Impact (49 page)

“Does Hawley have any tricks up his sleeve?” he asked as he was washing out the glassware.

Her laugh was bitter. “Why, Mr. Hawthorne. I believe you're asking me to betray my cause.”

He laughed. “So does he?”

“I certainly hope so.”

When he entered the courtroom some sixteen hours later, Alec Hawthorne was far less fearful of his future than he had been in a dozen months. But despite his powers of persuasion, Brenda still seemed determined to defeat the trial. Indeed, he wasn't at all sure he hadn't revealed to her more than he should have about the problems with the plaintiff's case, while learning nothing about what Hawley Chambers had in store for Brenda Farnsworth's former lover.

“Plaintiff calls Dr. Arthur Ryan,” Tollison was saying as Hawthorne took his seat.

The top of Ryan's head glowed in the fluorescent ether like a baseball just out of the box. His rumpled suit gave him an air of ascetic authority; his height made him seem too large to lie. Hawthorne smiled—he could not imagine anyone disbelieving the man.

The doctor swore to his oath while fingering his necktie like a rosary. Waiting for the formalities to conclude, Tollison seemed relaxed and personable. Out of the world of aviation, of which he knew little, into the world of medicine, where he had trod before, Tollison for the first time looked at home in federal court.

“What is your profession, Doctor?”

“I'm a physician,” Ryan answered.

“What is your specialty?”

“Neurosurgery.”

“Do you have hospital privileges?”

“I'm chief of surgery at San Jose Memorial Hospital.”

“How long have you held that position?”

“Six years as chief. I've held staff privileges for eighteen.”

“Are you a board-certified neurosurgeon?”

“Yes.”

“Do you hold any other professional honors?”

“I've been elected to the Congress of Neurological Surgeons and to the Harvey Cushing Society. I'm also a fellow in both the American and International College of Surgeons.”

“These are professional honors conferred by specialists in your field?”

“Yes.”

“Very impressive, Doctor.”

Chambers's voice dripped vinegar. “May we dispense with the editorials, Your Honor?”

Tollison apologized before the ruling. “Please tell the jury about your educational background.”

Chambers did not bother to stand. “In order to speed things along, we stipulate to Dr. Ryan's credentials.”

Tollison bent in a mock bow. “Your acknowledgment of the doctor's eminence is appreciated, counsel. But I believe the jury would like to hear his record for themselves.”

Hawthorne smiled—Tollison had avoided another trap. Chambers never yielded anything unless—sometime, somewhere—it would work to his advantage. By offering his stipulation, Chambers hoped to avoid the jury's being overwhelmed by the doctor's pedigree.

“I have a B.S. in zoology from Yale,” Ryan said easily, “and a medical degree from Tufts.”

“Where did you have your hospital training?”

“I interned and was a surgical resident at Sloan-Kettering in New York. After that I was a resident in neurosurgery at Stanford Medical Center. Eventually, I was chief neurosurgical resident at Stanford.”

“How long was your residency at Stanford?”

“Five years.”

“And since then you've specialized in treating injuries to the brain, have you not?”

“Yes I have.”

“How many brain surgeries have you conducted in the last eighteen years, Doctor? Just roughly.”

“More than a thousand.”

Pleased, Tollison nodded. Who could not be impressed with a thousand visits to the brain? “Have you had occasion to treat Jack Donahue, the plaintiff in this case?”

“Yes.”

“How did that occasion arise?”

Ryan crossed his legs. “Last March, when news of the SurfAir crash began coming in, the administrator at Memorial thought it possible that if there were many survivors, some would likely be transported to our shop, since next to the Stanford center we are the largest tertiary-care facility in the vicinity. After someone gave me a call, I went to the hospital immediately, both to see if I could be of help and to observe our emergency procedures in action. We believe we're prepared for a mass disaster, but you never know till it happens.”

“Were you at the hospital when they brought Jack Donahue in?”

“Yes.”

“What time was that?”

“May I consult my chart?”

