Good Medicine - Residency II
Copyright© 2025 by Michael Loucks
Chapter 58: Cross Examination
November 8, 1990, McKinley, Ohio
"Doctor, I remind you that you are under oath," Judge Maxwell said when court reconvened. "Ms. Temple, you may begin."
I wondered if they were going to tag-team me, or if they had decided Ms. Temple was a better choice to elicit the testimony they wanted from me.
"Good morning, Doctor Mike," Amanda Temple said.
"Good morning," I replied.
"Doctor, what are the symptoms of malignant hyperthermia?"
"The directly observable ones are very high temperature, tachycardia, abnormally rapid breathing, and rigid muscles. The measured ones include increased carbon dioxide production, increased oxygen consumption, mixed acidosis, and rhabdomyolysis."
"What causes it?"
"It has several potential causes, including anesthesia, some muscle relaxants, and intense exercise. There is some evidence for other causes, but you'd need to ask a specialist about those."
"Did Mr. Webber have, from your perspective, an unexplained increase in temperature?"
"He did, but only a single degree Celsius."
"You say 'only a single degree Celsius', but it concerned you enough to order cooling packs, did it not?"
"That's correct."
"And for the jury's benefit, that was close to two degrees in the usual way of reporting temperatures, correct?"
"0.9°C is about 1.4°F," I replied. "We use Celsius, but temperature gradients on thermometers used by the public are generally shown in Fahrenheit."
"Did Mr. Webber suffer from unexplained tachycardia? A high heart rate?"
"A brief bout that self-resolved."
"He also suffered from other unexplained irregular heartbeats, correct?"
"Yes. PVCs and V-fib."
"Isn't it true, Doctor, that V-fib — ventricular fibrillation — is a symptom of malignant hyperthermia?"
"Yes."
"So, Mr. Webber suffered an unexplained increase in temperature, tachycardia, and ventricular fibrillation, and yet you say he did not have malignant hyperthermia?"
"That is correct."
"How long had you been a doctor when you saw Mr. Webber?
"About ten months."
"And Doctor Lincoln?"
"About the same. We graduated from medical school at the same time."
"Is it fair to say you were very young doctors with limited experience?"
"That would be fair," I allowed.
"Do you feel you are qualified to make that statement about Mr. Webber's condition?"
"If I didn't, I wouldn't have made it. The post-mortem exam confirmed my analysis."
"We'll get to that in a bit. I want to ask again, Doctor — with an observed increase in body temperature and irregular heartbeat, you don't believe it was malignant hyperthermia."
"I do not."
"Then, to what would you attribute Mr. Webber's death?"
"I have no theory I am able to state unequivocally. I simply do not know."
"Did Doctor McKnight, the pathologist, say, and I beg the court's forgiveness for the coarse language, 'shit happens'?"
I looked to Leland to see if he would object, but he simply gave a slight nod, indicating it was OK to reveal what was said in the M & M. I was sure that was the case, because once Ms. Temple had asked the question, everyone would know what had happened if Leland objected, or if I refused to answer.
"That has been said to me by several physicians, including Doctor McKnight."
"Do you accept that?"
I decided I was going to lay a trap for her, though I doubted she was foolish enough to fall for it.
"I grudgingly accept that there are medical mysteries which we are unable to solve, including conditions we cannot detect. There are also conditions we are able to detect and are unable to treat."
"But in this case, Doctor, didn't you admit that you saw the symptoms but discounted them?"
"I saw a cluster of symptoms, but not in such a way that they were dispositive. I did not discount them, but I did not see other important symptoms, such as an increase in end-tidal CO₂, a further increase in temperature, or muscle rigidity."
"Are those always present in such cases?"
"As with any ailment, the cluster of symptoms varies from patient to patient. Not all patients exhibit every symptom, including for appendicitis."
"Yes or no, Doctor?"
"I stand by my answer."
"Your Honor?" Ms. Temple asked.
"I believe the jury is able to form an opinion based on the answer given by the witness. Move on, please."
