Cutter's Trial

by Allen Wyler

  Feet firmly planted, hands on his hips, Martin rotated right, then left, stretching his spine. “Don’t know what the hell I’d do.” He started to walk. Alex knew they’d start to run again once they finished this discussion, the day already too hot to talk seriously and jog. Two dogs that routinely barked at them lay panting in the shade of their porch, heads down, watching them pass.

  “One thing I sure as hell wouldn’t do,” Martin finally said, “is tell a damn soul I ever discussed it. And I sure as hell wouldn’t write anything in the chart.”

  “Let me tell you a story,” Alex said, choosing to open a part of his past that he’d only told Lisa. “Told you my mother died of cancer, didn’t I?”

  “Yep.”

  “It was in the era before CT scans, so she wasn’t diagnosed until too far along to do much other than biopsy it for a diagnosis. Not that it would’ve made any difference. She ended up sick as hell. Nausea, partial paralysis, the works. I lived with her at the time, but when she got too sick to live in the apartment, we moved her into her parents’ home. She continued to go downhill until it was impossible to care for her there either. She had to be moved into a nursing home. For some reason—maybe because I was her son—I was the one who was given the task of telling her. She knew what those places were like and that this was the end for her. She was already in diapers on a rubber sheet, too weak to even turn herself over in bed. Nothing but a skin-covered skeleton waiting to gasp her last breath. She knew her remaining days were going to be even worse.” Even this many years after her death, the memory still misted his eyes.

  “The morning the ambulance was scheduled to transfer her, she asked me to bring her her pills. I knew she had a prescription for Seconal. When I asked why she needed them, she said she wanted to OD when she still had an ounce of dignity. I understood why she wanted to do it, but another part of me—the son part—couldn’t bring myself to give them to her. Not because of any religious or ethical belief; I just couldn’t do it. Not to my mother. I couldn’t give her up.” He paused for a deep breath. “I told her no.” They walked a half block while Alex reigned in his emotions.

  “The nursing home turned out to be exactly what she envisioned and feared. Smelled of urine and feces. You could hear moans and every now and then a screaming sundowner. She lingered in that shithole for three goddamn weeks. It was awful, a real hell. I’ve never forgiven myself for not giving her the pills.”

  They started jogging again, Martin silent, waiting for Alex to finish his story. But Alex let it hang. Finally, a half mile from Alex’s house, Martin said, “Only one thing I can tell you, and it applies to every patient: do the right thing.”

  “My spies tell me you did a great job running things while I was gone,” Reynolds told Alex the following week, having returned from his Bethesda tour now that Desert Storm was wrapped up.

  “Good to hear.” Alex tried to hide his disappointment at relinquishing primary control of the residency. He’d been amazed at how quickly he’d taken to managing the residents, segueing the program from Reynolds’s dictatorial way to Waters’s gentler, reinforcing teaching style. It was gratifying to see firsthand the behavior produced by his changes. Steve Stein—his spy—joked that when residents saw Reynolds approach from down the hall, they dove for the first exit. In contrast, they gravitated to Alex for advice and instruction, eager to learn. Then again, there was always the possibility that Stein was simply giving him a verbal blow job. He hoped that wasn’t the case but knew most people tended to suck up to their boss.

  “You know, don’t you,” Alex said without trying to sound too hopeful, “that Dean Turner just announced his retirement.”

  Reynolds smiled. “Jesus Christ, Cutter, you need to learn to be more subtle. Diplomacy is an art, not a scud missile.”

  Alex felt his face redden.

  53

  “Got a sec?” Martin caught Alex returning to his office. “Have a case for you.”

  Alex veered off to Martin’s office. “Tumor?”

  “AVM.” Martin held up a CT scan and turned on the view box. “Here, have a look.”

  AVMs, Arteriovenous malformations, are congenital tangles of vessels in which arteries, carrying blood under high pressure, short-circuit directly into thin-walled veins designed to handle low pressure. The major risk of these lesions is spontaneous hemorrhaging that can cause death or brain damage. Luckily, most people with an AVM went undiagnosed and lived completely normal lives, a factor that made surgical removal debatable.

