Diagnosis Death by Richard L. Mabry Page A

site after an otherwise uneventful craniotomy. Elena knew that the most serious neurosurgical complications were vascular— either hemorrhage or obstruction to circulation. This one was unexpected but not what she'd consider major. Indeed, the patient responded well to antibiotics and had no further problems. Nevertheless, Matney spent fifteen minutes questioning the resident and his staff surgeon about how they might have prevented this postoperative infection.
    Elena felt her stomach doing flip-flops. If Matney handled the morbidity portion of the conference this way, what would he do when the mortality discussions started? She tried to dry her palms on her white coat, but it didn't seem to help. Her throat was parched, her heart was in her throat. She hardly heard Matney's next words.
    "Dr. Neely, tell us about Mr. Pulliam."
    This was the resident whose name Elena hadn't been able to recall, the one who had pronounced Chester Pulliam dead. He presented the facts in a monotone more appropriate for delivering an annual report to stockholders than a description of the death of a human being. Elena wondered if this was a coping mechanism adopted early in their training by neurosurgeons because they dealt every day with matters of life and death. She hoped she'd never become that callous about the loss of a human life. Then the irony of that thought brought her up short.
    Neely ground to a halt with, "The patient was maintained on life support, but showed no effective respiratory efforts and required IV dopamine to maintain his blood pressure. He had a diffuse dysrhythmia on EEG, showed a positive Babinski reflex, and we observed early decorticate rigidity developing. We discussed withdrawal of life support with his wife. Subsequently that was done and he expired quietly."
    That was it. No mention of an unidentified person disconnecting the respirator, or of the questionable DNR order. No finger-pointing by Clark or Matney. Instead, Clark encouraged the residents to maintain a high index of suspicion for arteriovenous malformations, the snake-like tangle of blood vessels around the brain that had ruptured and sent Chester Pulliam to his death. For the first time he looked at Elena and said, "Dr. Gardner, who's joined us today, did all the right things in getting immediate treatment for Mr. Pulliam. Unfortunately, his intracranial bleed wasn't a survivable one. That's why it's imperative to find these before they rupture."
    Matney and Clark engaged in a low-key debate about the best surgical approach to AVMs, as they called them, and one of the residents had a follow-up question. Then Matney called on the next presenter, and the discussion moved on.
    Elena let out a breath she didn't know she'd been holding. That was it. Could she slip out now? The clock was on the wall behind her. If she looked at her watch, Matney might see it. She decided to sit quietly until the conference ended. She might even learn something.
    After another half-hour the last presentation wound down. Matney made a few perfunctory announcements, and the conference was over. Faculty members and residents moved toward the door, most with pagers and cell phones at the ready. Elena insinuated herself into the crowd and inched out of the room, her shoulders hunched as though she could make herself smaller and avoid further contact with Matney or Clark.
    Once she was safely in the hall, she took a deep breath and strode rapidly toward the elevators. Three paces from safety, an all-too-familiar voice brought her up short. "Dr. Gardner. May I see you for a moment?"

    Elena followed Dr. Matney into his office.
    "Please have a seat." He hung his white coat carefully on a hook behind the door and took a seat behind his desk. "Thanks for coming to the conference. Your input wasn't necessary, but I wanted you to see for yourself that we are making an effort to put behind us the controversy about how Chester Pulliam's life ended. In the final analysis, whether you or