by Alec Peche
"There's a second measurement in regards to antibiotics and it's again attributed to individual physicians but it can also be about hospital process. You want to stop the use of antibiotics twenty-four hours after surgery because the incision is no longer open and overuse of antibiotics creates antibiotic resistance. The sticky problem is actually the measurement of the twenty-four hours. Pharmacy systems are highly computerized and medications are administered via barcode system so if the last dosage was supposed to be at ten in the morning and it was actually given at 10:15 then that's considered a failure to meet the standard of discontinuing antibiotics at the twenty-four hour mark. But again in the scheme of things, is this poor quality for the patients? No. Again it's not a reflection of the surgeon’s activity in the hospital; it's more likely nurses or pharmacists that are responsible for missing the deadline by fifteen minutes.
"Let’s return to this report. The good news is that for both measurements of starting and ending antibiotics that the numbers have improved for Dr. Lewis's patients over the past five years. So I would have no concerns with Dr. Lewis on this quality metric.”
“If I understand what you said about Dr. Lewis, there is nothing here so far to set him off with murderous intent,” Jo remarked.
“Not yet, let’s move on to attachment three,” Jill agreed.
She opened it and quickly put it aside. “That was his cardio-pulmonary resuscitation training records.”
After opening attachment four, and studying it for a moment Jill said, “This might be connected to something else. This is the annual volume of procedures that he does at the hospital which we discussed earlier, but this report has five years of data displayed. If I look back at prior years he was doing almost twice as many colon cancer cases two years ago. I wonder what caused the decline and who got the volume of his cases? Those cancer cases would have been his best reimbursed cases between the surgery itself and the aftercare in the hospital.”
“I’ll take a look at the information on all the hospitals in town and see if a new colo-rectal surgeon arrived and snagged his volume,” Jo remarked. “If not that, then his own fellow surgeons likely picked up his volume. I would only expect colon cancer cases to increase as more people get tested for detection and people live longer. A century ago, the average lifespan was fifty-two; people didn’t live long enough to develop cancer.”
“Great, thanks. Okay let's take a look at the next attachment. Hmm… this is information on surgical cases. Looks like a standard format report, not a special report for Dr. Lewis. Let’s see what they track here - they compare his number to a group average for other surgeons performing the same surgery. Okay, let’s see if he has problems anywhere,” Jill noted as she skimmed down the page of statistics.
“This is not an area that I know a lot of about. I did a surgical rotation while in medical school and that might be the extent of my knowledge. None of my medical school friends that I have kept in touch with: specialized in surgery. In skimming down the page, I can see that he's out of alignment with his peers for many of the metrics they measure. Give me a moment to figure out if that is good or bad.”
Jill studied the numbers. They tracked his performance for his five most performed surgical procedures. The length of time patients were under anesthesia was on average twenty-five minutes longer than those same surgeries performed by his peers. The list did not say what the expected length of time was for each case type, but an extra twenty-five minutes was way out of alignment. It also exposed the patient to the risks of anesthesia for an extra amount of time.
The next statistic looked at his on-time starts for which he had a first case of the day scheduled. Again he performed unfavorably compared to his peers, being nearly twenty minutes late to start each case. Any inherent delays caused by the operating room staff should have hit all of his peers and Dr. Lewis equally. Jill wondered what the problem was that would cause a twenty minute delay.
A third statistic looked at the costs of the instrument pack that he needed to complete a specific surgery. Physicians typically had preference cards which listed how many instruments like retractors, sutures, trocars, and forceps that a physician needed to complete a surgery. The trays were either labeled as standard appendectomy tray or Dr. Lewis’s appendectomy tray. Again the number of instruments that he seemed to need in his kit was larger than that of his peers. Jill understood surgical instrument kits as she had used them in the pathology lab. In her experience the use of additional instruments was usually due to an out-of-date preference card. Occasionally, a surgeon will 'overstock' their tray because at some time in their career they were missing a particular instrument when they needed it. For the rest of their surgical career, they made sure that every kit had two of the particular instruments so that they would never have an unavailable instrument again. In the end, Jill didn't know what to make of the statistic.
A fourth statistic examined complication rates. Included in this number were deaths, infections, and accidental nicks during the surgery itself. Dr. Lewis’s numbers were statistically worse in this area.
Jill tuned back into the room and noted her friends were speculating about the charity that had sponsored the golf outing. The tournament had been about a third complete when the murder occurred. The charity had already incurred the expenses of the food and beverages for the event. It also collected all of the green fees to play in the charity golf outing. In the end, they decided that without some of the fundraising that took place on the holes, and at the silent auction following the dinner the charity had lost out on some significant donations.
