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Prescription: MurderOver His Dead Body & A "C" Change
By William H. Simon
iUniverse, Inc.Copyright © 2012 William H. Simon, MD
All right reserved.
Chapter OneCarpe Diem
Take advantage of the day
The office door opened and a large man entered. He was six feet three and weighed around 230 pounds. He was big but not menacing. More huggable—like a large teddy bear. And he was slightly balding and stoop-shouldered.
The office door opened into a large waiting room of his medical practice. It had about twenty leather and wood chairs, oriental rugs on the floor and on the wall, and enlarged and framed photographs of many of the exotic lands the doctor and his wife had visited in the past twenty years. To his left was a reception desk, and beyond that was the business office where four white-coated women worked.
"Carpe diem," the man said.
But this wasn't a foreign land. And it certainly wasn't the land where this language was spoken. This was on Seventeenth Street, in the middle of Philadelphia, and he was speaking ancient Latin, the language of long-dead Romans. The four ladies in white replied chorus-like, "Good morning, Dr. Marks."
They had no idea what he had said to them. (Actually he had said in the other language, "Seize the day," a phrase that for him meant "Have a good day.") But they were so used to this man greeting them each morning with a Latin salutation that they continued on with their work as if it were an everyday occurrence—which it was for them!
The man was Ham Marks, MD, a fellow of the American College of Surgeons. He was sixty-three years old, and since he had recently given up an active surgical practice—he'd told his wife, "Leave it to the younger guys with less arthritis in their fingers"—most of his peers considered him a forensic orthopedist. Forensic, in this case, not referring to a CSI type but rather a trained orthopedic surgeon whose job was to figure out, by using his knowledge of anatomy, pathology, and physiology as well as his clinical and research knowledge of the musculoskeletal system, just what caused what. Did that fall down the steps at work cause the disintegration of the hip joint that necessitated a total-hip replacement? Or was it inevitable? Did that automobile accident, with its attendant "whiplash," cause the herniated disc? Or was it a degenerative condition that was just brought to light because of an investigation of neck pain? These were questions that fell into the realm of the medico-legal aspects of orthopedics, where money was involved—lots and lots of money.
The Latin thing, that was another story. Ham's mother had been a classicist, a teacher of ancient Latin and Greek. She had whimsically (or perhaps out of professional pride) christened him Homer Alcibiades Marks in order to connect him indelibly with two of her ancient heroes.
Times being what they were, Homer Alcibiades Marks quickly became Ham Marks, a nickname that permanently obscured the full name's ancient provenance through grade school, high school, Princeton University, Harvard Medical School, and beyond.
Ham moved down a short hall and then into his private office. He removed his hat and coat and hung them in a hidden closet behind a wall. The office was decorated with more oriental rugs and a large, polished mahogany desk, with two leather guest chairs in front and his own rotating leather chair behind. His chair sat in front of a wooden credenza that rested beneath a large panel of light boxes used for reading X-ray plates. The only whimsical bit of decor was the Phillies baseball hat that sat on the skull of his mounted skeleton. There were also a striped couch and a coffee table beneath the windows looking out on a view of the city. The window to the left of his desk presented a second urban view. His walls were filled with his many diplomas and award certificates and a large, framed copy of the Hippocratic Oath. Along the wall opposite the window was a floor-to-ceiling bookcase filled with his orthopedic reference books and his own bound writings. On the floor in front of the bookcase were large cardboard cartons stacked three high.
Outside his office door was a hallway connected to small rooms that consisted of his patient examination rooms and the utility rooms for patient medications and plaster cast applications At the end of the hallway were a room for taking patient X-rays and a room for the development and storage of the images. His patient assistant and X-ray technician inhabited this space.
His office manager and right-hand woman, Maria, entered his private office with his first cup of coffee of the day. Maria Cleopatra Gregorios was of Greek origin but was no Greek linguist, and she certainly did not understand Latin, so she was just as amused as the rest of the staff with Dr. Marks's morning greetings.
Maria was five feet four, slim, and had auburn hair (most of the time). Her prominent nose fit her face well. She said she was about the same age as Ham. She wore a starched white coat over her sweater and skirt. In fact, all of the women in the office wore either the long white coat over their street clothes or the nurse's outfit of a long, colorful shirt over pants. Ham, on the other hand, wore a suit and tie. He had had enough of starched white uniforms as an intern and resident.
Despite Maria's Greek heritage, Ham knew that she neither spoke nor understood Latin or Greek. But he got a kick out of the fact that her middle name was Cleopatra. It gave her a classical flavor.
"Those file boxes just arrived this morning, Doctor," Maria said while pointing to the large cardboard file boxes capable of containing thousands of pages of documents for the doctor's review.