"Doctor, is there a treatment for malignant hyperthermia?"
"The standard treatment is intravenous dantrolene."
"Was that drug available in the operating room?"
"Yes."
"Why wasn't it administered?"
"Because Mr. Webber did not suffer from malignant hyperthermia."
"Yes, you've said that, Doctor, but you've also testified that he had several symptoms, and you used cooling packs because you were concerned about malignant hyperthermia. Why not give the drug?"
"Because Mr. Webber's arrhythmia resolved without intervention and his temperature was stabilized."
"You stated you administered vancomycin prophylactically. Why?"
I knew exactly where she was going, and she was going to land a heavy blow on the hospital, and there was little I could do about it.
"To reduce the chance of infection or fight it as soon as it had started."
"Doctor, can dantrolene be given prophylactically?"
"It can," I acknowledged.
"And is there any reason not to give the drug?"
"There were no contraindications for administering it, except the fact that Mr. Webber did not have malignant hyperthermia, which was confirmed by the autopsy."
"The autopsy was inconclusive; was it not?"
"It was, but it found no signs of malignant hyperthermia."
"Except the ones you testified to, you mean?"
I could be cute and state those weren't found in the autopsy, but that didn't strike me as the correct approach.
"I'll rephrase — no blood markers that would indicate malignant hyperthermia."
"Can you provide another theory for Mr. Webber's death?"
"I'm not trained as a pathologist," I replied.
"But surely you have an opinion?"
"I do — and it is that we don't know what caused Mr. Webber to die, and I classify it as one of those mysteries which we are unable to solve."
"But it could have been malignant hyperthermia, correct? I'm not asking for certainty, just whether it could be that."
"In my professional opinion, it was not."
"Despite the symptoms to which you testified?"
"Yes."
"Let's discuss your initial evaluation of Mr. Webber. How did it differ from the one performed by Doctor Lincoln?"
"I ordered blood tests and an ultrasound."
"Why?" Ms. Temple asked.
"His physical exam indicated a strong likelihood of acute appendicitis, and those tests would help confirm it, as well as serve as pre-surgical labs."
"Why didn't Doctor Lincoln perform an ultrasound?"
"You would have to ask him," I replied.
"Did Doctor Lincoln ask for a surgical consultation for Mr. Webber?"
"Not according to the chart."
"Do you know why?"
"No."
"Let me ask the question a different way — to confirm appendicitis, hospital policy requires consultation from a surgeon, correct?"
"Yes."
"Was there a surgeon available for a consultation?"
"Yes. Doctor Robert Hodges was the Resident who would have consulted that night."
"He wasn't called?"
"That's correct."
"Why didn't you call for a consultation?"
"Because I'm on the surgical service," I replied.
"You, in effect, do your own consultation when you're working in the ER?"
"Yes."
"If you had seen Mr. Webber the previous night, would you have performed an ultrasound?"
"That is my usual procedure, as a surgeon, for non-specific periumbilical pain."
"Could you repeat that in layman's terms?"
"That's what I typically do as a surgeon when someone reports pain around their navel."
"Is it safe to say, Doctor, that had Mr. Webber seen you the previous evening, rather than Doctor Lincoln, he might still be alive?"
"No, it's not safe to say that. Given the totality of the circumstances, and the unknown cause of Mr. Webber's cardiac problems, it's my professional opinion that the results would likely have been the same."
"But you cannot say that with certainty, can you?"
"No, but it fits the facts as we know them."
"If someone with the same symptoms as Mr. Webber came into the ER today, would he or she receive an ultrasound?"
Another telling blow was about to be landed, and it was, in effect, self-inflicted by Moore Memorial.
"Yes," I replied.
"Why is that?"
"Doctor Wernher, the Chief of Emergency Medicine, changed the protocol for non-specific periumbilical pain."
"Do you agree with that change?"
"I do."
"That change was made in direct response to Mr. Webber's death, was it not?"
"I believe it was."
"That would appear, to any neutral observer, to be an admission of error, wouldn't you agree?"
