The Seven Trials of Cameron-Strange

By James Calum Campbell

'Fox stepped swiftly through the door. There was an audible click. And there came the sound of a bolt sliding into place. What follows is the stuff of nightmares...' Just when the bereaved and troubled Dr Alastair Cameron-Strange rediscovers his life on the other side of the world, the British authorities track him down. They recruit him on a mission which takes him to the farthest reaches of New Zealand, to Xanadu with all its grotesque gargoyles, chief among them Phineas Fox, the American business tycoon whose baleful eye is on the White House. There's something not quite right about Mr Fox, and Cameron-Strange, with the help of the beautiful Nikki, is determined to find out what it is. He survives six ordeals, but will he survive a seventh?

• Language: English
• Publisher: Impress Books
• Release date: Sep 9, 2021
• ISBN: 9781907605840

Book preview

DURANCE VILE

I

Friday, 15 April

‘I solemnly declare that the evidence I shall give shall be the truth, the whole truth, and nothing but the truth.’

Quentin Quint, for the prosecution, got to his feet. He was a middle-aged, somewhat portly man, balding, with a pleasant, chubby face, smooth and of pale complexion, above a jowlish double chin. He wore a black academic gown over a three-piece pinstripe suit. His smile was ready, but it was tight-lipped, and his eyes remained analytical and vigilant. He gleamed at me over his half-moons.

‘Could you state your full name for the court, please.’

‘Alastair Cameron-Strange.’

‘And your occupation.’

‘Medical practitioner.’

‘And your current post.’

‘I am a specialist emergency physician in the Department of Emergency Medicine at Middlemore Hospital.’

Mr Quint, ‘QQ’ to his colleagues, paused to examine his papers, chewing his lip. He was in no hurry. I took a quick glance around the court room. Te Koti Matua o Aotearoa. It was less intimidating than I had expected. It might have been a meeting room at a conference centre designed to accommodate a breakout group of a hundred people. There was the bench and, on either side of it, the witness stand, and the dock. Counsel occupied the area in front of the bench. Behind them were various court officials, and then the public area. It was a full house. The outcome to this trial was after all of some public interest. The jury sat on the left, close to the witness stand, and opposite the dock.

I was in the dock.

‘Dr Cameron-Strange, you were on duty in Middlemore Emergency Department on the evening of Sunday, January 24th, this year.’

‘Yes.’

‘At about 11pm, you treated a patient’ – he glanced at his brief – ‘at that point designated Unidentified Male, hospital number 5126EQZ –’

‘Sorry, I didn’t catch the number.’

Mr Quint raised his voice. ‘Five one two six Echo Quebec Zulu.’

‘Yes.’

‘Could you describe to the court the manner of this patient’s presentation.’

Mr Quint kept any interrogative up-speak out of his intonation. That was because he knew the answers to his questions before he asked them. This was merely the rehearsal of a script that had already been composed. Quint knew the script intimately. Quint had written the script; he was also a principal player in the drama, and, should I divert from the text, lose my way, improvise, and ultimately ‘corpse’, then Quint would fulfil the role of Prompt.

‘This patient was brought to the hospital by ambulance. He had been involved in a road crash. He had been entrapped in a vehicle on fire. He was severely burned.’

‘How severe was the burn.’ Again, no question mark in the voice. He already knew the answer. It had been written in the hospital notes, to which the court had had access. Quentin Quint was laying out the facts of the case as an anatomist might lay out the important structures of a segment of a limb in a meticulous dissection.

‘95 per cent. Full thickness.’

‘95 per cent of the total surface area of the body was completely destroyed.’

‘Yes.’

‘I see.’ Quint’s voice was dry as parchment. Flammable. Letitia O’Dwyer was shuffling her papers. I was aware my defence counsel was intimidated. I remembered her undisguised groan of dismay at the depositions stage. ‘Oh God. We’ve got Quint.’

