Mortal Judgment: A Legal Medical Mystery

By John A. Peak

Vicki Shea, a San Francisco malpractice lawyer with a medical degree, is a good choice for surgeon Arnold Jones. Jones faces a malpractice suit that could virtually wreck his career. He is accused of having caused the sudden death of a rich and powerful businesswoman. He is urged by everyone to settle, but he refuses. He knows he wasn't at fault, and won't say he was.

As Vicki begins work on the case, she finds that someone wants her to stop: a concrete block is dropped on her car on the freeway; there is missing information on the death certificate; both pathologists who look into the case for Vicki die suddenly; and the attemps on Vicki's life escalate.
In this dramatic thriller, where every medical and legal detail is accesible and engrossing, Peak has written his best and most important book yet.

• Language: English
• Publisher: Macmillan Publishers
• Release date: Jan 15, 1999
• ISBN: 9780312264611

John A. Peak

John A. Peak is a lawyer in private practice living in San Francisco , California. He spent 13 years with the office of the City Attorney for the City and County of San Francisco where he represented San Francisco General Hospital, the Paramedic Division and other health agencies. He has also represented a number of San Francisco police officers in civil cases, including a number of high profile trials.

Book preview

1

BLOOD PRESSURE’S DOWN a little bit.

No, Garrett! Don’t do that to me!

The anesthesiologist, Garrett McDonald, was hidden behind a tent, his voice coming through the green sterile drapes. What’s going on? Anything going on?

The surgeon paused, impatient to get on with what he was doing. He used one finger to push on a retractor and turned his head, trying to see deeper into the wound. He used the suction tip to clear blood. Nothing I can see. I’m out on the hardware right now. I can put my finger on the other side of the pedicle and the screw’s not touching anything. How far is it down?

Just a little. I’m gonna hit her with a unit of the homologous here. Garrett’s hand came into view and squeezed the blood bag hanging from a pole at his end of the operating table. Homologous referred to the patient’s own blood, predonated in anticipation of a possible emergency. Everybody seemed to wait, standing perfectly still, as though listening to the ventilator, a hollow, mechanical gasp. The Haemosal, a blood salvage machine, gurgled and slurped from the suction tip in the wound. Everyone was still except for the surgeon, Arnold Jones. He was bent over the patient’s back, twisting at a fixator nut, one last, meticulous turn.

How’s she doing now?

Looks better. McDonald, ensconced in his cockpit, hands presumably on the controls, sounded more confident. Looks okay now. Sure nothing’s going on?

Jones concentrated on his own hands. I promise.

Okay. She looks better, anyway. How much longer?

Half an hour? The surgeon’s voice sounded a little more relaxed. He glanced up quickly and then looked back down. The laugh lines around his eyes crinkled. Who’s hand is that? Are you left-handed?

Yes, Doctor. The nurse spoke with a thick Filipino accent.

Hold the suction a little to that other side, will you? No, the other way.

Yes, Doctor.

Jones glanced at the nurse’s eyes. She had remarkably pretty eyes. Do I know you?

The circulating nurse spoke behind him. "She’s new, Dr. Jones. Chris Bonillo, meet Dr. Jones.

The pleasure is mine, Nurse Bonillo. We just have a change of shifts or something?

Yes, Doctor.

Garrett’s voice came from behind his drape. Chris? Is that your name, the new nurse?

Yes, Doctor.

You know how to say ‘Fuck you’ in Tagalog?

The circulating nurse chuckled. Come on, Dr. McDonald, she’s brand new.

Bonillo’s eyes were shining with embarrassment, looking down at the operative field.

Garrett’s voice sounded boisterous. No, do you?

Yes. Her voice was shaky.

Jones glanced up at her quickly. No, no—this is a joke.

The nurse looked up, saw the laugh lines and relaxed a little. Oh. Okay, how do you say ‘Fuck you’ in Tagalog?

Everybody in the room said it in unison: Yes, Doctor.

Bonillo laughed merrily and involuntarily raised the hand with the suction as though to cover her already-masked mouth. She stifled it and returned to business.

Garrett’s voice sounded disgusted. I need a new joke.

No kidding.

How we doing, Garrett?

Looks all right now.

Just about ready to close. What do you think, Leila?

The assistant surgeon reached into the wound and gently tugged at the hardware, the cross-struts on the fixator, the screws through the pedicles holding two levels of lumbar spine fixed rigidly to the sacrum. The suction gurgled and swallowed. Feels good to me. She irrigated with warm saline, suctioned again, and peered into the wound. Want me to close?

