would it's just a moose or something, right? Well, yeah. So I I hear this, hmm.

SPEAKER_02: 2:56

Oh my gosh, like this sound outside. I swear it sounds just like that. And so I managed to record it. I kept going outside, and and the the darn thing would would would shut up while I was out there, and I was like, oh, because I was FaceTiming my daughter. I'm like, I think I'm surrounded by these moose. She's like, I don't hear anything, I don't hear anything. I finally got a really good recording because he was going to town, this this moose. And we Googled what moose sound like and compared it to this recording, and it it definitely sounds like a moose. So, and he sounds angry or at least looking for love.

SPEAKER_03: 3:33

I want to see if I can play it for everybody. I wonder if it'll come through to hear. I'm gonna see if not, you can edit it out.

SPEAKER_02: 3:42

I might drop a clip in later, but so I had my whole family convinced it was a moose, and I took it to work, and basically everyone laughed at me and said, That's a cow. But I'm sorry, I still think it's a moose.

SPEAKER_03: 4:10

I don't know. Oh my gosh. I don't know if you guys can hear this thing. But it does sound angry.

SPEAKER_02: 4:23

Yeah, that can't be a cow, really. Because also I haven't seen any cows. It doesn't mean they don't exist. But also, this is really late at night. This is like 10, 11 o'clock at night, it starts. Like cows don't cows don't complain at that time.

SPEAKER_03: 4:39

Like, yeah. Cows are sleeping then. You're like, do you have different cows up north than we do down south then? Or because our cows don't bellar in the middle of the night like that. It's a moose. Maybe it was a cow giving birth. Oh, really? This time of year? Oh, I don't know, but like sounded unpleasant. I'm just thinking, like, if it was bellering in the middle of the night, why could that be? Maybe it was like giving birth. And then if you look up, if you literally Google like moose, it sounds just like that. If you guys couldn't hear my recording, it does sound very similar to what she's doing. So she's got it done.

SPEAKER_02: 5:20

Because I kept popping outside. It's like below zero to like, okay, maybe the thing's singing again. Because I heard it from inside and then I went out and it would stop. And I go in and out, in and out. It's like this cryptid in the woods behind the house. Anyway, okay, well, I feel validated that someone else thinks that it's not just a silly old cow.

SPEAKER_03: 5:41

No. I mean, I didn't grow up with cows, but I grew up close enough to cows. Also, the timing is very suspicious.

SPEAKER_01: 5:49

Yes, I think it's a it's either an angry or horny or birthing. Oh yeah.

SPEAKER_02: 5:59

Oh, birthing. Whatever it is. I hope it's cozy in the snow. I haven't gone out to check on it tonight. So I'll be out there. Here, Cal. Here, Cowie! Oh man. But anyway, I think it's probably no better time to segue into something very near and dear to my heart, which is cocktails. Oh, and this is our sponsor number one. But this is a special cocktail called Kenshow Cocktails that were crafted by RSRV Collective and found at RSRV Collective.com. And these are premium non-alcoholic ready-to-drink beverages. So this is something you could potentially indulge in as well, Amanda, that deliver the sophistication of traditional cocktails without any alcohol. So the word kensho means self-discovery in Japanese. Kensho reflects the brand's dedication to crafting elevated experiences through bold, complex flavors. Their innovative approach to non-alcoholic drinks sets Kensho cocktails apart. Found at RSRV Collective.com, meticulously crafted with premium botanicals, natural citrus, and spices, these cocktails rival the depth and nuance of traditional mixology while remaining vegan, gluten-free, non-GMO, and low calorie. Each Kensho cocktail offers a distinct and sophisticated flavor. Botanica, inspired by Jan and Tonic, is a crisp and refreshing beverage with floral and juniper notes that's balanced by citrus. Evoking the bittersweet character of an old-fashioned, and then the sentence ends. I was gonna say worm, but I think they mean old-fashioned, which is a drink that is made with, is it ramboy and whiskey? I'll have to look it up. But anyway, an old-fashioned is a cocktail that's kind of an orange smoky whiskey flavor. So I imagine that's what this is. Rosato features rich cherry sweetness with a ginger finish. Walamari channels an Italian aperitif with herbs, spices, and dark citrus, finished with a subtle bitterness. Recognized by Bevnet as one of the best of 2023 non-alcoholic beverages and show cocktails crafted by RSRV Collective and founded rsrvcollective.com, perfect for any occasion. Serve them chilled with garnishes like lime, cherries, or raspberries for a luxurious alcohol-free experience. Listeners of our show get an exclusive 30% discount. If you use our promo code STAYSUSPIS at checkout, go to rsrvcollective.com and use promo code Stay Suspicious for 30% off your order of delicious, nutritious cocktails that give you that indulgent feel without the alcohol as you celebrate the holiday season.

SPEAKER_03: 8:55

Nice. And a generous discount. Yeah, that's a good discount.

