Читать книгу Bad Blood - James Baehler - Страница 12

Following the deposition Betty Wu and Cliff Harris went back to her office to discuss what had been learned from the deposition. “You did well, Cliff. Now you see the strategy of the plaintiff’s lawyer. Raise all kinds of absurd possibilities in the hope that the jurors will become confused as to what the actual medical situation was and whether you provided proper care. Unfortunately, jurors are seldom well versed in medical matters and a malpractice trial is often reduced to a seminar on what the practice of medicine really is. The reality is that the side that feels it has the weaker case will try to confuse the jury and I am not excusing defense attorneys from using that tactic. In this office, where there is clear negligence, we strive for an out-of-court settlement. Most of the time we are successful but if the plaintiff’s attorney insists on an unreasonable amount of money, we have to go to trial and hope the jury’s award is based more on the facts of the case rather than on sympathy alone. In this particular instance I believe you have a strong case and I’m optimistic you’ll prevail.”

Cliff said, “It was kind of an interesting experience. I might have enjoyed it more if I weren’t the target. I just wish Mrs. Wallberg had allowed the autopsy. I’m sure my diagnosis would have been vindicated.”

“I was thinking of that myself, and I’m going to suggest a strategy that has some risks.”

“What’s that?”

“I’m going to suggest to you that we file a motion to have the body exhumed.”

“Really. Can you do that?”

“Yes. If the court feels the information obtained from an autopsy is essential to resolving an important issue, it can be ordered. What do you think?”

Cliff said, “What risks would there be.”

“It’s possible there might be something in the autopsy that would help the other side.”

“What could that be?” Cliff asked.

“I have no idea.” Betty Wu responded. “Maybe there was some surgical error that you missed when you went in the second time. There was a lot of blood and you admitted that it was difficult to ascertain exactly what was causing the bleeding.”

Cliff shook his head, “When I closed him up the first time everything was perfect. I am confident there was no mishap.”

Betty said, “Are you willing to take the chance that an autopsy might turn up something that would hurt our case?”

“Let’s go for it,” Cliff said. “After all, that’s what I wanted as soon as he died. However, I think the wife will fight it. She was opposed to the idea then and I don’t see why her feelings would be any different now.”

“Well, we’ll see. Let’s file the motion and let the court decide.”

“When do you think you’ll be able to file?” Cliff asked.

“As soon as I can prepare the papers.”

“Please keep me posted,” Cliff said and departed after a few more observations were exchanged about the deposition.

**********

When Barbutti received the court filing to exhume the body of Victor Wallberg for the purpose of having an autopsy performed he informed Mrs. Wallberg who shrieked, “They can’t do that. My husband didn’t want it. They have to be fought.”

“Yes, I agree Mrs. Wallberg. We have every intention of opposing it. Your husband should rest in piece.”

“Why are they doing this?” she asked.

“It’s quite simple and I don’t blame them. If they can prove your husband had a severe DIC then Dr. Harris will be proven correct and there goes much of our case.”

There was no answer from Mrs. Wallberg.

“Mrs. Wallberg?”

“Yes? I’m just thinking. Mr. Barbutti, it’s all in your hands. I just can’t bear the thought of Victor being dug up and his body sliced apart. I want you to do whatever is necessary to prevent that.”

“I’ll do all that I can, Mrs. Wallberg,” Barbutti promised fervently.

He did just that and vigorously fought the motion for the exhumation, stressing that the wife insisted her husband told her he never wanted to be autopsied, and that the dead man’s wishes should be respected.

Betty Wu fought as vigorously for the autopsy stating that although her client met the standard of care in this case, the plaintiff was raising absurd doubts meant to confuse a jury. She stressed that they had confidence in the skill of the county medical examiner to autopsy the deceased and accurately ascertain the cause of death. In addition, she said that if the plaintiff’s attorney was truly interested in the truth, he should have no objection to her motion. Betty Wu asked for an expedited decision, stating that the longer the body remained in the ground with further decomposition, the less chance there would be that the medical examiner would be able to find the actual cause of death.

In ten days the judge rendered his decision ruling that the exhumation should proceed without delay and requesting an immediate autopsy from the medical examiner’s office. Veteran court watchers had accurately predicted the decision but were surprised at the speed with which it was rendered. For once, the leisurely pace of the Cook County courts had been accelerated. The quick action was attributed to the prominence of the parties involved. Betty Wu told Cliff that under normal circumstances, the decision would not have been rendered for months. Cliff’s sarcastic response was, “I’ll have to remember in the future to make sure only corporate big shots die on me.”

Just as quickly, Barbutti filed a motion to appeal the judge’s verdict. Betty Wu’s counter filing differed in no significant aspects from her initial pleading. Once again, she appealed to the court for an expedited decision. Once again the decision was quickly rendered. Thirty days after oral arguments, the appeals court upheld the hearing judge’s ruling and Victor Wallberg was ordered to be exhumed and autopsied.

