Bad Blood: A Medical Murder Mystery

By James Baehler, Sheldon Cohen and M.D.

A patient dies on the operating table and the surgeon, Dr. Clifford Harris, is held responsible by both the hospital administration and the police.

The cause of Wallberg's demise is at issue in the trial that follows.

The tension builds to a stunning climax when the truth finally emerges.

"Bad Blood" weaves realistic medical and trial procedures around a memorable cast of characters with a vivid and fast-paced literary style.

"Bad Blood" is a notable addition to the ranks of medico-legal mysteries.

• Language: English
• Publisher: eBookIt.com
• Release date: Apr 26, 2016
• ISBN: 9781456607333

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PART ONE

THE HOSPITAL

CHAPTER 1

Code blue! Code Blue! echoed over the intercom at Barrington Community Hospital. When it was followed by Surgical Intensive Care Unit, Cliff Harris knew that whatever catastrophic event occurred had to involve the patient on whom he had just operated. It was 11:30 p.m. and his was the only patient admitted to surgery in the last hour. Dr. Harris was sitting in the surgical locker room sipping orange juice and fighting fatigue when he heard the Code Blue. He ran back to the intensive care unit. As soon as he entered he saw the two ICU nurses working frantically on his patient. It’s your patient, Dr. Harris. I think he’s coding!

Shaking his head to help prepare his mind for yet another emergency he said, What happened?

He went into this rapid tachycardia, said the younger nurse pointing to the cardiac monitor above the bed showing the accelerated heartbeat.

Was he awake? Did he complain of any chest pain? asked Harris.

The nurse said, No, nothing like that.

A glance at the cardiac monitor showed a heart rate over 140. At least it was a normal sinus rhythm and not a serious cardiac arrhythmia. Could this represent a cardiac insult such as a post-operative heart attack? The tracing did not show any obvious electrocardiographic evidence. Harris quickly listened with his stethoscope, but all he heard was a rapid and regular cardiac rhythm. The patient’s blood pressure on the monitor was 120 over 70. That was a surprise and a relief and it told Cliff that in spite of the rapid heartbeat, the patient was maintaining his blood pressure. He lowered Victor Wallberg’s bed sheet and found the abdomen distended even more than it had been before surgery. Victor’s skin, conjunctiva, and nail beds were pale. From all the diagnostic possibilities that whirled through his mind, Cliff focused on one: A post-operative bleed? How could that be? Things had gone so well; Wallberg had been dry and stable after the earlier surgery. Regardless of that, the man was now in serious peril. Something had to be done and it had to be done now. He turned to the nurses. Let’s get him back to the OR, stat. Tell them we’re coming back. Call the lab. Get the blood I ordered earlier to the OR. How much urine in the Foley bag?

The older nurse, after a quick check at the bag hanging on the other side of the bed, said crisply, Thirty cc’s.

Empty and record the volume along with the exact time. I want to start surgery with an empty bag.

Yes sir.

Let’s move.

This was no time for theorizing while his patient could be bleeding to death. If he was, it had to be stopped. On the way to the operating room Harris said to the nurses, He’s bad. Something unusual has happened. I have to look for a bleeder.

The operating team and the anesthesiologist were arriving as the patient was wheeled in to the OR. In less than five minutes Victor Wallberg was anesthetized and on the table. Harris opened the previous incision made at the first surgical procedure. He noted with surprise some oozing but had no time to tie off individual tiny bleeders in the subcutaneous fat. A few rapid and deft movements and the peritoneal layer became visible. It was blue and bulging with blood. His worst fears had been realized. He opened the peritoneum with a single delicate flick of his scalpel. Blood welled up from the abdominal cavity. Harris desperately tried to suction out the blood so he could identify the source of the bleeding. He was able to remove enough blood to evaluate his recently done small bowel anastamosis and it was intact. The reconnected ends of the small bowel showed no suture disruption. But that was about all he could discern as the blood seemed to appear from everywhere to obscure the surgical field. The more he suctioned, the more the blood seemed to flow.