SPEAKER_02: 9:00

So today's episode, I don't really have any trigger warnings. And the majority of our resources by our, I mean my resources were from the San Francisco Chronicle and examiner articles, but and there was an oxygen episode about this. I think there was also an episode on Snapped about this. So I'll put those resources on our show notes, shall we? Let's do it. All right. It was a warm, sunny day on July 3rd, 1997, and Dr. Travis and his wife Deborah were late to work. They worked at his private practice, a plastic surgery clinic in Petaluma, and the couple had been out late the night before, celebrating Deborah's birthday. On the way to the office, they called their office manager, Kay Carter, to let her know their ETA. Their first patient would be checking in before they arrived. Kay was such a reliable employee, they could always count on her to be the first to the office and the last to leave in the evening. They could always rely on a fresh pot of coffee waiting for them each morning. I mean, everybody needs a K in our life. Yep. Sounds amazing. Yeah. But Kay didn't answer this morning. She didn't answer the phone, and that was weird. As the couple approached the parking lot, they noticed that Kay's car was there, but the clinic was still locked because they could see their 8:30 patient kind of standing outside the main doors of the clinic looking confused and definitely locked out. The Todd's wondered why Kay hadn't unlocked the door yet as they hurried into their usual entrance at the back of the building. Once inside, nothing seemed out of order. The smell of Kay's coffee greeted them as usual. Deborah went to finish putting her makeup on in the ladies' room, and her husband went to his back office to get ready for his day. Deborah heard a woman's calm and eerily threatening voice in the hallway shortly afterwards. I've been to 28 surgeons. Then her husband's voice pleadingly, I'm sorry, he said. I care. Gunshots split the air. One, two, there were more. She lost count as she fled out the back door to the clinic, calling 911 as she ran. Soon the perimeter was swarming with law enforcement officers. Side note, one of the news reports interviewed an employee from a physical therapy clinic right next door. They initially thought that the gunshots were early fireworks because it was July 4th. I know. Imagine their shock and horror when they saw the officers in the SWAT team swarming the area. It was super tense because officers didn't know if the shooter was still in the building and whether Dr. Tavas and Kay were hurt. Officers stormed the building and found Dr. Michael Tavas lying on his back in the hallway of his clinic, shot once in the chest and three more times in the back as he tried to run away. And this is so awful. He had fallen on top of the office manager Kay Carter, who had been shot in the head and was somehow still barely alive. Oh my God. Both were rushed by EMS to the hospital, but Dr. Tavas was pronounced dead at the scene. Kay survived, but she suffered severe brain damage, was wheelchair bound, and her life forever changed as a result.

unknown: 12:25

Dr.

SPEAKER_02: 12:26

Tavas was 53 years old. He was a beloved father, husband, and a surgeon. He and Deborah had only been married for a year. They met in a pottery class.

SPEAKER_03: 12:38

Oh my gosh, how wholesome.

SPEAKER_02: 12:41

And they fell in love. They both loved art. That was something they had in common. And they got married in Paris. I can imagine. And worked, both worked at his practice together. They should have been able to spend the rest of their lives living out their dreams. But to understand how this tragedy unfolded, it helps to zoom out for a moment. Plastic surgery in the late 1980s and early 1990s, especially breast reconstruction, was a high-stakes game. Implants were under public scrutiny. The FDA was raising eyebrows about silicone, and lawsuits were swirling in the background like a dark cloud over every elective surgery. Patients had high expectations. Some were realistic and some less so. And the surgeons? Navigating human psychology? Not so much. Into this arena stepped Teresa Ramirez. When Ramirez was diagnosed with breast cancer in 1988, she was in her mid-30s, working as a nurse for Kaiser Permanente in Santa Rosa. Colleagues remembered her as competent, organized, and blunt. She had no tolerance for sloppy charting or shortcuts in patient care. She had survived a difficult childhood as the oldest of three siblings. Nursing had become her proof of stability and usefulness. A cancer diagnosis disrupted not only her health but her sense of control, something she'd always guarded tightly. She underwent a bilateral mastectomy. And as with many mastectomy patients, reconstruction was not a superficial choice. It had emotional and practical dimensions: body image, sexuality, and the symbolic reclaiming of a body changed by disease. Ramirez followed her surgeon's recommendation and was referred to Dr. Michael J. Tavas, whose petaluma practice had a long-track record of reconstruction after oncologic surgery. By the time Teresa Ramirez walked into Dr. Tavas' office for her initial consultation, she was already a study in contrast. On the surface, she appeared polite, organized, and perfectly reasonable. She had brought charts, pamphlets, and a notebook that looked like it could have doubled as a law school syllabus. She asked questions about the surgical procedure, the recovery process, potential complications, and the timeline for seeing results. All very normal. But if you look closer, there were signs that something more intense was brewing. Teresa annotated every brochure. She cross-referenced every pamphlet with the notes that the staff gave her, and occasionally raised questions that had less to do with medicine and more to do with trust or perhaps suspicion. For instance, she would ask about who exactly was in the operating room during surgery, or if any extra materials were being used. And she did this with a calm, almost clinical insistence, the kind of persistence that would make most office staff nod politely while silently thinking, all right, that's thorough. For sure. I think we all have met somebody like this.

SPEAKER_03: 15:58

Uh-huh.

SPEAKER_02: 15:58

Yeah. They're just look it's almost like they're looking to drip you up or you know, they're going in with mistrust. And instead of granting it to you, you have to earn it first. Right.

SPEAKER_03: 16:09

It's almost like Which is like, I've never broke your trust before. How did we get to this plateau of mistrust? Who wronged you so badly that you're carrying it everywhere?

SPEAKER_02: 16:19

Right. Okay, so she was thorough, but that was a first step in a trajectory that would spiral tragically. Early interactions with medical staff indicated she was detail-oriented, but she had a growing need for control. And this need would intensify when post-surgical sensations failed to match her expectations. The surgery itself, performed in late 1993, went by all objective measures perfectly. Operative notes confirmed that Dr. Tavis followed standard procedure, the implants were positioned correctly, and there were no unusual occurrences. Postoperatively, she was healing within normal parameters. Vital signs were stable, the incision sites looked healthy, and follow-ups were routine. But Teresa's mind, as it often does in high stress scenarios, had its own narrative. To her, every twinge or sensation was suspicious. A tight feeling across her chest became proof of wrongdoing. A mild ache or shift, evidence of hidden tampering. The human brain, I know, the human brain is a remarkable pattern-seeking machine. And in Teresa's case, the patterns that she found were always sinister, according to her. According to court records and later trial testimony, Ramirez initially trusted Tabas. She had no reason not to. He was board-certified professional and experienced in postbastectomy reconstruction, a procedure requiring precision and careful staging. Reconstruction isn't one surgery, it's a sequence of surgeries. First you get expanders, then implants, sometimes revisions, sometimes grafting. No patient emerges from it unchanged. Over the next several years, Ramirez would undergo multiple procedures with him, some planned and others corrected. As with any long-term surgical patient, emotions and expectations grew complicated. After surgery, she began expressing her concerns, initially in polite letters and phone calls that might have seemed overcautious to staff. Quote, the implant feels different, end quote, she wrote. At this stage, most doctors would respond with reassurance, which is what Dr. Tavas did. He explained the normal healing process, the expected sensations, and the timeline for complete recovery. Medically, he was correct. Factually, nothing unusual had occurred, but the effectiveness of reassurance depends on the patient's ability to accept it. And Teresa's acceptance tank was empty. Soon her letters became longer and more insistent. The phone calls grew colder. In one call, she asked about surgical assistance, anesthesiologists, and even admin staff in a tone that was calm, almost clinical, but with a sharp undercurrent. It was a message that she was watching and analyzing. Staff recalled her polite demeanor, but remember the subtle chill that signaled that there was something. She was certain that something had gone wrong.

