A Mother's Trial

by Wright, Nancy

  Finally, Collins had Sara repeat testimony about Mindy’s CMV and its possible effects, including small head size, and potential liver disease. It was an important part of the defense’s case that Mindy be seen as a child who was intrinsically abnormal because that could raise doubt about the cause of her diarrhea.

  On redirect, Josh went right to the most telling point scored by the defense.

  “Dr. Shimoda, I want to refer your attention back to the question concerning Tia’s VMA levels. In your consultations with Dr. Solomon—the endocrinologist—did she give you any information concerning the significance of those levels?”

  “Yes. She said VMA could be elevated in a patient with no tumor. There could be other factors such as stress, certain dietary intake, starvation.”

  On recross, Collins asked only one question.

  “Doctor, laparotomies don’t always reveal the presence of a tumor, even if the tumor is there. Do they?”

  “That would be possible, yes,” Sara agreed.

  Sara was excused and Estol Carte took the stand, ending the day’s testimony with an account of his discovery of Mindy’s contaminated formula.

  Dr. Michael Applebaum was next to testily. Applebaum had confessed to his wife a certain nervousness about testifying. The jury might legitimately wonder how he could now be so certain that Tia and Mindy had been poisoned and yet originally have diagnosed Tia’s illness as an undiscovered disease.

  Applebaum had rarely felt comfortable around Priscilla Phillips. He was sympathetic to her and her situation during Tia’s hospitalization, but she had a nagging way about her, a certain belligerence, and a loud whiny voice that set him on edge. Even in the care of Tia, he had noticed that she was not warm, but rough and jostling. She was not the kind of parent who accepted the doctor, who told him to do what was necessary and trusted him to act competently. Everything was questioned; every issue a confrontation.

  As he began to recount to the jury the treatments Tia had undergone at Kaiser-San Francisco, Applebaum was reminded of his difficulties with the case. In retrospect it seemed a crazy idea, but Mike had decided that Tia’s high stool and urine sodium levels were a reflection of what had been in her blood earlier. He knew it was possible to achieve much higher sodiums in urine than in blood without any significance being attached to the finding. So he had bottled all the symptoms together into some insane sodium mixture and concluded that Tia merely suffered a syndrome that included disequilibrium of her salt metabolism. With the benefit of hindsight, he now realized this conclusion had been moronic.

  Only after Sara had called to tell him about Mindy’s illness had the seed of suspicion begun to ripen in Applebaum’s mind. But he had not placed Priscilla Phillips in the picture at that point, nor thought to test Mindy’s formula.

  And even now, he had to admit to himself, though he had studied the records and become on some level convinced by what they revealed, there was a portion of his mind that balked at the notion that Priscilla Phillips was responsible.

  He remembered visiting the Phillipses’ house after Tia’s memorial service. The house had been filled with many of the other mourners, but Steve and Priscilla had taken him aside and showed him about the house. They had led him into Tia’s room and pulled out pictures they had taken of her during her healthy periods.

  “I am so grateful to you for allowing her to be home as much as you did,” Priscilla had cried.

  And Mike remembered the four-page, hand-written letter Priscilla had written him after Tia’s death, thanking him for all he had done. That hardly seemed consistent with a murderer.

  “We were frustrated by the lack of abnormalities,” Applebaum said now to the court. “The only thing we could find wrong with Tia was a low pancreatic enzyme. We eventually decided that this was a secretory diarrhea—it’s related to cholera in that there are fluid losses in the absence of mucosal damage—and we thought a substance in Tia was causing diarrhea and there were some candidates. VIP and prostaglandin were the two most likely. So we did a laparotomy and removed an adrenal gland.”

  “Did you suspect that sodium was being administered?”

  “No.”

  “Why not?”

  “I was trained as a physician to look for medical causes. And because it was happening in a hospital setting,” he said, echoing Sara Shimoda.

  “I believe we’ve come to the time for our recess, Doctor,” said Judge Burke. “As you know, there is no court tomorrow, so we will reconvene at our normal time on Thursday. Remember not to discuss the case or form any opinion until the trial is completed,” he added to the jury.

