Ultimate Malpractice

Rogers

CHAPTER ONE

The polished stainless steel blade sliced cleanly through the skin and subcutaneous tissue. A trickle of blood ran down onto the pubis and was ignored. A man was lying on the table with a grossly distended belly. He looked nine and a half months pregnant.

Dr. Thomas MacAlister glanced quickly at the anesthesiologist before taking a trocar (a slim hollow tube through which instruments are passed) from the scrub nurse. He cocked the odd looking instrument and then thrust it, rather violently, into the abdomen. It was nearly four thirty in the morning. He’d been up since three following a call from the emergency room. A thirty-eight year old man drove himself to the hospital with a history of localized pain in the right lower side of his abdomen. The pain progressed to involve most of the right side of the abdomen and toward the lower midline. The patient’s name was Tony Hubbard and he was, except for diabetes which was well controlled on insulin, in reasonable health. He was a lawyer.

After introducing himself in the emergency room, Dr. MacAlister asked, How long have you had this pain?

About four days, Doc, and it’s getting much worse. I was finishing up a trial and couldn’t get away—hey, gotta be able to pay your bill, you know, chuckled Hubbard. This triggered another spasm of abdominal pain. His eyes narrowed.

I really don’t like being called, ‘Doc.’ You might try Dr. MacAlister. This isn’t funny. You have an advanced and serious abdominal problem here. It didn’t have to be this way. You got me up in the middle of the night with a problem that’s been going on for four days. This emergency sort of thing is preventable. Didn’t you feel pain? How could you let this happen? Don’t you have partners who cover for you?

Yeah, I’ve got a partner, but this wasn’t his trial. It was mine. He’s not getting any part of it. Why don’t you just tell me what’s wrong, and get started taking care of it.

The surgeon, after checking the patient’s head, neck and chest, began feeling the abdomen. The liver was not enlarged, although feeling deeply in the right upper side caused the patient to groan. As he felt lower, the muscles became rock hard. The tenderness was such that Hubbard impulsively, forcefully grabbed the doctor’s left hand.

Please don’t do that when I’m examining you, barked the physician. We can get this over with faster if you let me do my job. Then he pushed deeply into the left upper side of the abdomen—where there was no tenderness or pain—and suddenly snapped his fingers out. The lawyer shrieked, writhing on the examining table. ‘That’ll teach him.’ thought MacAlister, and then he said solemnly, This tenderness indicates the infection is localized to your right lower quadrant where the appendix is. The physical was completed with a very uncomfortable rectal examination.

Dammit Doc, did you train with the Spanish inquisition? groaned Hubbard. I’m going to make sure your next screw up comes to me. That’s what I’m good at. You’ll be worrying about a lot more than your beauty sleep.

MacAlister couldn’t believe how this lawyer was addressing him. This Doc business—what kind of a guy calls the surgeon something he asked him not to, particularly at this ungodly hour. Mr. Hubbard, I don’t think it’s a good idea to ruffle your under-slept surgeon as he’s about to operate on you.

Blood and urine samples, as well as a chest x-ray, had already been done and with the results in hand, the surgeon again approached his patient and began discussing the results of the lab tests and his examination.

Your blood pressure is elevated, but that’s expected under these circumstances. Your blood sugar is also high, but that happens when a diabetic gets an infection. I can handle that with insulin and close monitoring of your blood sugars. The urinalysis showed some red cells in the urine and this could be from a disease in your right kidney, although advanced appendicitis could show the same thing. The infection also caused an elevation in your white cell count, which is your body’s defense against infection. I can’t rule out a less common diagnosis such as ‘diverticulitis’ involving the right side of the colon. Actually, the list of possible causes is lengthy, and could include a fishbone perforation or a tumor.

A tumor? … Are you telling me I might have cancer? That’s a pretty casual thing to toss out. What kind of a doctor are you? exclaimed Hubbard.

I doubt a malignancy is involved, said Dr. MacAlister, but it’s a possibility. You might be familiar with the oft-used expression among doctors trying to put a finger on a diagnosis; ‘Hoof beats don’t always mean horses—sometimes they’re zebras’.