SPEAKER_03: 19:22

I don't remember when caller ID came out. This are we in the early 90s right now?

SPEAKER_00: 19:28

Yeah.

SPEAKER_03: 19:28

So I don't know. It was not a thing yet. But I'm like, if it was, can you imagine seeing her name flashing on the it's like, ah, it's your turn.

SPEAKER_04: 19:38

You do like not it, not it, not it.

SPEAKER_03: 19:41

She's calling again again, not it. Nose goes, no.

SPEAKER_02: 19:45

Oh man. Yeah. I mean, the staff, they thought she was anxious. She seemed rational, but they just continued to, as as they could, provide standard follow-up care. Anxiety is typically manageable with explanation, reassurance, or even therapy. This wasn't anxiety, this was obsession, especially when combined with a feeling of belief when being wronged. Obsession is a completely different trajectory. And so the stage was set. We have a patient whose anxiety and meticulousness morphed into mistrust and then into obsession. We have a surgeon who's competent and professional, but increasingly becomes the villain in a narrative entirely created in that patient's mind. And a medical system that in 1993 really had no structured way to flag the type of risk that would soon become tragic. So the first major complication was a suspected leak in her right implant. Silicone gel implants of that generation were known for silent rupture, which is a failure that might not be immediately obvious, but could produce changes in the breast shape, firmness, or mild inflammation. So these complications were not, medically speaking, unusual, but to Ramirez, they felt catastrophic. She reported pain, fatigue, and a constellation of systemic symptoms that she believed were connected to the leaking implant. So at this point, she's becoming hypervigilant and like anything she has, whether it could be like, you know, an ingrown toena. I'm just imagining like an ingrown toenail. Well, that's related to my kidney's inability to heal, you know. Like she's going to be blaming absolutely everything on this potential mishap. At the time, public concern about silicone implants was at a peak, so that didn't help. Lawsuits against manufacturers multiplied. Medical uncertainty swirled in the media. Experts disagreed whether over whether silicone leakage actually caused a stomach illness, fueling anxiety among patients. Ramira is already someone who needed answers that she could trust, found herself trapped in that uncertainty. She underwent revision surgery and then additional corruptive procedures. Records indicate she was never satisfied with the cosmetic outcome, but her dissatisfaction went far beyond appearance. She believed firmly that she'd been physically harmed by a device she had not fully understood and had been pressured into accepting. Whatever nuance Tavis tried to offer, that complications were common, that reconstructive surgery was inherently imperfect, felt to Ramirez like excuses.

SPEAKER_03: 22:24

But like, were there actually complications, or she just thought there were complications derived from the cell?

SPEAKER_01: 22:31

I think sometimes the leaks they would, because they're so minute, at least they have to go in to check.

SPEAKER_03: 22:38

But yeah, yeah. Because they wouldn't do a revision if unnecessary. So I guess yeah, that's the only way you can check.

SPEAKER_02: 22:45

But I'm like, I don't know. I mean, I'm I'm probably wrong, but yeah, you would think it sounds like there's a number of surgeries that are expected to happen along this process, and that things before they settle. And just looking into it a little bit, the recovery is a long time. And she had already started complaining before that there's swelling and and mis misshapenness as long as six to eight months after the surgery, from what I could read. So she was jumping the gun and I don't know, so persistent and insistent on her symptoms that, you know, they were taking her seriously. Eventually, her frustration became legal action. She filed a malpractice claim against Taggus and joined a larger suit against the implant manufacturer. She sought roughly$100,000 for corrective surgery. So she sought compensatory damage for the surgeries, lost work hours, and related damages. The case was settled in 1995 for$10,000, which is just 10% of what she wanted. Yeah. Probably one surgery comes back. You know, if not more, I didn't look into that. But she saw this as an insult. So this is the point at which her relationship with Dr. Tavis began to transform. It wasn't that she simply believed he'd harmed her, it was that she believed that he dismissed her suffering, minimized it, and then slipped out of accountability through a paltry settlement. In her mind, he had wronged her twice, first with the surgery and then with a settlement. After the settlement, Ramirez's behavior began to shift in ways that colleagues later described as unlike her previous demeanor. She became preoccupied with her health problems, and here's that hypervigilance, and the belief that nobody was taking them seriously. She'd been out of work since 1989 because of illness and chronic pain, which isolated her further. She had the medical knowledge to understand procedure notes and pathology reports, but also enough knowledge to catastrophize their implications. Friends from her nursing days noticed she was becoming increasingly distrustful of physicians. She believed Tavas and other doctors covered up their mistakes. She spoke about being ruined physically and financially. Her attorneys had moved on. The case was closed, and silicone implant litigation across the country was cooling as settlements and moratoriums were finalized. But Ramirez did not move on. In 1993, Teresa Ramirez crossed a threshold. Anxiety had become obsession, obsession hardened into conviction, and conviction had begun to outline a blueprint for action. No one in the clinic realized how close the situation had come to crossing the point of no return.