  As the courtroom emptied Ed Caldwell stopped for a minute to talk with the bailiff. It was not uncommon for attorneys to question bailiffs and court clerks about how well their points were coming across.

  “How are we doing?” he asked.

  “Okay. But you know your client is hurting herself.”

  “How so?”

  “Well, the way she’s always writing those damn notes and passing them up to you, and the expressions she gets on her face when she disagrees with a witness—like she’s overreacting or on stage or something. She doesn’t act like a defendant somehow. I know you can’t see her….”

  “Yeah, thanks. She’s so intense and hyped up, you know.”

  The guard nodded in sympathy. Ed crossed to the rear of the room and found Priscilla in the hall.

  “You’ve got to cool it with the notes, Pris—it’s making a bad impression.”

  “But I can’t stand it when they make a mistake. It drives me crazy.”

  “I know, but save it and tell me later, at recess or lunch.”

  “Okay, I’ll try.”

  Ed smiled and patted her shoulder. He intended to telephone Dr. Satten to ask him how he felt about prescribing a tranquilizer for Priscilla—not enough to sedate her, but just to dull the edge of her anxiety. Dr. Satten was still seeing Priscilla, and he hadn’t yet reached a conclusion on her case. His delay was probably contributing to Priscilla’s anxiety, Ed thought ruefully. But the next day Ed received a phone call that would take his mind off that problem for a while. A call that would alter the direction of the defense.

  On Thursday, Josh completed his direct examination of Mike Applebaum early. Although Collins was supposed to handle the medical witnesses, Ed had been enormously disappointed with his colleague’s cross-examination of Sara Shimoda, which he believed had been superficial. As a result, Ed cross-examined Applebaum himself. He took the doctor through a detailed description of Tia’s final illness. Applebaum mentioned that on occasion he had seen Priscilla adjust Tia’s IV. Later, he described Tia’s memorial service and his visit to the house afterward. In contrast to the ninety-minute cross-examination of Sara Shimoda, Ed’s cross-examination of Applebaum lasted all day.

  Bonnie Pritzker’s direct testimony did not differ markedly from what she had said at the preliminary. She had conducted a more complete autopsy on Tia than was normal because Tia had been her husband’s patient; in fact he had given her a laundry list of what to look for in the examination, she testified. She had paid careful attention to the brain, spinal cord, pancreas, and remaining adrenal gland in her attempt to find a small tumor. She had found none and was absolutely certain in her own mind that none was there. She could find no pathological causes for Tia’s diarrhea.

  On cross-examination, Al Collins established once again that a tumor could be microscopic, and that there was no way to establish by autopsy if Tia had died from sodium poisoning. Since one of the causes of Tia’s death had been listed as massive cerebral edema, Collins—in an attempt at introducing doubt as to the cause of this brain swelling—asked whether the edema might not have been the result of incorrect fluid replacement.

  “It’s unlikely but cannot be completely discounted,” Bonnie answered. In his place at the defense table, Ed Caldwell turned to smile at Priscilla.

  Josh Thomas then called Dr. John Iocco, Bonnie Pritzker’s supervisor, who had re
viewed her autopsy results. His own findings agreed with Dr. Pritzker’s, he testified.

  On cross-examination, Collins focused on Tia’s electrolyte imbalances, causing a series of objections by Josh Thomas, after one of which, Josh joked, “I better withdraw my objection because I forget what it was!”

  “That’s a sure test for Friday afternoon,” Judge Burke riposted as laughter rippled through the courtroom. “A juror has handed me a question,” the judge went on. “Perhaps you can answer it, Dr. Iocco? ‘If a tumor was so microscopically small as to go undetected during an autopsy,’” he read, “‘could it have caused the diarrhea problem being experienced by Tia?’”

  “I have never been convinced that it is possible for a tumor to be so small that a careful, thorough examination misses it. I’m just not convinced of that.”

  “In the course of the autopsy, it is true, is it not, that the gross examination of the body does not involve inspection of every cell of tissue?” Collins asked at once.