Hubbard cut him short with his trenchant wit: What about unicorns?

The ensuing silence was deadly. The tension was thick, and clearly the surgeon was restraining himself with difficulty. "I believe you have advanced appendicitis, possibly ruptured with an abscess. You need surgery immediately. After the anesthesia doctor puts you to sleep, I’ll make a small incision in your belly, distend your abdominal cavity with carbon dioxide and introduce a hollow tube called a trocar. When I put a camera through the tube, the gas will allow me to see what’s going on. Hopefully, I’ll be able to remove the appendix using several other small incisions for surgical instruments. If the infection is too extensive, especially with an abscess—or if you’ve a more serious diagnosis such as a perforated colon diverticulum—a larger incision will be necessary. In an extreme situation, a colostomy might be needed.

I’m going to ask you now to sign a statement saying I’ve discussed this plan with you, and informed you of other complications. A heart attack, infection, pneumonia and death, are possibilities.

What’s this, doctor? Death is quite a complication. You’re sounding more and more like a damn lawyer. Let’s get on with it and get me the hell out of the hospital. Gimme the paper—but I’ll tell you this—kidding aside, I’m glad you got out of bed for me. Just don’t mess up, or I’ll take your house, your money and maybe your wife.

MacAlister laughed and brushed Hubbard’s comment off. You’re welcome to all of them—except I don’t have a wife. Nurse, call the O.R. crew and get this man ready for surgery.

Although Dr. MacAlister had been in and out of operating rooms for the last twelve years, he never tired—as he was scrubbing his hands and lower arms with the disinfecting iodine soap—of gazing through the plate glass window. There was the burnished green tiled room, the operating table, the powerful overhead lights, the scrub and circulating nurses and the glistening array of sterile instruments. The anesthesiologist, sitting next to the large piece of equipment which would deliver oxygen and gas mixtures to the patient, was readying the plastic tube which would be placed through the vocal cords, into the main bronchus leading to the lungs. The operation would begin in a few minutes. MacAlister felt good, knowing he, and he alone, was the one in charge.

A needle was inserted and the abdomen was distended with carbon dioxide so all the organs could be seen and the surgeon had room to operate. Once the trocar was in place, the camera was inserted through the tube and into the abdomen. A brief look around showed the liver, gallbladder, stomach and spleen were normal. The appendix couldn’t be seen as loops of small intestine and fat from the greater omentum (a fatty apron hanging down from the upper part of the colon) was stuck to this area.

Dr. MacAlister asked the third nurse, acting as his first assistant, to hold the camera while he inserted two other trocars through the abdominal wall under direct vision. Then he slid two jawed instruments through the tubes into the abdominal cavity. The nurses, exchanging glances, could hear him muttering to himself, as he realized this was going to be a difficult dissection.

Son of a bitch! He would be a lawyer, growled the surgeon, as he pushed and pulled on the omentum and intestines trying to find the exact location of the appendix itself. The appendix is a three-inch hollow worm-like organ which, like the big hand of a clock, can rotate its tip in any direction. If it folds itself under the cecum (the first part of the colon), it’s particularly hard to find and remove. Infection starts at the tip. Eventually, the surgeon was able to follow the right side of the colon back down toward the cecum from which the appendix is suspended.

MacAlister’s frustration was manifest in the more forceful movements of his instruments. Sarah, the young assistant nurse holding the camera, started to say something, and then thought the better of it. The doctor looked up and barked, What?

When you were … pulling on it like that, I was … just worried … the intestine might tear. muttered the young nurse. Helen, an experienced scrub nurse, grimaced and shook her head at Sarah—but it was too late.

The suddenly flushed face of the surgeon above his mask made his anger obvious to everyone. Hey, if you know so much, come around here and do it yourself. I don’t appreciate crap from you in the middle of this mess. Shut up and stop shaking the camera.

