Читать книгу Bad Blood - James Baehler - Страница 11

The defense teams for the two doctors were pleased with the confidence of their expert witnesses. But this did not mean that the plaintiff’s attorneys were worried. Barbutti recognized the fact that he might have difficulty finding an expert in hematology to testify against Dr. Harris, so prior to his even trying he lined up a witness who dogmatically stated that Dr. Harris did not meet the standard of care. “No one in his right mind would use heparin under those circumstances,” he said. “He contributed to the patient’s death. Yes the patient was in extremis when he had the heparin injected, but that gave him the little extra push needed to send him to his maker.” This expert was Dr. Albert Burns, a thirty-year-old family practitioner, whose uncle was a prominent personal injury attorney. Dr. Burns was the exception to the rule in these times, electing a solo primary care practice in the days when solo practitioners were becoming a dying breed. The income from testifying in a number of trials was substantial and could sustain one while attempting to build up a practice. Dr. Burns was available to testify about a variety of medical situations and plaintiff’s attorneys were learning that he was reliable and cooperative.

Dr. Drossman was correct in his assumption. The two surgeons recruited by Barbutti to evaluate whether Dr. Harris met the standard of care, wrote back that they found no fault with his diagnosis or treatment, and that he did indeed meet the test of the accepted standard of care.

Not discouraged, Barbutti recruited a general surgeon, retired, from southern Illinois. Dr. Steve Dwyer was willing to testify that in his opinion, “Giving heparin under those circumstances was reckless, and playing God. Yes, when the patient’s blood pressure began to drop and there was no urine output it probably meant that death was imminent. At that point you’d have to be crazy to do what Dr. Harris did. There was little hope for the patient but what Harris did was seal his doom.”

Barbutti’s anesthesiologist expert witness, Dr. Adrian Tennant said, “This was a classic case when the anesthesiologist had every right to tell the surgeon to go to hell.”

“Isn’t the anesthesiologist required to follow the surgeon’s orders?”

“Once in a great while you have to stand up and be counted and go on the record for all to hear. I disagree and will not be part of this idea that an anesthesiologist has to do whatever the surgeon says, no matter how idiotic the demand. Dr. Madhava didn’t have the balls to refuse, so now he’s paying the price.”

The lines of battle had been drawn and were clear and distinct.

**********

Dr. Harris continued his busy surgical schedule. In the operating room his intense concentration allowed him to forget his pending lawsuit. The advice of the attorneys to keep quiet was observed by all concerned, but this, in and of itself, was insufficient to keep the filing of the suit secret. One needed only to read the Cook County Jury Verdict Recorder to learn about every malpractice suit filed each month in the county. The lawyers, after giving the advice to keep quiet, always added, “Everyone will find out soon enough, no matter how quiet you are, so just do your best to ignore the talk and concentrate on your work.”

The next stage in the process was the taking of various depositions. Attorney Betty Wu would be deposing Attorney Barbutti’s experts, and Barbutti would be deposing Betty Wu’s experts. Dr. Harris was told, “As the defendant you have every right to attend whatever deposition you want.” Cliff decided that suffering through his own deposition was more than sufficient. Cliff’s deposition was taken at Barbutti’s office. Harris was ushered into a large conference room where numerous strangers were in attendance. He felt as if he had been called before a congressional committee. The first to speak was the videographer. He read the details of the prodedures involved. The court reporter said, “Doctor, would you raise your right hand.”

Dr. Harris, somewhat overwhelmed by the formality, did so and was sworn.

The videographer said, “Would the attorneys like to identify themselves for the record, please.”

“Vincent Barbutti for Marilyn Wallberg.”

“Betty Wu for Dr. Clifford Harris.”

“Paul Stuart for Dr. Sanjay Madhava.”

“Thomas Luria for Barrington Community Hospital.”

“Thank you,” said the videographer.

Vincent Barbutti said, “Dr. Harris, may I have your full name please?”

“Clifford Brian Harris.”

“You are a general surgeon?”

“Yes.”

“Your medical school, Doctor?”

“Northwestern University.”

“Residency was taken where?”

“Illinois Research Hospital.”

“Are you Board Certified in surgery?”

“Yes.”

“Your hospital affiliations, Doctor?”

“Just one. Barrington Community Hospital.”

“Have you spoken to anyone about this case?”

“Yes.”

“Who?”

“My attorney, and of course my wife knows.”

“I mean anyone besides those two.”

“No. No one.”

“Doctor, I would like to ask whether you have reviewed any documents in connection with your deposition today?”

“Yes.”

“What records have you reviewed?”

“The patient’s chart.”

“Victor Wallberg’s chart?”

“Yes.”

“When you reviewed the chart, doctor, did you find that you had second thoughts about the use of heparin?”