Ten years of experience were brought to bear as Harris’s thought processes focused on the task at hand. He could find no bleeding vessel, admittedly a difficult task with what was happening to his patient. He knew he was headed for trouble. His lips were tightly closed, a look of intense concentration registered on his face.

Suddenly it hit him. He thought, ‘My God! This is a case of disseminated intravascular coagulation.’ He called to the anesthesiologist, Sanjay, look at his fingers…quick.

Dark blue, the anesthesiologist shouted back in alarm.

Blood pressure? asked Harris crisply.

116 over 56.

Still up, but lower thought Harris.

He called to the circulating nurse. Check the Foley bag.

She looked under the table and said, Foley bag still empty.

Is blood dripping at a wide open rate? Harris asked.

Blood bag wide open.

For a few seconds Harris continued his efforts. Just before he was about to call out his orders, the anesthesiologist said, Blood pressure dropped. 70 over 40

With that news, Harris knew his patient was going into shock. He had no time to lose. Vasopressors, he called. Sanjay, get me a blood sample, stat? Then give…

I’m trying, but his veins are collapsing, cried the anesthesiologist in dismay.

Jugular, brachial, femoral. Get some blood from some place.

What blood are you needing? asked the anesthesiologist anxiously.

Platelet count, PT, APTT, fibrinogen, fibrin degradation products, type and cross match four more units, and hematocrit. And then…

I can’t get blood! I can’t get it! cried the anesthesiologist.

Harris couldn’t wait. The patient was in extremis. He shouted, Give him eight thousand units of heparin!

The anesthesiologist stiffened. What?

Heparin, eight thousand units…bolus, stat! called Harris in a louder voice.

The anesthesiologist shook his head in violent disagreement. But he is already bleeding."

I know what I’m doing, Harris shouted. Just do it!

The OR nurses stood transfixed, their eyes swiveling from Harris to the anesthesiologist who had not yet administered the heparin. Do it, damn it! Harris shouted.

Dr. Sanjay Madhava was frantic, Heparin? He’s bleeding for God’s sake.

DIC, Harris said, the patient has DIC. Can’t you see that?

But they bleed with DIC. Heparin will make it worse!

They thrombose late, Harris said with conviction. The DIC will kill him unless we reverse it, so hurry up. We don’t have much time to lose. It’s his only chance.

The anesthesiologist stood like a statue, eyes opened wide, mouth agape. Harris, in a voice the nurses had never heard, and with eyes blazing over his surgical mask, roared, 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.

Shaken out of his immobility, the anesthesiologist reached over to his tray for a vial of heparin, inserted a syringe and extracted a dose. He reached up and inserted the tip of the syringe into the portal on the IV line closest to the insertion on the back of the patient’s hand. Slowly but steadily he depressed the plunger of the syringe until the cylinder was empty. The room was as silent as a tomb; none of the OR staff could ever remember Dr. Harris in a shouting match. The blood pressure maintained at 70 over 40 for a while. The cardiac rate began to slow. Harris worked feverishly suctioning blood and continuing to explore as best he could. Vasopressors were already in, but the blood pressure stubbornly refused to rise. Wallberg’s fingers remained cyanotic, the Foley bag remained empty showing no urine output. Abruptly, the cardiac rhythm slowed further and premature ventricular contractions developed. With horror-stricken eyes the doctors and nurses watched as an idioventricular rhythm developed.The patient was slipping into cardiac arrest. The monitor screen told its relentless story as Wallberg’s heart beat slower and slower and finally, a chaotic rhythm---ventricular fibrillation, the heart beating wildly out of control. Harris and his crew began frantic cardiopulmonary resuscitative measures. Adrenalin was injected directly into the heart. Harris called for defibrillator paddles and applied them to the patient’s chest. Wallberg jerked under the jolt of electricity but that was the only response. The chaotic rhythm on the heart monitor suddenly flattened out; the spiking demonstrating the heartbeats disappeared. More chest compression, more electrical jolts but still the patient remained unresponsive. The monitor showed a persistent flat line. After more long, discouraging minutes, Harris reluctantly signaled to the OR team that it was time to cease their efforts. The patient was dead.