The movements of the surgeon’s instruments, seen inside the abdomen on the two television monitors at the head of the table, became even less cautious and increasingly rough. Instead of employing the classic and safer technique of following the cecum itself to the base of the appendix, MacAlister began pulling on the fat and small intestines where they were stuck to its infected tip. Suddenly, yellow pus flowed out from underneath the colon and over the small jaws of both surgical instruments.

God damn it, I warned him there might be an abscess. Give me the sucker, start antibiotics and send a culture off to the lab shouted MacAlister.

The pathology became obvious as he moved the sucker into the abscess cavity. The appendix tip had rotated underneath the cecum, burst, and formed an abscess. So far, the surgeon’s vigorous dissection hadn’t done harm, except for some superficial abrasions and tears on the outermost layer of the small intestine and some oozing from the omental fat. He still had to remove the infected, ruptured appendix. The tissues in the area were red and swollen from the effects of the infection. The rest of the operation would be difficult … even in the best of hands.

Unhappily, earlier in the previous evening, Dr. MacAlister had another argument with an ex-wife. It upset him. He hadn’t slept more than a couple of hours, fitfully, tossing and turning. With stress like this, it was particularly hard for him to use his instruments with delicacy and patience. Dr. MacAlister had a stellar start in his medical practice, but in more recent years, there were a number of times when his trembling, his lack of caution, his simmering anger, interfered with a previously flawless record.

In the four days since the start of the infection, the surrounding tissues, as well as the appendix itself, became progressively inflamed, swollen and stuck to each other. Their separation takes a gentle touch. The doctor began to pull on the remaining appendix before it was totally dissected and the organ tore free from its base, leaving a one centimeter hole in the cecum itself. The appendix, dangling from the jaws of the instrument, was seen on the TV monitors by everyone in the room. The appendiceal artery, which wasn’t clipped, was spurting bright red blood into the abdomen. That was a problem; blood is one of bacteria’s favorite foods.

In the operating room, the stunned silence was interrupted by an Oh, my gosh from the assistant nurse. Young Sarah Webber couldn’t control herself, and was now gripping the camera white knuckled, waiting for the surgeon to lash out at her. Dr. MacAlister, to the astonishment of everyone who expected him to react violently, simply shrugged his shoulders, pulled the jawed instrument holding the swollen appendix out through the tube, and deposited the specimen on the scrub nurse’s instrument stand. He located the appendiceal artery, squeezed the handle of his long forceps to pinch it off, and then took a clipping instrument and placed two stainless steel clips on the artery.

Not a problem. I’ll sew up the hole, irrigate the abdomen, place a drain, and we’ll be out of here for breakfast. Give me 2-O chromic catgut on a small round needle.

The doctor didn’t deal well with stress—it was known to alter his thinking. The surgeon chuckled to himself, remembering that catgut suture has nothing to do with cats. Usually it’s made from a sheep’s intestinal tissue, and eventually dissolves and is absorbed by the body.

Helen, starting to hand him a synthetic suture, said, Doctor, did you say catgut? I have a synthetic ready for you.

Give me what I asked for.

The much older veteran scrub nurse grimaced, then handed him the more quickly dissolving catgut. She glanced over at the circulating nurse, who was shaking her head with a worried look on her face.

MacAlister, using a tiny needle holder, closed the hole in the cecum with three chromic catgut sutures, which he tied with four knots each. He then irrigated the whole right lower quadrant of the abdomen with copious amounts of saline, followed by an antibiotic solution. A single thin soft rubber drain was placed into the abscess cavity and the end was brought out the closest trocar incision and sutured to the skin.

The choice of this small drain caused Helen to glance over at the circulating nurse again and shrug a shoulder. The Mission General Hospital in Vista, California, had a fine reputation and the instrument nurse, Helen, who’d been there longer than anyone in the operating area, hated to see a surgeon stray from her own high standards. She felt a powerful possessiveness about the hospital, probably compensating for not having a devoted husband.