  Alex studied the scan a moment. “Garrison seen it?”

  “Yep.”

  Alex shot him a questioning glance. “And?”

  “Says he won’t touch it.”

  Made sense. But why was Martin asking him about it? “What about the patient?”

  “Yep, that’s the rub. He wants it taken out.”

  “Why? It’s a big one, exactly the kind that carries less risk of a bleed.”

  “I told him exactly that, but he says now that he knows it’s in there, he’s going crazy worrying about it every damn minute of every day. Says he can’t do anything, out of fear it’ll explode. Thinks it’s a ticking time bomb in his brain. Can’t have sex with his wife now because of it. Tried to steer him away from surgery, but he’s dead set on having it out.”

  “Bad choice of words.”

  “Yeah, guess so. But you get my drift.”

  Alex glanced at the scan again. “What about Clarence?”

  “If it’s coming out, I want you to do it. That is, if you think you can do it.”

  Alex studied the images more closely, weighing the best approach. The trick to removing these things was to isolate and shut down all the feeding arteries first to relieve the high pressure in the thin-walled veins. Once that was done, removing the actual malformation would be similar to removing a tumor. But shutting down the feeding arteries would be extremely difficult for this one. And once you opened the head and started in on it, you couldn’t stop until the malformation was completely removed.

  “Why not Clarence? He’s Garrison’s prodigy.”

  “C’mon, Alex, Garrison had the scan for two days before giving me an answer. You know damn well those two conjoined twins looked it over together. If Garrison said no, Clarence will say no. More than that, I just don’t want to deal with him if I can help it.”

  Alex continued to study the images, thinking through strategies. The angiogram clearly showed the feeding arteries. Could he do it?

  “If anyone can do it, you can,” Martin said, as if reading his doubt.

  Alex shook his head, more as a way of casting out doubts than a response. “I don’t know. Need to think it over.”

  “If you don’t do it,” Martin added, “I know he’s going to end up getting cut by someone like Friedman and Cramer. I’d hate like hell to see that happen. With you he gets the best shot of coming through intact.”

  Alex hesitated, balancing conflicting thoughts of confidence and self-doubt. Why should he think he could successfully tackle a case Garrison went thumbs-down on? Yeah, he was good, but was he that good?

  “I want to talk to the patient before I make a decision.”

  “Figured as much. C’mon, he’s waiting on you.”

  “What? He’s in clinic now?”

  Alex left the exam room worried that the patient didn’t grasp the relative risks of surgery versus leaving it alone. Making matters worse, the patient resonated with him immediately. When this happens, a patient often credits their surgeon with greater skills than is really the case. Alex suspected this just happened. Within minutes of meeting each other, the patient believed Alex was the only surgeon who could safely remove the AVM. Worse yet, Alex knew his own confidence was swayed by the patient’s opinion of him.

  I really shouldn’t touch it. A wise, capable surgeon once told him, “The best case I ever did was the case I didn’t do.”

  On the other hand, I do difficult tumors day in and day out with an envious success rate.
Maybe Martin’s right, maybe I am the one to tackle it.

  Then again, the smart thing might be to leave it alone.

  He stopped by the scheduling desk to pass the patient’s chart to the duty nurse. “I want Mister Foxx scheduled for surgery, but this isn’t a routine case. I want him to be the only case that day, and I want it on a Thursday. That Tuesday I want him admitted for John Stern to do an intervention on him. I’ll discuss it with John today.” Stern was an interventional radiologist, a new specialty in which radiologists treated various surgical problems using special techniques and catheters. Alex planned on having Stern plug the major arterial feeders before surgery, making his job easier and less risky. More and more surgeons were adopting this strategy to shut down feeders to both AVMs and vascular tumors. In addition, he wanted Stern to do a Wada test to determine if speech was in the right or left side of the brain. “It also has to be on a Thursday when Doctor Cole and Chuck Stevens will be there. I want the A-Team in on this one.” With the die cast, a foreboding budded in the very depths of his gut. Rescind the request. It’s not too late. But then what do I tell the patient?

  “Yes, Doctor.”

