Conscious Bias

by Alexi Venice

  “Sustained,” Judge O’Brien said. “The jury will disregard the witness’ description of Abdul Seif’s fall.”

  Halliday shook his head in protest, as he lowered himself to his chair.

  “What did the Seifs say when you spoke to them?” Dominique asked.

  “They cried.” Dr. Khouri’s voice cracked, but he quickly regained his composure. “They asked appropriate questions.”

  “Did you give Abdul a medication called Mannitol in the ED?”

  “No.”

  “Why not?”

  “Dr. Rice and I discussed it, but Abdul’s brain wasn’t swelling at that time, and Mannitol doesn’t prevent the brain from swelling later. It barely works when we see swelling. It’s an unreliable drug for treating the brain.”

  “How about an intracranial pressure monitor? Did you consider inserting that?” she asked.

  “That’s outside my specialty. I would defer to Dr. Rice about an ICP monitor.”

  “Was there any other medical intervention you could’ve done at that time?”

  “None that I’m aware of.”

  “What did you do for Abdul’s broken nose?”

  “We cleaned the dried blood, and I examined it. There was a hairline fracture, but it still had good alignment, so no intervention was necessary.”

  “Would you describe Abdul Seif’s injuries as ‘serious?’” Dominique asked.

  “Yes. He arrived unconscious and suffered a substantial brain trauma that ultimately killed him,” Dr. Khouri said.

  Monica saw some jurors writing that down.

  “Thank you, Doctor. No further questions.” Dominique returned to her chair.

  Halliday stood and went to the podium. “When you spoke to the Seifs by telephone the first time, what language did you speak?”

  “Arabic,” Dr. Khouri said.

  “You speak the same language as the Seifs, correct?”

  “Yes,” Dr. Khouri said.

  “And, you’re from the same country, correct?”

  “No. I’m from the UAE, and they’re from Saudi Arabia.”

  “Neighboring countries though, correct?” Halliday asked.

  “Yes. I’m from Dubai, and they live in Riyadh.” To his credit, Dr. Khouri was patient with the line of questioning designed to elicit bias.

  “Friendly countries?”

  “Yes.”

  “Allies?” Halliday asked.

  Dominique slapped her hand on the counsel table, an uncharacteristic gesture for her, and stood. “Objection, Your Honor.”

  Judge O’Brien flinched. “Counsel, approach the bench.”

  Halliday and Dominique rushed to the judge’s desk and leaned over. The judge put his palm over the microphone. “DA Bisset?”

  “This line of questioning isn’t relevant and is highly prejudicial, Your Honor.”

  “I disagree,” Halliday said. “I’m merely attempting to show the bias of a witness due to his allegiance to the victim’s country, culture and people.”

  “I’ll allow a few questions to elicit bias,” Judge O’Brien said, “but I’m going to cut you off if you take it too far, Mr. Halliday. Let’s stick to the facts of the case. The jurors can draw their own impressions.”

  Counsel returned to their tables.

  “I believe we left off with my question of whether the UAE and Saudi Arabia are allies,” Halliday asked.

  “Yes. They are,” Dr. Khouri said.

  “Same objection, Your Honor,” Dominique said.

  “The Court recognizes your standing objection,” Judge O’Brien said.

  “Turning to Abdul’s care,” Halliday said. “You testified that he had a fractured skull and blood on his brain, right?”

  “Yes.”

  “Have you treated head trauma like that before?”

  “Yes. Many times.”

  “Do you anticipate brain swelling with that type of trauma?”

  “It can.”

  “That wasn’t my question,” Halliday said. “Do you anticipate it?”

  “Yes.”

  “Does Mannitol reduce brain swelling?”

  “Not necessarily,” Dr. Khouri said.

  “What does it do then?”

  “It’s most commonly used to force urine production in people with acute kidney failure. It’s a strong diuretic with serious side effects.”

  “What’s a diuretic?”

  “A drug that has the osmotic effect of pulling water from the body’s system. Mannitol can pull fluid from the brain and eyes, but a three-percent saline solution has a similar osmotic effect, and, used with sedatives, which decrease the body’s response to pain, fear and anxiety, can decrease intracranial pressure. The patient was on both sedatives and a saline-solution.”