"This cover letter came with the boxes from defense attorney Albert Broder," she continued as she handed a four-page, single-spaced letter to the doctor. "He made an appointment to talk to you about this case tomorrow morning. Is that all right with you?"
"That's fine. Thanks, Maria," Ham acknowledged.
Maria turned, her stiff white coat brushing against the office door, as she left Ham to read the letter and stare pensively at the large file boxes stacked against his bookcase.
The letter explained, in some detail, the medical malpractice case that Mr. Broder was defending and exactly what he would like Ham to do in his role as consultant forensic orthopedic surgeon. Mr. Broder had made it quite clear that this case was big. It involved suits against multiple people and organizations, potentially for millions of dollars.
There was even the possibility that a criminal charge of murder could be brought against the operating surgeon in the case, a circumstance that would involve a criminal defense attorney, beside Mr. Broder. It was a circumstance that Ham would have to consider in his evaluation of the medical facts of the case.
In brief, the case involved a suit brought by the wife of the deceased patient, in this case, himself a malpractice attorney, who had entered the University of Philadelphia hospital to undergo bilateral, total-hip replacements performed by the hospital's chief orthopedic surgeon. Forty-eight hours after the operative procedure, the patient died for unknown reasons.
The wife, representing the deceased lawyer's estate, was suing everybody: the surgeon, the hospital, the HMO that insured her husband, the anesthesiologist, the internist who cleared the patient for surgery, and the hospital consortium of which the hospital of the University of Philadelphia was just one part. Albert Broder, JD, was the lead defense attorney for all of the entities.
The plaintiff attorney, Claude Matthews, was the law partner of the deceased, Evan Stoner, Esq., in the law firm of Stoner & Matthews. He had also convinced the deceased's wife to initiate a criminal case for murder against the operating surgeon, Professor Edward Miller, MD, PhD, and FACS, since the doctor had previously lost a two-million-dollar medical malpractice lawsuit brought by Evan Stoner. To the plaintiff and her attorney, it was obvious that Stoner's death was the doctor's retribution. Why Stoner would want this man to operate on him in the first place was a curious question with an even more curious answer. In the first place, no other surgeon wanted to risk being sued by Stoner, and Dr. Miller with "evil and pathologically egotistical intent" convinced Mr. Stoner that he was the "most accomplished" and possibly "only" surgeon capable of doing this major surgery.
Stoner's wife, Marion, his second, was out for blood—blood from a Stoner. She would share any inheritance with Stoner's two children from his first wife. And besides, she was convinced, with the aid of her attorney, who was no devotee of Stoner and who himself had made a ninety-yard pass at Marion, that Stoner had cheated her in his prenuptial agreement by not listing all of his assets. It was a continuance of the fraud he had perpetrated during the divorce settlement with his first wife.
The widow was suing for damages for a number of reasons: lost earnings (the fifty-nine-year-old lawyer brought five to ten million dollars a year to the law firm and could be expected to continue to do so for many years), the pain and suffering Stoner endured, loss of consortium (a personal concept that reflected the normal sexual relationship between a man and his wife but was anything but normal in Stoner's case), loss to the children of a father's love and care (Ham laughed at that one), and the special medical costs of caring for Stoner in his last few days. Missing from this list was the actual causing of the death of Stoner, the punitive damage charges, and the charge of murder against the operating surgeon.
As it turned out, the filing of death charges was complex, requiring additional court maneuvering, and did not pay as well as loss of consortium charges anyway. The punitive damage request would require an additional legal filing. And the murder charge would be the job of the district attorney's office, if he could be convinced, and was actually just an attempt at leveraging the defense to come up with a whopping settlement. Marion did not actually care if Miller was charged and convicted. All she wanted was money. And some final revenge.
The reasons that Marion Stoner (through her lawyer) thought that she warranted all this money were many and varied. First in the list of complaints was that the double hip-replacement surgery was contraindicated because of preexisting medical conditions (which would be expanded upon later in the discovery process). Next, they claimed that Stoner was not properly informed that one of the possible complications of his surgery was death forty-eight hours after the operation. And they claimed the surgeon had not performed the surgery in a "workmanlike manner." In other words, he screwed up somewhere during the surgery. They further charged that there was improper pre- and postoperative testing, negligence in the postoperative care, and failure to obtain the proper postoperative consultants who could have prevented his death. Finally, they charged that the operating team had given the improper medication postoperatively.
