Nancy spoke, “That’s a good question. There’s no denying that it’s extremely stressful and constantly present. Some people go see a therapist, which you may want to consider.”
“I don’t need a therapist,” snapped Jenna.
Nancy tried to smooth things over, “I’m sorry, Jenna. I didn’t mean to insinuate that you do. I just know it helps some people to have someone besides us and their spouse to talk to.”
“No, I’m sorry,” Jenna said. “It’s just that it’s bad enough that this is happening. The thought of seeing a shrink is just too much right now. I’m not ready to be sued and crazy all at the same time.”
“Don’t give it a second thought. Jim and I have pretty thick skin, so no worries. And no one thinks you’re crazy.”
“So this really could take over a year?” asked Jenna, attempting to get back on target.
Nancy responded, “The only way things may conclude sooner is if we settle with Ms. Hollings. At this point, I think it’s premature to pursue that option. We have no idea if what they wrote in this complaint is true. For all we know, Michelle Hollings may have had hepatitis C before she ever came to St. Augustine for her surgery. The discovery process will help sort that out. As things start to take shape, we may come to the conclusion that settling is in your best interest.”
“You mean,” asked Jenna, “if it looks like we’re going to lose?”
“Basically, yes,” replied Nancy. “Some cases are stronger than others. I’m not saying that we feel that way about your case right now, but things can and do change. Just so we are clear, the decision to settle is ultimately yours. We can give you our input and advice, but neither we nor your malpractice carrier can force you to settle.”
Jenna asked, “After the discovery process and all the depositions are taken, then what?”
Jim replied simply, “Then we go to court next January. Our trial has been scheduled to last three weeks.”
Jenna sighed. “It’s the gift that keeps on giving.”
Neither of her attorneys replied. There was really nothing either of them could say. The air in the room was thick with emotion. Jim finally asked Jenna if she had any more questions.
There were so many things she did not understand. Jenna felt like a traveller in a foreign country where every aspect of life was different – the language, the logic, the customs. She was an uninvited visitor in a world she did not recognize.
“First of all, if this patient is suing St. Augustine and me together, do we have to coordinate our legal defenses? I don’t see how that would work.”
Jim set his pen down and rested his hands on the conference table. “Most likely, if the case ends up going to trial, the jury will be asked to determine the percentage of liability for each party, Hillary Martin included. For example, they may find that Hillary Martin is ninety percent responsible, the hospital is eight percent responsible, and you are two percent responsible. Then whatever amount the jury chooses to award, if it goes that way, will be applied to each of the three parties according to their degree of responsibility. You and St. Augustine will both be on trial together, but not necessarily on the same side. Each party is going to be looking out for their own best interests.”
Jenna’s eyes bore into Jim’s as she said, “Which means that, more likely than not, the hospital is going to sacrifice me.”
“They can and probably will try to do that, at least to some degree,” Jim admitted. “The facts are that Hillary Martin was their employee, not yours. They hired a drug addict. We strongly suspect their background check on Ms. Martin was inadequate, at best. Otherwise they would have uncovered truths about her that certainly would have precluded her from being hired. If Hillary Martin had never been employed by St. Augustine and had never been permitted to be in the operating rooms, this whole catastrophe would never have occurred.”
“I have another question,” said Jenna, wild-eyed. “I know this sounds irrational, but it really scares me. What about the media? Do you think I’ll end up in the press?”
“Anything’s possible,” answered Jim. “As you probably know, a case filed against one of your partners ended up on the front page of the Sunday paper. Anders just so happens to be the attorney on that case, too. She loves the press and uses it to trash and intimidate the doctors she sues. I don’t see any imminent stories coming out, but it’s something you have to prepare for. You will need to prepare your family, as well.”
Mental images flashed in Jenna’s head of Mia going to school and having some other kid say, “Hey, my mom saw your mom on TV. Did your mom really give some lady a bad disease?”
