by Alec Peche
“Jill, that was a good explanation and we can see why it is hard to quantify poor individual quality. Where does that leave us? What do you tell Nick to look for if he does hack into the quality records?”
"Frankly, I think we ask him to look for any document that has Dr. Lewis's name on it. Without sorting through it myself, I can't begin to direct Nick as to what's important and what is not.”
"That could be very time-consuming and what are we going to do with the information that we illegally obtained?” asked Jo.
"What I'm hoping to do with any information that Nick finds and regarding Dr. Lewis is to verify that he should continue to be on the top of our list for suspects. I would hate to be so focused on him that we ignored another clue we should've been following. The second thing I'm hoping is that with the information revealed, if we see a problem we'll know which way to direct someone to obtain it legally. The legal path will be very difficult because physician performance data is protected under special laws called physician privilege. I think this is an instance of we'll decide what to do with the information once we see what it contains."
"That's a fair assessment of where we stand with this case," noted Marie, her face wearing the disappointment. "We have a lot of coincidences, but we’re no closer to solving the case then when we heard the sound of the gun ring out in the air on the golf course. I really thought it was going to be much easier than this seems to be.”
Jill acknowledged the statement with a nod of her head and began typing on her laptop "I'm going to drop a quick note to Nick and ask him to look for anything with Dr. Lewis's name on it - e-mail, data, event reporting. Then I suspect the detectives will arrive soon and so I think we should agree to avoid the entire surgeon quality discussion with them. I'd like to concentrate on how the employee is doing at the hospital and whether they've got any toxicology tests back on her. In addition we should plan on gathering more information on Dr. Phillips’s death. Unfortunately we can’t admit to our suspicions of Dr. Lewis to Dr. Phillips’s widow so we’ll have to be very cautious if they ask her permission to exhume the body.”
Angela added another angle, “I think Nick has Dr. Lewis’s social security number from the driver's license application so Jo may be able to get some personal financial information.”
“Having his social security number gives me considerable ability to look into his financials,” agreed Jo. “It’s not legal for me to do that but I have to run with the idea that this guy may be our killer and we’re looking for evidence and links. When the Detectives Van Bruggin and Haro arrive I would like to question them about what data they have access to through their law enforcement systems. If we can direct them to get some of this data legitimately through their system that allows us to stay clear of prosecution - especially if we are wrong about Dr. Lewis.”
They heard the doorbell ring. Jill took a look at the murder board and everything they had up on their screens or lying around. She saw none of their research gained by unauthorized methods in view of anyone casually looking around the room. She signaled to Marie that it was safe to let in the detectives.
Van Bruggin and Haro were looking frayed around the edges. Their clothes were wrinkled, Haro was working on a five o’clock shadow and Van Bruggin had very pale skin reflecting the lack of sun on the skin in the deep winter of Wisconsin rather than the pleasant sixty degree plus days of May. This time, when Marie offered them a drink and cookies, they acquiesced, gulping down diet coke and managing to chew and swallow three cookies so quickly that Jill had to look twice to verify the speed with which they had devoured Marie's cookies.
"How's Helen doing?" asked Jill.
"The hospital has her stabilized," Haro announced. “She has not regained consciousness and they will be putting her through a series of tests over the next twelve hours to determine her brain function. Given that she was blue and breathing poorly when her supervisor arrived, her doctor says she may have sustained some brain damage from the event. She's in the ICU with a police officer guarding her around the clock."
“I think we have to presume that word of her condition has reached Dr. Lewis by now,” Angela suggested. “This is a small town and word of a cop guarding a patient for her own protection at a local hospital will have the gossip lines buzzing. If he has done all that we suspect him of, I wonder what his next steps will be.”
“That is indeed an interesting question,” agreed Haro.
“Do you have him under surveillance?” asked Jill.
“After our conversation at Helen’s house, we placed him under light surveillance,” noted Van Bruggin. “He has the resources to easily be a flight risk, but I am very uneasy about keeping him under surveillance. We are doing drive-byes of his residence and work locations. We're also monitoring if he tries to depart airports. We can’t afford to have him, or really anyone else, discover our surveillance. If he is innocent, we would harm his reputation. On the other hand, if he goes into the hospital, he is impossible to track as he has access to places our officer doesn’t and there are too many exit doors. I have asked to be alerted if he goes through airport security or crosses into Canada, so hopefully these actions will stop any flight risk.”
Angela repeated her question, “What do you think Dr. Lewis’s next actions will be? Personally, my vote would be to try to harm Helen, and beyond that to take care of anyone else at Our Lady who knows something that they shouldn’t about Dr. Lewis.”
“What do you mean knows something that they shouldn’t?” probed Van Bruggin. “What would a random collection of hospital employees know about Dr. Lewis that is a threat to him? Was he having an affair? Is that what he was afraid would get out?”
