Crisis

7

The first thing Jack was aware of was a distant verbal disagreement followed by the concussive force of a door slamming. For a brief moment, he tried to incorporate the sounds into his dream, but it didn't make any sense. Instead, he opened his eyes only to have not a clue where he was. After checking out the fountain bathed in bright sunlight outside the bow window as well as the interior of the study, it all came back to him in a flash. In his hand was a deposition of a nurse named Georgina O'Keefe from the Newton Memorial Hospital, which he had been in the process of rereading when he'd fallen fast asleep.

Gathering up all the papers from the Stanhope vs. Bowman malpractice case, Jack slipped them into the manila envelope. It took some doing to get them all in. Then he got to his feet. A wave of momentary dizziness made him pause briefly.

He had no idea what time he'd fallen asleep. He'd read through the entire collection of papers and had been in the process of going back over those parts he thought most interesting when his eyes closed involuntarily. To his surprise, he'd been captivated by the material from the start. If the story didn't indirectly involve his sister, he would have thought it an entertaining script for a soap opera, since the colorful characters' personalities leapt off the pages. There was the gifted and dedicated but arrogant and adulterous doctor; the nubile, spurned, and angry lover; the precise and rather laconic bereaved spouse; the knowledgeable but contentious experts; the parade of other witnesses; and finally the apparently hypochondriacal victim. It was a comedy of human foibles, except for the unfortunate fatal outcome and the fact that it had ended up as a malpractice suit. As far as the probable outcome of the suit was concerned, at least from reading the material, Jack thought Alexis's concern and pessimism were well founded. With his grandiosity and arrogance, which came out in the latter stages of his deposition, Craig did not help his cause. The plaintiff's attorney had succeeded in making Craig sound as if he believed it was an outrage that his clinical judgment was being questioned. That wouldn't play well with any jury. And on top of that, Craig had implied that it was his wife's fault he'd had an affair with his secretary.

Whenever Jack was pressed to describe the goal of his job as a medical examiner, his usual response, depending to a degree on the inquirer and the occasion, was to say he "spoke for the dead." As he read over Stanhope vs. Bowman, he found himself ultimately thinking mostly about the victim and the unfortunate but obvious circumstance that she could not be deposed or serve as a witness. Playing a game in his mind, he considered how it would influence the case if she were able to participate, and thinking along those lines made him believe that she was the key to a successful resolution of the case. It seemed to him that if the jury believed she was the hypochondriac Craig said she was, they'd have to find for the defense, despite her final symptoms being all too real and despite Craig's narcissistic personality. Thinking in this vein emphasized the unfortunate reality that there had been no autopsy and, accordingly, there was no medical examiner on the defense's witness list to speak for the deceased.

With the manila envelope under his arm, Jack snuck down the hallway toward the basement stairs beneath the main staircase. As scruffy as he was, he preferred not to run into anybody. As he started down the stairs, he heard more yelling above by one of the girls and another door slam.

Down in his quarters, Jack shaved, showered, and dressed as quickly as he could. When he got back upstairs, the entire Bowman clan was in the great room. The atmosphere was strained. The three girls were at the table behind cereal boxes. Craig was on the sofa hidden behind the The New York Times with a mug of coffee on the coffee table in front of him. Alexis was at the counter, busily making sandwiches for the girls' lunches. The TV above the fireplace was tuned to the local news, but the sound was barely on. Sun streamed in through the bow windows. It was almost blinding.

"Good morning, Jack," Alexis said lightly when she noticed him standing in the doorway. "I hope you slept okay downstairs."

"It was very comfortable," Jack said.

"Say good morning to your uncle," Alexis advised the girls, but only Christina did so.

"I don't know why I can't wear the red top," Meghan whined.

"Because it belongs to Christina, and she says she prefers you don't," Alexis said.

"Did the plane burn with your daughters in it?" Christina asked.

"Christina, that's enough!" Alexis said. She rolled her eyes for Jack's benefit. "There's fresh juice in the fridge and fresh coffee in the maker. What do you usually have for breakfast?"

"Just fruit and cereal."

"We have both. Help yourself."

Jack went over to the coffeemaker. As his eyes began to search for a cup, a mug came sliding down the granite countertop, thanks to Alexis. He filled it with coffee and plopped in a spoonful of sugar and a dollop of cream. As he stirred, he again took in the room. Christina and Alexis were now embroiled in a conversation about after-school plans. The two other girls seemed silent and sulky. Craig had not emerged from behind his newspaper, which to Jack seemed an obvious slight.

Refusing to be cowed and believing a good offense was the best defense, Jack walked over to the mantel. He was now looking directly at Craig's newspaper, which Craig was holding up to its full extent like a barrier wall.

"Anything interesting in the news?" Jack asked while taking a sip of his steaming coffee.