  Halliday didn’t like that answer, so he consulted his notes, angling for a verbal win in this sparring match. “Well, with a head injury like Abdul Seif’s, you could have administered Mannitol, couldn’t you have?”

  “I can administer a variety of drugs, Mr. Halliday, but I do so only when medically indicated. I constantly weigh the risks and benefits of drugs to fit each situation. The side effects of Mannitol can be serious, so we use it sparingly. We had a three-percent saline drip going, so there was no reason to use Mannitol in Abdul’s care in the ED.”

  “What are the side effects of Mannitol?” Halliday asked.

  “Dehydration, heart failure, kidney failure, and, ironically, increased intracranial pressure in some patients,” Dr. Khouri said.

  Some of the jurors took notes, attentively listening to Dr. Khouri’s testimony.

  “If sedatives help keep the brain from swelling, why did you wean Mr. Seif from sedatives, allow visitors, and allow him to call his parents on Monday?” Halliday asked.

  “Again, I defer to Dr. Rice because she was in charge of the patient’s care in the CCU. However, the normal protocol for head trauma patients is to wean them off sedatives while performing neuro assessments.”

  “You testified that you’ve treated many head injuries. Is that correct?” Halliday asked.

  “Yes.”

  “Have you ever seen someone crack their head from falling?” Halliday asked.

  “Of course. The injury depends on the height of the fall and the surface they land on,” Dr. Khouri said.

  “Well, Abdul Seif fell several times while he was drunk the night he came into the ED. Have you ever seen someone crack their skull from falling down drunk?”

  “Object,” Dominique said. “Assumes facts not in evidence.”

  “Sustained,” Judge O’Brien said.

  “I’ll rephrase,” Halliday said. “Have you ever seen someone crack their skull from falling down drunk?”

  Even though Monica had prepared Dr. Khouri for this question, he waited a second, giving the impression that he was considering for the first time the types of head injuries he had treated. “Yes. From falling backward off a barstool and from horsing around on the ice.”

  “Could Abdul Seif have fractured his skull from staggering and falling on his own to the sidewalk outside the bar the night in question?” Halliday asked.

  Dr. Khouri rubbed his chin. “It’s possible.”

  Halliday quickly moved on to his next question, not giving Dr. Khouri the opportunity to clarify or amend his answer.

  “Do you usually continue providing care to patients in the CCU after they’ve left the ED?”

  “Not usually, no,” Dr. Khouri said.

  “But you continued with Abdul Seif’s care. Why?”

  “I thought I could be of assistance in contacting his parents and speaking to them,” Dr. Khouri said.

  “Did the neurosurgeon, Dr. Rice, ask you to stay involved?”

  “Yes. We coordinated our calendars to call Abdul’s parents together.”

  “And, you were there when the Imam said prayers over Abdul’s body, were you not?”

  “Yes,” Dr. Khouri said.

  “And, you helped the Imam wrap Abdul’s body
according to Muslim protocol, correct?”

  “Yes.”

  “Taking special care to do that correctly, right?”

  “Yes.”

  “You don’t do that for every patient, do you?”

  “No,” Dr. Khouri said with a heavy voice.

  “Is it true that you met with the Seif family a few days ago?” Halliday asked.

  Monica’s pulse quickened. How did Halliday find that out?

  “Yes,” Dr. Khouri said.

  “Why?” Halliday asked.

  “They wanted to talk directly to Dr. Rice and myself, then to visit the CCU room where their son…” Dr. Khouri choked up then said with a strained voice, “where their son died.”

  “No more questions, Your Honor,” Halliday said.

  “Any redirect, Ms. Bisset?” Judge O’Brien asked.

  “Just a few, Your Honor,” she said. “Dr. Khouri, do people routinely fracture their skulls when falling?”

  “No.”

  “Do people die of brain swelling when they fall and hit their heads?”

  “Only if it involves a significant force, like falling from a substantial height or being hit by something.”