Ham put down the letter and turned his attention to the three large file boxes. They contained, according to Broder's list, legal documents; depositions of various parties, including Marion Stoner, the two Stoner children, Stoner's first wife, operating surgeon Ed Miller, Stoner's pilot, Stoner's horse trainer (all of whom had visited him in the first forty-eight hours of his hospitalization), and the medical consultant who had cleared Stoner for surgery; all of the hospital records; nurses' notes for the stay at the hospital, including the autopsy records; plus statements from investigators hired by the defense to dig into Stoner's life—and the lives of all the involved parties.
Ham's job was to determine "with reasonable medical certainty" that none of the people sued were responsible for Evan Stoner's death.
Ham thought, Time to open Pandora's boxes!
Chapter TwoModus Operandi
The way of doing it
The hospital records that Ham perused first were voluminous. While some of the information was in computerized form, many records were still in longhand, the hand of a doctor or nurse. Nurses wrote clearly, but doctors, for some perverse reason, had abominable handwriting. Twenty billion federal dollars spent on electronic medical records couldn't correct any medical errors made by not being able to decipher a doctor's illegible scrawl. The pages had been scanned into a computer, but the handwriting often remained difficult, if not impossible, to read.
The preadmission history, physical examination, and presurgical medical consultation had cleared Evan Stoner for the bilateral, total-hip replacements necessitated by avascular necrosis. Avascular necrosis of the hip joints was a condition in which the bone cells of the ball of the hip died and the ball collapsed, leaving a deformed and very painful hip joint. The origin of the condition was known to be associated with diabetes mellitus (which Stoner didn't have), strange blood diseases (which he didn't have), deep-sea diving (which he didn't do), and alcoholism (which, it turned out, he had). However, 70 percent of the time no reason could be associated with the condition.
His liver function blood studies were abnormal, but other than that he passed his preadmission testing with flying colors.
Upon reaching the operating room, he was identified by his wristband, which listed his name, age, sex, and hospital file number. Also noted was the marked presurgical dressing on both hips, indicating that both were to be operated on—no possibility for a left-side or right-side mistake here. He had signed a standard hospital form that explained the upcoming procedures, including the anesthesia, the possible complications of the procedure (including death), and his alternatives. He could get up off of the gurney, if he so desired, and go home!
An intravenous line was established in his arm, and the board-certified anesthesiologist gave him a spinal anesthesia, which numbed him from the waist down. He would be awake during the operation but under medication that provided him with what the anesthesiologist called a "twilight sleep condition" as well as loss of memory of any of the sights or sounds that accompanied the procedure. This was the safest type of anesthesia for this patient.
The surgical team consisted of Dr. Miller, a resident orthopedic surgeon, a board-certified orthopedic surgeon serving as Dr. Miller's "hip fellow," and another orthopedic surgical resident. Surgical nurses were at the operating table and helping from the sidelines. The anesthesiologist stayed at the head of the table and tended to Stoner's comfort and vital signs.
The surgery proceeded with the usual cutting, tying of blood vessels, suturing, sawing, reaming, and placement of the plastic socket component and the metallic hip prosthesis without a hitch. Dr. Miller moved from one side to the other to perform the major portions of the surgery.
The anesthesia record noted a temporary drop in blood pressure when the metallic hip implants were hammered into place within the femoral shafts, but this quickly returned to normal. Two units of blood were given during the two-hour procedure, but they were autologous blood units that Stoner himself had given prior to surgery so there was no possibility of incompatibility. A postoperative X-ray showed the prosthetic implants to be in excellent position, and the patient was transferred to the recovery room.
After four hours of being monitored in the recovery room, Stoner was transferred to his private room while his intravenous line was still running. His postoperative orders included pain medication at first given intravenously, then intramuscularly, and finally by mouth. He was given several doses of antibiotics for twenty-four to forty-eight hours and was given low doses of heparin, a blood thinner, to prevent the formation of blood clots in his legs. Otherwise, clots might float in his bloodstream to his lungs as an embolism.
For the first day, he was allowed no visitors. But on the second day, not only was he allowed to see visitors but also he was allowed to sit on the side of his bed to converse with them for brief periods.
The nurses posted the visitor list. The list of people who visited him briefly on the second postoperative day included his wife, Marion; his two children; and his first wife's twin sister (who looked exactly like his first wife and had been, like his first wife, a nurse). The first wife did not appear. His personal pilot, his horse trainer, and finally the captain of his private yacht also visited him.
The nurse's notes recorded a perfectly benign postoperative course, according to the listing of vital signs and clinical notes.
After visiting hours, at approximately eight o'clock in the evening, the floor nurse entered his room to check on him. She found him unresponsive and not breathing. She immediately issued a code blue and within one minute the medical team was attempting to resuscitate Stoner.
Excerpted from Prescription: Murder by William H. Simon Copyright © 2012 by William H. Simon, MD. Excerpted by permission of iUniverse, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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