I could vividly recall the grotesque, black, chargrilled fragment of human life and in particular the spastic fixed flexion of the non-viable limbs held petrified, the destroyed digits flaking to the lightest touch, like cinder-shard. The globes of the eyes, fried sightless in their sockets. The huge segments of bland, grey, full-thickness-burned skin of the trunk. And no hair! Absolutely no hair at all. Scalp, eyebrows, nasal hairs, torso, pubis – all gone. And the smell. Smell evokes memory, but it also works the other way. Standing in the dock, I had an olfactory hallucination. Pork.

And I could remember the involuntary gasp of disgust and dismay from the nursing staff as the body was wheeled into Resuscitation. We had all seen plenty of trauma, gross injury, dreadful sights, scraped off Highway One as it snaked through Auckland’s southern suburbs, but this was something else again.

‘Dr Cameron-Strange, from my reading round the subject, I am given to understand that the key elements of resuscitation bear the mnemonic ABC, that is to say, Airway, Breathing, and Circulation. I understand that assessment of these elements comprises the emergency physician’s so-called Primary Survey.’

‘Yes.’

‘With regard to the Primary Survey, what was your assessment in this case?’

‘The burn extended into the pharynx and trachea. There was evidence of a severe smoke-inhalational injury. The airway remained patent –’

‘Patent?’

‘Open.’

‘The patient could breathe?’

‘Yes. But the airway was rapidly closing off because of severe oedema.’

‘Oedema?’

‘Tissue swelling around the neck.’

‘Ah-ha.’

Mr Quint was chewing his lower lip and studying his brief again.

‘I understand, again from my reading – correct me if I’m wrong – that such findings would normally direct the physician to take control of the breathing, to intubate the trachea, to ventilate the patient.’

‘That is correct.’

‘Yet you did not do this.’

‘No.’

‘Why not?’

‘I did not think it appropriate.’

‘Isn’t it true, Dr Cameron-Strange, that you had made up your mind, virtually as the patient was wheeled through the door, that he was not going to survive.’

‘Virtually.’

‘I see.’

There was another pause. Quint was a master of the pause.

‘Proceeding to the next part of the resuscitation, the C of ABC, the circulation, you did, however, think it appropriate to insert an intravenous cannula.’

‘Yes.’

‘Why was that?’

‘I thought it would be the best and most rapid way to administer pain relief.’

‘Was it a technically difficult procedure?’

‘Yes. The limbs were so burned that no adequate peripheral venous circulation could be found.’

‘How did you circumvent this problem?’

‘I inserted a central line.’

Quint consulted his notes. ‘You cannulated the internal jugular vein.’

‘Yes.’

‘Charge Nurse Mulholland in her testimony has stated that you established intravenous access in about 20 seconds.’

‘Perhaps. I couldn’t be exact. I had no problem with the procedure.’

‘I congratulate you on your proficiency, doctor. Am I right in saying that the internal jugular vein flows directly into the right atrium of the heart?’

‘No. The internal jugular vein flows into the brachiocephalic vein which in turn flows into the superior vena cava. This is the vessel which flows into the right atrium.’

‘Yes, yes.’ There was a trace of testiness. ‘But you take my point. It is all one vessel, rather like a thoroughfare which changes its name as tributary roads join it.’

I shrugged.

‘Having established access, doctor, you proceeded to order narcotic analgesia from Charge Nurse Mulholland.’

‘Yes.’

‘What did you prescribe?’

‘Morphine sulphate.’

‘Indeed. Charge Nurse Mulholland has stated in her testimony that she drew 5 milligrams of morphine sulphate into a syringe and handed it to you. She stated that your comment on receiving the analgesia was …’ Quint studied his notes and said with pedantic precision, hanging gravid quotation marks round his speech, I asked for analgesia, not bloody homeopathy. Tell me, doctor, is it your regular practice to swear at the nursing staff?’

‘Objection!’

‘I withdraw the question.’ Quint moved swiftly on. ‘We have already stated that this incident took place around 11pm on a Sunday evening. For how many hours had you been on duty by this time?’