  “Would Trevor McKnight’s punch to Abdul Seif’s face, the one that broke his nose, be considered a strong force?” Dominique asked.

  “Yes,” Dr. Khouri said.

  “Strong enough to crack his skull?”

  “Yes.”

  “Strong enough to cause brain bleeding and swelling?”

  “Yes.”

  “To a reasonable degree of medical probability, was Trevor McKnight’s punch to Abdul Seif’s face a substantial factor in causing a fractured skull, brain bleeding and brain swelling?”

  “Object, Your Honor,” Halliday said.

  Judge O’Brien waited while Halliday gathered his thoughts. “Lack of foundation,” Halliday said. “The doctor didn’t witness the altercation or Mr. Seif’s falls.”

  “Sustained,” Judge O’Brien said over the rim of his half-glasses.

  “Let me rephrase,” Dominique said. “To a reasonable degree of medical probability, in your opinion, Dr. Khouri, what was the cause of Abdul’s death?”

  “Brain swelling.”

  “Why did his brain swell?” she asked.

  “From a forceful head trauma that cracked his skull.”

  “Would a punch to the face that broke Abdul’s nose, be a strong enough force to cause such a head trauma?”

  “Yes,” Dr. Khouri said while looking directly at the jury.

  “Nothing further,” she said.

  “Dr. Khouri, you’re excused. Thank you,” Judge O’Brien said. “The prosecution may call its next witness.”

  Dr. Khouri left the witness box and walked toward the exit. His back to the jury, he looked at Khalid Seif with a mixture of compassion and resolve, as he passed him.

  Chapter Twenty-Six

  Dominique turned and scanned the courtroom, finding Monica’s eyes. She raised her eyebrows and turned back to the judge. “The prosecution calls Dr. Danielle Rice.”

  Monica slipped out of the courtroom behind Dr. Khouri and opened the door to her small conference room. “They’re ready for you, Dr. Rice.” Monica thanked Dr. Khouri, shook his hand, then led Dr. Rice into the courtroom.

  After Dr. Rice passed through the bar into the courtroom theater, Dominique guided her to the court clerk, who administered the oath.

  “Come right around here,” Judge O’Brien said, pointing to the witness box entrance.

  With the caution of someone whose every move is being observed, Dr. Rice scanned the foreign environment, as she settled into the witness chair and adjusted the small microphone to her mouth. She lay her hands on her lap, out of sight from Monica’s perspective, but Monica pictured Dr. Rice subtly pushing back her cuticles.

  Consistent with her daily hospital appearance, Dr. Rice wasn’t wearing a spec of makeup. Her black hair, streaked with a few greys, was pulled haphazardly into a short pony. She sat a bit slouchy for Monica’s taste, but Monica had come to associate the relaxed posture with doctors in surgical specialties, a symptom of spending too many hours on their feet and grateful for a short rest.

  “Please state your full name for the record,” Dominique said.

  “Danielle Rice, MD.”

  “Where do you reside?”

  “Apple Grove.”

  “What do you do for work?”

  “I’m a neurosurgeon at Community Memorial Hospital.”

  “How long have you been a neurosurgeon?”

  “Eight years.”

  “Are you board certified?”

  “Yes.”

  “Did you have occasion to treat the victim in this case, Abdul Seif?”

  “Yes.”

  “When did you first meet Mr. Seif?”

  “In the Emergency Department the night he was brought in by ambulance.”

  “What did his CT scan show?”

  “That he had a fractured skull at the base—here,” Dr. Rice said, pointing to the base of her own skull.

  “Would it help your testimony if we used an anatomical model of the human skull, Dr. Rice?”

  “Yes.”

  Dominique turned and removed from a banker’s box the skull Monica had provided. “Your Honor, I’d like to mark this as a demonstrative exhibit.”

  “Any objection?” Judge O’Brien asked Halliday.

  “Is she moving it into evidence?” Halliday asked.

  “No,” Dominique said. “Only demonstrative.”

  “No objection,” Halliday said.

  Great, Monica thought. A three-hundred-dollar skull, now an exhibit in the case. The hospital will be lucky to get that skull back in six months.