The institution had over four hundred beds, served a large area including Oceanside, Vista, Carlsbad, and areas east and south, and had physicians in all the major specialties. It had been in service for decades, and could use some sprucing up, but the nursing service and quality of care set the standard in excellence. As in most hospitals, it was the operating nurse who knew what was really going on, which surgeons got rattled, which ones had the highest complication rates, which ones were cheating on their wives and which had personality flaws. Thankfully, there weren’t many, but this MacAlister, he certainly had become one. He was obviously bright and, at least in the beginning, skilled in the different aspects of general surgery.

However, Dr. Mac—as he was called by almost everyone—was never popular because of his ego and his eye for the ladies. Nevertheless, Helen felt a certain responsibility for every unconscious patient lying on her operating table and would do what she could to keep them safe.

Having worked with MacAlister for years, it was plain to see his arrogance had grown as he got into more and more hot water. When he first came to Mission General, he was competent enough, but—so the rumors went—marital problems with a couple of bimbo ex-wives, appeared to have affected his judgment, resulting in malpractice suits, and closed-door meetings with the Surgical Standards Committee. There were no secrets at The Mission.

Helen was confident if she said anything to any other surgeon about the drain size, he would probably think for a second, thank her, and ask for several larger rubber drains. It was essential to have a big enough tract to the surface to prevent another abscess forming. After all, everyone in the O.R. was on the same team. But Dr. Mac, increasingly, seemed to take her suggestions as a personal affront and then stick to his guns no matter what.

CHAPTER TWO

Dr. MacAlister was worried. The damn lawyer festered in his mind much of the last three nights. The patient had a rising fever and more pain, certainly a complication of some kind. He had no surgery scheduled this morning and he thought a drive—a bit out of his way—along the Coast Highway might cheer him up.

The surgeon had spent weeks in New York and Chicago, mostly for continued medical education seminars and courses. He liked Chicago better … at least in warmer weather. It seemed more intimate and doable, with all the restaurants and culture that he wanted. However, big cities were not his cup of tea. The traffic, the noise, the air, the trash and the expense, all grated on his sensibilities. San Diego had music, theater and museums. Los Angeles had all that and more, much more. Along with New York, London, Paris and Zürich, the City of Angels was in the top tier of everything artistic.

Oceanside was a city with a population of a hundred and eighty thousand, but with a small town feel. It had all the basic amenities one could possibly want and, most important, it took the surgeon only ten minutes to drive from his home to the hospital. Try that in the big city. It was a forty-five minute easy drive to San Diego and ninety minutes to Los Angeles. MacAlister loved to drive up to LA on a Saturday morning, go to a museum, see a show and spend the night. The next day, he would visit several galleries, have a great lunch and then drive leisurely home. Hassle free heaven … especially if he brought a willing woman along.

Highway 101, the Coast Highway, was almost free of traffic today. The long stretch of white sandy beach always had a few sun worshipers kneeling on it, even on weekdays and, at this distance, the surfing dudes in their wet suits were bobbing offshore like little floating blueberries. With well-kept homes to the east and the glorious Pacific to the West, it should have been a soothing drive—but not today.

On the fourth day after his appendectomy, Dr. MacAlister was standing at Tony Hubbard’s bedside. Mr. Hubbard, I know you’re upset, but I can’t send you home with a rising fever and a white blood count that’s now higher than when I saw you in the ER. You told me last night the pain had begun again. I started to pull the drain out a bit yesterday. There wasn’t much drainage, which is a good sign, but I have to be sure you don’t have an infection building up again in the area where the appendix was.

What the surgeon didn’t say, was the small amount of drainage that came out was brown colored and had an odor. He knew there must be feces leaking from the colon. Some of the sutures either dissolved too soon, or pulled through the tissue. If he could get adequate drainage, the leak should stop and the hole in the cecum close up by itself.

I understood the drain would prevent that said Tony with a wave of his hand, and don’t give me the old saw about the bumper sticker which says, ‘shit happens’ because I really trusted you to do a good job.