‘I had come on duty in the Emergency Department at 5pm the previous Friday.’

‘You had been on duty for 54 hours.’ Quint did not pause to make a calculation; he had already done his arithmetic. Now he paused, to let the information sink in.

‘I had thought inhuman working hours were a thing of the past, even in medicine.’

‘We had a staffing crisis, due to illness. I volunteered to help out.’

‘Did you get any sleep over the course of that weekend?’

‘Objection.’ Letitia was shuffling papers again. ‘Your Honour, where is this line of inquiry leading?’

‘Your Honour, I think we have to allow for the fact that by 11 o’clock on the Sunday evening, Dr Cameron-Strange’s judgement may have been clouded by overwork, and fatigue. I would have thought defence counsel would have been happy to establish this point, which could well be seen as a mitigating circumstance in the defendant’s favour.’

Letitia O’Dwyer stood up. ‘My client was perfectly in command during the incident in question. He does not need any mitigating circumstances and I do not need help from the prosecuting counsel in the defence of my client.’ It crossed my mind that Ms O’Dwyer, even in formal court dress, when summoned to anger, was attractive.

The Honourable Justice Lowell, who up until this moment had appeared to be taking an afternoon nap, leaned forward and enveloped us all in his avuncular beam. ‘You may pursue this line of enquiry a little further, Mr Quint, but keep to the point.’

‘Thank you, Your Honour.’ Mr Quint bowed his head in acquiescence. ‘Dr Cameron-Strange, how much sleep did you get during the course of the weekend in question?’

‘I’m not sure. Perhaps about six hours.’

‘And how many patients did you treat over the weekend?’

‘I couldn’t say.’

‘Would it surprise you to learn that this unfortunate man who suffered such terrible burns on Sunday evening was the one hundred and thirtieth patient you personally had seen in the department since Friday evening?’

‘That sounds about right.’

‘But you were, at least according to your counsel, perfectly in command.’

It wasn’t a question, so I didn’t answer it.

‘During this one hundred and thirtieth consultation, you proceeded to demand of Charge Nurse Mulholland that she break open five vials of morphine sulphate to draw up a total of fifty milligrams. Is that correct?’

‘Yes.’

‘What was Mrs Mulholland’s reaction?’

‘She queried my request. She thought the amount excessive.’

‘How did you, in turn, react to her query?’

‘I told her that I thought the patient would require that much analgesia in order to control his pain, perhaps more.’

‘Yes, I see. Charge Nurse Mulholland stated in her testimony that your precise words were, Stop arguing and just do your job. And yet, nursing staff have a right, and indeed a duty, to question the prescribing of doctors when they observe, shall we say, unusual activity. Are you in the habit of browbeating nursing colleagues?’

‘Objection!’

‘Withdrawn.’ Quint waved a hand.

‘Dr Cameron-Strange, at the time of this incident, you were not a regular employee at Middlemore Hospital.’

‘No.’

‘You have recently spent time abroad. You were in locum tenens.’

‘Doing a locum. Yes, that’s correct.’

Mr Quint picked up a medical journal from his desk. ‘I wonder if you are familiar with a paper in the New England Journal of Medicine, October 2014, by Priestfield, Dickie et al., from Ann Arbor in Michigan, entitled, Tissue harvesting in the management of extreme percentage burns.’

‘Yes I am.’

‘You’ve studied it.’

‘Yes.’

‘The paper announces some dramatic results in survival rates among patients inflicted with injuries not dissimilar to those we have been describing. Is this not so?’

‘Yes.’

Quint laid the journal back down. ‘Now, doctor, one element of your patient’s condition, which we have not touched on, was his neurological status. In your notes, you record this briefly as GCS 15. Could you tell the court what this means?’

‘GCS stands for Glasgow Coma Scale. It’s an index of conscious level.’

‘And a score of 15. Is that good or bad?’

‘It’s excellent.’

‘Does that mean that this burned man was fully conscious on arrival in hospital?’