Silently the tubings were removed and the body placed on a cart. No one spoke. When the task was done, the anesthesiologist, Sanjay Madhava, said bitterly, Heparin? I sure hope you know what the hell you did.

Wearily, Harris replied, I knew very well what I did, Sanjay. When I’m a little less tired someday, I’ll explain it further to you. Madhava turned away with a disbelieving shake of his head. Harris was now too fatigued to do anything more than dwell on the fact that he was now involved with his first intraoperative death. He was devastated and it showed on his face. He dreaded the coming talk with the patient’s wife. Slowly, he made his way from the operating room to the Waiting Area outside the ICU. He stopped for a moment and drew a deep breath before entering. One look at his stricken face and Marilyn Wallberg knew what had happened. She made as if to rise, but slumped back instead. Dr. Harris sat next to her and said, I’m so very sorry, Mrs. Wallberg. Your husband developed uncontrolled bleeding and everything we tried didn’t stop it. We couldn’t save him.

She looked at him, her features frozen into an expression that Harris couldn’t identify. He put his hand on her shoulder. She looked directly at Harris. What caused the bleeding? she whispered."

Harris said, I’m so sorry, Mrs. Wallberg. I’m certain that your husband developed disseminated intravascular coagulation. It’s a bleeding complication that once in a great while appears after major surgery. There was no way to anticipate it and no way to control it.

Still unbelieving, she said, But…but I don’t understand. I thought it was a simple operation.

The surgery was relatively simple, Mrs Wallberg but your husband then developed the DIC condition I just described and despite our best efforts, we couldn’t save him.

Beginning to show anger as her eyes filled with tears, she said, But how can that be? Aren’t you prepared for that sort of thing?

I’m sorry, Mrs. Wallberg but there is no way to prepare for disseminated intravascualar coagulation. It is an extremely rare condition that appears without warning and there is no way to prepare for it.

In a despairing voice, she said through her sobs, I don’t understand any of this. My husband was alive and well a few hours ago and now you tell me he’s dead and there was nothing anyone could do about it.

Harris started to speak when she broke in. What am I supposed to do now. I have two children to take care of and my husband is dead. Her voice rose to a wail as she buried her head in her hands and wept uncontrollably.

Not knowing what else to say, Harris could only gently pat the grieving woman on the back as she sobbed.

Finally raising her head and speaking in a low voice Marilyn Wallberg said, Why did Victor call you, of all people? After what happened between the two of you, why?

I thought the same thing, Mrs Wallberg. But it just told me how desperate he had become. Just speaking to him on the phone, I knew he was helpless to help himself. He wouldn’t have been able to get to his car. He had all the symptoms of a complete intestinal obstruction. Surgery was the only thing that could have saved him, but it was too late. He developed disseminated intravascular coagulation. He bled and clotted profusely. It couldn’t be reversed. We got him too late.

Mrs. Wallberg stared straight ahead, eyes wide, her expression frozen. She shook her head. Then she said, bitterly, I know him. He never went to doctors. He probably developed symptoms and when they got worse he was sure they’d go away. He always did things like that. Only this time he got fooled and it cost him his life. She broke down again.

Harris said, You may be right. If he had gone to a physician at the start of the symptoms, this might have been prevented.

Bitterly, his widow said, That wasn’t Victor’s style. Everything had to be done his way. He would never listen to anyone else or take anyone’s advice. He was always so sure he knew best.

Harris said, We need to learn more, Mrs. Wallberg. It can’t end here. Would you consider an autopsy?

She straightened and without looking at Dr. Harris, shook her head and said firmly, "No autopsy. I’m not going to have Victor cut up when you say you already know why he died. In any event, he thought autopsy was butchery and I am not going to go against his beliefs.

Mrs. Wallberg, the decision is yours and I understand and respect it.

Thank you, doctor.

Would you like some time alone with your husband?