Not to mention her colleagues. Jenna could easily picture them turning on her. Goosebumps raised the hair on her arms as she imagined their critical stares and condemning comments about her inadequacies and failings.
Then there would be the everyday people – her neighbors, her hairdresser, other parents. Would they go out of their way to avoid her? Would they also judge her?
Jim had no way of knowing the destructive thoughts that were running rampant in Jenna’s head, but the expression on her face spoke volumes. Her skin was as white as the snow covering the city.
Trying to nudge Jenna back on track, Jim asked, “Do you have any more questions about the complaint or what to expect as things move forward?”
“No,” answered Jenna dryly. “I think you guys covered it pretty well.”
“Well then,” Jim continued, “we have copies of your anesthesia paperwork for Ms. Hollings. If you feel up to it, we would like to go through it with you. However, if you’ve had enough for one day, we understand. We can reschedule for later this week.”
Jenna was tired and emotionally drained. However, the last thing she wanted was to have to come back tomorrow or the next day.
“No, I’m okay. Let’s keep going. I just need five minutes to use the restroom and call home.”
“Absolutely,” Jim replied. They all stood, and Jenna left the room.
CHAPTER 28
In the restroom, Jenna splashed cool water on her face. Although it did not ease her pain, it did help to revive her. She called Tom and told him she would probably be several more hours. He asked how things were going, but Jenna did not want to discuss it, certainly not in the women’s restroom at her attorneys’ office. Jenna hung up with her husband and made her way through the labyrinth of cubicles back to the conference room.
She took her seat, and Jim handed her a stack of papers.
“We would like to go through all your documentation, piece by piece, so that Nancy and I are sure we understand everything. Let’s start with your pre-anesthetic assessment sheet.”
Jenna rifled through the stack of papers laid out in front of her and found the copy.
Jim asked, “As you look at your preop assessment, is there anything remarkable about Ms. Hollings as a patient?”
Jenna traced her finger over every word and shook her head. “The patient is completely straightforward. Ms. Hollings was young, thin, and healthy.”
Instantly, Jenna was consumed with self-reproach. Michelle Hollings was healthy, she thought, up until the point I injected hepatitis C into her bloodstream.
Next, Jim asked Jenna to refer to the anesthesia record. Jenna found her copy and motioned for Jim to continue.
“Can you walk us through this record? It would be particularly helpful if you could read and explain your notations and abbreviations, the drugs you gave and why, and Ms. Hollings’ vital signs during the procedure.”
For several minutes, Jenna silently scrutinized the anesthesia record. She felt a small amount of relief in being the one who understood everything, rather than the one who understood nothing. At least for now, Jenna was the expert. She slid her chair closer to the table and tucked her hair behind her ears.
“To start with, I documented that she had a peripheral IV in her left upper extremity, and it ran well. She was NPO, meaning no food or water, nothing by mouth, since midnight. The patient w
as brought to OR 2 and placed in the supine position, meaning that she was laying on her back on the operating room table. She had a smooth IV induction, which indicates that I gave her the intravenous medications to knock her out, and there were no complications. Her eyes were taped shut, to protect them from inadvertently being scratched.”
Jenna shifted her attention from her document to her lawyers. Reassured that they were following her, she continued.
“She was easy to mask ventilate, and her intubation was uncomplicated and atraumatic. I noted that her arms were extended from her sides for surgery. Her extremities were padded, to avoid nerve injury. The last notation I make about the start of the case is that a warming blanket was placed over her lower body.
“Further down, in the notation section, I document that at the end of the case, the patient met all the criteria for extubation. Once the breathing tube was removed, the patient was taken to the PACU – the recovery room – in stable condition with supplemental oxygen delivered through a nasal cannula.”
Jenna’s attorneys furiously scribbled notes on their copies as she spoke. Jenna waited for them to catch up. She was starting to calm down. Going through her anesthesia record felt safe and familiar.
