When Selby was training, the surgery was still largely experimental. Facing much less demand for organs and less regulation than today, "we wouldn't think twice about transplanting a liver into a patient in critical condition, watching it fail and then trying again or even a third time," said Dr. Maureen Martin, a former transplant surgeon who worked with Selby in Pittsburgh for seven years.
"What we did 15 years ago, we certainly wouldn't do now," said Martin, now chairwoman of surgery at Kern Medical Center in Bakersfield.
She described Selby then as a quiet man, inclined to stand up for the underdog. "He didn't care about making big bucks and becoming super famous," she said.
By the time he opened USC's program in 1996, five liver transplant centers were vying for organs in the area. UCLA cast a long shadow, dwarfing the others in both size and prestige.
Selby "got into a very competitive neighborhood," said Dr. John J. Fung, director of Cleveland Clinic's transplant center, who worked with Selby in Pittsburgh. "It's hard to compete against a 900-pound gorilla."
Still, Selby, now 56, developed a reputation as a skilled surgeon, committed to his patients.
"If I needed a liver surgeon, I'd probably go to Rick," Fung said.
USC steadily picked up speed. It went from four liver transplants in 1996 to 92 last year. Although it still performed fewer than half as many as UCLA, it outpaced all but 22 programs nationwide. Along the way Selby added five transplant surgeons to his staff. His brother, Brad, took over as administrator.
Within a few years of the program's opening, patients were surviving their transplants at a greater rate than expected, according to a government-sponsored analysis.
In a field where death was common, USC seemed to be beating the odds.
Statistics take a turn
Sometime in 2003, however, the program's fortunes turned: Patients began dying more often than they should have.
At USC, fewer than 76% of the patients who received a transplant from January 2003 to June 2005 survived at least a year, according to statistics released in July of this year. The program's expected survival rate was 86% -- about the national average.
The difference may seem small, but in a program that performed dozens of transplants a year, the numbers added up.
Relatives of more than 10 people who died said they didn't receive satisfactory or complete explanations.
"They just said, 'We don't know what happened,' " recalled Annette Ostoich, whose 54-year-old husband died during transplant surgery in August 2004.
Said Griselda Luna, whose 36-year-old sister, Sandra, died the same month: "After she passed, the doctors wanted her to have an autopsy.... They were puzzled."
When asked in July about the extra deaths, Rick Selby offered technical explanations that were at odds with statistics and the views of transplant experts. "It's clearly not because we don't know what we're doing," he said.
He has since declined to comment. In their statement, USC and the hospital suggested that the national data didn't reflect just how sick their patients were, perhaps making survival expectations artificially high.
Although the statistics are adjusted for the condition of patients and donated organs, they do not take into account every possible risk factor.
According to medical and internal records, USC was taking in patients with serious coexisting conditions -- bacterial infections, vascular disorders and extremely low blood pressure -- that experts say would have ruled out transplants at more conservative programs.
The high post-transplant death rate was not the only statistic that raised questions about the program: USC patients also had a greater chance of dying before surgery.
In 2005, USC's was the sole liver program in California that had significantly more deaths than expected among patients awaiting livers. Fifty-eight USC liver candidates died, about 14 more than statistically expected, according to the Scientific Registry of Transplant Recipients.
Among other things, experts said, this suggests that USC may have been choosing poor candidates for liver transplantation or not managing their cases well.
Fung, director of the Cleveland Clinic's transplant center, said programs have a responsibility to study their survival statistics long before national data are released.
"You use your own database and follow your outcomes and make mid-course adjustments," said Fung, who added that he reviews his program's performance monthly.
Referring to USC, he said, "I think they would want to figure out why they had all these extra deaths."
But as its death rate crept upward, USC continued to take chances.
Fatty livers sought out
Pam Deneau recalls her giddiness in July 2003, when a liver and kidney became available for her critically ill husband, Scott.