  “Yes,” admitted the pathologist.

  “And the microscopic examination involves only a selected sample of tissues?”

  “Yes.”

  “Isn’t it possible that tissue that has not been examined either by the naked eye or been placed on slides could contain the microscopic tumors that we have been speaking of?”

  Dr. Iocco answered as he had before. “I’m not convinced of that,” he said.

  “What’s up next week?” Ted asked Josh at the end of the day.

  “The big guns—Stephens and Holliday.”

  Ted nodded grimly. Those two doctors were the heart of the case because they had no ax to grind, no involvement prior to the investigation. They had convinced him he had a rock-solid case against Priscilla Phillips. Now all they had to do was convince the jury.

  Week 4

  San Francisco coroner Boyd Stephens led off Monday’s session testifying that Tia’s and Mindy’s high sodium readings could only be explained by an outside administration of sodium.

  His testimony on sodium levels explained that material passes from the mouth to the anus of a child with severe diarrhea in a minimum time of two to four hours; that toxic levels of sodium could cause convulsions, high temperature, and death; that serum sodium levels are variable and may or may not coincide with the onset of diarrhea. This last was an important point for the prosecution to make, since with Tia there were many instances of diarrhea without increased sodium levels charted, as well as instances of increased diarrhea and vomiting during which electrolyte levels were normal. On cross-examination, Ed Caldwell went straight to this issue.

  Using the charts prepared for the jury, Ed pointed to entry after entry on Tia’s records.

  “From March eighth to April nineteenth, the sodiums were not elevated but there was lots of stooling and vomiting. To what do you attribute this?”

  “It could be, Counsel, that a bacterial infection or a possible viral infection produced the stool at that time,” replied the coroner.

  “From June twenty-first to July seventh she had stool and vomiting and it seems to me that the blood serums were normal.”

  “Yes, that’s correct.”

  “Can you tell the jury what the cause of diarrhea and vomiting was at that time?”

  “I cannot give a definitive diagnosis. A urine culture during that time included an increased level of organisms. And a pancreatic enzyme was recorded as low—that can cause diarrhea.”

  “From April first through May twenty-third, there were a number of incidents of stooling, vomiting, and fluid loss and yet the serum sodiums were not elevated,” Caldwell continued.

  “The serum sodiums were within normal limits.”

  “And the sodiums were measured often?”

  “Almost daily for part of the time, then every other day.”

  “And to what do you attribute the multiple instances of diarrhea and vomiting between April twentieth and May thirtieth?”

  “There is no specific diagnosis that I am aware of that will identify all of those instances, Counsel,” Stephens admitted.

  Later, Ed questioned Stephens about Mindy’s condition. “Can cyanosis be caused by sodium bicarbonate ingestion?”

  “Yes.”

  “Is CMV in any way productive of cyanosis?”

  “It can be—in those conditions where a child’s nervous system is affected so that it might not have the normal ability to regulate blood flow.”

  Ed finished his cross-examination, pleased with the chinks in the wall he had hammered out, and the daylight he could see on the other side.

  But Josh Thomas lost no time in attacking the points Caldwell’s cross-examination had raised.

  “Would secretory diarrhea result in Tia’s symptoms?” Josh asked his witness.

  “No. The variety of tumors known to cause secretory diarrhea in a child are not associated with this volume of stool or this electrolyte imbalance and are not always associated with either the rapidity of onset or the severity of her symptoms. With secretory diarrhea, usually the potassium goes up, the chloride goes up, and the carbon dioxide goes down—not at all what we saw with Tia.”

  “What about the decreased pancreatic enzyme?”

  “It would not cause the massive stooling we saw with Tia.” On recross, Caldwell introduced several articles from medical journals, one a discussion of a fifty-five-year-old Air Force sergeant whose chronic ingestion of sodium bicarbonate had led to severe hypertension. There was no record of Tia suffering from high blood pressure, Caldwell remarked. Stephens countered immediately.