"Perhaps it is an affair that he wants to keep hidden from his family. Who knows? We don't even know if he is our killer," Jill reminded the two detectives. "All we have is extreme coincidences. We did a legal proceedings search on Dr. Lewis and we found financial distress about twenty years ago as well as some driving under the influence charges in the past five years that were dropped. We’re wondering what you can find in your systems regarding his activities. Both wife number one and wife number two seem to come into his marriage with financial assets. Wife number one died about ten years into the marriage. We found no explanation for her death. That is not to say there isn't a good explanation; rather we haven't found any reason in any newspaper articles about her death.”
"Before we came over here, I made a call to the office and I have an analyst pulling data on Dr. Lewis. Since you dropped his name on us an hour ago, we’re behind compared to you.” noted Van Bruggin. “If he is indeed our killer, if he is Dr. Phillips’s murderer, and should we prove that he killed his first wife, we'll need to call in additional resources as this case has become huge. These are all “ifs” that we have not proven a single theory yet. This could all be a wild goose chase blinding us from the real killer.”
“Yeah, we were worried about the distraction from the real killer as well,” Marie agreed. “We talked about that just before you arrived. We noticed a string of financial difficulties about two decades ago. Do your computer systems have more information on legal proceedings? I would have thought that in any financial distress lawsuits that Dr. Lewis would've had to provide some financial information about himself at that time. He's gone through a lot of money and we’re wondering why. Is he a gambler? Does he have a drug habit? Does he have an offshore account that he's storing spare money in?”
"Great questions - and I'm not sure we have the answers, yet. I'd like to connect you folks to my team back at the station. We don't have a medical expert connected to the force and there seems to be some connection to medicine that we can neither see nor understand,” Haro commented. "We're heading back to the station now; are you available to meet us there in say, an hour?”
The four women looked over at the clock and then at each other. The two detectives watched as the women seemed to be able to read each other's minds. Finally, Marie spoke.
; "We are meeting Michelle Easley at the upstairs parlor of Captain’s Walk Winery later for wine, and conversation. We haven't had an opportunity to interview her yet. As she is our client, it's been a hole in our investigation. I think she finally got beyond funeral plans and the immediate changes to her life so she can take a moment to sit down and tell her story. We can give you about two hours at your station and then we'll have to leave.”
"We interviewed her yesterday and she couldn't point us in any direction to find the killer. Mostly, she must've told us ten times, what a wonderful human being her husband Doug was and how could this happen to him. I hope for the sake of this investigation that you get more out of her. However, if Dr. Lewis is the source of the problem with this case, Michelle Easley likely wouldn't have any knowledge of Dr. Lewis.
“Dr. Quint,” Haro continued, “we would also like you to talk to our Lieutenant about the typical process for re-examining the cause of death for Dr. Phillips."
"I would be happy to discuss the process with anyone on your staff or in your district attorney’s office if it comes to that. We will be at your office in an hour. I assume the meeting is at police headquarters on Adams Street."
"Yes ma'am and thank you.”
Soon the two detectives were leaving and there was a slight expulsion of hot air since the women knew they could now return to not so legal means to collect information about the case. Jill was the first to reach her laptop to see if Nick had found any material for them to look at. She was probably expecting too much from Nick as it had only been about half an hour since she had sent him the request for more hacking.
"Hey there's an e-mail from Nick here. He says ‘there are several files for Dr. Lewis. It was easier to hack into as it runs on a separate administrative system. Since there is a lot of medical terminology I don't really understand the content. So I have saved the files and sent them to a cloud storage drive. I think it better if I save materials to an encrypted cloud rather than leave an e-mail trail. I’ve sent Angela a picture via Snapchat of the password to reach the cloud storage. The picture will disappear forever ten seconds after you open it.'”
"Good thing I have a Snapchat account. This is increasing my anxiety about this case since he's going to extra lengths to encode his data.”
"Of course you have a Snapchat account – you are a photographer and it's your business to put new and beautiful pictures out in cyberspace. Let me know what the password is so I can dial into this cloud storage thing. I hope he doesn't get more technical than this because I maxed out on my understanding of the internet.”
Soon Angela was sharing over the password with Jill who logged in to the cloud storage drive. She began pulling up files and explaining to the others the content of the file.
"This is Dr. Lewis’s credentialing file. Every hospital has a file on every physician. These files are critical to a hospital being licensed. They typically include a driver's license picture of the physician. First and foremost, they need to prove that they are who they say they are. Next you usually find copies of their medical degree, their state license, and their specialty board certification. The medical staff and then the hospital board of directors are required to approve each physician who is given privileges to care for patients at a hospital. The medical staff department maintains these files which is no easy feat. Most hospitals have at a minimum three-hundred to five hundred physicians that go through this process every three years. There is also probably a hundred or so other positions like physician assistants, certified nurse anesthetists, midwives, or nurse practitioners that must also be privileged. So you have to stay on top of these files, making sure those licenses and specialty boards are kept current by the physician.
