Until I got to be this age, I didn't even know there were bounds.
DAY 7/30
At half-past-seven there's a knock on my hotel room door. I answer, and there stands Kelly Larsyn, dressed to the nines in Ito Benellini shoes, a perfectly fitted Verleta suit, and a silk shirt and tie. He's holding an orange and two Starbucks coffees. He thrusts the larger of the two coffees at me.
"Take and drink. Do this in remembrance of me."
"Really, Larsyn? Must you?"
He smiles. "It's all I had on a moment's notice. Next time I'll have something more contemporary."
"How about, ‘I just jumped out of the clown car to come up here.' That work?"
"It works. And so do we. That table there?"
He's indicating the dining table/desk that occupies the far wall in my suite, just below a second window filled with morning sun.
"Yes, that table. What's in your briefcase?"
"Yellow legal tablets and a laptop. Plus my pills."
"What pills?"
"Anxiety meds. This case is wearing on me. It's been almost two years, Michael."
"Which reminds me. There's something I've meant to ask you."
"Shoot."
"Who ended up filling Judge Wilberforce's seat on the bench? Who got the judgeship?"
Larsyn tosses his bag onto the table and hops up on a dining chair. He places one foot under the other leg as he prepares to work. But my question bothers him. I can see it in his eyes and his stony face. He's doing his best to register no response.
"I don't think they've filled his seat, although I don't follow the politics all that closely."
"Would you be interested in serving?"
"Can't. This case is still pending, and now you've roped me in for another four or five months, it looks like. I'm guessing they'll have someone appointed any day now."
"And they didn't come talk to you?"
"Someone might've called me. I truly don't remember. Now, what's our strategy, Michael? You've hired me, and I'm ready to get it on."
We're finished with the topic, as far as Larsyn's concerned. But his answer has been vague. Lawyers like Larsyn know precisely what's going on with judgeships and vacancies where they appear in court. It's as natural as breathing, to an attorney. Larsyn will need to be watched. And I'll put Marcel on the judgeship issue the next time I speak with him. If Larsyn is withholding something, Marcel will snoop it out. I smile inside. Larsyn just doesn't know who he's dealing with, when it comes to keeping a secret from the likes of Marcel. We're only getting warmed up here.
"I want to head off in a new direction today," I tell him. "I want to establish that Cache is still alive even though unconscious and unresponsive. I want to establish that she's not brain dead. Once we can do that, we can avoid the state trying to use brain death against her."
"How would they use it against her?"
"By proceeding as if it doesn't matter what they do. They'll try to argue she was dead anyway, that they were just cleaning up her room."
"That's interesting."
"It would be an interesting argument for the state to make. And could very likely be made. I just don't want to be blindsided by some genius at the AG's office suddenly hitting on the idea that my daughter is already dead and it's just a matter of unplugging the life support and letting her body go."
"Had not thought of that. Michael. You're already impressing me."
"I'm not here to impress you, Kelly. But just think how we'd look if we weren't ready for some bright assistant AG to make that case. So, we make ready for that."
"By establishing that medically she's still alive."
"Yes and that legally she's still alive, too. The two aren't the same."
"No, I think I knew that."
"The issue is in flux. In many medical circles, no brain stem activity means she's medically dead. Which usually means legally dead—but not always."
"Sure."
"So, this morning we're meeting with Cache's patient care team. They're going to decide in the next twenty-four hours whether Cache is alive. The team consists of a neurologist, a neurosurgeon, and a priest—don't forget, we're talking St. Anthony Hospital."
"Got it. The logic in a team like that is obvious."
"We want the scientists to be very careful about all this. Both for legal and medical reasons but also for spiritual reasons, at least in my universe."
"Don't want to be spanked by the Big Guy?" says Larsyn.
I ignore it. "Let's talk about the doctors involved."