  “In that case, the man was taking bicarbonate continuously, at the rate of over a box a week, because he believed he had a peptic ulcer. In the case of the Phillips children, the exposure was episodic rather than continuous.”

  “Did the man die?” asked Caldwell pointedly.

  “Counsel, as I recall, he did not. Once he stopped taking the bicarbonate, he recovered and his blood pressure returned to normal.”

  “Thank you, Dr. Stephens. That’s all I have.”

  Court was adjourned for the day.

  Stanford Hospital’s Dr. Philip Sunshine took the stand Tuesday morning. He spoke of having received Tia’s history from Dr. Applebaum, and of how surprised he was that Tia appeared so well.

  “Mrs. Phillips told me that even if she looked well now, that Tia had episodes where she didn’t.”

  “Did Mrs. Phillips appear upset in any way when you indicated to her that Tia looked pretty good?” Josh asked.

  “I don’t know if she was upset. It was just—I don’t know how to describe it. She was just not happy with my response.” Sunshine could not completely articulate the strange feeling Priscilla Phillips’s attitude had left him with but he still remembered the awkward moment.

  He went on to testify about Tia’s course at Stanford, explaining that he had ordered a stool sodium test after Tia’s bout of diarrhea but that the test had never been run because Tia’s diarrhea had stopped and no sample was obtainable.

  “Had the test been run and showed high sodium, how would you have explained it?”

  “It would have been very difficult to explain. The only thing we could have come up with would be that sodium-containing solutions were being given to her orally,” he said.

  “What about a diagnosis of secretory or viral diarrhea?”

  “In typical secretory cases, the diarrhea is basically continuous. I have had two such patients—and in neither case was there high sodium. Usually the potassium was depleted because it was lost in the stool. And if the diarrhea was the infectious or viral type, you would see the chloride tend to rise—which was not the case for Tia.”

  “What diagnosis did you finally decide on?”

  “We could not explain Tia’s diarrhea based on biopsy results or the other tests. We speculated—”

  “Did you speculate that it might be a secretory tumor?”

  “That was our best bet—but again, it didn’t add up—it wasn’t a good
diagnosis. It was something that we suggested that could be looked for, but we couldn’t even use that diagnosis as an explanation for her symptoms or her lab findings.”

  “Other than the reason you mentioned, were there additional reasons why you could rule out viral or infectious diarrhea?”

  “Yes. When you have diarrhea caused by virus or bacteria the stool sodium can reach a hundred milliequivalents, but very seldom more. Even in cholera, it’s rarely above a hundred twenty.”

  “Can the stool sodium ever exceed the serum sodium without ingestion of sodium into the gastrointestinal tract?” Josh Thomas asked.

  “In my experience I’ve never had that occur.” Then Sunshine continued, demonstrating the classic reason why attorneys ask their witnesses never to expand on an answer. “I haven’t reviewed the world literature on this but I can imagine that on occasion this can be found. I’m just not acquainted with it,” he said.

  At the defense table, Ed Caldwell made a note but Al Collins did not pursue this matter when he rose to cross-examine. Instead he questioned the alternate diagnoses Sunshine had listed on Tia’s discharge summary.

  “We just listed them because we didn’t know what was going on. We never seriously considered them,” Sunshine remarked.

  Josh Thomas asked only one series of questions on redirect. “Dr. Sunshine, with respect to the two cases on intractable diarrhea you mentioned for which you could find no cause; were the serum sodium levels as high as for Tia Phillips?”

  “We did not find elevated serum, urine, or stool sodiums,” Dr. Sunshine said firmly.

  Dr. Malcolm Holliday was relaxed and confident when he took the stand. A man in his mid-fifties, he looked considerably younger despite deep lines running from nose to mouth. A University of Virginia graduate, Holliday had been an accelerated student, soon making a name for himself at Children’s Hospital in Boston working under the renowned Dr. James Gamble in the field of body fluid physiology. He was currently the head of the Children’s Renal Center at the University of California in San Francisco, and he was the specialist to whom Boyd Stephens had turned for an opinion after Stephens had reviewed the case.