SPEAKER_04: 25:28

And with that, we're going to take a little break for our cha cha.

SPEAKER_02: 25:43

Nope, nope. Tis the season. Welcome to the Chart Note, where we learn about what's happening in medicine and healthcare. Let's take a moment and pause the darkness of our story for a breath of light, because while the world of medicine can be harsh, traumatic, and tragic, there's also remarkable progress happening. And one of the most heartening is how artificial intelligence is changing the game for cancer detection. In 2025, a landmark study led by researchers at UCLA Health and published in the Journal of the National Cancer Institute revealed something powerful. AI tools helped detect what are called interval breast cancers, tumors that were present but missed on initial mammograms, and which sometimes show up between routine screenings. The AI software flagged 76% of mammograms that had initially been read as normal, but later turned out to have cancer, and it correctly identified 90% of cases where human radiologists had missed visible tumors, meaning many cancers that might otherwise go undetected were caught early. Overall, incorporating AI-based review and screening protocols could reduce the rate of those interval cancers by an estimated 30%. That's not a small improvement. That's a potential difference between early-stage treatable cancer and late-stage disease. Even broader studies reinforce these findings. A large-scale national screening program published in 2025 showed that when AI-supported workflows were used instead of standard mammogram protocols, the rate of cancer detection increased by 21.6%. And it wasn't only about finding more cancer. AI also helped improve efficiency. In other real-world implementation, radiologists using AI spent 43% less time reviewing normal exams. Yet, despite that faster workflow, cancer detection improved, while recall, false alarm rates actually dropped. So, what this means for patients and providers is earlier detection, which means better outcomes. Tumors that are caught earlier are often smaller, less aggressive, and easier to treat. And that means fewer invasive procedures, less aggressive therapy, and better long-term survival, less stress for patients, fewer false alarms. So with AI improving accuracy without increasing false positives, patients can avoid unnecessary recalls or biopsies. So fewer scares, fewer procedures, fewer bills, and fewer nights lost to worry. It also could potentially mean more equitable access. So for people in rural or underserved areas where skilled radiologists might be scarce, AI-assisted screening offers a promising route to bring high-quality diagnostics to more people. And less burnout leads to more human care. Radiologists and medical staff are under intense pressure. By offloading the routine image review to AI, clinicians have more time for what machines can't do, providing empathy, patient conversation, complex decision making, and follow-up care. So although this is a hopeful and exciting development, AI isn't magic. It doesn't replace human judgment. In some studies, AI still produces false positives or misses certain cancers, especially in challenging cases like dense breast tissue. But when used as a support tool, a second set of eyes, a safety net, AI is proving to be a powerful ally. Instead of replacing radiologists, many experts now view AI as a collaborator. Human plus machine equals better results than either alone. And there's more coming. In late 2025, a major multi-institutional trial, the PRISM trial, launched in the United States with$16 million of funding. It will evaluate AI-assisted mammography across hundreds of thousands of screenings to assess not just detection accuracy, but patient experience, anxiety, recall rates, and equity across populations. If it succeeds, this could reshape standard screening protocols across the country, making early detection more accurate, faster, and available to more people than ever before. In the middle of stories like Teresa Ramirez, stories about mistrust, pain, and tragic outcomes, it's easy to get lost in despair. But this advancement reminds us that medicine isn't static. It evolves, it learns, and sometimes it builds tools that give hope, especially to people who might otherwise fall through the cracks. Although we often tell stories of suffering and tragedy, we can also light a candle because for many, AI-assisted detection might mean catching cancer when there's still time, choosing less aggressive treatment and walking out alive. It isn't a cure for all, but it's a big step forward. Back to the story. By late 1993, the dynamic between Teresa Ramirez and Dr. Travis had shifted from routine follow-up to something far more dangerous. What began as polite questions and careful notes had transformed into rigid, unshakable narrative in her mind that she had been wronged. Not in some abstract metaphorical sense, but in a very concrete, personal, and terrifying way. Every twinge of discomfort, every shift in her implants, every standard post-op sensation was now interpreted as proof of deception. The letters poured in, each one longer, more detailed than the last. The tone of her letters were changing, where once she'd asked questions, now she was making statements. You're hiding something, she wrote. Only her certainty mattered. Phone calls became an art form of persistence. They were calm, polite, and clinical, but underneath the calm was an icy precision. I need the exact details of the procedure, she said one time. Who was present in the room at every moment? What materials were used? Why don't my records match my experience? To any listener, these might sound like reasonable questions, but there was a tone in her voice that left staff unsettled. A silent message that she was already framing this as a confrontation rather than a conversation. In 1996, she returned to Tavis's office, demanding her medical records. Not just her records, but every scrap of documentation related to her procedures. I mean, this is within her legal rights, but the intensity of her demands alarmed staff. According to later reports, she insisted that the doctor was hiding something. She believed somewhere in those files was proof that he'd knowingly implanted a defective device. Staff members recounted that she grew agitated when they when they told her that certain documents did not exist or that old records required time to locate. At one point, she accused employees of deliberately stalling. She insisted on waiting in the office lobby until everything was produced. Tavis eventually had to bring her into a private room to calm her. He didn't foresee her as a dangerous, as dangerous. Irritated, yes, litigious, certainly, but not dangerous. He had dealt with difficult patients before, many surgeons do. Reconstruction carries intense emotional weight. Surgeons learned to absorb that. But Ramirez wasn't just venting, her fixation deepened. The more she believed she'd been victimized, the more she convinced herself she was entitled to answers that no one would give her. She was convinced Tavas had betrayed her trust deliberately. She saw malice where there was documented complication. She saw conspiracy where there was routine post-op imperfection. And this is where psychology enters the narrative. Teresa had developed a fixed belief system, a mental framework in which she was the victim and Dr. Tavas was the perpetrator. In psychiatry, this is often described as a delusional intensity combined with personal conviction. She wasn't paranoid in the classical sense. She wasn't seeing hidden figures behind every corner, but she was completely convinced that someone had wronged her and that no one would admit it voluntarily. During these months, she became obsessed, more and more obsessed. She documented everything, tracked every staff interaction, every response from the clinic, and every statement in her medical record. And here's the part that's terrifying and strangely relatable. We've all known people who obsess over perceived slights, maybe a coworker, someone who convinced someone stole credit for a project, or a neighbor who interprets every glance as judgment. Most of us stop at irritation, social distancing, or passive-aggressive emails, but Teresa Ramirez did not. Her obsession, combined with a growing sense of injustice, became a blueprint for violence. It's a sobering reminder that obsession can metastasize if unchecked. And sometimes the warning signs are subtle until they aren't. In 1993, risk assessments for potentially dangerous patients were nonexistent. There were no protocols, red flags, no watch list, just polite staff and a professional surgeon doing his best to reassure a patient who wasn't interested in reassurance. She wanted a confession. She began showing up unannounced at the clinic, citing urgent concerns, insisting on seeing Dr. Tavas directly, bypassing staff. And during these visits, her calm exterior remained, but the intensity of her questioning suggested internal calculation. Later, psychiatric evaluations would reveal that she had developed hyperfocused cognitive patterns, meaning her mind could not process alternative explanations. Every answer given was filtered through a lens of suspicion, reinforcing her delusional certainty. Small interactions became battlegrounds. For instance, when Dr. Tavas explained that post-op shifts and implants were normal, she would nod, record the statement, but her inner narrative immediately concluded he's lying. He must admit it. He has done something wrong. So, in short, rational communication failed entirely. Reality, fact, and medical expertise were irrelevant to her constructed story. And by July 4th, 1997, she took matters into her own hands. The aftermath of the shooting was unsurprisingly a whirlwind. Police secured the seam, forensics combed every corner of the clinic, and neighbors watched in stunned disbelief as ambulances and squad cars converged. The investigation moved swiftly. Officers interviewed staff, patients, and neighbors, gathered in statements, timelines, and medical records. Everything pointed to a chilling conclusion. The act had been premeditated, deliberate, and personal. Officers went through the list of suspects, the wife, the pissed-off patients. Everyone checked out, except for one, Teresa Ramirez. And she was not anywhere that she could be found. Until four days later, when police got a call from the San Francisco Police Department. Apparently, two days earlier, they'd been called to the Harbor Court Hotel about an unconscious woman. And this is where things get even stranger. The woman in question had checked into the hotel on July 3rd at 5 p.m. When housekeepers went in to clean her room the next day, they found her passed out on the floor, totally unresponsive. The paramedics were called and she was rushed to the hospital, where it was discovered she was in a diabetic coma. The reason that the San Francisco Police Department thought that this information might be useful to the Petaluma Police Department was for a number of reasons. First and foremost, when police searched her hotel room, they found she'd registered under a false name. She signed in as Teresa Brew, but the ID in her handbag said Teresa Ramirez. And then it's like you can't even use a different first name. And then they found a number of puzzling things, including$5,000 in cash, a train ticket to Van Nuys, two handguns, and then most disturbingly, a notebook with a handwritten list of names. In this list were details about every person on the list, including their addresses. And there were 20 names on this list. Jeez. Dr. Tavas was on this list, and so were 19 other doctors. The first name was Dr. Robert Fees. Dr. Fees was a medical director for the HMO that had that carried Teresa Rivera's health insurance. His job was to evaluate patients' readiness for surgery. So he was the physician that would decide whether they were suitable, not just physically, but mentally as well. Turns out a couple years earlier, Teresa had gone to Dr. Fees after having 13 surgeries for breast implants and adjustments, and she hadn't been happy with any of them. She basically burned bridges with her discontentment with a myriad of surgeons to the point where many of them refused to see her again. Dr. Fees was concerned that she'd had so many surgeries and insisted on a one-on-one consult with her before he would approve anymore. On the day of her consultation with him, he described her as nervous and fidgety. He told her that in order to make sure she was a good candidate for any future surgeries, he would need her to see a psychiatrist. I mean, bless up. Yeah, good for him. Without any notice, I can't believe she did that. Without any notice, she rose out of her chair, ripped open her shirt, saying, Here, this is why I need more surgery. And just like that, wow, she thrust the twins in his face. He ended up having to having to call security, who promptly escorted her and the girls out of his office, securing him a place on her hit list.