‘Yes.’

‘So, despite this horrendous injury, his brain was not insulted, not damaged?’

‘I think that the patient had suffered a global insult which would certainly go on to threaten his brain, but, I agree, at the time of the acute admission, there was no evidence of any brain damage.’

‘Did the patient speak to you?’

‘Yes.’

The next pause was unscheduled. Quint opened his mouth as if to proceed, then closed it again. It occurred to me that his last question – ‘Did the patient speak to you?’ – was the first question thus far that Quint had not already known the answer to. I wonder if my answer surprised him. For a moment I thought Quint was going to pursue this line of enquiry, and then he thought better of it. Maybe there were murky waters there. He didn’t want to head off into the unknown. He went off on another tack.

‘Charge Nurse Mulholland has stated in her testimony that she drew up 50 milligrams of morphine into a syringe, as directed by you, and handed it to you.’

‘Yes.’

She had in fact slapped it into my hand and narrowly escaped giving me a needle-stick injury. ‘There you are doctor.’ Her tone had been frigid. ‘The medication you ordered.’ It had been like this all weekend. Every exchange between us had been difficult. Every request I made she had tried to thwart. ‘Yes doctor, but …’ I wondered if it was a reflex, if she had built a career out of wheedling, niggling, and frustrating doctors. The other members of the nursing staff had been terrific, had worked solidly with me over what had been a frightful weekend. We had shared tasks; we had even recreated some of that Dunkirk spirit you sometimes came across in chaotic English NHS hospitals. They had even to an extent protected me from Mulholland. Don’t worry about her! Old bag. Of course it was Mulholland who had landed me in it, who had phoned the New Zealand General Medical Council, had ultimately, I suspect, phoned the newspapers and blown the whistle on me.

‘How much of the morphine did you administer, doctor?’

‘I gave it all.’

‘And how did you deliver it? Intramuscularly? Intravenously?’

‘I gave it via the central line.’

‘Ah yes. Through that vessel which travels straight to the heart. Over what sort of time period did you give the medication, doctor?’

So. Here it comes. The heart of the matter. The killing ground. All the rest has been chit chat and window dressing. Here was what mattered. Here, ultimately, would be the area in which the fusty old appeal court judges – should it go that far – would haggle over obscure points of law. I was merely a pawn in a game to be played out in chambers. And what bearing did any of it have on reality, the reality of life, the blood and thunder of a hospital emergency department? No bearing whatsoever. I began to sense that my situation was Kafkaesque. I had an insane desire to burst out laughing. I suppressed it.

‘I would say that I gave the entire dose over about five minutes.’

‘Not as a single dose?’

‘No. I titrated it in.’

‘Titrated it against what?’

‘Against the patient’s response.’

‘What would you expect to happen to a patient’s respiratory rate when you infiltrate such a large dose of narcotic?’

‘It would become suppressed.’

‘Would this be significant in a patient with damaged lungs and airways?’

‘Yes.’

‘Could he stop breathing altogether?’

‘Yes.’

‘Dr Cameron-Strange, was it your intention, when you administered this medication, to kill your patient?’

Here it was. I had wondered about this question, I had asked it of myself, many times. How should I play this? What sort of message to convey? There are a hundred different ways of skinning a cat. Maybe. But there is only one truth. What was the truth?’

‘It was my intention to give him pain relief.’

‘Let me rephrase my question for you, put it another way. When you administered 50 milligrams of morphine to a severely traumatised patient with a major insult to the respiratory system, what did you expect the ultimate outcome to be?’

‘I believed I could make him comfortable.’

‘Yes, but what did you expect the ultimate outcome to be?’

‘I believed that, no matter what I did, even if I pulled out all the stops, my patient had no chance of survival. I also believed that in view of the particular nature of his injury, survival would not have been in his best interests.’

‘Ah yes, you decided, turning your back on an evidence base of which you testify you are aware – I think we have concluded that much …’ – Quint brandished his copy of the New England Journal of Medicine – ‘you decided, did you not, that your patient could not survive.’