  Dominique carried the skull to the court clerk who slapped a sticker with #34 written on it and handed it back. Dominique brought the skull to Dr. Rice, who received it with reverence and dexterity, as she cradled it in her gifted hands.

  “Doctor, can you show us on the model where Abdul Seif’s skull was fractured?”

  Dr. Rice pointed to the rear base of the skull while holding it up for the jury to see. “Here. At the occiput.”

  “What’s the significance of a fracture to that region of the skull?”

  “It’s the thickest part of the skull, so it tells me that some degree of force was inflicted on the patient.”

  “What do you mean?” Dominique asked.

  “We usually see a fracture like this if someone is hit in the back of the head with a hard object, like a metal pipe. Or, if someone is hit by a car. Or, I’ve seen this from ATV accidents. There’s either a moving object that hits the person, or the person is in motion and suddenly comes to a stop, hitting their head.”

  “Do you think Abdul Seif could have sustained this fracture from falling down drunk on his own?”

  “I doubt it,” Dr. Rice said. “Only if he fell from a height taller than himself, like a balcony or out a window.”

  “Objection. Calls for speculation,” Halliday said.

  “Sustained,” Judge O’Brien ruled. “The jury will disregard the last remark.”

  Dominique regrouped, coming at her question from a different angle, her thumb and forefinger smartly adjusting her left lapel. “In your experience, Dr. Rice, in a man who is barely five-feet-ten inches tall, would his drunken collapse to the ground result in a force great enough to fracture the occiput region of his skull?”

  “No.”

  “What was your diagnosis when you initially saw Abdul?” Dominique asked.

  “A broken nose, a fractured skull, and brain trauma with some oozing on the brain.”

  “How did you treat his brain trauma?”

  “I admitted him to the CCU, kept him intubated so we could sedate him, and ordered neurological assessments every 30 minutes. I also ordered repeat CT scans.”

  “Did you give him Mannitol to prevent brain swelling?”

  “No.”

  “Why not?”

>   “Because Mannitol doesn’t prevent the brain from swelling, and it has serious side effects like dehydration, pulmonary congestion, irregular heartbeat, and blurred vision in a patient we will want to test vision.”

  “Did you consider putting an intracranial pressure monitor in Abdul’s brain?”

  “Absolutely not.”

  “Why not?”

  “Because his brain wasn’t swelling. I ordered a CT scan to be performed every 12 hours. When we weaned him off the ventilator and sedation, he started talking. His Glasgow Coma Scale was a 15 out of 15, so an ICP was contraindicated.”

  “Let’s break down what you just said, Doctor,” Dominique said. “What’s a Glasgow Coma Scale and why is 15 good?”

  “GCS is a neurological assessment of a patient with a head injury. It measures eye movement, verbal ability and body movement. There are five points for each category. Abdul’s eye movements were awake and alert. His verbal skills, while sluggish, were oriented to person, place and time, and he was conversing normally. In other words, he had his wits about him. He also moved his arms and legs and was sensitive to painful stimuli.”

  “Would it be fair to describe him as injured, but awake and talking?” Dominique asked.

  “Yes.”

  “Why wouldn’t you put an ICP monitor in his skull to measure brain swelling?”

  Dr. Rice blanched. “That would be medical negligence. To insert an ICP, we bring the patient to the Operating Room, anesthetize him, and drill a hole into his skull here,” she said, indicating on the model. “There are significant risks to this surgery, including bleeding, infection, injuring the brain, and brain herniation through the hole.”

  “Anything else?”

  “Yes,” Dr. Rice said. “If the patient becomes agitated in the middle of the night, and pulls out the ICP, that would be catastrophic.”

  Dominique nodded. “So, what was your best measure of how Abdul was doing?”

  “His clinical signs. The fact that he was awake and able to call his parents. His neurological exam. His CT scan that was unchanged. These were all good signs pointing toward recovery.”

  “On Monday night, did Abdul’s condition change suddenly?” Dominique asked.

  “Yes. That’s the reason I ordered the neuro assessments, so we would catch a change as soon as it occurred, if it did occur.”