Yes, I would like that.

Come with me, Harris said, leading her out of the room.

Is there anyone you would like me to call? Harris said as they proceeded down the hall.

Not right now, thank you, was the reply. They reached the room where Wallberg’s body lay.

Harris said, Please let me know if there’s anything else we can do.

Thank you, but I can’t think of anything right now.

I understand, Harris said and turned away from the widow of a patient who had died under his knife. He went back to the surgery area where he dictated his surgical report. It was detailed and lengthy. Soon he would have to face the scrutiny of his fellow doctors as this was a surgical death, and all such are peer reviewed.

Harris now realized he had no way of getting home. It was 2:00 a.m. and he was scheduled to perform a 7:00 a.m. surgery that morning. To go home he would have to call his wife, wake her up and have her come to the hospital. It wasn’t worth it. He went to the dormitory area set aside for house staff on night call. He grimaced at his appearance in the mirror. He noted his disheveled hair. His gray eyes had lost their luster. The muscles of his wiry frame that he tried to maintain with semi-regular exercise seemed flaccid. His shoulders drooped making him look shorter than his six feet. He called the hospital operator and asked for a 6:15 AM wake up call. He fell exhausted into bed, his last thought on the man he had just operated upon; a man who had raped his wife.

CHAPTER 2

As Dr. Harris was falling asleep after his most hectic of nights, his mind went over the details of the evening that led up to the death of Victor Wallberg. Office hours that were supposed to end at 4 p.m. had ended at 7:45. He got home at eight and his wife greeted him as he entered the kitchen through the door that led to the three-car garage. She gave him a quick hug and turned to the microwave to heat the dinner she had prepared earlier for him. Laurel had long since accepted the long hours Cliff’s work demanded. In a good week he managed two or three evenings with his wife and family. She accepted the fact that he was a serious dedicated surgeon who believed in putting his patients first. Laurel sat with him while the meal was warming, bringing him up to date on the activities of their twin twelve-year-old daughters. Halfway through his meal the phone rang. Laurel picked up the phone, listened for a moment and handed it to Cliff with a grimace of distaste on her face. I don’t believe this, she said, handing him the phone.

Is this Dr. Harris? said a croaking, strained voice.

Yes, who’s this?

It’s Victor Wallberg.

Harris stared at Laurel, an expression of amazement on his face. You’ve got a lot of nerve calling me, you bastard. I don’t get it.

Wallberg’s voice was strained and barely audible. I have no place to turn. I can’t move. Something bad’s happening… I’ve got a pain in my belly like…you couldn’t believe…it even hurts to talk. I’m desperate.

Jesus, he sounds like he’s in extremis, thought Harris. Is your wife there?

She’s at a friend’s house, was the reply through gritted teeth.

Can you call your regular doctor?

I don’t have one, Wallberg said, followed by a deep moan. I know how you feel, doc, but I think I’m dyin’ here. Wallberg’s usual tone of arrogant command had been replaced by the fearful voice of a man in a high state of pain and anxiety.

For perhaps the first time in his life, Cliff Harris regretted the Hippocratic oath he had taken upon becoming a physician. With a sigh of frustration he said, All right, I’ll be right over.

It was obvious that Wallberg was in danger. There was no sense wasting time with any further phone questions. Wallberg had to be desperate to call him. However, the man now had become a patient. Once Harris told him he’d be right there, in his mind it meant he had a verbal contract to care for this patient, and that contract had to be fulfilled.

Harris turned to his wife, I have to go next door. Wallberg sounds like he’s dying. I’m going over there and see what I can do. I’ll fill you in later.

But… Laurel began to expostulate and stopped when she saw the expression on her husband’s face.