Dr. Jacob Epstein of the Cook Count Medical Examiner’s Office performed the autopsy. He was an experienced and competent pathologist in whom both sides had confidence. The results indicated that the union of the two sections of resected bowel was intact and the surgery performed was sound. There were no cut blood vessels. Cliff was in Betty Wu’s office going over the autopsy findings with her and was gratified to read that part of the report. He breathed a sigh of relief; it would be difficult for Barbutti now to claim surgical negligence in the death of Victor Wallberg.

The autopsy report further disclosed that not only had there been an abdominal cavity bleed, but there was also blood in the chest cavity, the urinary tract, and the brain. This was all grossly consistent with DIC, but when the microscopic and blood analysis was performed it was determined that DIC was not the cause of death! Cliff shook his head in puzzlement. What the hell had killed this guy? The next paragraph provided the answer. Cliff’s eyebrows rose in shock as he read further.

The pathologist concluded that Victor Wallberg died from a massive injection of heparin, which caused his uncontrollable bleeding and subsequent death. Heparin, as Cliff well knew, was a naturally produced substance that thins blood and is used with cardiac, pulmonary, and surgical patients to help prevent or treat blood clots. The presence of large amounts of heparin in Wallberg’s blood was confirmed by coagulation studies and the presence of microvascular white clots, formed by platelet aggregation alone and seen only as a consequence of a heparin overdose, not DIC.

Cliff turned to his attorney, “Betty, there is no way Sanjay could have injected this amount of heparin into Wallberg.”

“Are you sure?” Betty asked, her features showing her bewilderment. “Perhaps he made a mistake and gave too large a dose.”

Cliff shook his head, “I just can’t see it. Sanjay would have had to empty an entire vial of heparin to produce this result.”

Betty was not convinced. “Did you watch him inject the heparin?”

“Of course not. I was too busy trying to keep Wallberg alive.”

“Then how do you know he didn’t make a mistake?”

“It would be almost impossible. The normal dose is one-tenth or less of a full vial. How could a competent anesthesiologist make a mistake like that?”

Wu was insistent, “How else could the heparin have gotten into Wallberg’s blood stream?”

Again Cliff shook his head. “I don’t know. That’s what’s so crazy here. This just doesn’t make sense.”

Wu probed further, “Could one of the nurses in the operating room have taken it upon herself to administer the heparin while you were shouting at Madhava?”

“Not a chance. First, I don’t think it could have happened that way without someone seeing what was going on. Second, if a nurse did that, she would be instantly terminated and probably not allowed to work in a hospital again. I can’t tell you what a serious violation of operating room procedures that would be!”

Wu was exasperated. “Cliff, so far all you’ve done is tell me how a massive dose of heparin could not have been injected into Wallberg, yet the autopsy says that is exactly what happened. How can you explain that?”

In a confused voice, Cliff said, “Betty, I can’t explain it. This is just inconceivable. If the autopsy weren’t so conclusive, I would assume that a mistake had been made. All I can tell you is that a large amount of heparin was administered to Wallberg but there is no way it could have happened.” He uttered a small laugh of disbelief at his own words.

”This is ridiculous!” Wu cried out in frustration. “If you didn’t administer the heparin, and Madhava didn’t, and the nurses couldn’t, then how the hell did it get into the man?”

Equally frustrated, Cliff said, “I don’t know, Betty. I just don’t know.”

With an effort, Betty Wu regained her composure. “All right. Let’s settle down. We’re not getting anywhere like this. Let me think for a minute.” She closed her eyes, mentally reviewing the case.

After a minute or two she opened her eyes and smiled at Cliff. “Well, there’s one thing for certain here. There’s no basis for a negligence suit against you. On the basis of the autopsy report I am going to ask the court to remove you from the list of defendants.”

Cliff brightened, “Will the judge do that?”

“Why not? The cause of death is a massive dose of heparin and no one is claiming that you could have done that. The way I see it, the hospital is on the hook because there had to be negligence somewhere for this to happen. And Madhava is not in the clear. You say it’s impossible for him to administer an overdose but I guarantee you that Barbutti won’t see it that way.”

“Betty, I don’t know if Sanjay made a mistake or not. But I am not going to rest until I find out how that much heparin got into Wallberg’s bloodstream.”

Wu was skeptical. “How do you propose to do that?”

“I don’t know. All I do know is that I can’t just close the book on this and not know how a patient died while under my care.”

Wu thought for a moment and said, “Let me ask this, how long would it take for a dose of heparin this large to manifest itself?”

Cliff thought for a few seconds and said, “There’s no way to be sure but it could be anywhere from fifteen minutes to half an hour.”

“Why the difference?”