Sure. How long did that take?

McDonald’s voice came out of the recesses behind the drapes. Ten hours, fifteen minutes.

Yeah? Jeez! Well, but did you see how that nerve root at L-5 was squished in there? See that? He pulled a stool near the operating table and sat on it, tugging at the cuff of his glove, ready to take it off but not doing it yet.

The assistant surgeon, Leila Monscharch, nodded her head while she looked at the sutures on the tray. Yes, I saw it. Then to the nurse: That one right there. Use the hemostat.

I should’ve got a picture of that, the way it was squished in there before we did the foramenotomy.

Definitely squished.

That’s what I’m gonna put in the op report. ‘Nerve roots on the right side, colon, squished flat.’ No wonder it hurt, huh?

Leila was suturing. Yeah. Must’ve been a real pain in the ass.

No kidding. You know what she said yesterday? You should have been there, Garrett. She said if the pain continued like it had been, she didn’t want to live with it. That’s what she said, that she didn’t want to live.

Leila pointed at the tray. Okay, now that one for the next layer.

It must have hurt like hell, huh?

Well, it ought to be better now. Leila’s eyebrows came together in irritation. Shit, I thought we had hemostasis here.

Arnold Jones stood up and looked into the wound. Just a little oozing.

It was dry a minute ago.

That’s nothing.

But it was dry.

Don’t worry about it. He sat back down and talked to Garrett over the drapes. That posterior column was so unstable it had actually shifted enough to let the lamina come directly in contact where the nerve roots were coming through, and it trapped that whole section of the thecal sac. Must have been two or three millimeters, just flattened out against the bone, you know? I mean we had her on like a zillion Decadron and she still couldn’t hardly even walk.

Look at that, it’s still oozing.

No big deal.

Okay, you say so. Ready to turn her?

Leila stepped back out of the way and a gurney from the recovery room was pushed in place next to the table. The anesthesia drapes came down, pillows and pads were removed and dropped onto the floor. The IV line that had been in the back of one hand slipped out and ran dark red blood over the sheets. Garrett grabbed it up and muttered, almost to himself, Shit. Let’s get her turned; then I’ll fix it. Both surgeons and the two nurses cooperated in logrolling the inert patient onto the gurney.

Jones stared at the patient’s face. It had gone completely white What’s going on? Garrett?

"Goddamn it! Code Blue! Goddamn it!"

The circulating nurse jumped for the phone to give the alarm, Jones stepped up and pushed hard with both hands in the center of the patient’s chest. Get that line back in there, Garrett, let’s get her pumped up! He swiveled his head to see the circulating nurse. Get me a vascular surgeon, please. There’s gotta be a big bleed somewhere. Get radiology, tell ’em they might want ultrasound.

McDonald sounded calm again. I think I’m in the vein, I just can’t move anything.

Arnold Jones looked at the patient’s neck and he could see a pink spread turning dark red. Blood was oozing out of her skin creases, trickling from the corners of her mouth, running from the former site of the IV line in her hand. Blood had begun pouring from the operative wound in her back, pooling on the gurney and dripping to the floor. He yelled this time. This is DIC! Get hematology, now! Here! Take over this!

The scrub nurse stepped up next to him and took over the two-handed pumping action of chest compression. The OR doors snapped open and the code team moved in, an ER tech taking over the chest from Bonillo. Garrett’s voice was sounding frustrated. I can’t get a peripheral vein here. I’m going to get something bigger. Try a cut-down, down there.

Bonillo, the scrub nurse, hauled the instrument tray back to be next to Jones. He reached up, grabbed a scalpel, and deftly incised just above the ankle mortise. Blood flowed rapidly out of the wound and Bonillo irrigated it, flushed it out of the way. The scrub nurse was holding a large-bore needle right in front of his face for a moment before he saw it, grabbed it and slipped it into the biggest vein he could see.

Okay, got one in here. The doctor from the ER, a tall, thin man, elbowed Jones out of the way and took over his port. He filled vials from the vein and passed them off. "CBC, DIC panel on this one, coagulation times right now, and I mean right now. He glanced up. As the lab tech disappeared through the door, he called after him. We got a type/cross?"

Garrett was hovering near the patient’s head. This is homologous right here, and we got type-specific on the way up.

The ER doc nodded and officiously shoved on the nurse’s arm. "Push that in right here, and I mean wide open, wide open."

Jones stepped back and looked. His patient was leaking droplets of blood from all the skin creases; blood was coming from her nose and out of her vagina. Where the hell’s hematology?