Harris donned his heavy coat and picked up his medical bag. The crisp cold of a northern Illinois winter struck his face as he quickly crossed the wide expanse of the two lawns that typically separated homes in the upscale community of Barrington Woods. As Harris approached the front door, it opened to reveal his neighbor bent over in an almost ninety-degree stoop. The effort to come to the door and open it had been exhausting and painful and Harris helped the man to a nearby couch. Wallberg could not lie flat. In order to be examined he had to lie on his back and keep his knees elevated. Seeing this, an alert rang in Harris’s mind that was reinforced when he saw that Wallberg had unstrapped his belt and unzipped his pants. Both signs suggested an abdominal emergent event, confirmed by a quick look at Wallberg’s features; his teeth were clenched and there were wrinkles on his face etched there by pain. His abdomen was markedly distended and exquisitely and diffusely tender. Harris attempted deep palpation but it was impossible. The sudden release of his palpating fingers elicited an agonized guttural groan from the throat of the patient. Clearly he had rebound tenderness, a sign of peritoneal irritation. Examination with a stethoscope revealed high-pitched bowel sounds. Harris knew he was dealing with a surgical belly. There were unmistakable signs of an intestinal obstruction, with possible perforation and peritonitis. Wallberg’s pulse rate was 116 and his respiratory rate was thirty-four. An immediate operation was called for.

We’ve got to get you to the hospital, Harris said with conviction.

I knew it, Wallberg replied in a weak voice, perspiration bathing his face.

Are you allergic to any medicines?

No.

Harris called Laurel and told her he was taking Wallberg to the hospital. He asked her to call the paramedics and tell them to hurry. If there was going to be any delay to call him back. Then he called the hospital emergency room. I’ll be there in about fifteen minutes with a patient exhibiting all the signs of a surgical abdomen. Have you got a pen in your hand?

Uhh…yes, the emergency room nurse replied.

Write these orders down. I don’t have time for a full diagnostic work up, but we’ll at least get the routine pre-surgical blood tests and make sure the CBC, electrolytes, BUN. and creatinine are done, stat. Also a stat type and cross match for four units of whole blood. He’ll need an immediate intravenous. Start normal saline and pour it in when we arrive. Get a blood culture. He’ll need a pre-op antibiotic, so give him a bolus of two grams of Ancef after the blood culture. Have the emergency room x-ray ready for an abdominal obstructive series. After that you’ll need to insert a gastric suction tube, and a Foley catheter. Call surgery for me and tell them to be ready in one-half hour. Get anesthesia on call, stat. See you. Be ready. You got it all? Read it back quickly. The nurse did so, accurately and completely.

There were a few minutes of anxious waiting before the ambulance arrived. Harris identified himself to the paramedic and with his help placed Wallberg in the ambulance amid much groaning and cursing on the part of the patient. Wallberg lay on his side with his knees almost touching his chest. Harris sat facing Wallberg, assessing his condition while the paramedic monitored the patient’s vital signs. As they sped to the hospital Dr. Harris said to Wallberg, I’ve got five minutes to learn all I can about your medical history. This is very important. Can you take some questions?

Yes, Wallberg answered in a hoarse and whispery voice.

Tell me how and when this all started.

Haltingly, Wallberg offered, I didn’t feel too well the last few days. My stomach started hurting and I became nauseated. I vomited once last night and felt a little better. I went to sleep and got up early. I had to be at the office for a crucial meeting, so I couldn’t let whatever this was stop me. All day my stomach was hurting and I got home earlier then usual and the shit hit the fan about ten minutes before I called you. The pain became unbearable and cramping had sort of spread all over. My stomach started blowing up. I couldn’t walk and could only get a little relief lying on my back or side with my knees drawn up. I vomited two more times.

Point with one finger to the part of the abdomen where your pain started.

Wallberg placed his index finger about one inch below his navel. Is that where it still hurts now? Harris asked.

No it hurts all over. The ambulance went over a bump and Wallberg groaned loudly. Raising his head slightly, Wallberg said, Will you tell that sonofabitch to drive more carefully. Godammit. I’m in pain here. Harris smiled sardonically. This was the Victor Wallberg he knew, forever berating those on a lower social level. The young paramedic beside Wallberg was doing his best to make Wallberg comfortable and to monitor his vital signs at the same time. Wallberg ignored his ministrations.