Jim stopped writing and glanced up at Jenna. “Now I’d like you to look at the drugs you gave, the corresponding vital signs, and explain Ms. Hollings’ operating-room course.”
Jenna moved her finger along the anesthesia record. “It looks like Michelle Hollings got 2 milligrams of Versed in preop, before she got to the OR, to help her relax. That’s pretty standard. Apparently, she must have not have felt much of an effect, because I gave her 2 more milligrams of Versed in the operating room, before putting her off to sleep.
“Her first blood pressure upon entering the room was 140/80, and her heart rate was 105. That would indicate that she was probably nervous, which is very common. Then it looks like I induced anesthesia, meaning I knocked her out. I gave her 100 milligrams of Lidocaine, 250 micrograms of Fentanyl, and 200 milligrams of Propofol – Michael Jackson’s milk.”
Jim and Nancy, caught off guard by Jenna’s humor, started laughing. Nancy looked at her client and realized this was the real Jenna Reiner – spunky, off-color, and down to earth.
Jenna smiled at their appreciation for her joke and continued.
“The last induction drug I gave was 50 milligrams of Rocuronium, a paralytic. Once the patient was intubated, I secured the breathing tube in place with tape. Then I turned on the Sevoflurane, which was the anesthesia gas I used to keep her asleep during the procedure. After induction, her blood pressure dropped to 90/60, and her heart rate was in the 90s. That’s a very typical response. Most of the anesthesia medications and the gases used for induction dilate blood vessels and depress the heart to a certain degree. As a result, most patients will show a drop in their blood pressure and heart rate.
“Then, it looks like, right at the time of surgical incision, Ms. Hollings’ blood pressure rose to around 160/90, and her heart rate increased to over 100. I gave her 10 milligrams of Morphine and increased the concentration of the gas.”
Jim interrupted, “Why did you switch narcotics?”
“Morphine lasts longer. I’m sure I figured it would help her wake up more comfortably. Anyway, it looks like her blood pressure remained elevated, even after the first dose of Morphine should have kicked in. I administered another 5 milligrams and further increased the concentration of Sevoflurane. After that, her blood pressure came down to around 100/50, and her heart rate dropped into the 90s. Her vital signs stayed in that range for the rest of the case.
“During the surgery, Ms. Hollings also received some anti-nausea medications and an antibiotic.”
“Do you see any evidence that she didn’t respond to the Fentanyl you gave at the beginning of the case? What I’m getting at is whether it looks like she got Fentanyl or saline?” asked Nancy.
Jenna studied the chart closely. Looking at Nancy, Jenna replied honestly, “I would say, based on this record, Ms. Hollings responded appropriately to the Fentanyl. She dropped her blood pressure following intubation, which is a very stimulating and painful event if a patient is inadequately anesthetized. There is nothing in my documentation that leads me to believe that what I injected wasn’t Fentanyl.
“It’s not uncommon to see patients require additional narcotics once the surgical incision has been made. After intubation, there’s a period of about ten minutes where the patient is being positioned and prepped. Since none of that is painful, you often see their blood pressure and heart rate decrease as the vasodilating effects of the gases and medications are unopposed. At the time of incision, the noxious stimulus causes the patient to release adrenaline, and their blood pressure and heart rate increase. Not every patient needs additional narcotics at the time of surgical incision, but it’s not uncommon, either.”
“What about the Morphine?” Jim asked. “You indicated that 10 milligrams was a pretty hefty dose, and she got a total of 15 before her vital signs settled down. What do you make of that?”
Jenna replied quickly, “It tells me that Ms. Hollings, like many other young people, probably likes to party. When people routinely drink, do drugs, smoke pot, things like that, it’s not uncommon to see their anesthetic requirements increase. According to the record, I gave her 10 milligrams of Morphine, and she showed virtually no response. It took another 5 milligrams before her vital signs indicated the drug was having any effect. For whatever reason, she had an apparent tolerance.”