A half hour later, we're headed for the hospital and a meeting that I've arranged with the patient care team. We hurry through the hospital's main doors and take the elevator to the neuro floor. Larsyn stares at the elevator's floor lights as we ascend. I admit I'm perplexed about the whole judgeship thing. And whether Millie heard what she thought she heard about Judge Maxim telling Larsyn that he was going to fast-track the dwarf's appointment to the Wilberforce court. Or was she wrong about that? Knowing Millie and her patient, scientist's way of understanding the world, my money's on her having heard right. Larsyn has become my target. And even now, Marcel has begun nibbling around the edges of the issue, thanks to a text I sent him before leaving the hotel. Larsyn couldn't be more at risk than he is today. Why would I say that? Because if I find he purposely kept Cache from testifying in order to secure a judgeship for himself, there will be blood. That's a promise.
The elevator doors whoosh apart, and I smile at Larsyn and let him go first. He has no clue.
We find the chief neurologist's office and take-over the small waiting room. Larsyn picks up a copy of Neurology. I find the People and start thumbing and quickly realize I haven't heard of most of the people inside.
At nine o'clock an Asian woman peers through the inside door and asks us to follow her. We're led down a narrow hallway with maybe a half-dozen offices, all with closed doors, along either side. At the end is a door with a glass pane on either side. She pushes it open and stands aside. "Dr. Collingsworth," she says with a smile.
Dr. Collingsworth rises from his desk and shakes our hands after saying his name. He is a clear-skinned, white-haired physician wearing a sparkling white lab coat. He smiles and asks us to sit down. Now that we're introduced we can get right to it.
"You're not only the patient's lawyer, but you're also her father," he says to me.
"Yes. And Mr. Larsyn here is the attorney who's been there for her up to this point."
"Why haven't you been on her case? Don't lawyers help family members, like doctors don't treat their own family?"
"I didn't know she even existed until recently. It seems her mother was keeping her existence hidden from me. Now, I've spoken with you by phone, Dr. Collingsworth—"
"Matt. Please call me Matt."
"—Matt. You're at a point where you can do some necessary testing, as I understand."
"Yes; if you like, I can give you the twenty thousand-foot view of what I have planned for Cache."
"Please do."
He leans back in his chair and shuts his eyes for a moment. Then he comes forward in his chair.
"Our first inquiry has to be whether Cache's brain-stem is alive. There are various steps we follow. The first step is to establish whether a competent cause of brain-stem death exists. In other words, just because someone is unconscious, we don't suspect they are whole-brain or brain-stem dead. There has to be a significant injury. So give me the particulars that you have."
He looks at me.
"Well, it appears Cache was lying on the mattress in her cell at lights-out. Exactly at ten o'clock, which is when the last roll-call of the night was taken. Alive and well. She is said to have even told the guard goodnight."
"Okay, that's what I've been told."
"At four a.m. There's another round by the night guards. This time she's found slumped against the bars of her cell, her body facing inward. There's a makeshift noose of mattress ticking that has been looped up and over the topmos
t horizontal bar of her cell. Then it runs down to the noose, and that's where she's found, dangling with her legs crumpled up beneath her."
"So maybe as many as four hours have passed with her in this death pose."
"Death pose?"
"That's what we'll call it. Meaning she's not moving and maybe there's no pulse, no breathing."
"That's what the hospital medics said. They worked on her twenty minutes with the shock paddles and breathing bag and finally got her heart started and her breathing restored. ‘Diminished breath sounds' is how I think they put it."
"Yes."
"She was then rushed here, to St. Anthony. You know more about her than I do since then."
"A four-hour passage of time would definitely establish the first criteria: a significant injury. In this case, a compromised airway. We've made extensive inquiries and done tests to prove or disprove. We have also had to rule out other causes of deep coma, such as hypothermia, hypotension, drug overdose, and a small group of neurologic conditions. CT scans and an MRI have done this work already. We can confidently say it was the self-imposed strangulation that brings her to us."
"What comes next?" asks Larsyn. He's been furiously tapping our conversation thus far into his laptop. I like him just a little bit more for it.