SPEAKER_03: 39:08

Oh my. Yeah. I don't think he's and you had been wondering this um the whole time, but probably so do we know if she had a psyche valve before this elective initial elective surgery? Or maybe that was not a thing yet. We because now this is 13 surgeries later. I don't know how much time is in between there, but I know like even our implant patrons have to Yeah.

SPEAKER_02: 39:34

So she got cancer in 89 and she had the mastectomy. So I think, and then this is all happening in early night, like 92, 93. Yeah.

SPEAKER_03: 39:44

I don't know where we are now.

SPEAKER_02: 39:45

Yeah, so she shot, so she ended up, I think she had 13 surgeries before she saw Dr. Fees. When did I say she saw him? Like in '93. And then she murdered Dr. Tavas in '97. So I think this was before she had seen Dr. Thomas. And so I don't know how she got her insurance to cover this if she didn't have the obviously Dr. Fees isn't going to be writing her anything. So but she was doing a lot of shopping, and a lot of people not, you know, you know how people do that. They cover up the tracks or they go and throw the last clinic under the bus, come in for a second opinion, and this kind of stuff.

SPEAKER_03: 40:29

And I mean, she has a compelling story on top of it. She had breast cancer, mastectomy, like people were gonna want to help her.

SPEAKER_04: 40:37

She had the lingo down. Uh-huh.

SPEAKER_02: 40:41

But in all I do remember reading some more that she paid for because insurance stopped pain. I don't know at what point they stopped pain, but she used some of her money that she'd gotten from her settlement to pay for another surgery.