The surgeon replied, I’m going to send you down for a sonogram of your abdomen to see if I can locate a pocket of pus. Then I’ll come back and tell you … if it’s there … how I can fix it. Another operation may not be necessary, but just in case, I’m don’t have any food or drink from now on. You have our best antibiotics going through your I.V. So, until we get the test results, there’s nothing more we can do.

Tom, said a Cheshire-smiling Hubbard, deliberately using the prohibited short version of the surgeon’s name, if I need another operation, I may well ask for a second opinion.

Dr. MacAlister knew better than to rise to the bait, and further aggravate this patient. He told him he could do whatever he wished—but their first order of business was to get the x-ray study.

In a matter of minutes, the patient was on the way to the radiology department for a sonogram. This would be performed by an invasive radiologist who was trained, not only to interpret the shadows on an x-ray film or a computer screen, but also to employ invasive techniques to correct many problems, thus avoiding a formal surgical intervention.

The surgeon asked the radiologist to call him when the sonogram was done so they could look at it together. When the radiologist called, the surgeon’s diagnosis of another abscess was correct. A five centimeter localized collection of fluid could be seen adjacent to the cecum. The x-ray doctor was confident he could, under local anesthesia, insert an adequately-sized drainage tube through the skin into the cavity, and the infected liquid could be sucked out and the cavity thoroughly irrigated. The tube would be left in for several days until the drainage ceased, and then gradually removed, allowing the tissues in the area behind it to heal. There would be a leakage of feces from the hole in the cecum—a far more serious complication than a simple abscess—but hopefully for a limited time.

Well, Tony exclaimed MacAlister entering the sonogram room where his patient was lying on the x-ray table. I’ve good news. My diagnosis was correct. You have a small abscess near the area where the appendix was attached. Our excellent radiologist feels he’ll be able to place a catheter down to this area and remove the pus. He’s going to give you an injection to numb the skin where there’s tenderness and pain. The insertion should bother you very little. You will need to stay in the hospital for a few more days until we’re sure this complication has been taken care of. I’m going to put you on clear fluids until this heals, as we don’t want any irritation in that area.

The surgeon wished he’d used a much larger drain and hoped his patient wouldn’t notice the color of the drainage. He didn’t want to explain how and why feces was coming out of his belly.

Well, Thomas said Hubbard, mimicking the doctor, I do thank you for finding the problem and getting it fixed without an operation. But I wish this hadn’t happened in the first place.

I put a drain in the area to prevent such a complication, said MacAlister, and I don’t know why it didn’t do its job.

Looking skeptically at him, lawyer said I thought you were going to tell me bad things can happen even in the best of hands. Mother Nature isn’t always kind, but that’s what a jury would decide. Anyway, it’s a relief I seem to be on the way back to a normal life. Now please get me back to my room. I need another pop of morphine.

*****

Thomas MacAlister had been courting Betsy Coqueville for almost three months before she agreed to come home with him for an after-dinner drink. He’d spent a considerable amount of money romancing her, taking her to one expensive and trendy restaurant after another. They spent long hours together, from dawn until dusk on the weekends, getting to know each other, going places, doing things. They watched the horses at the Del Mar racetrack in late July, visited museums in Balboa Park, toured the aircraft carrier Midway in San Diego harbor, and often biked up and down the coast. His physical desire for her was greater than ever. But she was coyly evasive, not seeming to pick up on his less than subtle hints for more intimacy. She’d never been to his home. His mood about her elusiveness vacillated between growing irritation and begrudging deference.

Betsy had been unable to finish college. When her alcoholic father died early from cirrhosis of the liver, she was the only one able to keep the family afloat and she left in her junior year and went to work. Her mother wasn’t strong, and her younger sister had been traumatized, incapacitated, by her father’s drinking. In high school, Betsy had shown great promise. She graduated near the top of her class, and although she made the cheerleading squad, she hadn’t been elected class president—which surprised her, and set her back emotionally. Maybe her drive and ambition had been interpreted by her classmates as willfulness and egocentricity.