“None.”

“Would you have met the standard of care if you did not use heparin?”

“I don’t understand,” Cliff replied.

“Objection to this line of questioning as to relevancy and form,” said attorney Wu.

“Join,” said attorney Stuart.

Barbutti quickly added, “You can still answer the question, doctor.”

Dr. Harris turned to Betty Wu, his eyebrows lifted as if to say what do I do now? Then he turned to Attorney Barbutti, and said, “I don’t understand why I’m being asked a question about what I didn’t do. Clearly I gave heparin convinced in my mind that I was doing the right thing. If you’re asking me about another physician’s action, my answer would be, I don’t know what any other physician would do.”

Barbutti said, “I understand in medicine that there may be many different methods to treat each patient for a specific illness. I just want to know if this applies here.”

“I’ll say again, I don’t understand the relevance. Don’t you have to prove that my treatment did not meet the standard of care for this case? That’s what I thought this was all about. I’m well prepared to defend my action, not to discuss what another doctor may have done under similar circumstances.”

Barbutti was not to be deterred. “Do you think it would have been proper not to use heparin on Mr. Wallberg.”

“I thought I just answered that.” Cliff had become irritated and it showed.

“The question calls for a simple yes or no, doctor.”

Testily, Cliff replied, “I don’t care how many times or how many ways you ask the same question. My answer will be the same. I did what I had to do, and what I did met the accepted standard of care.”

Barbutti realized he was at an impasse; there was no way Dr. Harris was going to admit that no heparin would also be appropriate in Wallberg’s treatment thus opening up doubt in the jurors’ minds. He would have to change tactics and open up another line of questioning, perhaps returning to this issue at a later and unexpected time. “Tell me, doctor, about the argument you had with the anesthesiologist Dr. Sanjay Madhava.”

“Objection,” said attorney Stuart. I object to form. The question is argumentative.”

“Same objection,” said attorney Wu.

“Join,” said Attorney Luria.

“You can answer, doctor.” Barbutti said.

“I did not have an argument with Dr. Madhava.”

“But you insisted he give heparin to your patient when he didn’t want to.”

“Yes, I would say he was reluctant to do so, but when I explained to him the necessity, he gave it.”

“Are you saying he didn’t know anything about DIC?”

“You just said it. I didn’t.”

“But did he know anything about it?

“Objection,” said attorney Stuart.

“Join,” said attorney Wu.

“You must have an opinion about that, doctor,” Barbutti persisted.

“I do. Neither Dr. Madhava nor I are experts on DIC. Thank God I have only been subjected to this deadly condition about three times as I can recall. One was a patient in severe septic shock following trauma, the other was a patient with a metastatic malignancy, and the third was Mr. Wallberg. But I remembered exactly what had to be done in order to attempt to reverse this process. I did it. And Dr. Madhava to his credit followed my instructions. Also to his credit he demanded a reason to use heparin and when I gave it he complied. So if you want to characterize that as an argument, there’s nothing I can do about it.”

Barbutti referred to his notes and said, “Let me offer a quote of what you actually said in the operating room to Dr. Madhava. Quote, ‘There’s no time for didactics, damn it. Am I going to have to scrub out and do it myself? There’ll be shit to pay if that happens.’ End of quote. Does that sound familiar, doctor?”

Calmly, Harris replied, “Yes, I said that.”

“That sounds like an argument to me.”

His composure intact Dr. Harris said, “Yes, I could understand why anyone who heard that statement would think I was arguing, but I wasn’t. Time was running out on Mr. Wallberg. Dr. Madhava was unsure and that resulted in his reluctance. Yes, I used those words. I had to stress the urgency. If you had my entire discussion during that time you would also have me explaining my rationale for the heparin to Dr. Madhava. Once he heard that, he complied with my order. Never forget that we work as a team in surgery. Patient welfare is paramount.”

“Don’t you agree that not to use heparin could meet the accepted standard of care?”

“You’re asking the same question again.”

“Yes or no doctor.”

“All I know is I met the standard.”

In a challenging tone, Barbutti said, “What if I were to tell you that I had experts who would have never used heparin?”

“Then I would tell you that your experts don’t understand the pathophysiology of DIC and are unable to recognize the late clinical manifestations of the disease.”

“You would disagree with experts?”

“I would first need to have the word expert better defined.”

That stopped Barbutti. He was not about to put on record that his expert was a thirty-year-old general practitioner. He changed the subject. “Let’s go back to the beginning doctor. Describe your first contact with Mr. Wallberg.”

“I arrived home from work, and received a call from Mr. Wallberg. He was home and I could tell by his voice that he was in great distress. He lived next door and I went to his house to determine the problem.”

“Were you his personal physician?”

“No. I never saw him as a patient before.”