Any prior surgery of any kind?

No. Goddamit. Are all these questions necessary?

Only if you want me to save your life, Harris said with a distinct edge to his voice that caused the paramedic to look up.

Any problem with your health before this?

No.

Did you ever have an ulcer?

No. We should be at the hospital by now, damn it. Wallberg’s pain could not completely override his combative nature.

Are you taking any medicine now?

No. None.

When did you eat last?

I couldn’t.

Thank heaven the surgery would be performed on an empty stomach, thought Dr. Harris.

Any problem with your heart or lungs?

No.

How much do you smoke?

About a pack a day.

Alcohol?

Just on social occasions.

Yeah, sure, thought Harris. I bet he put away ten drinks at one neighborhood party I can remember.

What’s wrong with me? asked Wallberg in a worried voice.

You’ve got an intestinal obstruction. At this point I only have a list of possibilities as to the cause.

What possibilities?

Dr. Harris’s mind was racing. Statistically the most likely possibility was an acute appendicitis, but this case was atypical, because an intestinal obstruction doesn’t usually accompany appendicitis. The diagnostic possibilities rushed through his mind like a drum roll. He called them off for Wallberg with simple explanations: Small bowel intestinal obstruction or a blockage of the intestine; ruptured intestine; peritonitis; inflammation of the peritoneum which is a smooth, transparent lining around the cavity of the abdomen that folds inward over the abdominal and pelvic organs; intestinal inflammation; intussusception, the slipping of one part of the intestine into the part below it; volvulus, a twisting of the bowel upon itself; diverticulitis, an infection of a diverticulum, a small outpouching of the intestinal wall… then a long pause… Perhaps a hidden malignancy.

You mean cancer? queried Wallberg apprehensively.

It has to be considered, said Dr. Harris, without inflection.

Oh, Jesus. Wallberg moaned.

Dr. Harris continued. What I’ve just given you is part of the informed consent process. You need to also know that there is some risk to the surgery.

What risk?

Coldly, Harris answered, Infection, bleeding, anesthetic complications, blood clots, even death.

Wallberg raised his head and looked directly at Harris. You don’t mind giving people bad news, eh, doc?

The paramedic was listening in rapt attention.

Looking steadily at Wallberg, Harris spoke in a flat, even tone, The alternatives to surgery are none in my opinion. Not to operate could mean your death in a matter of days. When we get to the ER you’ll need to sign a consent form saying that you understand the risks and that I have informed you of the risks, benefits, and alternatives. How can I get hold of your wife?

She’s at a friend’s house, Lily Santos, 546-7823.

Wallberg stared at Harris, a look of bitter resignation on his face. Harris knew that a man like Wallberg could not tolerate this state of dependency, but he had no alternative. They arrived at the hospital emergency entrance. Two nurses were there with a gurney. They wheeled Wallberg into the hospital and the work up Harris had ordered was completed in eight minutes, including the four x-ray abdominal views. Holding the x-rays to the light, Harris needed only a few seconds to see the distended loops of small bowel and the air fluid levels. He confirmed his suspected diagnosis of a small bowel obstruction. A gastric tube and Foley catheter were put in place, the insertion of the catheter provoking an angry outburst from Wallberg, telling the nurse to be careful as she was messing with his most precious possession. There was no time to wait for results of the blood tests, the patient had to be moved to the operating room. While Wallberg was wheeled out, Harris made a call to Lily Santos’ house and spoke to Wallberg’s surprised wife. This is Dr. Harris. I’m in the emergency room at Barrington Community Hospital with your husband. He called me from your home and I found him in extreme distress. The tests and x-rays confirm that he has an obstruction in his small bowel. I’m preparing him for surgery as we speak and as soon as I finish talking to you, I’m headed for the operating room.

Oh, my God! she exclaimed. I don’t believe this.

I know what you’re thinking. I don’t either, but he called me. I’m hopeful we caught it in time. Once we get the obstruction repaired, he should be fine. Your husband will be in the intensive care unit at least overnight and will be sedated probably until tomorrow.