SPEAKER_03: 40:57

I was wondering if that's where too. She's like bought her two guns, had 5k in cash.

SPEAKER_02: 41:02

Like, yeah, where's this coming from? Yeah.

SPEAKER_03: 41:05

Yeah. I don't know how much a gun costs, but to have two? Yeah, what do you need two for? Um she got two hands. Yeah. She's coming in like an old western cowboy. Pew, pew, pew. Right? Gunslinger. That's not funny.

SPEAKER_02: 41:23

We need a little bit of respite from. This dark place that she is.

SPEAKER_03: 41:27

Um okay, so she showed the tatas, the sissies, like this is why I need more surgery. And he was like, Audio sister, not signing off, and then he's like on her hit list.

SPEAKER_02: 41:41

He was number one first hit. She actually went by his house. She drove by his house the day that she murdered Dr. Tavas. And if Dr. Fees had been home that day, he would have met a different fate in life.

SPEAKER_03: 41:54

Same story as last week. You would have been there, you'd have been a goner. Yikes. Oh, okay.

SPEAKER_02: 42:00

So so she shoots him on July 4th. And July, I forget. She checked into this hotel July 3rd, and then I think it was the evening of the fourth. She was discovered there. They took her to the hospital. They let the Petaluma PD know on the 7th. And then she woke up in the hospital from her coma on July 9th. So four days later. It was just in time for them to investigate her. So they put her under arrest, right? Good morning.

SPEAKER_03: 42:29

Do we have some questions for you?

unknown: 42:31

Yeah.

SPEAKER_03: 42:33

I hope you had a good rest. We have a long day ahead of us. Yes.

SPEAKER_02: 42:36

Get ready to answer some questions. So they put her in, they arrested her there in her hospital bed for first degree murder and attempted murder. And at Teresa's trial, chilling evidence was revealed. The office manager, Kate Carter, had come into the workplace that morning, just like any other morning. She put on a pot of coffee and was ready to start her day. Teresa appeared in the doorway and just shot her in cold blood, no hesitation. Kayleigh bleeding for about 30 minutes while Teresa hid in one of the offices until she heard Dr. Thomas and his wife come in. When he went into the hallway, Teresa chased him down the hall, shooting him in the side and in the back as he tried to run to safety, and then she left him to die. So cold. Her defense was that she shot these people, but that she wasn't in her right mind at the time because of her body dysmorphia.

SPEAKER_03: 43:28

I mean that ain't gonna fly, I hope.

SPEAKER_02: 43:30

Her lawyer spoke about how when they were preparing for the trial, he could hardly get her to talk about the case without talking about how horribly disfigured her breasts were and how these evil doctors had ruined her life. Psychologists were brought in to evaluate her mental state. They examined her letters, phone calls, clinic visits, and the meticulous notes that she kept about every interaction. Their conclusion was that she suffered from delusional obsession, a condition in which a person's beliefs are unshakable, impervious to evidence, and capable of overriding moral and social constraints. In lay terms, she believed so thoroughly in her version of reality that she felt morally compelled to act. And in that moral compulsion lay the danger. The trial began in February of 1999 and quickly captured public attention. Headlines oscillated between horror and fascination. Patient turns killer, obsession leads to murder, plastic surgery case ends in tragedy. The media's focus, often sensational, obscured the underlying human and systemic dynamic, a patient whose mental state deteriorated unchecked, a medical system unprepared for extreme obsession, and a tragedy that might have been prevented with earlier intervention or awareness. Courtroom testimony was as gripping as it was heart-wrenching. Staff described Teresa's visits, her letters and phone calls with meticulous detail. They recalled how polite, composed, and articulate she'd seemed, even as her obsession escalated. Psychologists testified about her fixation, explaining how her perception of reality had diverged entirely from objective fact. Experts described patterns of delusional thinking, obsessive rumination, and cognitive rigidity, highlighting how these factors had made rational communication impossible. The prosecution painted a picture of premeditation. They emphasized the planning evident in her notes, the calm deliberation of her actions, and the fatal shooting itself. They argued that her conviction and a false narrative had driven her to kill, and that no medical error had occurred. The defense, meanwhile, attempted to contextualize her actions through the lens of mental illness. They highlighted her obsession, her inability to accept contrary evidence, and the intense psychological pressure she placed on herself. The courtroom became a battleground of narratives: law versus psychiatry, evidence versus perception, tragedy versus crime. Ultimately, the jury was presented with a complex portrait, a patient whose obsession had overridden reason, a competent surgeon whose only fault was being caught in the trajectory of another person's delusion, and a legal system tasked with balancing justice, mental health considerations, and public safety. In the end, Teresa Ramirez was convicted. The jury found her guilty of first-degree murder and attempted murder and sentenced her to two life sentences without the possibility of parole. Teresa's reaction to her verdict was difficult to ascertain. She sat without emotion on her face, silent and quiet. Kay Carter died in 2012 from complications related to the shooting. She left behind four children. And Michael Tavis's family lost him. His new wife, his children, and the patients who relied on him were left without him. The trial left an indelible mark on everyone involved, the surviving staff and the medical community, the legal teams, and even the public following the case. It highlighted vulnerabilities in patient management, the subtle but real dangers of obsession, the need for vigilance, and recognizing early warning signs, and perhaps most poignantly, it revealed the tragedy often arises not from a single factor, but from a confluence of personality, circumstance, and systemic blind spots.

SPEAKER_00: 47:19

For the surviving staff of Dr. Thomas's clinic, the aftermath was devastating.