"Next came the physical exam. Or exams, I should say. We have determined that she's in a very deep coma state, unresponsive to any stimulation and not breathing on her own. If there is any response, the patient isn't brain-stem dead. So far there's been no response."
"I think I've seen some of that testing going on," I say. "Maybe a nurse or two have tried a few things with her with me there."
"Sure. We've also established by step three there are no functions by the brain-stem. This means looking for reflexes whose pathways run through the brain-stem. If any of those reflexes are present, it means those pathways still work and at least part of the brain-stem is alive."
"These reflexes are what?"
"Well, there are six of them. Eye reaction; eye movement doll's eyes; eye movement cold caloric; and eye movement blink or corneal reflex; number five is gag reflex; and the sixth is the apnea test,"
"I expect these have all been performed?"
He moves his computer mouse and clicks through a few screens. "Yes, several times now. A bright light has been shone into her eyes on ten different occasions the first full twenty-four hours. The pupils are so far fixed and dilated. No neurological response."
"And ‘doll's eyes'?"
"If the head is moved rapidly from side-to-side the eyes will move in their sockets and remain fixed as if staring at a spot straight ahead. This is the result of a neurological reflex. If, on the other hand, the eyes move side-to-side with the rolling head, then this indicates no neurological function. This demonstrates that the brain-stem is not working."
"How did she do?"
"Let me just gloss over them first and then we can get down to the specifics, okay?"
"Okay," I agree, although the waiting is painful. There must be something positive about all of this, otherwise, why haven't they indicated that removal of life-support is indicated?
"The next is eye movement, cold caloric. When ice-cold water is injected into the ear of a normal person, it cools down the balancing movements in the inner ear and triggers eye movement. If there is no eye movement, then this tells us the brain-stem isn't working."
"Good heavens," says Larsyn. "That sounds terrible."
Ignoring him, Dr. Collingsworth continues. "Number four is the eye reflex by the blink or corneal reflex. When the brain-stem is working, the eyes blink when the cornea is touched. When the brain-stem is not working, no blinking occurs, no matter what the stimulation to the cornea. Gag reflex, number five, works much the same. We use an instrument to touch the back of the throat. If there is no gagging that tells us the brain-stem isn't working."
"Good God," I mutter.
"I know," he says with a shake of his head. "Some of this is pretty primitive and off-putting. Ordinarily, I don't do details like this with family because most people don't want to hear specifics. That's most people; some do. And of course in legal cases such as this one we always give up everything we know."
I just want to finish the preliminaries. "What about the apnea test, number six?"
"Apnea testing is the most important test used to confirm brain-stem death. The short description is that the ventilator is shut off and if the patient is not breathing then this shows that the brain stem has no function."
"Sounds pretty cruel," Larsyn mutters.
The doctor turns to him. "Not if you're dead, Mr. Larsyn. And if you're alive you're usually unaware."
"Can we back up to the machine testing?" I ask. "So that I can make my list of what's been done insofar as imaging and machine testing?"
"Confirmatory testing is done by my orders after the functional testing we've been talking about. This consists of repeating the CT and MRI scans. Then I order an electroencephalogram. I also use brain blood flow studies. These are of three types. I use the nuclear blood flow method."
"That's it?"
"Pretty much. It's very thorough, and I'm in the highest ninety-nine percentile of certainty when I'm finished, if not one-hundred percent."
"The confirmatory studies are mostly about blood flow to the brain?" I ask.
"Exactly."
"And when will the final pronouncement be made in my daughter's case?" This is the one I've hesitated to ask. This is the one I've dreaded asking.
"Well, before we do anything final, there's something I want you to see. Let me buzz up an RT, and we'll meet in your daughter's room. You can run along now, and I'll be there in about thirty minutes."
Larsyn and I back out of the room. He suggests we drop by the cafeteria for coffee. I tell him to go ahead, that I'll meet him in Cache's room.
