scrub out and do it myself? There’ll be shit to pay if that happens.’ End of quote. Does that sound familiar, doctor?”
Calmly, Harris replied, “Yes, I said that.”
“That sounds like an argument to me.”
His composure intact Dr. Harris said, “Yes, I could understand why anyone who heard that statement would think I was arguing, but I wasn’t. Time was running out on Mr. Wallberg. Dr. Madhava was unsure and that resulted in his reluctance. Yes, I used those words. I had to stress the urgency. If you had my entire discussion during that time you would also have me explaining my rationale for the heparin to Dr. Madhava. Once he heard that, he complied with my order. Never forget that we work as a team in surgery. Patient welfare is paramount.”
“Don’t you agree that not to use heparin could meet the accepted standard of care?”
“You’re asking the same question again.”
“Yes or no doctor.”
“All I know is I met the standard.”
In a challenging tone, Barbutti said, “What if I were to tell you that I had experts who would have never used heparin?”
“Then I would tell you that your experts don’t understand the pathophysiology of DIC and are unable to recognize the late clinical manifestations of the disease.”
“You would disagree with experts?”
“I would first need to have the word expert better defined.”
That stopped Barbutti. He was not about to put on record that his expert was a thirty-year-old general practitioner. He changed the subject. “Let’s go back to the beginning doctor. Describe your first contact with Mr. Wallberg.”
“I arrived home from work, and received a call from Mr. Wallberg. He was home and I could tell by his voice that he was in great distress. He lived next door and I went to his house to determine the problem.”
“Were you his personal physician?”
“No. I never saw him as a patient before.”
“And your findings?”
“All consistent with an intra-abdominal catastrophic event.”
“I need details of your physical findings, doctor.”
“Yes, all right. His appearance was that of a man in severe pain. Facial grimace, wrinkled brow, anxiety, bent over almost ninety degrees, belt open and pants zipper unzipped.”
“Unzipped pants? What does that tell you?”
“He was relieving the distention of his abdomen.”
“Bent over ninety degrees?”
“Same reason.”
“What was there about his abdominal findings that led to your diagnosis?”
“His abdomen was distended and his bowel sounds were high pitched. That suggests obstruction. He had vomited three times and that is consistent with obstruction as well. His abdomen was tender and he had rebound tenderness.”
“And what is rebound tenderness?”
“Press the abdomen with your fingers, release quickly and severe pain is felt.”
“What does that tell you?”
“It suggests that the peritoneum is irritated or infected. The peritoneum is the thin membrane that lines the wall of the abdomen and covers the organs in it.”
“Does that mean surgery is necessary?”
“Not necessarily.”
“What brought you to the decision to recommend surgery?”
“My clinical judgment confirmed by x-rays that proved an intestinal obstruction.”
“Do you always have to treat intestinal obstruction surgically?”
“Not necessarily. Sometimes conservative measures are effective.”
“Why didn’t you use conservative measures?”
“He had a severe obstruction proven by x-ray. For all I knew his intestine was already gangrenous.”
“But you didn’t know that.”
“But I was worried about the possibility.”
“So, perhaps conservatism might have worked?”
“Not a chance. His x-rays showed advanced obstruction.”
“How can you be so sure? Perhaps if he had been treated conservatively he’d be alive today.”
“I wish you were right, but you aren’t. He also had a congenital band, which resulted in an obstruction of the small intestine. Some of his intestine was gangrenous and adjacent parts were pre-gangrenous. Those parts had to come out. You don’t survive gangrene of the bowel unless it’s removed.”
“What about his vital signs when you first saw him?”
“Pulse was 116 and regular. Respirations were 30 per minute.”
“Blood pressure?”
“It was 120 over 70.”
“So he wasn’t in shock, doctor?”
Dealing with the medical situation, Cliff’s equanimity had returned. “Probably not. I have no knowledge of his blood pressure under normal circumstances.”
“Could your patient have had DIC before you took him to surgery.”
“It’s not impossible. He had the prerequisites for the syndrome.”
“Did you think of that possibility?”
“Specifically, no. I just knew that such a complication could occur and that’s why I was prepared for it when his clinical story suggesting DIC began to manifest itself.”
“Would one operate on a patient if he had DIC?”
“A patient like Mr. Wallberg?”
“Yes.”
“Yes, if the risk of not operating is greater than the risk of DIC.”
“It would be dangerous wouldn’t it?”
“Yes, but at the same time it would be therapeutic. DIC will resolve itself if the underlying condition is corrected.”
“Then why didn’t Mr. Wallberg’s DIC resolve itself when you corrected his surgical catastrophe?”
“You’re