SPEAKER_02: 47:23

They returned to work in the weeks following the shooting, but nothing was the same. The routine of patient care, once considered ordinary and comforting, was now shadowed by a quiet awareness of how quickly safety could be shattered. Some staff sought counseling, and others quietly changed jobs or left the field altogether. The incident became a cautionary tale. Check your patient's intensity, listen, but watch carefully. The medical community at large absorbed a painful lesson. While malpractice, procedural errors, and litigation were perennial concerns, the Ramirez case underscored an entirely different risk. The danger posed by a patient whose obsession and delusion had become fixated on a medical team. This was a wake-up call for everyone. Policies began to evolve, security protocols, patient risk assessment, and communication strategies were reconsidered. While no system could have predicted that Teresa Ramirez specifically would have done what she did, the concept of identifying, escalating, fixation became a focus in medical safety. Psychologists and psychiatrists studying the case highlighted the subtle signs that had been missed. It wasn't the polite letters, the detailed questions, or even the obsessive note-taking that made her dangerous. It was the combination of rigid conviction, perceived betrayal, and the inability to accept evidence. But by the time those traits were apparent, the tragedy was almost inevitable. Experts emphasize early recognition of obsessive delusions, especially when paired with anger or fixation on a particular authority figure, is critical in preventing escalation. Compassion is still essential, even here. Teresa Ramirez was not born a violent person. She was a human being grappling with fixation, mistrust, and an ability to reconcile perceived injustice. Her actions were absolutely unforgivable and the consequences catastrophic. But her psychology offers lessons about empathy, early intervention, and the complexities of the human mind that are invaluable for medical and mental health professionals alike. The Bureau of Labor Statistics reports that in the five years from 2018 to 2023, healthcare workers made up almost 75% of all nonfatal workplace injuries and illnesses due to violence. The American College of Emergency Physicians recently found that violence against ER staff has gone up 24% in the past four years. In one survey, 75% of all ER dogs reported getting at least one threat of violence from a patient in the previous year. And 30% of those had actually been assaulted, some inside the ER and some outside it. Meaning a patient attacked them at home or somewhere else, which is absolutely terrifying. In the words of Dr. Shamed Charles, an ED physician, quote, I have three rules for early career medical professionals. Be on time, be prepared, and know your patients. And number four, never wear your stethoscope around your neck, end quote. It's scary. He goes on to say the fourth rule is because a patient once tried to strangle one of his fellow doctors with her stethoscope. Fortunately, she survived, but she was scarred emotionally and years later quit medicine altogether. For listeners, the story is cautionary and reflective. It asks us to consider how do we balance trust and vigilance? How do professionals navigate difficult personalities without underestimating potential danger? And how do we, as a society, recognize the subtle signs of obsession before they escalate into tragedy? There are no easy answers, only lessons learned the hard way.

SPEAKER_03: 51:08

That was a great it was a bad story, but a great telling of the story. Thank you. Yeah. You did a great job. This this is a tough one, right? Because I feel like it's so tragic. She started out with the breast cancer and that, like going through all of that. It's just a shame that it turned into this. Yeah. And now you're living the rest of your life out in prison.

SPEAKER_02: 51:31

Yeah. Yeah. And people had to die for it, you know, or yeah. Basically, yeah. I mean, poor Kay ruined her life.

SPEAKER_03: 51:42

Well, yeah, her life was completely altered from what 997 to 2012. Yeah. She died like early because poor quality of life.

SPEAKER_04: 51:50

Yeah.

SPEAKER_02: 51:54

So, and I realized after after writing this, this is a totally different set of circumstances that I was like, I just uh the reading the column case where she's shot a man. But I mean, let's face it, he you know, I'm not really good deserved, but but yeah, this is a patient, not an abused uh woman. So yeah, I'm gonna try and switch it up. No, so I'm gonna pick something different.

SPEAKER_03: 52:22

I felt like it was really different. It didn't feel the same to me. And the way you told the story was different and gripping and great.

SPEAKER_02: 52:32

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SPEAKER_03: 52:45

Maybe once. Please remind me.

SPEAKER_02: 52:48

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SPEAKER_03: 54:23

Yummy. Time for a medical mishap. Let's do it. The the subject line is longtime listener, first time emailer with a medical mishap. You'll appreciate. Well, thank you. Hi, Doctoring the Truth team. Hello. Hello. I've been a loyal listener since your body broker episode. That was a good one. I just said that was a good one. This person did not write that. I'll start over. I've been a loyal listener since your body broker episode, and I love your show. You help me pass the time during my long commute to work, and I love your style. I get to laugh, cringe, and learn all in one show. I'm finally writing in because I recently had a healthcare mishap that feels spiritually aligned with your show. Not life-threatening, not lawsuit worthy, but absolutely the kind of thing where afterward you sit alone in your car and think, did that seriously just happen? Oh my gosh, tell me more. A few months ago, I managed to break my wrist in an incident so embarrassing I considered lying about it. Yauchies, I've broken both of mine. This is Amanda talking. And youch, that's not great. So this the writer says, for a brief moment, I almost told people I fell while rescuing a child from a purple building. But the truth is I tripped on my dog's squeaky toy while trying not to carry a plate of nachos on the couch. Oh God, a nachos sounds so effing good right now.

SPEAKER_01: 56:04

Oh my god. But also those squeaky toys. I'm always tripping over those darn things. They're everywhere.

SPEAKER_03: 56:09

They're always everywhere. Actually, Raven does this really cute thing where, like, if she wants a new toy, she'll carry the one she's playing with and put it in her doggy bin and then she'll get a new one.

SPEAKER_04: 56:20

She's so well behaved and you're not gonna be able to do it. She's done a good girl. Yeah. Mine is to go to it to take them out, but will not put them back. Sure, sure, sure.