One day, three months after they started dating, when Dr. MacAlister went into the pharmacy to have a few words with her, he was told Miss Coqueville was no longer working there. His initial panic changed quickly when the pharmacist, guffawing, told the suitor she was now one of the pharmacy’s two assistant managers. Her office was upstairs. Thomas’s heart had plunged, and he realized he didn’t want to let this one get away. He located her in her new office and was overjoyed when she accepted his invitation to visit his home.

*****

Hello, Miss Coqueville. Welcome to my modest abode. said MacAlister, as she pulled into his driveway. I’ve heard it said one can tell a lot about a person by looking at their house. Seeing Betsy was always a joy; she was a natural beauty. Her blonde hair accented large blue eyes and her makeup was so subtle you saw her face as a whole, rather than in bits and pieces. Some women’s lipstick is so red and their eye shadow so black, it was all you noticed about their faces. And the way she walked—oh my!

I’m not so sure about that, said Betsy, taking his extended hand to get out of the car. It’s hard to judge someone by their house. Regardless of whether one owns a home, a man’s character lies deep within himself. Gandhi was homeless and walked barefoot through many countries. We recall him only by his wisdom. No matter, Thomas, I’m delighted to be here with you. The proximity to the beach was inviting and the ocean view was magnificent. His home differed from his stuccoed neighbors. It was contemporary in shape—but not a glass house—with clean lines and diagonals set at 45°. ‘So like Thomas,’ she thought, ‘no broken roof lines or porches for him.’

Thomas escorted Betsy up the flagstone path, their arms interlocking. As Betsy walked alongside him, her attention drifted to the striking order of the place, as though she were in a botanical garden. For starters, the lawn was beautifully manicured, the hedges neatly trimmed, not a blade out of place. When Betsy stepped up on the stone landing by the front door of the house, she turned around and looked behind with an expression of wonder.

Thomas, my God, that’s the most beautiful walkway. What a wonderful welcoming entrance! Those flagstones—how did you ever find light gray flagstones so evenly matched? And— my goodness—they’re completely uniform, each is exactly the same size. She stepped back onto the walkway and looked at the spaces between two or three of the stones. Then she said, The space between each is probably an inch—right?

The surgeon grinned with pleasure and answered, Yes, exactly an inch. I spent some time researching and choosing the stonemason who did this job. I hired him for his reputation for precision, and when he started laying these, I came out and measured them myself. I’m glad you appreciate the work here. I do too.

On this particular evening, Thomas noticed a certain guarded formality in Betsy and he couldn’t put his finger on it. She was acting professional, more like the manager of a pharmacy, serious and thoughtful. Maybe she was feeling a bit uneasy about being in a new setting, at his house for the first time. She had refused all of his previous invitations. His vague discomfort found expression in a flash of self-doubt. It occurred to him that she might be getting ready to end their relationship.

Thomas decided it might be wise to make a special effort to be courteous and sincere so she’d relax and get a sense of how he felt about her. For the first time, in as long as he could remember, he was unsure whether he should ask her to spend the night. God, how awkward was this adult dating game!

The house was wonderfully ordered with framed art on the walls, comfy sofas, and varied moods, well thought out in every room. On the ground floor, she was walking on what appeared to be highly polished Mexican tiles. In actuality, the ocher color approximated the genuine article, but these were totally without blemish and the color was even throughout. As she realized they weren’t genuine, Betsy smiled—those would be too maverick for his taste.

As they sauntered together on a grand tour, they passed a nice sized working office. A quick glance showed the massive desk was clear of everything—no books or papers. Off to one side, two identical pens and three sharpened pencils were lined up. The walls were lemony yellow, and coordinated with a green, red and brown Persian rug. A forest green leather chair fit well into the scheme, with a lighter green folding blind which was dropped to cover half the window. A matching green leather wastebasket was empty.

Moving along, Betsy glanced into the kitchen and said, My goodness, Thomas, living by yourself, how can you possibly keep everything so neat and tidy? You must have a maid coming every day to keep the granite clean. It looks like it was put in yesterday. Say, what’s that machine over there?

"No, once a week is all the help I get. I don’t think there’s any harm, when you’re treating sick