“I don't pretend to be an operating room expert, but it looks to me like Dr. Lewis has some performance problems. I can't imagine that the report itself was worth killing over, but the question was with the problems spotlighted in this attachment,” said Jill pointing to her laptop screen, “What was the hospital doing with the information? Certainly they should have been alarmed with the complication rates."
"I've heard discussions before about physician quality issues and the actions that people take," Jo disclosed. "I can't say that I paid attention to the discussion as it was often times too medically technical for me to understand. Hospital people speaking a lot of acronyms can make it difficult to follow a conversation.”
"I think I have one more attachment to open here and perhaps that will have information on actions the hospital was planning to take in regards to Dr. Lewis's performance.”
Jill then took a moment to study the final attachment. She had never been credentialed by a hospital so she was somewhat unfamiliar with their process. As a medical resident, her performance was not tracked in the way that this surgeon was tracked. It was comforting to see that the hospital was trying to measure physician performance. Yes, medicine was an art as much as it was a science, but that philosophy shouldn’t be a cover for never measuring how well someone was performing.
“It looks like this is a listing of where Dr. Lewis’s performance was discussed throughout the hospital. He has spoken with the Surgery chairs - both of them, the medical executive committee, and the credential committee.”
“Did he retain an attorney for those discussions?” asked Jo.
“I can’t tell since I don’t know any of these names. There is a list of people and I can’t tell what their credentials are. Something is going on with Dr. Lewis but I can’t figure out what the hospital is doing. I think the files are deliberately vague because they may be discoverable under state malpractice laws.”
“So what are our next steps?” asked Marie. “I know with some personnel matters that we are vague so as to not leave much of a paper trail. In those cases, you usually have to talk to someone verbally to get the scoop. If the hospital is smart, they will not have left a paper trail. It seems like we need a contact inside the hospital that would be willing to talk. Also, I guess we need to ask ourselves what do we share with the detectives? We certainly can’t tell them where we came by the information.”
&nbs
p; “Good points, Marie,” Jo agreed. “I think we need to think strategically on a couple of issues. How do we get insider information from the hospital? What do we share with the detectives? How to we talk Dr. Phillips’s widow into exhumation? Where has Dr. Lewis spent his income that would account for the need to file bankruptcy? Are we going completely down the wrong road with Dr. Lewis? Who might he need to kill next to keep this story covered up?”
Jill had been writing down Jo’s questions as she spoke. Now all four friends stared at the murder board thinking about all of the right questions and what their next steps would be.
Marie added to the list, “Does Dr. Lewis have an alibi for the time that Doug was shot? If he has a rock solid alibi, then all the other questions go away because the killer is not Dr. Lewis.”
“Thanks Marie, for that succinct question. That is a bottom line key question we need answered. Any ideas on how to go about getting that answered?”
Angela replied, “Ah, could the police just ask him?”
“They could ask him, but I don’t think they have probable cause at this time to even have him on a suspect list,” Jill mused. “He is not a dumb man, and would ask why they were asking the question. Without a good reason I don’t think they have a legal right to ask the question. So perhaps we need Nick to do some more hacking for us. What if we got the physician on-call list for the day of the golf event and the surgery schedule? If he is not on either list, then he might still have an alibi if he was in his office seeing patients, which would be a whole other system to gain access to.”
Angela put another call into Nick asking for the information with a few hints of where he might find those two lists. Given that he could use a specific day and Dr. Lewis’s name, he thought he might have the answer for them in an hour as he had two variables to search with.
While they were waiting for an answer from Nick, Angela suggested they circle back to Michelle.
“Is there anything more we need to research on Michelle? We didn’t get a good vibe last night, but what do we do with that feeling, if anything? What research have we already done on Michelle? We looked at her business tax returns, right? Have we done a background search on her?”
“I have not done a background search on Michelle,” noted Marie. “Give me a few minutes and let me see what I can find.”
“I’ll take a second look at her business financials to see if we learn anything,” Jo stated. “We are a little further along in this investigation, so maybe something will call out to me in a second review.”
“I’m just going stare blindly at our murder board and see if any other ideas come to mind,” Jill remarked. “It feels like all of you need about an hour to come up with new information.”
Angela announced, “I’m going to go for a walk for inspiration. I have my phone with me to record any brilliant ideas or to hear the arrival of Nick’s email ping. Cheers.”
Soon, silence reigned in the room, except for the clacking of Jo and Marie’s computer keys making a sound. Jill listened to the rhythm of Jo’s typing for a while. There would be silence, followed by a flurry of key sounds, and then sounds would trail off to one key every few seconds. Marie, likewise, would have a burst of speed and then longer periods of silence as she was reading something on the screen. She typed in a softer manner than Jo.
