Chapter 28: End of Rant

June 8, 1990, McKinley, Ohio

Late on Friday morning, Mary was deposed by Amanda Temple. I found it amusing that Arthur Braun only attended my depositions, and it felt as if he was going to be a lifelong nemesis.

"How did it go?" I asked when she returned to the ED.

"They really focused on the second bounceback, exactly as you predicted. I handled it the way you suggested — that I could not offer an opinion because I wasn't involved in the evaluation the previous night. They pushed, but Mr. Crowe eventually insisted they move on."

"I think we may need to print ultrasound images out of self-defense when the findings are inconclusive. In fact, I'm going to suggest that to Doctor Wernher in the Monday morning staff meeting."

"I was surprised you didn't object to that!"

"Even more surprising, I'm attending voluntarily!"

"I believe, at this point, Doctor Saunders would say 'You are weird, Petrovich'!"

I laughed, "I'm sure she would. But it's a 'stand up' meeting in the ambulance bay with a ten-minute time limit. That's the kind of meeting I can get behind. Owen encouraged me to attend, but I was going to attend anyway."

"I'm going to grab a walk-in chart."

"OK."

I managed to have lunch with Clarissa, as there was a lull in the ED during her scheduled break.

"You are really enjoying tweaking me through Mary," I observed when we sat down.

"I don't see you enough, so I need to do it via proxy!"

"Why do I have this feeling you're going to team up with my sister-in-law to encourage my daughter to give me a rough time?"

"Because you're smart!" Clarissa declared. "But I don't think Lyuda needs any help."

"I don't think Rachel needs any help!" I chuckled. "I see so much of her mother in her."

"Speaking of mothers, how is Kris doing?"

"A week ago, she said she was feeling like a pregnant elephant!"

"And you find that incredibly sexy, don't you?"

"Of course I do!"

"Ten days or so, right?"

"Yes. I arranged with Owen Roth to start my vacation the day Kris goes into labor. Mary will cover the ED, and there's a good chance she'll be able to do chest tubes, central lines, and pericardiocenteses by then. If not, whichever PGY2 or PGY3 covering the surgical ward will come down."

"That quickly?"

"You know me! I started teaching her day one! I have to ensure she's self-sufficient by the end of August."

"Basically the opposite of Rafiq when you needed him to teach you."

"I'm very glad he's in Michigan and not here."

"Are you and Kris coming out tonight?"

"No. Kris is too tired and uncomfortable. We'll just have a quiet evening at home. Rachel is visiting Abi and staying the night at Abi's house. Milena will bring her to band practice tomorrow, and Anicka will be in her office in case Kris needs to call me."

"It's too bad there is no cellular telephone service here."

I chuckled, "Right, because I'm going to spend a couple grand on a phone and a hundred bucks a month just to make it easier for people to bother me? I already wear an electronic leash!"

Clarissa laughed, "I am SO happy I only have to do that during my on-call week."

"I did tell Kris that if she does need me in an emergency, she should call the Charge Nurse, who'll page me."

"Wise."

We finished our lunch, and I returned to the ED. Later that afternoon, Mary and I attended the M & M Conference with our students. Mary would be paged if there was a surgical consult, but because she was just completing her first week, I'd go with her. She and I sat down next to Clarissa and Shelly Lindsay, and our students sat behind us.

The topic for the day was a missed stroke diagnosis, but I knew from Leland Crowe that Doctor Cutter was going to say something about the leak, which the more I thought about, was someone who thought they were a 'whistleblower' while in reality they were actually a «стукач» (stukach)." ("snitch")

"Doctors, nurses, technicians, and students," Doctor Cutter said. "We have a pressing concern that must be addressed today. As all of you are aware, Morbidity & Mortality Conferences are privileged in the same way attorney-client and doctor-patient conversations are privileged, or, for those of you who are in a church that practices confession, the penitent-clergy relationship.

"That means you DO NOT, UNDER ANY CIRCUMSTANCES, reveal anything that is said in these conferences, no matter what, to anyone who is not on staff at the hospital. Not to your spouse, lover, parents, children, friends, therapist, or clergyman. That privilege is intended to ensure we can have frank discussions about cases with poor outcomes, without risking exposure in malpractice suits.

"Someone, and I mean to find out who, leaked information from the M & M Conference that covered the incident where a patient, Mr. Ken Webber, coded in the OR and could not be revived. Someone, possibly in this room right now, disclosed a statement by Doctor McKnight, either directly to the parties to the lawsuit or their attorneys, or to someone who then disclosed it to them.

"That disclosure has put us at a severe disadvantage in defending against the wrongful death lawsuit. It also opens the door for other statements made during that inquest, and others, to be subpoenaed by the plaintiff's attorneys. Mr. Crowe believes we can have those quashed under state law, but there is a risk that, because we broke privilege, we've waived it in this case.

"I know what I'm going to say next will be unpopular, but it has to happen. Each and every attendee of that conference will need to file a statement with a list of everyone they spoke to about the conference and will be interviewed by Leland Crowe. You do not have an option. Failure to comply will result in disciplinary action."

"Witch-hunt, as you predicted," Clarissa said quietly.

I nodded, "It sucks, and I don't like it, but when I spoke to Melody, she said pretty much what Doctor Cutter just said."

"Doctor Mike, Doctor Saunders, do you wish to share?" Doctor Cutter asked sharply.

I stood up.

"Sorry, Doctor Cutter," I said. "I apologize on both our behalves for the lack of respect."

"Take your seat."

I nodded and sat down.

"Smooth," Shelly said sotto voce, while looking forward.

"Every staff member," Doctor Cutter continued, "will find a form in the box on Monday morning. Fill it out, sign it, and return it to your Chief, your Resident, your Charge Nurse, or your supervisor. Failure to turn in a complete and accurate form will subject you to discipline. If you do not remember who you spoke to, you must disclose that on the form."

"Bullshit!" a male voice declared, masked with a cough from a group of doctors to our right.

"Whoever said that should have the courage to stand up and say it to my face and defend his position," Doctor Cutter said. "If our comments here are not held in complete confidence, we will all suffer, and our patients will suffer. I don't like this any more than any of you do, but it is where we find ourselves because someone couldn't keep their goddamned mouth shut! But that's enough. Doctor Baker?"

Tim Baker led the discussion of the missed diagnosis for the stroke victim, which was, when it came right down to it, a question of resources. We couldn't run CAT scans on every patient who showed slight memory loss or confusion, nor could we run one for short-term aphasia in an elderly patient who suffered from the onset of senile dementia. The diagnosis had only become clear when the patient had returned, this time presenting with hemiplegia and muscle weakness of the face.

In the end, the conclusion was that it came down to a judgment call about the use of scarce resources and the criticality of the patient being examined. In this case, the symptoms had mimicked a worsening of the patient's dementia, which meant both the ED and Medicine had missed the diagnosis.

"What do you think?" Mary asked when we left the conference.

"If we had infinite resources and infinite time, we could make more accurate diagnoses, but even if that were true, we'd still miss some because symptoms vary by patient and there are symptom clusters which can point to widely differing diagnoses. Think about this situation and tell me why it was missed."

"Everyone assumed the mild stroke symptoms were simply a worsening of the already diagnosed dementia."

"Correct. Why?"

"Because they had a diagnosis in hand, and everything fit that diagnosis. And according to Neuro, even a CAT scan might not have found the clot from the initial mild stroke."

"Exactly right. I think it sucks, and I wish things were different, but I don't see how we could have done anything differently with the evidence on presentation and the fact we have only one CAT scanner, and it's expensive to use."

"Who did you talk to about the Webber M & M?"