"That it would appear that way? Yes. That it is an admission of error? No."
"How could we not draw that conclusion?"
"In the same way that it would not be accurate to call what happened to my wife a missed diagnosis, even though that is how it was reported in the newspaper article."
"Isn't it true that the diagnosis was missed?"
"She had a condition no available medical technology could detect, and even if it had been detected, no treatment existed, nor does one exist today. You can't 'miss' what you can't measure or detect."
"Sophistry, Doctor," Ms. Temple said.
"Logic, Counselor," I replied.
"How much sleep did you have the night before the surgery?"
"About six hours, which was typical for me."
"And your student?"
"I don't know, but she was fresh and alert when she came into the Emergency Department that morning."
"Is it true that Doctor Flynn had been on the night shift and was called back to the hospital?"
"Yes, though he reported that he had slept for several hours on the couch in the Attending's office. He did not appear to be fatigued or tired."
"What about Doctor Burnside?"
"He had been in another surgery and was called to our OR."
"When did his shift start?"
"I believe it was 5:00am, which is typical for surgical teams and anesthesiologists who are handling scheduled surgeries."
"That's very early."
"The first scheduled surgeries usually begin around 6:00am."
"How did Doctor Burnside appear to you?"
"He did not appear to be fatigued."
"How was his speech?"
"Clear, concise, and to the point, which is typical for everyone in the OR."
"He did not appear to be impaired?"
"No."
"Did you smell alcohol on his breath?"
"I did not, and I was standing relatively close to him for several minutes before the surgery began."
"Are you aware, Doctor, that Doctor Burnside is an alcoholic?"
"I was made aware of that allegation when the lawsuit was filed, but beyond that, I have no knowledge."
"Wouldn't that be important for a surgeon to know?"
I shook my head, "No. Our concern would be if he, or anyone, were impaired, be it from alcohol, illicit drug use, lack of sleep, emotional distress, or illness. So long as he is not impaired, it's not my concern unless he were to bring it to my attention."
"Doctor, would you say you are a good judge of character?"
"I'd like to think so, yes."
"Who is Ronald Oaks?"
I suppressed a groan, because he had hoodwinked everyone about his identity, though absolutely not about his skills and abilities.
"A medical student who was using a false identity."
"Were you aware of that before he was arrested?"
"No."
"Was he allowed to examine patients and perform procedures?"
"He was my student for less than two weeks, and as an MS3 — a student in their third year — he mostly observed. According to his procedure book, during his first clinical rotation in Family Practice, he took a few histories, drew blood a few times, and administered a pair of injections. I observed him taking histories and examining patients, as well as drawing blood and hooking up monitors and EKGs."
"And you had no idea he was pretending to be a medical student?"
"He was actually a good medical student who had completed an undergraduate degree, scored well on the MCAT, and had completed two years of medical school using an assumed identity. You are correct that I did not detect the fact he was using an assumed name, but he was not 'pretending' to be a medical student; he was a medical student."
"You don't think he put patients at risk?"
"I saw nothing that would indicate he wasn't a competent Third Year medical student. The procedures he performed were similar to those a nursing student would perform after having a single year of classroom education following High School graduation."
"You don't question your judgment?"
"Not about how he handled his medical training."
"Doctor, who was Deborah Bailee?"
"A patient who presented with multiple stab wounds."
"Did she die as a result of a procedure you performed?"
"That is the sequence of events, but the procedure did not cause her death. She had at least three fatal stab wounds, out of a total of fourteen, plus defensive injuries on her hands and arms."
"But she bled out after you performed a procedure you knew might cause her to bleed out."
"That's true, because the options were to allow her to die untreated, or to try what you might call a Hail Mary procedure. In consultation with another physician, we tried the Hail Mary and the patient exsanguinated. The autopsy confirmed that would have happened no matter what we had done."
"Doctor, have you heard the maxim that a physician is not 'real' until he or she has killed a patient?"
"I have heard that, but I have never said it, and I do not agree with it."
"But that is a common saying amongst medical professionals, is it not?"