“And your findings?”

“All consistent with an intra-abdominal catastrophic event.”

“I need details of your physical findings, doctor.”

“Yes, all right. His appearance was that of a man in severe pain. Facial grimace, wrinkled brow, anxiety, bent over almost ninety degrees, belt open and pants zipper unzipped.”

“Unzipped pants? What does that tell you?”

“He was relieving the distention of his abdomen.”

“Bent over ninety degrees?”

“Same reason.”

“What was there about his abdominal findings that led to your diagnosis?”

“His abdomen was distended and his bowel sounds were high pitched. That suggests obstruction. He had vomited three times and that is consistent with obstruction as well. His abdomen was tender and he had rebound tenderness.”

“And what is rebound tenderness?”

“Press the abdomen with your fingers, release quickly and severe pain is felt.”

“What does that tell you?”

“It suggests that the peritoneum is irritated or infected. The peritoneum is the thin membrane that lines the wall of the abdomen and covers the organs in it.”

“Does that mean surgery is necessary?”

“Not necessarily.”

“What brought you to the decision to recommend surgery?”

“My clinical judgment confirmed by x-rays that proved an intestinal obstruction.”

“Do you always have to treat intestinal obstruction surgically?”

“Not necessarily. Sometimes conservative measures are effective.”

“Why didn’t you use conservative measures?”

“He had a severe obstruction proven by x-ray. For all I knew his intestine was already gangrenous.”

“But you didn’t know that.”

“But I was worried about the possibility.”

“So, perhaps conservatism might have worked?”

“Not a chance. His x-rays showed advanced obstruction.”

“How can you be so sure? Perhaps if he had been treated conservatively he’d be alive today.”

“I wish you were right, but you aren’t. He also had a congenital band, which resulted in an obstruction of the small intestine. Some of his intestine was gangrenous and adjacent parts were pre-gangrenous. Those parts had to come out. You don’t survive gangrene of the bowel unless it’s removed.”

“What about his vital signs when you first saw him?”

“Pulse was 116 and regular. Respirations were 30 per minute.”

“Blood pressure?”

“It was 120 over 70.”

“So he wasn’t in shock, doctor?”

Dealing with the medical situation, Cliff’s equanimity had returned. “Probably not. I have no knowledge of his blood pressure under normal circumstances.”

“Could your patient have had DIC before you took him to surgery.”

“It’s not impossible. He had the prerequisites for the syndrome.”

“Did you think of that possibility?”

“Specifically, no. I just knew that such a complication could occur and that’s why I was prepared for it when his clinical story suggesting DIC began to manifest itself.”

“Would one operate on a patient if he had DIC?”

“A patient like Mr. Wallberg?”

“Yes.”

“Yes, if the risk of not operating is greater than the risk of DIC.”

“It would be dangerous wouldn’t it?”

“Yes, but at the same time it would be therapeutic. DIC will resolve itself if the underlying condition is corrected.”

“Then why didn’t Mr. Wallberg’s DIC resolve itself when you corrected his surgical catastrophe?”

“You’re assuming he had a DIC to begin with. I don’t assume that.”

“Why?”

“Well for one thing, my clinical judgment. Also, I ordered a great many studies to determine his pre-operative status.”

“And?”

“These results came back and the platelet count was not indicative of DIC.”

“What was the platelet count?”

“135,000.”

“What’s normal?”

“150,000 to 400,000.”

“Your result was a little low, correct?”

“A little. If you’re suggesting that a slightly reduced platelet count always signifies DIC then you’re plain wrong. Many people with slightly reduced levels have no problems of any kind.”

“What other tests did you do for DIC?”

“Prior to surgery?”

“Yes.”

“None except for a routine complete blood count that is mandatory for surgery.”

“Why not.”

“At that stage I really had no reason to believe the patient had DIC.”

“Maybe you were wrong.”

“Maybe? I don’t think so. What I did met the standard of care. I ordered all the proper studies prior to surgery necessary for the circumstances.”

“But the platelet count was a little low. Maybe DIC was starting.”

“I explained that once. Even if I had diagnosed DIC, he still needed the surgery. And if he really was beginning to get DIC the surgery was his best chance for nipping it in the bud. Remember the best cure for DIC is the elimination of the precipitating cause, which in his case may have been the intestinal obstruction and gangrene of the bowel.”

“Let’s talk about the surgery, doctor.”

“Lets. What do you want to know?”

“What did you do?”

“I resected a gangrenous and pre-gangrenous bowel, and removed it along with the congenital band that that had caused the intestinal obstruction. I then anastomosed the healthy ends of the bowel.”

“There must have been a lot of bleeding?”

“Surprisingly little.”

“One would have to assume that a man who bleeds extensively after surgery did so because you missed or improperly tied off an artery.”