Jim asked, “Jenna, I know from the records that you drew up the Fentanyl in advance, but what about the Morphine? When would you have accessed that drug?”
“I would have obtained it during the case, when it became apparent that additional narcotic was required. I would have checked it out from the Accudose machine and injected it immediately.”
Jim placed his elbows on the table and moved closer to Jenna. “Just so I’m clear, there would be absolutely no way that anyone could have tampered with the Morphine that you administered to Ms. Hollings? And, furthermore, she required high doses of that drug before you saw the desired effect?”
Jenna could see where Jim was going with this. Grinning, she replied, “That’s one hundred percent correct.”
Jim then said, “Let’s move on to the Accudose record that we obtained. The Accudose is the machine from which you check out narcotics, correct?”
“Correct,” replied Jenna.
“So,” Jim continued, “it looks like you checked out 250 micrograms of Fentanyl and 2 milligrams of Versed at 7:38, but Ms. Hollings’ case didn’t start until 8:27. Can you explain why you checked out the narcotics in advance and what you did with them from 7:38 until 8:27?”
Jenna wanted to lie. She wished she could tell her lawyers that she kept the drugs in her pocket the whole time. Nancy’s advice rang through her head – the way doctors hang themselves is by being dishonest. Besides, Jenna was not a liar, and she would not start now.
Peering down at the record, Jenna locked her sight on the documented times. With downcast eyes, she said, “Most likely, I checked them out and drew them up around 7:38. My practice was to always be prepared. I would have all the routine drugs drawn up and ready to go before each case started. That way, if any issues arose, any unanticipated emergencies or whatnot, I wasn’t caught off guard. Then I probably stuffed them in a drawer of my anesthesia machine and went to interview the patient.”
“You never left your drugs out on top of the anesthesia cart in plain sight?” asked Jim.
This time, Jenna raised her head and faced Jim directly. “Never. I always hid them in a drawer under supplies.”
“Had that always been your practice with respect to your drugs?” asked Nancy. “To draw them up in advance and hide them in the anesthesia cart while you tended to things outside the OR?”
“Yes,” said Jenna. “That’s what I was taught to do in residency and what I continued to do in private practice.”
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Jim and Nancy could see Jenna starting to fade. They had been going strong the entire afternoon.
Nancy looked sympathetically at Jenna and said, “Kiddo, I think we’re done. Do you have any questions?”
Jenna knit her brow. “How do you both feel about the strength of our case, right now, based on what we’ve talked about?”
Jim cleared the table in front of him. “Jenna, I’ve been a malpractice attorney defending doctors for over twenty years. I’ve tried a lot of cases, and I’ve settled a lot of cases. I’m pretty good at sniffing out the ones that stand a chance with a jury. I think your actions are defendable. There are a lot of holes in this story that we can use to our advantage.”
“Such as?” asked Jenna skeptically.
“To begin with, there is no proof that Hillary Martin stole your syringe of Fentanyl. There is no proof that Michelle Hollings became infected from a contaminated Fentanyl syringe. Even if Ms. Hollings did acquire hepatitis C from Hillary Martin, it still doesn’t explain how it happened. Hillary Martin could have used saline from the surgical table to refill syringes that she stole from other doctors. That saline, not your Fentanyl syringe, could have been the source of contamination.
“There’s also the issue of standard of care. We’ve done some preliminary investigation and the consensus, so far, is that there really was no clearly defined, nationally accepted standard of care when it came to securing narcotics in the OR. Your practice was absolutely not out of line with what many, if not most, other physicians were doing.
“As far as the negligence per se claim, we will poke holes at what it means to have drugs secured. Our contention is that the operating room itself was a secure environment. Hillary Martin changed that, of course, but prior to her crimes, operating rooms were considered protected areas. Therefore, storing your drugs in your cart within the operating room should constitute securing your drugs. The key here is the law that Anders refers to in the complaint is extremely vague. It states that drugs should be secured, but doesn’t go on to clearly define what ‘secure’ means.”
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