We separate and I walk through a short maze until I find Cache's nurses' station and then head directly down the hallway to her room. She's inside, under the watchful eye of Millie. Millie hardly acknowledges me when I enter. But then I see why: she's been crying and doesn't want me to know. Her hand clutches a wad of tissue that she uses to blot her eyes. Then she turns to me and smiles. "Here's our daughter. Just like we left her. And isn't that tragic?"
"I just finished with Dr. Collingsworth. He's going to show us something when he gets down here in about thirty minutes."
"Show us what?"
"He didn't say. But I've got a feeling we're just around the corner from learning whether Cache's brain-stem is dead. Do your praying, if you pray."
"I pray to the thing that makes it rain. That's my higher power."
"Whatever," I say, and scootch beyond Millie, up beside Cache's head. I bend down and kiss her forehead. I'm sure I'm not the first to do that today. She doesn't move, and her eyelids don't flutter, unlike movies where a kiss awakens a patient from a deep sleep. Not this time. So I squeeze her hand and take the chair on the other side of Millie.
Nothing is said. We listen to the sounds the life-support makes, the sounds the monitor makes, and our own breathing. Twenty minutes tick past. Then Larsyn appears in the doorway, a 20 oz. Styrofoam cup in hand. He nods at Millie and fastens his eyes on Cache. I try not to think about him colluding to prevent her testimony about the rape by Wilberforce. But a wild, animal feeling drives up through my chest, and I want to attack the dwarf, to crush him into the tile beneath our feet. It passes; I remind myself that nothing is certain about Larsyn and Judge Maxim; Millie could've just heard wrong. But still, there is the fact Cache didn't testify. The absence of her testimony has his fingerprints all over it, of that I am sure. Bastard, anyway. Then I'm angry again, and that's how I feel when Dr. Collingsworth and two other people stroll into the room.
"Everyone, this is Dr. Munoz, a staff neurosurgeon, and this is Father Monsini, a Franciscan priest on the staff of St. Anthony."
"Hello."
"I understand you practice in Washington, D.C.," Dr.
Munoz says to me. "I went to med school at Johns Hopkins, just down the road. Have they changed presidents since I left?"
"Have they changed presidents?" Then I realize he's making a joke at probably the worst moment for me. "Yes, they've changed. So what are we doing, doctors?"
"We're waiting for a respiratory therapist."
She hurries into the room at that moment. She's wearing navy slacks and a white coat with a large nameplate and her photo hanging from one of those self-retracting gadgets. She is quite pale, but her lips are glossy red. I don't catch her name; I'm scared to death of what's about to happen because I think I've just figured it out.
"Just to recap, one of our most reliable tests is the apnea test where we remove the patient's breathing tube. Actually, we don't remove it; we just disconnect it. Maria? Would you?"
The newcomer in the white coat steps around us and slides along the bed to the respirator. Her body blocks us as she lingers there, arms moving, bent to her machine and our daughter.
Dr. Collingsworth narrates. "The apnea test will test for the absence of autonomous breathing. This is breathing by the patient without the machine. This is the most important test used to confirm brain-stem death."
The respiratory therapist turns her head to us. "The short description is that the ventilator is shut off and if the patient is not breathing then this shows that the brain stem has no function. Are you ready, Dr. Collingsworth?"
"Go ahead, Maria."
"The tubing attached to the ventilator is being removed from the patient. Notice that the tube going into the patient's trachea is left in place. Oxygen is now blown into the lungs. I'll now monitor her for eight minutes or until her carbon dioxide reaches a specific level that tells me to stop. It would do that because there's no transfer of CO2 for oxygen."
Dr. Munoz speaks up. "Any movement of the chest during the test is considered a sign of breathing. Also, our monitors can measure even the most minute movements of respiratory muscles. If the brain-stem is totally destroyed, no sign of breathing or attempted breathing will be seen. If not, we will catch even the slightest movement."
30 Days of Justis Page 8