Chapter Seventeen
Marie had been scanning through the social media sites looking for additional information on Michelle, but that was not where she discovered the most interesting piece of information. She was skimming through Michelle's interior decorating website when she hit the critical connecting piece.
She looked up at her friends and said, “Hey I think I found a link between Michelle and Dr. Lewis.”
Jill and Jo looked up and both said simultaneously, "What!"
“Come over here and look at my computer screen and tell me if you see anything unusual."
Marie had Jill looking over one shoulder and Jo the other while they examined the website displayed on Marie's screen. They both looked and initially saw nothing then they saw the significance of the picture that had caught Marie’s attention.
"Marie, that is brilliant!” Jo noted. “I had taken a look at the website and I missed this the first time through.”
Michelle had pictures of the interior design work that she had done for clients. On the screen were pictures of the living room, dining room, and master bedroom. The pictures referenced that they were from the home of Susan and Bradley Lewis.
"Did we asked Michelle when we interviewed her if she knew Dr. Lewis?" asked Marie. There was silence in the room as they all thought back to the conversation the night before over wine. They would check with Angela when she returned home but so far no one could remember that Michelle mentioned any clients by their name.
Angela chose that moment to return to the house. As she walked into the kitchen she said, “I got an e-mail back from Nick and he was able to verify that Dr. Lewis was not on the call schedule for the hospital during the charity golf outing nor was he scheduled for any surgeries."
Jill added, "That is interesting news. That means he could have been free to be our killer although we still have to check with his office to see if he was seeing patients in the clinic that day. Angela, guess what Marie found on Michelle's website?"
"What did she find?” asked Angela, smiling at the anticipation in Jill's voice.
"Angela, come take a look at this website and tell me if you see anything unusual about it." Angela walked over to the computer where they were all standing and studied the information that was pulled up on the screen. She seemed to read every word of text and then they watched as her eyes flew back to the point that had startled Marie ten minutes previously.
"Oh my gosh, she did an interior design job for Dr. Lewis and his wife.”
"Angela, do you remember if Michelle mentioned any of her clients and/or Dr. Lewis when we spoke with her last night?" Marie asked.
Angela stood there a moment longer and then shook her head indicating she did not remember a conversation about any clients, let alone Dr. Lewis. She added, "This could have been an honest omission and it could be nothing; or it could be our connection between Michelle and Dr. Lewis if the two of them are somehow involved in Doug's murder. So what are our next steps?"
“I think we have two new threads to research. We need to find a way to see if Dr. Lewis was in the clinic seeing patients at the time of the murder,” Jill suggested. “Then we need to do a deep dive on Michelle Easley to see if we have a solid connection or just a random piece of information. In a town this size, it would not be unusual for some physicians and their families to hire Michelle to provide interior design services. Maybe this is a coincidence but you all know how I hate coincidences.”
"Any thoughts about how we can check into whether Dr. Lewis was seeing patients in his clinic that day?” Jo asked.
"How about if I called the office and said that I had forgotten to show up for my appointment at one o'clock two days ago and I wanted to reschedule,” Marie proposed. “I'll get one of two answers - either I'll be told that Dr. Lewis had not worked that day or they’ll transfer me to an appointment desk for rescheduling at which point I end the call. I'll make the call now before I lose my nerve.”
Marie was soon punching in the number for Dr. Lewis’s office and she began the story just as she had suggested. Soon they could hear on her side of the call that she was apologizing for being mixed up and it must be a different physician that she had her appointment scheduled with and she ended the call. Her friends were soon clapping and congratulating her on a job well done. None of them were good actresses or liars, so this was positively an academy award winning performance on the part of Marie.
“Okay so we know he doesn’t have an obvious alibi so far,” Jill noted. “Let’s look for a link beyond the interior design business. Are they connected through their kids? Do they live geographically close? Do they attend the same church?
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��I think we also need more research on the family finances. Is there a life insurance policy that Michelle will receive? Marie, did you find anything else on Michelle other than the huge discovery on the website?”
“The remainder of what I located on Michelle is not worth mentioning. She is just your average wife, mother, and business owner going through life. I’ll go back and take a second look for any additional Lewis connections, but I think I would have found them the first time.”
“Jo, can you work any new angles on the finances?”
“I think we should take a break for lunch,” Jo replied. “How about if we go to lunch at Curly’s at Lambeau Field. I would think that football setting would perhaps “cleanse our brains of the trivia involved in this case’ and then perhaps we can re-focus and go back at it again in an hour.”
Marie who had joined Jill and Angela in laughter, said, “Cleanse our brains in a football setting? Jo that is so Zen of you! Perhaps the ghost of Vince Lombardi will steer us in the right direction.”