"It is, but it's no more true than the idea that eating an apple a day keeps the doctor away."
"And yet many physicians believe it, do they not?"
"Some do, but physicians also rejected the idea of hand washing in the nineteenth century on the silly notion that a gentleman's hands could not transmit disease. That belief changed over time and upon evidence, as will the maxim you mentioned."
"Doesn't it feed into, and the court will please forgive me again, the idea that 'shit happens'?"
"I suppose, but as I said earlier, I don't buy into either of those. And more importantly, neither does Doctor Wernher, the Chief of Emergency Medicine."
"You've had disputes or disagreements with other physicians, have you not?"
"I have."
"About what?"
"Training methods, diagnoses, treatment programs, and hospital policy. All of those are part and parcel of being a medical student, a Resident, or an Attending."
"Isn't it true that there are physicians at the hospital who think you're a 'cowboy'?"
"There are, but I believe that is mostly related to the fact I am in a completely new specialty and have an aggressive training program. That said, I have never knowingly put a patient at more risk than if they were left untreated."
"Very carefully stated, Doctor."
"Had I said 'never knowingly put a patient at risk', you would have reminded me of Ms. Bailee."
"Doctor, are you aware of a previous case where a patient died unexpectedly during surgery?"
"I only have specific knowledge of one other case. During my pathology rotation, we examined a patient who had an MI — myocardial infarction, or, in layman's terms, a heart attack — during surgery. We could not find a cause."
"What is the usual rate of unexplained deaths during surgery?"
"The published mortality rates attributed to anesthesia show around eight per million, or less than one per 100,000 surgeries."
"How many surgeries have occurred during your time at Moore Memorial?"
"I do not know for sure, but I would estimate about 15,000 over the past five and a half years."
"I believe that works out about 12 per 100,000, does it not?"
"Roughly, yes."
"And that rate is more than twelve times the published numbers?"
"Yes," I agreed.
"What does that say to you, Doctor?"
I wanted to answer that we were just unlucky, but I didn't feel that would go over well with the jury.
"That the 'law of averages' isn't what most people think it is," I replied. "If we include all the surgeries performed since the mid-70s, the average is closer to the reported one."
"That doesn't concern you?" Ms. Temple inquired.
"Of course it does! Any death, explained or unexplained, concerns me. I'm simply pointing out that, over a longer period, the numbers are not out of line, even if they are tragic for all who are involved."
"Are you aware of any other cases similar to those two?"
This was the question Leland and I had discussed, and I knew how to answer.
"Not from personal experience nor from a Mortality & Morbidity Conference."
"But otherwise?"
"I honestly cannot recall whether I heard offhand about other cases. In the case of Mr. Webber and the other one I mentioned, I was in the OR or participated in the autopsy."
"There have been no other cases of heart trouble in the OR?"
"Brief arrhythmia under general anesthesia is fairly common, with around 10% of patients having some kind of arrhythmia. In almost every case, it self-resolves, or resolves with minimal intervention."
"And when it doesn't?" Ms. Temple asked.
"We proceed along the same lines as we did with Mr. Webber — we administer drugs, defibrillate if indicated, and use CPR to maintain circulation."
"You said brief arrhythmia is common; what about severe arrhythmia, such as Mr. Webber suffered?"
"I don't know the specifics of any case, except where I was involved," I replied.
"Have you participated in a case where the patient suffered severe arrhythmia, and they survived?"
"Yes."
"What differentiated the cases?"
"The presenting condition, the type of surgery, as well as the patient's age and sex. I don't believe it's possible to draw any parallels because the other patient was receiving a kidney transplant due to chronic kidney disease. That placed her at severe risk for complications due to renal insufficiency, something that Mr. Webber did not have."
"What happened in that case?"
"The young woman had two runs of V-tach — ventricular tachycardia. The first one resolved on its own; the second one resolved only after administration of lidocaine. She then went into V-fib, which required two attempts to cardiovert and two doses of epinephrine to restore sinus rhythm."
"Did that patient recover fully?"
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