  “And make sure the lab types and crosses him for eight units with another eight on standby.”

  The nurse shot him a look of surprise. “Eight units?” It was unheard of for his cases.

  “Eight units,” he verified.

  CT scan and angiogram in hand, Alex headed for the stairwell. No better time to talk with Stern than right now. The agreement he made with the patient was that if Stern didn’t believe he could successfully embolize the feeders, Alex would not do the case. Part of him hoped Stern would say no.

  Stern stood at the view box studying the contrast-enhanced CT scans, the contrast lighting up the arteries, defining their lumens. He’d been at it for ten minutes now. Each second that ticked slowly past increased Alex’s anxiety. Stroking his chin, Stern nodded to himself. “Yeah, I think I can shut down some of those pipes for you.” He shook his head. “Shitload of blood going through them. Whole lot of blood. I can see why you want this as a first step.”

  “I’m scheduling surgery for a Thursday. We’ll coordinate with your scheduler so you can embolize him on that Wednesday.”

  “Smart. Keep me posted.”

  54

  “Hey, are you Alex Cutter?”

  Alex sat on his haunches washing the wheels of his Audi with a large sponge and a bucket of soapy water, a typical Saturday afternoon chore he found soothing. So many hours of his days were devoted to precise, meticulous work that a job like this, completely without risk, was a welcomed distraction. He also loved leaving the metallic gray paint shiny, the black leather interior spotless. Lisa’s car, on the other hand, was a perpetual disaster he tackled only once a month. Even then he simply washed the exterior, because any interior work would be in vain.

  Startled, Alex glanced over his shoulder at the voice. Behind him stood a middle-aged stranger in jeans, camouflage T-shirt, camouflage fishing vest, and aviator sunglasses, wearing a huge, shit-eating grin over his face.

  “I am.” Alex stood.

  The grin enlarged as he pulled a folded paper from inside his vest. He handed it to Alex. “Here.” He turned toward the street.

  Alex accepted the paper. “What’s this?”

  “Get it?” the man yelled to a partner aiming a telephoto lens at them from across the street.

  The photographer nodded. “Hell, yeah.”

  The process server said to Alex, “You’ve been served,” then turned and walked away laughing.

  Served? What the …? Then it dawned on him. He dried his hands on a rag stuck in his back pocket and carefully unfolded the sheet of paper.

  “What do I do now?” Alex asked Garrison. He was on the kitchen phone, the unfolded summons on the counter.

  “Nothing for the moment. I’ll notify our attorney now and set up a meeting for Monday morning. This being Saturday, there’s not a damn thing we can do till then. It ain’t going away, that’s for damn sure. Just try to calm down.” Garrison paused. “But I gotta ask you, any truth to the allegation? You have anything—anything at all—to do with this woman’s suicide?”

  Alex didn’t answer immediately, so Garrison pressed the issue. “Well?”

  Alex swallowed. “She had a glioblastoma. I operated on it, then had it radiated. That’s it.”

  “Then you have nothing to worry about. This your first? Malpractice suit I mean.”

  Alex dropped heavily into a chair. “Yeah. Aw, Jesus, ten million dollars.” For the first time since joining the clinic, he wondered how much his insurance covered. What would happen if they won and were awarded the entire amount but he had only five million dollars of coverage? What then? Would they take his house, car, retirement? Why hadn’t he been concerned enough to pay attention to these things?

  “What else do they want in damages? That is, if you don’t mind me asking,” Garrison said.

  “They want my state license revoked.”

  “Suspect they’re going to have a problem with that one. Can’t remember that kind of thing ever happening, especially with this being your first suit. Keep the faith; you’ll persevere. What d’ya have going Monday morning?”

  “One case. Shouldn’t run past noon.” He’d purposely scheduled a light week in anticipation of the AVM Thursday.

  “I’ll be seeing patients by the time y’all finish. Run me down soon as you’re free.”

  Alex was still sitting at the kitchen table, phone in hand, when Lisa came in from the carport carrying a bag of groceries. She set the bag on the counter with a grunt. “What’s wrong?”