“That is the first thought that every surgeon would have if bleeding occurred after surgery.”

“So you thought that?”

“Yes I did, but I had a hard time believing that to be the case, because when I closed him up he was dry. I stress dry. There was perfect hemostatsis.”

“Then why did you re-operate? Why didn’t you diagnose DIC?”

“I had no reason to think it was DIC. Bleeding in the abdomen after abdominal surgery is assumed to be due to a leaking blood vessel until proven otherwise. I had to act. Re-exploration was mandatory.”

“Was he in shock?”

“Not yet. His blood pressure was low normal. But going into shock was a definite risk. That’s why I had to act fast.”

“Why did you remove the urine from the Foley bag?”

“I wanted to be able to exactly measure urine output, if any during surgery.”

“The record states that you found no bleeder.”

“That’s correct.”

“It was difficult surgery, wasn’t it?”

“Yes.”

“Then you admit, it might have been possible for you not to find a bleeder.”

“I looked very hard. In spite of the abdominal blood I believe I got a good enough look to say emphatically there was no specific bleeder. The bleeding I would characterize as a slow diffused ooze.”

“How were his vital signs through all this?”

“They remained stable.”

“But it says in the record the blood pressure was seventy over twenty. Do you call that stable?”

“You’re jumping ahead of the story.”

“What do you mean, doctor?”

“While I was sucking out the abdominal blood, his blood pressure was stable. And when I found no bleeder, and the blood continued to ooze, I began to think of DIC. So I immediately asked Dr. Madhava to check the patient’s fingers and asked the nurses to check the Foley bag for any urine. I was told that the fingers were dark blue and the Foley bag was empty. That’s when I began to think that DIC was present and was rapidly progressing to the end stage where thrombus forms and plugs up vessels causing gangrene and kidney failure.”

“Hold it doctor.”

“What?”

“This man was heading into shock. Isn’t that enough to explain the blue fingers and empty Foley bag?”

“Then the prognosis would be grave and the patient would need vasopressors. But remember, his blood pressure was still holding up when I asked for the appearance of his fingers and Foley bag check for urine output. It would be unusual to see such intense finger cyanosis while the blood pressure was still satisfactory. Yes, he could have some reduced urine output at that time, but the oozing of blood and the intense cyanosis of the fingers plus the absence of urine output, all in the presence of a pretty good blood pressure, to me meant DIC. I was about to order heparin when I was informed by the anesthesiologist that the patient’s blood pressure was falling, seventy over twenty to be exact. The heparin was given. It was a last ditch effort. I had no choice.”

“Others would not be so venturesome, or foolish as some might choose to call it.”

Cliff’s anger was re-ignited. “I’ll defend my actions until the day I die. I understand your tactics. You will throw so many variables into this equation that the average person will be thoroughly confused. Then it will be a battle of the experts, but whatever the outcome, my conscience is clear.”

“We’ll just present the facts, doctor.”

“Yeah, right. I’ll do the same.”

“Your notes say the patient’s wife refused an autopsy.”

“That’s correct.”

“How hard did you try?”

“To get her to approve an autopsy?”

“Yes.”

“I simply asked and she just as simply and emphatically refused.”

“How hard did you try?”

“I asked. She said no. I accepted her decision but I wasn’t happy. I will always have to wonder about this case.”

“Wonder what.”

“Every time a doctor loses a patient, especially a young one like Mr. Wallberg, you replay it over and over in your mind. I suspect I will for a long time, but I have to bring it under control for I have many other patients that need my concentration. It’s something you learn early in your career, and if you don’t learn it, then your efficiency will be reduced and that’s unfair to your other patients.”

Barbutti sat silent for a few minutes looking through his papers. Looking up, he said, “I think, doctor, we can end this deposition now. I invite any of the other attorneys present to ask questions of the deposed.”

Betty Wu said, “Dr. Harris, how did you get to the hospital with Mr. Wallberg?”

“I called my wife to let her know what was happening and had her call an ambulance while I did my best to relieve the patient’s distress.”

“And you rode in the ambulance with the patient. Is that not so, doctor?”

“Yes.”

“Thank you doctor.”

Paul Stuart, Sanjay Madhava’s attorney asked, “Tell me doctor, have you been doing surgery since the Wallberg case?”

“Yes many times.”

“Have you worked with Dr. Sanjay Madhava?”

“Yes several times.”

“How is your relationship?”

“Good.”

“Does he show any animosity toward you?”

“Not that I am aware of. Immediately after Mr. Wallberg died, Dr. Madhava arranged not to scrub in with me for a while but since then we have worked together without a problem on a number of cases.”

“And you bear no animosity to Dr. Madhava?”

“None whatsoever.”

“Thank you, doctor,”