Can I see him in the recovery room?

I’m afraid that at this time of night the recovery room is closed. Surgical patients are taken directly to the ICU.

Can I see him there?

That’s up to the nurses in the ICU. If you want to stay in the Waiting Area outside the ICU, I’ll stop by after surgery and let you know how things stand.

In thirty minutes from the time of arrival in the emergency room Dr. Harris was making the initial incision into Victor Wallberg’s belly. Harris would need plenty of room, so a large vertical incision was made. He was not surprised when he identified a normal appendix. He would have to search for the affected part of the small bowel. A brief exploration revealed that about twenty-four inches of it was blue and gangrenous caused by an obstruction that had shut off the blood supply. He would have to remove the affected area and anastomose the two viable ends together. The obstruction was caused by a volvulus, the intestine had twisted upon itself affecting its blood supply. To his surprise Harris also discovered a congenital band, an accident of embryonic development that produced a band of fibrous tissue about four inches long creating a tunnel into which the intestine protruded, twisted and trapped itself thus blocking its blood supply. This was a first for him. As he deftly worked, his mind filled with thoughts long buried. Most patients could live with a congenital band and never know they had one, but complications often made its presence known. One such complication was a volvulus causing an obstruction when the intestine pushes through an opening made by the band and then gets stuck. This was the problem that Cliff Harris faced as he worked on Victor Wallberg. Harris now applied the technical competence that had caused the operating room personnel to dub him, The Wizard. The analysis of the patient’s condition was over and his mind shifted into a mechanical mode. He worked silently; the scrub nurses accustomed to his style did their best to anticipate his needs. Rarely did his eyes leave the open incision. The only verbal utterances were calm, clear calls for instruments, and simultaneously with the call, his right hand, palm up, moved toward the instrument table. The instrument was slapped into his hand, and brought to its task in Wallberg’s belly. Harris’s surgical assistant was well trained and together they collaborated like two dancers, moving in unison, scarcely missing a beat.

The gangrenous bowel segment and the congenital band were removed and the two viable ends of the small intestine joined together. Then Harris performed a full abdominal exploration. Liver, spleen, pancreas, gallbladder and ducts, stomach, remaining small intestine, colon, mesentery were all normal and pink. The anastomosis was tight with sufficient space inside to ensure against future problems. The repaired area showed no signs of blood leakage. The abdominal cavity was free of blood. Harris was satisfied. He closed Wallberg’s incision they took Walberg directly to the intensive care unit that served as a recovery room in the late evening, staffed by the ICU nurses cross-trained in recovery room procedures. Blood transfusions had not been necessary. Dr. Harris wrote his post-operative orders for the ICU nurses, and spoke briefly to them. He stepped into Victor Wallberg’s room and stood for a moment at the foot of the bed realizing that for the first time in his life he was looking at a man he had once threatened to kill. He took one last look at Wallberg, thought about the power of an ancient oath that would cause him to do what he did tonight, and left the room and walked toward the Waiting Area farther down the hall to see Wallberg’s wife.

Marilyn Wallberg had gone from a reasonably attractive forty-year-old to someone who seemed to have little concern for her appearance. She was above average height, her unlined face wearing a perpetual frown. Her dark eyes showed little vitality and her dark, unkempt hair evidenced the first barely visible signs of gray. Harris had noted that as some wives aged, they put on weight or they lost their animation or they neglected their appearance. Marilyn Wallberg had managed to touch all three bases. Not for the first time Harris thanked the stars that his wife, Laurel, had retained the look and enthusiasm of youth. In fact, with maturity, he now considered her even more beautiful than when they had first met in college.

The Wallberg’s had moved to Barrington Woods when Wallberg assumed a position as CEO of Technical Dynamics Inc. three years earlier and moved next door to the Harris’s. When Harris walked into the waiting area Mrs. Wallberg was sitting quietly in the waiting room.

As Dr. Harris reported his findings at surgery her expression never changed. She listened intently with her eyes fixed on Harris’s face, her features registering no visible response. He should do well now, ended Dr, Harris.