  His mind was consumed by a toxic brew of anger at the process server and the Costello family. Meredith had claimed she was all alone. So why was the family now pressing charges? He held up the paper for her to see. “I’m being sued for malpractice.”

  She sat in the chair opposite him. “Oh my God! What did you do?”

  “Nothing. The patient died from a glioblastoma. A sister I didn’t even know existed claims I killed her with a prescription of Nembutal.”

  “Did you?” Lisa asked matter-of-factly.

  Ah, man … “No.”

  Years ago when they were still learning about each other, he had shared the story of his mother’s death in the nursing home, how he regretted not helping her commit suicide. Lisa had been shocked, believing neither a patient nor their doctor had a right to intentionally assist in suicide, regardless of the circumstances. Her belief was based on the simple conviction that life is a gift that no human has a right to take, regardless of how well-intentioned their actions. Alex had argued that a physician’s most important obligation to a patient was to relieve suffering, that nothing in the Hippocratic oath stated that physicians should prolong life. He strongly believed that if the final terminal stage of disease increased suffering, it would be more humane to provide the patient the option of a merciful alternative. She had found his argument abhorrent.

  “I don’t believe you. Why? Because I know you,” she said in a matter-of-fact tone. “And if I don’t believe you, what’s a jury going to believe?”

  55

  “We sure Cole and Chuck are scheduled for the case?” he asked Ellen, the head of surgery.

  “They are,” she confirmed, but her words didn’t do a thing to ameliorate his anxiety.

  “How about the type cross-match?” His gut was churning like the wake of a speedboat, causing him to gasp a deep breath every now and then. Stop freaking out. Calm down. You’re going to do fine.

  “Done. Blood bank’s sending them over first thing in the morning.”

  Alex slipped silently into the angiography suite to watch from behind the lead-impregnated glass of the control room. The overhead fluorescents were off, making the glow of the flat-screen monitors feel intense by contrast. Stern, fully gowned and gloved, a lead shield bulking out his gown like a Kevlar vest, stood at the side of the radiology table. He carefully wo
rked the long catheter through the patient’s blood vessels, watching his progress on the fluoroscopy screen. A CD played Beethoven softly in the background. Not wanting to startle anyone if they looked up and noticed him suddenly behind the glass, Alex cleared his throat as a warning. Stern glanced up and recognized him, his face etched deeply with concern. Stern stopped what he was doing and walked over to Alex.

  “How’s it going?” Alex asked, hoping for good news.

  “Not well. That thing’s the monster that ate Chicago,” he whispered. “Each time I plug one vessel, another opens up. Never seen anything like it. You got a tiger by the tail on this one, Bubba.”

  “What about the Wada test?”

  Stern let out a derisive laugh. “Didn’t work. The left side is stealing so much blood from the right side we weren’t able to get any drug effect. Nothing. I gave up trying so I could put the effort into the embolization. Figured that was more important.”

  Alex’s heart dropped. To properly guide the catheter into the correct vessels, small boluses of contrast agent were injected periodically to show the position of the catheter tip on the fluoroscopy screen. Because the contrast agent was excreted through the kidneys and was slightly toxic, there were limits to how much could be safely injected in one twenty-four-hour period without impairing renal function. And normal kidney function was essential for the long surgery ahead. “How much more can you get away with? I need every bit of help you can possibly give me.”

  Stern thought for a moment. “I can probably shut down two, maybe three more vessels. After that I don’t know. I’m pushing the limit as is.”

  Needing every possible feeding artery closed, he was tempted to cajole Stern into exceeding the pharmaceutical company’s recommended labeling limits. After all, the patient was a healthy male, and manufacturers intentionally erred on conservative estimates when labeling a drug. But with such a high-risk case, any bad outcome or complication might cause the family to sue. If the plaintiff’s lawyer discovered any evidence in the chart that Stern exceeded the prescribed limits, he and Alex would be no-contest dead ducks. Up until his pending malpractice suit, Alex never would’ve considered making such defensive practice decisions. Now things were different. Instead of doing everything possible to increase the odds in favor of his patient, he would choose self-preservation. He didn’t dare think of pushing Stern. “Appreciate your help,” Alex said.