Bad Blood. James Baehler
have a written, signed and witnessed amendment to this will, his burial wishes will have to be carried out.”
“The only amendment I have is what he said.”
“As I said, it must be in writing and made a part of the will.”
Marilyn Wallberg rose from her chair in agitation. “Damn it! He never told me anything about anything. He had to die before I could find out what was in his mind.”
Orleans chose to view this outburst as the reaction of a bereaved wife excusable during periods of stress. “I’m sorry Mrs. Wallberg, there’s nothing I can do.”
“I know. I know. I just…I’m sorry. I just don’t know what I’m going to do.”
Her brother reached over to pat her shoulder. In a resigned voice, Marilyn said to Orleans, “Thank you. I do appreciate your kindness.”
Marilyn and her brother left the attorney’s office and drove to the funeral parlor to make arrangements to have Victor Wallberg buried in accordance with the instructions in his will. Richard consoled his sister with the knowledge that her financial situation was not as dire as she had supposed and with three months of salary to be paid, she had at least that much time to consider her options.
CHAPTER 4
Dr. Andrew Lassiter, chairman of the surgical committee, reviewed Victor Wallberg’s chart, presented the details to the committee to familiarize them with the case and to provide an opportunity to ask questions. Five days after the death of Victor Wallberg, Harris was called before the committee. Lassiter opened the discussion. He was a seventy-year-old general surgeon who still worked part time. At his age, and by medical staff rule, he was no longer allowed to take emergency room call. He was a soft-spoken, plain-looking man with a subtle sense of humor, well respected by hospital personnel. He had been chairperson of the surgical case review committee for twelve years, a position he held at the insistence of the surgeons who recognized him as totally impartial, knowledgeable, and honest.
“I thoroughly reviewed your case Cliff,” Lassiter said, “I’ve had a few congenital bands in my day, but I can’t remember one this patient’s age.”
“Yes, it’s unusual. I was surprised.”
“As I evaluate your work in the chart I do want to say that your documentation was superb, and as best as I could tell you corrected all the problems that your patient presented so acutely.”
“Thank you.”
Lassiter continued, “We have no problem with your initial operative procedure. You promptly made a correct diagnosis, and the case, although a difficult one, did go smoothly. So take it from there please. Tell us what happened after the first procedure.”
Gathering himself Harris said, “Well as you know, the patient initially left the operating room in good condition. There was no bleeding, and his vital signs, except for his temperature were all normal. After he was made comfortable in the ICU, I issued the usual written orders for the nurses and went down to the surgical locker room. While I was still there, I got a call from ICU and I rushed up to find the patient in extremis with severe pallor, tachycardia and a distended, tense abdomen. My first thought, although I couldn’t believe it, was that maybe an arterial tie broke loose and he was bleeding internally. My decision was to return him to surgery immediately. When I opened him up his belly was full of blood. I suctioned what I could, and I found no discrete bleeding source, but admittedly it was difficult through all that blood. The anastomosis was intact. But as I suctioned out the blood, more would appear, so this suggested that a DIC had developed, and indeed his fingers were cyanotic and his urinary output was nil. Since his blood pressure at that point was still stable, the significance of his physical findings took on greater meaning and impelled me to a diagnosis of disseminated intravascular coagulation. Then I had to make a rapid decision because his blood pressure was falling and he was in extremis. I gave him heparin to reverse what I diagnosed as the endstage thrombotic manifestations of DIC. But it was to no avail. The patient died.”
“So as best as you can say there was no surgical misadventure. You didn’t leave an oozer or a surgical tie that broke loose.”
“No. I don’t believe I did.”
Dr. Lassiter said, “When I started out in practice we knew of no such an entity as DIC. And I don’t recall ever having a patient who bled so profusely as did yours after surgery. Refresh my memory, doctor. I’m not ashamed to say that I need some update on DIC.”
“In an acute fulminating disseminated intravascular coagulation, clotting factors are consumed you might say, and this results in a severe bleeding tendency. It’s seen as a complication of some obstetrical emergencies, severe infections, surgery, malignancy, and shock from any cause. My patient had some of those causative triggers.”
“Yes that’s clear. What are the treatment options?”
“At milder and chronic levels of DIC, the elimination of the underlying trigger could reverse the process. In severe acute cases, such as this one, treatment is usually futile, but believe it or not heparin is sometimes used.”
“Heparin? In a patient who is bleeding? It sounds counterintuitive. I need your explanation, please.” Lassiter was skeptical but willing to listen.
“The use of heparin may be appropriate when developing thrombotic complications manifest themselves by absent urine output caused by kidney capillary bed glomerular fibrin deposition or when progressive cyanosis of the fingers and toes suggest the development of incipient gangrene. My patient had both of these clinical manifestations. It was all academic however because the patient died.”
“One unlucky guy,” said Dr. Lassiter. “I note that the wife refused autopsy.”
“Yes. She was adamant, and I didn’t argue with her, of course.”
“Does anyone have any further questions,” asked Dr. Lassiter.
Receiving none, Dr. Lassiter said, “Thank you. You’re excused doctor.”
The questions before the committee were did Dr. Harris’s treatment meet the accepted standard of care for this hospitalized patient? Did he do what any reasonable physician would have done under the circumstances? Was there any omission or deviation from the accepted standard of care? As chairman of the committee Dr. Lassiter asked the other members, “Does anyone have any questions or comments now that the doctor has left?”
One young general surgeon offered, “I think under the circumstances he did an outstanding job and was able to think quickly on his feet.”
Another surgeon said, “Frankly I wouldn’t have given the heparin, but to be honest I doubt that I would have had the smarts to think of DIC in the first place.”
“Yes, I know what you mean,” said another surgeon. “Even if I had thought of DIC, I don’t think I would have had the courage to give the heparin, because at that point the patient was clearly heading south, and there was a good chance that, regardless of what was done, it was too late. So now this doctor is on the record of giving a drug that probably had a ten percent chance of doing anything. That’s medico-legal dynamite. I’m not criticizing the therapy mind you; he has made a compelling case for what he did.”
Silent up to this point, Dr. James Philips, a senior attending general surgeon who had been on the staff almost as long as Dr. Lassiter, raised his hand.
“What is it, Jim,” said Dr. Lassiter.
“You guys are all talking as if you are qualified to make a judgment about the treatment of DIC. When’s the last time any of you dealt with a case?”
There was no response.
Finally Lassiter said, “What are you getting at, Jim?”
“What I’m getting at is this: is it appropriate for us to be giving our opinion based upon admitted incomplete knowledge about a rare event