"This next document outlines what exactly the privileges are. For example, if you are a urology surgeon you will have to be granted the privilege to operate a robot in the operating room. Each physician by specialty has core privileges that likely every surgeon has – so again going to the urologist, it's a core privilege to perform removal of the prostate gland. Every surgeon is expected to not only have done this surgery in the residency but to have done a certain quantity of these surgeries in residency. If they want to do this surgery with a robot then that is a separate privilege.
“The next document is about ongoing education. Different specialties and different accreditations require certain amounts of ongoing education. For example, a trauma surgeon may be required to take twenty hours of intensive care education for the critically injured trauma patient training every three years. Then there are routine certifications like advanced cardiac life support.
"At the time of re-credentialing, the hospital typically checks with the state medical board and the national practitioner database to see if their license has been restricted or if they've had malpractice claims settled against them. These can be red flags. Not always, but they can be.
"So, Dr. Lewis took his general surgery boards at a time when that certification was lifelong. So he is grandfathered-in as newer regulations require recertification every five to ten years depending on the specialty. What this file tells us is he is allowed to do the full range of general surgery services. Within general surgery in the past decade, breast cancer surgery and colo-rectal surgery have become subspecialties of general surgery. The hospital has been tracking the number of the different types of surgery that Dr. Lewis has performed. In looking at this document you can see in the past year that he's done fifty removals of the appendix, twenty breast cancer surgeries, sixty hernias, ninety gallbladder surgeries, and fifteen surgeries for colon cancer. The hospital likely has a minimum required number of each of these surgeries for a surgeon to retain the privilege. Certainly, you would worry about the quality of the surgeon who may only do one colon cancer surgery a quarter.”
"Okay this is really complicated," Marie declared. "However, I must say I am impressed with the regulations that require this extensive physician training documentation. I feel more protected as a patient. Certainly when my sister had gallbladder surgery last year not one of us thought to ask how many gallbladder surgeries the physician had performed in the last year. Where are the alarm bells for us in this documentation? Is it that national practitioner database with reports of lawsuits?"
Jill had paused to sip some ice water after her lengthy explanation of a physician credentialing file. With a final sip she continued, “The national practitioner database contains settled lawsuits and lawsuits in process. The settlement of a malpractice case often assigns responsibility between different parties that might have caused or cared for the patient. Maybe it's the surgeon, a bedside nurse, a pathologist analyzing the specimen, a radiologist reading an x-ray. Most errors result from more than one person. So even though a person is named in a malpractice case you have to look at the details to know if it's a problem. Typically you have a physician from the same specialty read the details of the settlement and discuss with other medical staff members in a meeting concerning individual blame versus a full range of risk factors. The trouble with medical malpractice cases is that it takes several years to settle. So it's not necessarily a very timely assessment of physician skill. The other trouble with lawsuits is mistakes are made every day in the healthcare setting and not all of them end up in court. It is often just the tip of the iceberg. There are lots of journal articles about how charisma and bedside manner absolutely reduce the filing of lawsuits.
“Dr. Lewis has no reportable events. He has no admonishments from the state medical board. His license and required continuing education are up to date. He appears to be a physician in good standing. There should be more information about his performance in his record. These are reportable complications that a hospital is required to track. Included in this list of complications are: retained foreign objects, antibiotics started and ended on time, and unexpected perforations requiring repair or return to the operating room. We don't have that data yet from Nick.”
“What's a retained foreign object?” asked A
ngela. “That sounds really awful and gross. Like you sewed the person up over some big metal thing like a scalpel or pliers or a saw.”
Jill answered, "It's rare that it's something like what you just named. Most often, it is a sponge that is the retained foreign object. Before you imagine the sponge at your kitchen sink being left in your body; it's often something much smaller. The term sponge refers to a two inch by two inch piece of gauze - perhaps the same size as has been placed on your arm after blood has been withdrawn. Sponges are used to soak up blood in the surgical space and because they're covered in blood, they often fit right in with the appearance of tissue. For the past one or two decades hospitals have required sponge counts at the end of surgery to make sure they got them all out. Sometime in the last decade, they've added radiopaque qualities to the sponge so that you can easily see it on x-ray in the operating room. I believe it's still the number one reported complication in the United States."
"So tell us about perforations," Marie requested. "Exactly what gets perforated and why does it matter?"
"Perforations occur for a variety of reasons. You can lose track of where you are inside the body because you're operating in a small bloody space. Some perforations are small and easily repaired and inconsequential. Other perforations cause massive bleeding or they may leak stuff from one organ to another. Since the intestines are so dirty if you puncture them then that dirt or bacteria gets out and causes infection. So bleeding and infection are the primary reasons a hospital tracks perforations.”
Angela was really starting to look squeamish, "Has that complication ever killed someone? Like could you accidentally puncture the heart?"