‘Objection!’

‘Now we hear you decide, on the basis of – what? – two minutes’ acquaintance? – that your patient should not survive.’

‘Objection!’

‘My patient’s life expectancy could be measured in minutes to hours – maybe a day, if we had been really aggressive.’

I felt myself getting a little heated, and I’d told myself not to get heated. Letitia had told me not to get heated. We had even rehearsed this scenario, with one of the junior counsel taking Quint’s role and being as obnoxious as possible. ‘Whatever you do,’ Letitia had said, ‘don’t lose your temper.’ I think she must have sensed that I had a propensity to do just that. ‘Remember, Quint will test your evidence. He’ll try one line of attack after another. Just keep your cool and, no matter what, keep telling him you gave that morphine solely to provide pain relief. Got it?’

‘I ask you again, doctor. Did you intend to end your patient’s life?’

‘I intended to palliate his suffering.’

‘And wasn’t it a corollary of that, that you knew your patient would die?’

‘My patient was going to die, come what may.’

‘But you helped him along a bit, didn’t you? Oh come on, doctor! You didn’t give him 50 milligrams of morphine to take away his pain, you gave him it to kill him, didn’t you?’

‘You’re making a distinction that I don’t think exists in reality. I don’t think you know what it was like in that resuscitation room.’

‘Well then! Please enlighten us!’ Quint had lost his dry detachment. He was suddenly animated. He was like a hound who had picked up a scent of quarry. He was casting around the court room, making expansive gestures, summoning the spectre of Sir Edward Marshall Hall. ‘Perhaps you could tell us what happened in that emergency room. Tell us, for example, what happened to your patient over the next few minutes following the injection of narcotic.’

‘He lapsed into unconsciousness.’

‘Yes. Indeed he did. But more than that. Charge Nurse Mulholland has described to us how the oxygen saturation of the patient, measured by the technique of pulse oximetry, fell from 94 per cent to 73 per cent literally on the end of your needle. And she has explained to us, in clear, lay terms, what this means. We have also heard how, in the ensuing minutes, your patient suffered a cardiac arrest, which has been described as a hypoxic arrest, and that you ordered the nursing staff neither to assist the patient’s ventilation, nor to proceed with cardiac resuscitation. All this, doctor, literally on the end of your needle.’

Quentin Quint had become more and more animated as he described these incidents. Now he did something which caused the whole court room to jump. He had returned to his desk and he now proceeded to cast his notes thereon, and to swing round to face me again. He brought his clenched fist down on the lectern with a thump. ‘I ask you one last time. Isn’t it true that you intended to kill your patient?’

‘Yes! But you’re missing the point …’

Quentin Quint raised his arms aloft in a gesture of benediction and allowed them to slap down against his sides. ‘Thank you doctor! Thank you! I may be missing the point, but I have no further questions.’

Letitia O’Dwyer arose and moved into the cross-examination immediately. She did not wish to delay and allow the jury to recognise that an important point had been established. She approached the dock. She was a tall and attractive woman in her mid-thirties, with long dark hair worn up. She was dressed severely in an academic gown on top of a white blouse; a calf-length, dark-blue pleated skirt; dark stockings; and black shoes in patent leather with a slightly raised heel. Her candid, level blue eyes held no glimpse of sympathy or humour. They were grave and professional. Her features were even, the nose straight, and the chin firm. She walked with a long-limbed grace that might have been studied. All in all she was a powerfully attractive woman made, paradoxically, the more sensuous by the constraints of the dress code of her profession.

‘Dr Cameron-Strange, you have stated in your testimony that, in your view, survival for this patient would not have been in his best interest. Why is that?’

‘The patient had no viable limbs. The injury not only to the skin but also to the other tissues, fat, muscle, nerves, blood vessels, would have necessitated four amputations. In addition, the patient had lost sight. There was a very severe injury to the respiratory system which would almost certainly have resulted in chronic problems. Then