Injuries of the Heart

He sat next to the judge in the witness chair. Of medium height and build with a clean shaven head, he recalled the night in the hospital where he lost his dad, role model, grandfather to his newborn son and best friend. In the small courtroom he spoke directly to the jury about the fear and apprehension the night his father was admitted to the ICU. He talked about the pain his father experienced just before his eyes rolled up in his head. He recounted running into the hallway, desperate, yelling for a nurse, for anyone to come to his father’s aid. He described the profound loss, the hole left in his family’s life after his father arrested and died that night, five years ago. I was sitting 15 feet away, almost directly in front of and facing this gentleman. Because the hospital and I were on trial for the wrongful death of his dad. 

I have wrestled many times with my role as a physician after the death of a patient or a “bad outcome” or “adverse event.”  Could I have figured things out faster? Was there a delay in making a diagnosis? Did I start the right medicine? Was there an intervention not chosen or an action not taken that might have made a difference? These thoughts plague many doctors, particularly in the arena of the ICU, where the rapid pace of care unfolds before our eyes. The hard truth is that there is a lot of uncertainty in my world, more than the non-medical public would like to know.

As I sat at the table, with the eyes of the jury drawn in by the sincere and profound loss displayed by this gentleman, the seriousness and weight of my situation was juxtaposed by the absurdity of how several events had played out to this point.

  1. Five years had passed since that night. Three years since my first deposition. Years of reading repeatedly a chart detailing the care of a patient I had never participated in. Three years of waiting to be dismissed from the case. Three years of angst, anger, and mostly exasperation because…
  2. I truly had nothing to do with this patient. I had no role in his care. The patient died before I had the opportunity to be involved. However, I was linked to his chart, and thus his death, by a resident’s electronic medical record (EMR) template that placed “discussed with attending” automatically at the bottom of every note. Initially, I thought these facts would protect me from both legal and emotional involvement. My presence in the courtroom was proof that my initial thought was wrong.
  3. Despite the truth of not being involved in his care, my lawyer was adamant that my defense strategy was not going to be based on that fact. What was charted was gospel. So my mantra of “I never talked to the resident” was changed to “I don’t remember talking to the resident.” My defense would be based on a timeline that made my charted notification irrelevant. Because his death was not preventable. The truth was not my defense.
  4. The plaintiff’s attorney was well aware that I had no involvement. But he was willing to argue to the contrary and see if a jury could be convinced otherwise. Leveraging the risk of the jury finding me guilty, he offered several times to drop me from the suit in exchange for “throwing” the residents under the bus, by calling into question their decisions and care.
  5. I decided to take my chances and trust the jury.
  6. On day four of the trial, my trust in the jury seemed misplaced when Juror #9 fell into such a deep state of slumber, he slid out of his chair into a heap on the floor.
  7. The commotion around juror # 9, distracted the judge, and enabled me to check my list of waiting text messages.  What little humor I felt over the situation was immediately erased as I read my wife’s text: “HEADED TO HIGH SCHOOL. POLICE INTERVIEWING OUR SON.”

The next hour was a bit of a whirlwind. A recess took place in order to figure out what to do with the very sleepy, and probably intoxicated, Juror # 9.  At this point of the trial, the “timeline defense” had been established and the attorneys agreed that I would be dropped. I was excused early to figure out what was going on back home. Freed from what turned out to be quite a bizarre fourth day of trial, I walked out of the courtroom.

On my way to the elevator, I was approached by the gentleman who initiated this lawsuit. We had met briefly on the first morning of the trial. It felt “off” to me not introducing myself. Against my lawyer’s advice, I crossed the room, shook his hand and offered my condolences. We had exchanged simple eye contact and a nod of our heads each morning as a hello. Now, standing in front of me, he asked if we could talk for a minute.

“I just wanted to know. What happened. I wanted to know what happened to my dad. I never really wanted a trial. I just wanted the hospital to sit down with me.” He was looking past me, tired and depleted. I realized then that his past five years had been immeasurably more difficult than mine. “When this is all over, could we talk? I’d like to know what you think happened.”

I gave him my phone number. I told him I would try and help provide some sense of closure. We shook hands for a last time and I walked out of the courtroom and back to my life.

The car ride home gave me time to pause. My son was fine, a bit of a misunderstanding. No emergency there. I was able to reflect on some lessons learned from my experience.

First, EMR’s and their templates can lead to a legal nightmare. Second, my naïveté about the judicial system was no more, and I learned that the truth may not be what sets you free. Third, although cliché to be critical of attorneys, this one was truly special. He pushed a bad patient outcome on a reluctant client and played games with my innocence to try to make a better case. Fourth, for a few days, my fate was in the hands of a jury in which not all took their responsibility as seriously as I would have appreciated.

But surprisingly my thoughts turned to the only person in that courtroom who had anything truly on the line. Not the lawyers looking for a check mark in the won/loss column and a possible payday. Not the hospital. Not myself, although I may have felt differently, had I actually been involved in the care of the patient. But it was the man, of medium height and build with a clean shaven head, who lost his best friend. It was clear from day one, his pain was genuine. His loss complete. His lack of closure from that night, was raw and apparent. He was living with the picture of his father, those last few moments in pain, falling back in the bed. He was coping with the memory of the critical care team trying unsuccessfully to resuscitate his father. And he just wanted to understand how and why it all happened.

I knew why. I had read the chart a thousand times. There was no error or malfeasance. He was not a victim of bad doctors doing the wrong thing, or even good doctors making a poor choice. He had an atypical presentation of a usually fatal injury to his aorta, the largest vessel in the body. A small tear in aorta’s wall had tracked backwards. Blood then filled inside the pericardium, the lining surrounding his heart. As more fluid filled the pericardium, pressure increased on the heart’s muscles making it impossible to pump blood forward. Difficult to treat under the best of circumstances. Almost impossible with his presentation. Had I actually been involved with the residents that night, there would have been no change in the outcome. Walking into the courtroom four days ago, I thought I knew everything that had happened. But now, I recognized two people suffered devastating injuries to their heart that night. And one was still very much in pain.

It has been over a year since I walked out of that courtroom. I have not heard from him. I would have liked to sit down with him and learn a little more about his dad. Hear how his newborn son is growing up. I would share my impressions about what happened the night his father died; that I don’t believe there was negligence, but that his father’s death is a painful example of how fleeting and unfair life can be. I would like to give him a bit of closure to that night. I fear it eludes him to this day.

I still wait and hope for his call.