Thank you so much for your help, doctor. I know it must have been difficult for you and I appreciate it. She gave him a grateful smile.

"No thanks are necessary, Mrs. Wallberg. Your husband required immediate medical care and I provided it.

Well, anyway, I want you to know I’m grateful. Harris gave her a reassuring smile.

Harris returned briefly to the ICU where he told the nurses that Mrs. Wallberg was in the Waiting Area and that when Wallberg awakened she might want to see him. Harris went back to the surgical locker where he helped himself to a glass of orange juice and was exhaustedly contemplating the day’s events when he received the cell phone call, and the chain of events unfolded that resulted in the massive bleeding, the second operation, and the death of his patient.

CHAPTER 3

All clinical departments of a hospital have a department chairperson who has full responsibility for the medical affairs within the department. This is a physician usually appointed by the Board of Trustees whose job description is fully detailed in the medical staff bylaws. In essence the four most important responsibilities of any department head are education, credentialing, peer review, and performance improvement. The latter is ongoing and involves physicians and all hospital employees in a collaborative effort to develop systems promoting patient safety and quality of care.

Over the years it has been recognized that most tragic occurrences in hospitals are more often than not a system failure rather than a physician’s error. This is not to say that physicians do not make errors or mistakes in judgement. They do, and it is for this reason that in all accredited hospitals, a peer review committee reviews the performance of each physician. Criteria are established for each department mandating peer review for certain untoward events. A hospital death, by rule, must be reviewed, and an intra-operative death receives particular scrutiny.

At Barrington Community Hospital Victor Wallberg’s chart was immediately placed on the death review list of the Department of Surgery. The surgical peer review committee consisted of seven members who took turns on a monthly basis reviewing the charts of surgical procedures that did not meet pre-established criteria. Each procedure was detailed in a case review form. Deaths and other unusual incidents would then be reviewed each month at a meeting of the surgical committee. Cases were either cleared or set aside for further review. Those set aside required either a written response from the surgeon or a personal appearance before the committee. In an intra-operative death a personal appearance was mandatory.

The evening after the death of Victor Wallberg, Cliff and Laurel sat in their living room discussing Cliff’s expected appearance before the review committee. Cliff was obviously tense and Laurel sought to alleviate his anxiety. I’m sure the review committee will find you did everything possible to save Victor Wallberg’s life.

Ordinarily, I wouldn’t have any concerns, Cliff said, but I did get into a shouting match with Sanjay in the OR and the use of heparin in treating a case of DIC is not that well known. If I have to educate the members of the committee about it, I may have a problem.

I’m sure they’ll understand once you explain it to them, Laurel said with certainty.

I hope you’re right. I’ve never been reprimanded by the committee before and I would hate to have that black mark on my record now.

I can’t believe it would come to that, Laurel said shaking her head with conviction.

Gloomily, Cliff said, It could be worse. They could order me to take some remedial training and suspend my hospital privileges until I was, in effect, recertified again.

Laurel was appalled. Oh, Cliff! That couldn’t possibly happen!

It might. I don’t believe it would come to that, but remember these hearings are secret. There’s no telling what may come out of it this time.

Cliff and Laurel mulled over the problem for some time and then decided the only sensible course was to get a good night’s sleep and deal with whatever happened as it came along. They walked down the long corridor to their bedroom, arms around one another, each endeavoring to draw strength and encouragement from the other.

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Marilyn Wallberg’s older brother, Richard Spehn, of Chicago, drove out to Barrington Woods to be with her and offer whatever assistance he could provide in her bereavement. He was a businessman and investor who had a number of business interests including a string of Subway sandwich franchises in and around the city. A high energy level and an astute business sense had allowed him considerable financial success at a relatively early age. A native of Chicago and a product of the Catholic school system, at age forty-five Spehn retained much of the physique of the defensive back that had earned him a year at Marquette University. There he found the college’s requirement that he actually attend classes while performing on the football