judgment. Also, I ordered a great many studies to determine his pre-operative status.”
“And?”
“These results came back and the platelet count was not indicative of DIC.”
“What was the platelet count?”
“135,000.”
“What’s normal?”
“150,000 to 400,000.”
“Your result was a little low, correct?”
“A little. If you’re suggesting that a slightly reduced platelet count always signifies DIC then you’re plain wrong. Many people with slightly reduced levels have no problems of any kind.”
“What other tests did you do for DIC?”
“Prior to surgery?”
“Yes.”
“None except for a routine complete blood count that is mandatory for surgery.”
“Why not.”
“At that stage I really had no reason to believe the patient had DIC.”
“Maybe you were wrong.”
“Maybe? I don’t think so. What I did met the standard of care. I ordered all the proper studies prior to surgery necessary for the circumstances.”
“But the platelet count was a little low. Maybe DIC was starting.”
“I explained that once. Even if I had diagnosed DIC, he still needed the surgery. And if he really was beginning to get DIC the surgery was his best chance for nipping it in the bud. Remember the best cure for DIC is the elimination of the precipitating cause, which in his case may have been the intestinal obstruction and gangrene of the bowel.”
“Let’s talk about the surgery, doctor.”
“Lets. What do you want to know?”
“What did you do?”
“I resected a gangrenous and pre-gangrenous bowel, and removed it along with the congenital band that that had caused the intestinal obstruction. I then anastomosed the healthy ends of the bowel.”
“There must have been a lot of bleeding?”
“Surprisingly little.”
“One would have to assume that a man who bleeds extensively after surgery did so because you missed or improperly tied off an artery.”
“That is the first thought that every surgeon would have if bleeding occurred after surgery.”
“So you thought that?”
“Yes I did, but I had a hard time believing that to be the case, because when I closed him up he was dry. I stress dry. There was perfect hemostatsis.”
“Then why did you re-operate? Why didn’t you diagnose DIC?”
“I had no reason to think it was DIC. Bleeding in the abdomen after abdominal surgery is assumed to be due to a leaking blood vessel until proven otherwise. I had to act. Re-exploration was mandatory.”
“Was he in shock?”
“Not yet. His blood pressure was low normal. But going into shock was a definite risk. That’s why I had to act fast.”
“Why did you remove the urine from the Foley bag?”
“I wanted to be able to exactly measure urine output, if any during surgery.”
“The record states that you found no bleeder.”
“That’s correct.”
“It was difficult surgery, wasn’t it?”
“Yes.”
“Then you admit, it might have been possible for you not to find a bleeder.”
“I looked very hard. In spite of the abdominal blood I believe I got a good enough look to say emphatically there was no specific bleeder. The bleeding I would characterize as a slow diffused ooze.”
“How were his vital signs through all this?”
“They remained stable.”
“But it says in the record the blood pressure was seventy over twenty. Do you call that stable?”
“You’re jumping ahead of the story.”
“What do you mean, doctor?”
“While I was sucking out the abdominal blood, his blood pressure was stable. And when I found no bleeder, and the blood continued to ooze, I began to think of DIC. So I immediately asked Dr. Madhava to check the patient’s fingers and asked the nurses to check the Foley bag for any urine. I was told that the fingers were dark blue and the Foley bag was empty. That’s when I began to think that DIC was present and was rapidly progressing to the end stage where thrombus forms and plugs up vessels causing gangrene and kidney failure.”
“Hold it doctor.”
“What?”
“This man was heading into shock. Isn’t that enough to explain the blue fingers and empty Foley bag?”
“Then the prognosis would be grave and the patient would need vasopressors. But remember, his blood pressure was still holding up when I asked for the appearance of his fingers and Foley bag check for urine output. It would be unusual to see such intense finger cyanosis while the blood pressure was still satisfactory. Yes, he could have some reduced urine output at that time, but the oozing of blood and the intense cyanosis of the fingers plus the absence of urine output, all in the presence of a pretty good blood pressure, to me meant DIC. I was about to order heparin when I was informed by the anesthesiologist that the patient’s blood pressure was falling, seventy over twenty to be exact. The heparin was given. It was a last ditch effort. I had no choice.”
“Others would not be so venturesome, or foolish as some might choose to call it.”
Cliff’s anger was re-ignited. “I’ll defend my actions until the day I die. I understand your tactics. You will throw so many variables into this equation that the average person will be thoroughly confused. Then it will be a battle of the experts, but whatever the outcome, my conscience is clear.”
“We’ll just present the facts, doctor.”
“Yeah, right. I’ll do the same.”
“Your notes say the patient’s wife refused an autopsy.”
“That’s correct.”
“How hard did you try?”
“To get her to approve