“It depends on the patient’s speed of circulation of blood and where in the IV line the port is located into which the heparin is injected. There may be a high port that goes right into the IV bottle and if you inject into that one the heparin would eventually go into the lower part of the IV bottle after dilution. Then it would take longer to fully get into the blood stream as it has to travel down the IV tubing before it gets into the patient’s body. There is a lower port where the needle or the cannula goes directly into the vein. That’s the port we use when we’re in a hurry to get the medicine in.”

Now Wu was completely confused, “You mean the heparin would not be injected directly into a vein?”

“No, we can’t take time to locate a vein and probe with a needle every time a medication needs to be provided to a patient. That is one of the functions of the IV line, which has the two ports that allow the insertion of a syringe and the introduction of whatever medication has been ordered. Now, if I want a medication to take immediate effect, as I said, I will order it given quickly in one shot. That is known as a bolus and is given in the port close to the vein in the back of the patient’s hand or arm.”

Wu said, “Okay, I got it now. So the higher the port where the medication is injected, the longer it takes to reach the patient. In your case with Mr. Wallberg you wanted to give it fast so the port next to the vein was used. Right?”

“Correct.”

Wu followed the explanation. “Okay, so in this case there might be a lag of at least fifteen minutes and as much as thirty minutes before the overdose of heparin caused the rapid heartbeat and evidence of bleeding that brought Wallberg back to the operating room.”

“That’s reasonable.”

“Let me ask this,” she said in a thoughtful tone, “after surgery you saw Wallberg in the ICU, gave written orders to the nurses there, and spoke briefly with Mrs. Wallberg, right?”

“That is correct,” Cliff replied wondering where all this was going.

“How long did all that take?”

“I don’t know. Five or ten minutes at the most.”

“Then you went down to the surgeon’s locker room and had some orange juice before you received the call from Intensive Care, right?”

“That’s right.”

Wu leaned forward staring intently at Cliff. “From the time you left the ICU until the call how much time had expired?”

Cliff thought for a moment. “I’d say twenty to twenty-five minutes.”

Wu leaned back in satisfaction and said, “Here’s another way it could have happened; someone administered the heparin to Wallberg after you left the ICU.”

Cliff reeled back slightly in amazement. “You’re saying one of the ICU nurses gave Wallberg the overdose?” His face registered extreme disbelief.

“Somebody did,” Wu said with certainty. “If it wasn’t a nurse, who was it?”

Vehemently, Cliff protested, “But I left no orders for heparin to be given to Wallberg! There’s no way a nurse could have misunderstood.”

Wu remained unperturbed, “What exactly were your orders?”

“Morphine as needed for pain, an antibiotic every six hours, continued gastric suction and of course nothing by mouth. As with any patient, I would check back after my surgery schedule the next day to see if any change in the orders was warranted. That was it.”

Wu pressed on, “Were these handwritten orders you issued?”

“Yes,” Cliff replied, “and I see where you’re going with this. Unlike many doctors, I have always prided myself on the legibility of my handwritten orders. In fact, they’re printed, not written, so there can be no possible misunderstanding. There is no way anything on those orders could have been interpreted as calling for heparin.”

Wu was not dissuaded. “Is it possible one of the nurses made a mistake?”

“What kind of mistake?” Cliff asked defensively.

“Is it possible that a nurse gave Wallberg a shot of heparin instead of morphine?”

Cliff was outraged, “She would have had to be dead drunk to make a mistake like that. The vials in the drug cabinet are clearly marked. How could she read a label that says morphine and think it was heparin?”

“I don’t know,” Wu replied calmly. “All I know is that someone gave an over dose of heparin to Wallberg and if it wasn’t Madhava then one of the nurses looks like the most likely suspect.”

Cliff shook his head in disagreement. “I just can’t see that happening.”

“All right, how about this? Could the vial of heparin been mislabeled as morphine?”

Cliff thought for a moment. “I suppose that’s possible but I have to tell you, it is highly unlikely. The vials are labeled by the manufacturers and it is hard to imagine that on an assembly line in a pharmaceutical plant one vial could receive a wrong label. I suppose it’s possible that an entire run of vials could be mislabeled but if that had happened, all the hospitals that received a shipment from that run would have been notified.”

Wu smiled complacently. “Dr. Harris, we’re talking about human beings here and any time humans are involved, errors are not only possible, they are inevitable.”

“I can tell you this, there were no reported instances of mislabeled vials, either before Wallberg died or after. So the scenario you outlined was only possible if one vial was mislabeled and that seems extremely unlikely.”

“Dr. Harris, everything about Wallberg’s death seems most unlikely. We only know two things for sure, he’s dead and an overdose of heparin killed him.”

Harris could not reply and they stared at one another for a few seconds before Betty Wu said, “I’m sorry, there are three things we know for sure. The third thing is that a jury will find the hospital negligent. Even if it is never determined exactly how the heparin got into Wallberg’s body, there is no way it could have happened without someone in the hospital doing something wrong somewhere along the line. I’d say you’re in the clear and the hospital is going to have to pay and pay big.”