The top edge of the paper came down slowly, progressively revealing Craig's puffy, slack face. His eyes were like bull's-eyes with dark surrounding rings, while his sclerae were webbed with minute red capillaries, giving him the visage of a man who'd been out on an all-night binge. In contrast to his weary face, he was dressed in a freshly pressed white shirt and conservative tie, while his sandy-colored hair was neatly brushed with a slight sheen suggesting a dab of gel.

"I'm hardly in the mood for small talk," Craig said morosely.

"Nor am I," Jack responded. "At least we agree right out of the starting gate. Craig, let's clear the air! I'm here on my sister's behest. I'm not here to help you. I'm here to help her. If I help you, it's fallout. But let me tell you something; I think it stinks that you've been sued for malpractice. In my estimation from what I know of you professionally, you're the last one who should be sued for malpractice. Now, there are some other social areas in which you don't shine from my perspective, but that's another story entirely. As far as the case is concerned, I've read the material and I have some thoughts. You can hear them or not, that's your call. As far as my staying in your house, that's also your call, since I demand unanimity on the part of couples when I'm a guest. I can easily move to a hotel."

Except for the muted sounds of the local news and some twittering of birds outside, the room went silent and still. No one moved until Craig noisily collapsed his papers, folded them haphazardly, and tossed them aside. A moment later came the renewed clink of flatware against cereal bowls from the table. From the sink came the sound of the faucet being turned on. Sound and action had returned.

"I have no problem being up-front," Craig said. His voice now sounded more tired and sad than morose. "When I heard you were coming, I was irritated. With everything that's going on, I didn't think it was an appropriate time for company, especially since you'd never bothered previously to come for a visit. Frankly, it irked me that you might harbor the mistaken illusion you were the cavalry riding in at the nick of time to save the party in peril. Having you tell me right off that that's not the case makes me feel differently. You're welcome to stay, but I'm sorry I'm not up to being much of a host. As far as your thoughts about the case are concerned, I'd like to hear them."

"I don't expect you to be a host at all, considering what you are going through," Jack said. He sat on the corner of the coffee table diagonally across from Craig. The conversation was going better than he'd anticipated. He had in mind to further the cause by paying Craig a compliment. "Along with all the court-related material, there were a couple of your most recent research papers. I was impressed. Of course, I'd be more impressed if I understood them."

"My attorney has in mind to introduce them as evidence of the extent of my commitment to medicine. The plaintiff's attorney according to his opening statement is going to try to prove the opposite."

"Certainly can't hurt. I can't imagine how he's going to present them, but I'm no lawyer. If he does, I have to give you credit, Craig. You are amazing. Most every doctor I know thinks they would like to do a combination of clinical work and research. It's the ultimate ideal absorbed in medical school, but you're one of the few that actually does it. What's so surprising, it's real research and not those 'reports of an interesting case' type papers that try to masquerade as research."

"There's no doubt it is real research," Craig said, perking up a tad as he warmed to the subject. "We are learning more and more about voltage-gated sodium channels in nerve and muscle cells, and it has immediate clinical application."

"In your last paper in NEJM, you talked about two different sodium channels, one for heart muscle and one for nerves. How are they different?"

"They are structurally different, which we are now determining at a molecular level. How we knew they were different was because of their marked difference in their response to tetrodotoxin. There's a thousandfold difference, which is extraordinary."

"Tetrodotoxin?" Jack questioned. "That's the toxin that kills people in Japan who eat the wrong sushi."

Craig laughed in spite of himself. "You're right. It's sushi made by an inexperienced sushi chef from puffer fish at a particular time of their reproductive cycle."

"Remarkable," Jack commented. Having accomplished getting Craig to perk up, he was eager to move on. Craig's research, although interesting, was far too esoteric for his liking. Jumping directly from one subject to another, Jack brought up his feelings about how the victim, Patience Stanhope, was the key element to win his malpractice case. "If your attorney can indisputably establish the fact in the jurors' minds that this woman was the kind of hypochondriac she was, the jury will have to find against the plaintiff."

For a few seconds, Craig merely stared back at Jack. It was as if the conversational transition had been so abrupt that his brain had to reboot itself. "Well," he said at length. "It's interesting you say that, because I already said as much to Randolph Bingham."

"Well, there you go. We're thinking on the same plane, which lends more credibility to the idea. What did your attorney say?"

"Not much, as I recall."

"I think you should bring it up again," Jack said. "And while we're on the subject of the deceased, I didn't see an autopsy report. I'm assuming there was none. Am I correct?"

"Unfortunately, there wasn't an autopsy," Craig said. "The diagnosis was confirmed by the biomarker assay." He shrugged. "No one expected a malpractice suit. I'm sure if they had, the medical examiners would have opted for a postmortem and I would have requested one."

"There was one other small point in the record I thought was curious," Jack said. "An ER nurse by the name of Georgina O'Keefe, who was the admitting nurse at Newton Memorial Hospital. She wrote in her notes that the patient had marked central cyanosis. The reason it jumped out was because she didn't mention it in her deposition. I went back and checked. Of course, the reason I was sensitive to the issue was because in your deposition, you said you were shocked at the degree of cyanosis when you saw the patient. In fact, this issue was a point of disagreement between you and Mr. Stanhope."