I’m hematology. A too-young-looking woman in street clothes was standing next to him, studying the patient without touching her. She glanced at Jones and apparently saw the lack of reassurance. The attending will be here by the time the labs are back. What happened?

Nothing! Absolutely normal orthopedic procedure on her spine, and then this! Where the hell’s that ultrasound?

Right here, Doctor. We’ll find the bleed in a minute.

"I would swear to God there isn’t any bleed. Nothing happened. This wasn’t a disk procedure; she already had her disk out before. I couldn’t even reach anything deeper from where I was operating."

Garrett was back at his instruments, but visible now, his magic out in the open. She lost a little blood pressure about a half hour ago but came right back up with a little blood and a little bit of pressor. Then when we turned her over she just crashed. I don’t get it.

Bonillo was swabbing the patient’s abdomen with Betadine, painting amber around the ultrasound probes, barely staying out of their way. She, at least, acted as though she had a diagnosis and she wasn’t waiting to be told to get ready to open this patient up and find the spurting artery that she seemed to be sure must be in there.

Arnold Jones, boy wonder, thirty-seven-year-old orthopedic surgeon extraordinaire, had to stand by and watch everybody else try to save his patient. He stared at the ultrasound screen and looked at the radiologist. The other doctor glanced back at him and then stared hard at the screen. Nothing here. I don’t see any pools, not a damn thing. There’s fluid in the stomach and the small bowel, but not in the peritoneum.

Bonillo had already opened the laparotomy tray and stood patiently by, waiting for somebody to do the obvious. She glanced at the blood line going into the ankle. That isn’t moving, Doctor.

The ER doc looked at it. What?

Aware of her accent, she spoke slowly. It isn’t infusing. It is not dripping.

I can see that! He took up another large-bore needle and went to work, high on the inside of the patient’s thigh. Goddamn DIC. Where’s hematology?

Right here. The too-young doctor and another, an older man, were studying lab slips, the older man on the phone, presumably to the lab to confirm what he was looking at or to order more tests.

The ER doctor was getting testy. DIC, right?

Maybe, Rick. I’m not really sure what this is.

Well, how about a suggestion?

Oh, yeah. Whole blood through that femoral line and let’s start some Coumadin through that saline line. No, scratch that. Can we get some potassium citrate in that instead? Shirley, can you calculate the amount? Can somebody get me a CV line started? He looked around at Jones. Arnie, this isn’t exactly adding up.

You’re telling me!

I mean, there’s no big internal bleed. How’s she going to get DIC? Her PTT’s out at about 45, but she’s also got a super elevation of leukocytes from somewhere. Could she be infected?

The ER doctor looked up suddenly. Has this patient got AIDS? He was up to his elbows in blood.

No.

You test her?

I test everybody. But look at her. This isn’t AIDS, for Christ’s sake!

Garrett’s voice sounded calm. Okay, we got a blood pressure.

Sweet Jesus! The chest compressions stopped.

Got a tachycardia going right up the scale now. Sinus tach at about 118. Blood pressure holding 125 over 80. I want some arterial blood gasses; still got an A line?

The ER doctor straightened up and watched Garrett. Okay, we’re drawing that right now.

Oh, shit!

What?

There she goes again. Sinus tach at 145, BP is 105 over 59. What the hell?

The ER doc yelled this time. Where’s that whole blood?

Bonillo pointed. It’s hung.

Going wide open?

Yes, Doctor.

Taching right along here, at about 160. BP is 95 over 48, oximeter showing an A-sat of 78. Come on, sweetheart!

The attending hematologist scratched at his chin in thought. Nurse, let’s put packed red cells into that subclavian. You can just port the citrate into that, can’t you?

Sure.

Garrett looked up at the ER doc. This is pulmonary hypertension, huh? I mean, I have her on a hundred percent oxygen, so why isn’t her A-sat any better than that?

The ER doc looked over at the circulating nurse. Would you please get pulmonology up here? I don’t know what the hell this is. Let’s get a chest film, okay?

Coming back again now. BP is 110 over 72.

The hematologist nodded. The citrate’s breaking it up now. She should hold on there or come on back.

A small man in greens came in. Got here as soon as I could. Somebody call for a vascular surgeon? What we got here?

Never mind.

What?

Can’t find a bleed.

Isn’t this the patient in DIC?

Something like that.

Then there’s a bleed. We just have to find it, right? He looked directly at the hematologist, apparently knowing him.

The radiologist was still moving one probe over the abdomen, another was in the vagina. Look for yourself, George. I don’t see anything.

"Nothing? How about