A Mother's Trial (31 page)

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.

From that very first phone call, when Boyd Stephens had presented him with the facts of Tia’s case, Mac Holliday had been certain of the cause of the child’s illness. “Jesus, Boyd,” he had said, “somebody gave that kid an awful lot of bicarbonate!”

The inconsistencies in the medical records didn’t bother Holliday. As he had explained to Josh Thomas, when a child receives a huge load of sodium, this causes diarrhea. A large expansion of fluid is produced and then excreted, and this expanded phase is followed by a period of contraction—or dehydration.

“The body behaves in a very different way depending on whether it is in a state of expansion or contraction,” he told the district attorney during a pretrial conference. “Particularly in terms of urine output and electrolyte levels. A spot electrolyte sample taken at any particular point could make the results inconsistent depending on whether the sample was taken during the expansion, contraction, or rehydration period. But the essentials for deducing an exogenous administration of sodium are present and clear to anyone who has the least propensity for suspecting such things.” And Mac Holliday—unlike the Kaiser doctors who treated Tia—was trained to look at input.

Holliday came to the stand late on Tuesday afternoon, leaving only enough time for Josh to take him through his medical credentials. Speaking in his careful Virginia drawl, Holliday detailed his extensive background as a body fluid specialist. When direct examination was resumed on Thursday morning, Josh ran Holliday through testimony that was finally becoming repetitive.

After the morning recess, Holliday indicated specific points in Tia’s chart where he believed Tia must have had either an extraordinary loss of water or a gain of sodium into her body fluids.

Holliday pointed at the entry of Tia’s chart for October eleventh. “The concentration of sodium measured in two different samples here were three hundred fifteen and three hundred forty milliequivalents. Both of these are outside any experience I’ve had or could find. Now despite a very high replacement input of dilute solution intravenously, there was an
increase
in sodium concentration. There had to be an unexplained source of sodium entering the body and leaving the gastrointestinal tract simultaneously.”

Josh Thomas continued after lunch with more entries on the charts, and the same ground was covered until finally the judge spoke up in exasperation. “It seems to me this is cumulative. There has to be a limit,” he said.

Josh then turned to Mindy’s chart. Holliday drew the identical conclusions he had with Tia.

“I have no further questions, Your Honor,” Josh said.

ii

Dr. Holliday handled Collins’s cross-examination with casual ease. In an unusual reversal, the witness was perfectly relaxed, while the attorney grew frustrated and upset. The resulting exchanges were not without light moments. At one point, Collins referred to a chart entry that had been circled in green to denote an abnormal stool reading.

“Is it your understanding that the circling in green does not indicate that they’re abnormal?” Collins asked.

“No, that green circle indentifies them as stool, I believe,” Holliday replied.

“Well, how about these tests, which reads ‘stool sodium sixty-two’? You’ll observe there’s no green box around it.”

“That’s correct.”

“Did those figures appear to you more normal than the ones we looked at a moment ago that did have a green box around them?”

“Yes,” Holliday returned gently. “They’re more normal—but not because they don’t have a green box around them.” He smiled sweetly as a wisp of laughter sounded from the courtroom.

During recess, Ed Caldwell turned to his associate to offer condolence. “That Holliday’s a tough cookie with his hokey southern accent,” he said. “We’re not going to get anywhere with him.”

“Yeah,” Collins answered with a rueful grin.

He was not able to make a dent in Holliday’s self-confident armor for the rest of the afternoon, not even when he questioned the doctor about why the Kaiser doctors had not spotted sodium poisoning.

“I had a very different perspective and I had the benefit of hindsight,” Holliday said.

“But would you agree that other explanations may exist?” Collins persisted.

“I haven’t found one, and I have looked for it.”

“What about the one month of diarrhea Tia is reported to have suffered in Korea?”

“Whatever its cause, it would not explain the later findings,” answered Holliday imperturbably. And court was soon after adjourned for the day.

But something of significance had happened. During one of the recesses, a woman had approached Josh Thomas. Josh knew her because she was the head of the Victim-Witness Assistance program that was a service that ran out of his own office.

“I just happened to stop by here,” she told him, “and I recognize one of the jurors. I’m pretty sure he has been involved in a possible incest charge involving his young daughter. He goes to Parents United.”

“Oh, God, that’s all we need: a child molester on the jury!” Josh turned to Lindquist. “Ted, see what you can find out about this juror. We’re going to have to inform the defense and the judge about this. But I don’t know what position I want to take. My gut feeling is that we want him off the jury—that he’d sympathize with another child abuser.”

“I’ll see what I can dig up.”

The session on Good Friday was scheduled to last only until lunch. Monday was to be a holiday. On Friday morning Dr. Holliday took the stand once again and Al Collins resumed his cross-examination. He asked Holliday about the period directly before Tia’s death when her serum sodium continued to rise. How was this possible, Collins wanted to know, given that the child was comatose, on a respirator, and attended constantly by nursing staff?

“Either she had a reservoir of hypertonic solution—a solution where the proportion of salt is greater than occurs naturally in the body—occurring in her gastrointestinal tract, or she had some other solute there that was extracting water at a greater rate than it was excreting salt from the body.” Collins walked over to the defense table and picked up a copy of the preliminary hearing transcript that he had marked. Holliday’s answer had opened a small hole, Collins realized.