"It certainly was a disagreement," Craig said defensively. Some of the original sullenness returned to his voice. "Mr. Stanhope had said on the phone, and I quote, 'She looked rather blue', whereas when I got to the house, she was floridly cyanotic."

"Would you have labeled it central cyanosis like Ms. O'Keefe?"

"Central or peripheral, what's the difference in this kind of case? Her heart wasn't pumping her blood fast enough through her lungs. There was a lot of deoxygenated blood in her system. That's what generally causes cyanosis."

"The issue is the amount of cyanosis. I agree the deep cyanosis certainly suggests not enough blood was going through her lungs or that not enough air was getting into her lungs. If it were peripheral cyanosis, meaning blood just pooling in her extremities, it wouldn't have been so conspicuous or even."

"What are you implying?" Craig asked aggressively.

"To be honest, I don't know. As a medical examiner, I try to keep an open mind. Let me ask you this: What kind of relationship did the deceased have with her surviving husband?"

"Somewhat strange, I suppose. They certainly weren't affectionate in public. I doubt they were close, since he did commiserate with me about her hypochondriasis."

"You see, we medical examiners from experience are naturally suspicious. If I were doing this autopsy and considering the cyanosis, I would look for any signs of smothering or strangulation just to rule out homicide."

"That's absurd," Craig snapped. "This wasn't a homicide. Good grief, man!"

"I'm not suggesting it was. I'm just thinking about it as a possibility. Another possibility could be the woman had an undiagnosed right-to-left cardiac shunt."

Craig impatiently ran his fingers through his hair, which changed his appearance from looking tired but neat to tired and mildly disheveled. "She didn't have a right-to-left shunt!"

"How do you know? She didn't let you do any non-invasive cardiac imagery like you wanted after her questionable stress test, which, by the way I couldn't find."

"We haven't been able to locate the tracing yet at the office, but we have the results. But you're right. She refused any cardiac studies."

"So she could have had a congenital right-to-left shunt that was undiagnosed."

"What difference would it make if she had?"

"She could have had a serious structural problem with her heart or major vessels, which raises the issue of contributing negligence, since she refused follow-up studies to your stress test. More importantly, if she had a serious structural defect, then one might argue the outcome would have been the same even if she had been taken to the hospital immediately. If that had been the case, then the jury would have to find for you and you'd prevail."

"Those are interesting arguments, but unfortunately for me, it is all academic. An autopsy was not done, so it will never be known if she had a structural abnormality."

"Not necessarily," Jack said. "An autopsy wasn't done, but that doesn't mean one couldn't still be done."

"You mean exhume the body?" Alexis asked from the kitchen area. She'd obviously been listening.

"Provided it wasn't cremated," Jack added.

"It wasn't cremated," Craig said. "It was buried in Park Meadow Cemetery. I know because I was invited to the funeral by Jordan Stanhope."

"I guess that was before he sued you for malpractice."

"Obviously. It was another reason I was so taken aback when I was served with the summons and the complaint. Why would the man invite me to the service and then sue me? Like everything else, it doesn't make sense."

"Did you go?"

"I did. I felt obligated. I mean, I was upset I'd not been able to resuscitate the woman."

"Is it difficult doing an autopsy after being buried for almost a year?" Alexis asked. She'd come over and taken a seat on the couch. "It sounds so ghoulish."

"You never know," Jack said. "Two factors are the most important. First: how well the body was embalmed. Second: whether the grave stayed dry or if the seal on the casket remained intact. The reality is you never know until you open up the grave. But regardless of the situation, a lot of information can be gleaned."

"What are you guys talking about?" Christina yelled from the table. The two other girls had disappeared upstairs.

"Nothing, sweetie," Alexis said. "Run up and get your things. The school bus is going to be here any minute."

"This could be my contribution to the case," Jack said. "I could find out the procedure for exhumation here in Massachusetts and do an autopsy. Short of my providing mere moral support, it's probably the only way I could offer to help in this affair. But it's up to you guys. You tell me."

Alexis looked at Craig. "What do you think?" she asked.

Craig shook his head. "To be honest, I don't know what to think. I mean, if an autopsy were to prove she had some major congenital cardiovascular problem such that any delay getting her to a hospital had no significance, I'd be all for it. But what are the chances? I'd have to guess rather small. On the flip side, if an autopsy were to show her myocardial infarction was even more extensive than one might expect, maybe the autopsy would make things worse. It seems to me to be a wash."

"I'll tell you what," Jack said. "I'll look into it. I'll find out all the details, and I'll let you know. Meanwhile, both of you can give it some thought. What do you say?"

"I say it's a plan," Alexis responded. She looked at Craig.

"Why not?" Craig said with a shrug. "I've always said more information is better than less."