SPEAKER_03: 56:34

So the nachos just survived the fall. The dignity of this writer did not, unfortunately. The urgent care was straightforward enough. X-ray, confirmation of the world's least heroic fracture, and a bright pink cast applied by a tech who said, This will be your friend for the next six weeks, which bold promised. I agree. Yeah, casts are the worst. The first week was fine, annoying, itchy, the usual cast owner complaints, but on day eight, I noticed something strange, a faint smell. Nothing terrible, just suspicious. Like a damp towel that's been left in the back of your car for a week. I cleaned around the edges of the cast and convinced myself it was nothing. By day 10, it was something. And by day 12, it was a crime scene. Oh no. I couldn't ignore it anymore. I went back to urgent care, hoping they wouldn't treat me like a person who had marinated their limb in swamp water. The nurse walked in smiling, asked how I was doing, and then without warning, took one sniff and staggered back like she'd been hit with pepper spray. Oh, wow, she said. Not not a phrase you want to hear about your body. No. For anyone listening, we don't make comments about people's bodies. Okay. No. She asked, have you gotten it wet? I said no. She raised an eyebrow so high I thought it might detach and float away. Are you sure?

SPEAKER_05: 58:11

Oh my gosh, I want to smell her.

SPEAKER_03: 58:13

I was sure. I was sure. I had been guarding the cast from water like it was made of sugar. They decided to cut it open to investigate. And as they cracked it apart, I braced myself for something horrific. Mold, fungus, maybe a portal to hell. Oh my god, you are so funny. But no, inside the cast was a fruit fly. One single, tiny, tragically deceased fruit fly. Apparently, it had flown or fallen into the cast one day, become trapped, and because of the universe enjoys comedy, managed to create enough moisture and irritation to turn my wrist into a lightly scented biological experiment. The doctor took one look and said, perfectly deadpan. Ah, this can happen. LOL. Do you see this happen, officer? Yikes. Sir, with all due respect, what do you mean this can happen? Sorry, you and me are on the same wavelength, writer. We should hang out. No part of medical school should include the phrase: insects sometimes colonize casts. That's not a thing we should accept. That's a thing we should ban with legislation. I know. They cleaned it out, disinfected everything, and gave me a new cast. This one was blue, which felt like a witness protective protection program for my arm. Before I left, the nurse gave me a list of instructions: hydration, elevation, pain management, yada yada, and then slid a new one in at the bottom. Try to avoid environments where bugs may enter the cast. Environments? What environments am I going to be stepping outside, avoid fruit, declare war on nature? The weirdest part is that I genuinely do not know how the fly got in. I wasn't gardening, I wasn't wandering through the orchids like some kind of Victorian fruit picker. I was sitting on my sofa watching parks and wreck and least hazardous environment known to man. Anyway, fast forward a month later, the cast finally came off. My wrist healed nicely, my pride slightly less so. And now I have a very irrational fear of any small flying insect that comes within three feet of me. Warranted. If a gnat even looks at my arm, I relocate. But honestly, it gave me a story, and it made me feel slightly less cursed when I listen to your show and hear that someone, somewhere out there, has had absolutely a worse day in healthcare than I did. Thanks for making me laugh at the absurd stuff, and thanks for proving that even the routine medical moments sometimes deserve their own episode of Doctoring the Truth. Stay safe and stay suspicious of this seemingly innocuous fruit fly. Love Taylor, a devoted listener with a fruit fly free arm and an anti-bug force field of pure willpower. Oh my god, Taylor, I'm obsessed with you.

SPEAKER_02: 1:01:15

You are amazing. You're so funny. What a great I mean, it's not like I hope some other mishap happens to you, but if you have others, please.

SPEAKER_03: 1:01:23

But like if you have any other ones. Please send them.

SPEAKER_02: 1:01:27

Beware of two details and um always protect your nachos at any price.

SPEAKER_03: 1:01:32

This story reminded me of another husband's story.

SPEAKER_04: 1:01:36

Oh yeah.

SPEAKER_03: 1:01:41

Maybe. Do you think we can get him on the pod to read it?

SPEAKER_02: 1:01:45

Yeah, I mean not.

SPEAKER_03: 1:01:46

Yeah, I think we should. I think he's like. Raven, do you think your dad will come on the pod?

SPEAKER_01: 1:01:53

He's kind of famous.

SPEAKER_03: 1:01:54

She's like, pick me, pick me. Raven. Oh my gosh, Raven. Actually, you have a part in the story too. You do. Oh my gosh, we should go. We should should we consult your dad about it? Yeah, I think we should. Okay, good talk.

SPEAKER_04: 1:02:12

Oi they well, with that.

SPEAKER_03: 1:02:16

What can our listeners expect to hear next week, Amanda? This age-old question. You know, I can't believe a week has already passed since we were last here. I know. And you know what? It's gonna be a surprise again.

SPEAKER_05: 1:02:31

Surprise for all of us.

SPEAKER_03: 1:02:34

But I think I know what we're doing for a medical mishap. So we've got that going for us. See, yeah. Yeah, okay. You're gonna talk to your dad about that one, right? Yeah, okay. So until then, don't miss a beat. Subscribe or following nope. Subscribe or follow us on Doctoring the Truth wherever you enjoy your podcast for stories that shock, intrigue, and educate. Trust, after all, is a delicate thing. You can text us directly on our website at DoctoringTheTruth at Buzzsprout.com. Email us your own story ideas, medical mishaps, and comments at Doctoringthe Truth at Gmail. And be sure to follow us on Instagram at Doctoring the Truth Podcast and Facebook at Doctoring the Truth. We are on TikTok at Doctoring the Truth and at oddpod e-d a u d. Don't forget to download, rate, and review so we can be sure to bring you more content next week. And until then, y'all stay safe, stay bug free, and stay suspicious. Taylor, we love you. We love you and stay on the screen. Okay.

SPEAKER_05: 1:03:41

Bye.

SPEAKER_03: 1:03:46

Okay. Oh my gosh, you're doing the moose. I was gagging about the gnat thing.

SPEAKER_02: 1:03:55

I was like, why are you gonna throw your phone?

SPEAKER_03: 1:03:57

Did you hit stop? No. Did you? Oh, we should do that. Three? Or do you want to say more? Three, two, one. Goodbye.