“Was it made contemporaneously with the events it records?”

“Yes.”

“Do you rely on it in the course of your work?”

“Of course.”

“Please consult it.”

Ryan flipped a page of the sheaf in his hand. “I first saw Jack Donahue in the emergency room at eight forty-five that evening. March twenty-third.”

“Have you been in charge of his treatment ever since?”

“Yes.”

“Is that treatment continuing to this day?”

“Yes, it is.”

Tollison nodded. “What exactly was wrong with Mr. Donahue when they brought him to the hospital?”

Ryan recrossed his legs. “I'll start with the easy ones. He had broken each arm—the left in the deltoid area of the humerus, the right at the radius and ulna of the forearm, near the styloid process. His left foot was badly crushed—the metatarsals were fractured, as were other major bones, and damage to the ligature was severe as well. He had lacerations and contusions front and back, first- and second-degree burns over his upper body, and significant pulmonary impairment. And that doesn't even get us to his main problem.”

“Which was?”

Ryan looked at the jury. “Brain damage, to put it simply.”

Tollison left time for the image to become as concrete as the imaginations in the jury box could make it. “Let's leave the brain for the moment and get back to the other injuries. Which of them, if any, will result in permanent disability?”

Ryan frowned, doubtlessly remembering the preparation session with the lawyers and his irritation at Hawthorne's suggestion that he answer the question with unalloyed assurance. “Aside from his neurological impairment, the arms are fine except for minor scarring. There may be residual restriction in his foot as a result of the fractures and dislocations. But the primary chronic condition—again, aside from his intracranial injury—is pulmonary.”

“What is that condition, exactly?”

“Mr. Donahue suffers from adult respiratory distress syndrome. His bronchial and lung passages were damaged from inhaling toxic substances, to the extent that his respiratory capacity will be impaired for life.”

“By how much?”

“I'd say between forty and sixty percent.”

“What does that mean to Mr. Donahue as a practical matter?”

“His physical activity will be limited because of his reduced capacity to absorb oxygen, and he will be more vulnerable to environmental irritants such as air pollution and the like, and hence to respiratory disease.”

Tollison nodded. “Thank you. Now if you will, Dr. Ryan, please tell us about Mr. Donahue's head injury.”

Ryan looked toward the ceiling, as though Jack Donahue floated like a satellite amid the lights and tiles. “When he was brought to Memorial, Mr. Donahue was unconscious. His head had swollen and was purplishblack in color. Blood and brain tissue were oozing from a wound in his skull. His blood pressure was two-fifty over two hundred, his pupils were dilated, and he was not responsive to stimulus, at least initially. But we didn't need to diagnose symptomatically—it was obvious his skull had been pierced by a foreign object.”

Tollison nodded. “At this point I'd like to take Mr. Donahue's initial treatment step by step, if we may. When he reached the hospital and you recognized the symptoms of brain injury, what exactly did you do?”

Dr. Ryan flipped some pages. “First, we performed general emergency procedures. We gave him primary ventilatory assistance—a mask and air bag. We sandbagged his head and neck as a precaution against spinal jeopardy. We put him on cardiac and blood-pressure monitors to watch for Cushing's Triad, which is indicative of subdural hematoma. We put him on a Mannitol IV to counteract cerebral edema and to shrink brain tissue to relieve intracranial pressure. We cross-matched blood for surgery and ran a blood count and blood-chemistry profile to get a line on the toxins.”

“What was your general assessment of his condition?”

“He was in bad shape. Death was certainly a possibility. Painful stimuli—sticking him with a pin—resulted in bilateral decerebrate posturing—the extension of arms and legs while the body arcs at the torso, indicative of deep cerebral dysfunction. Our initial evaluation placed him at level five on the Glasgow Coma Scale.”

Tollison nodded. “We'll return to that in a minute. What did you do next, Doctor?”

“We administered drugs to control the posturing and broad-spectrum antibiotics to guard against infection, and gave him a tetanus shot. We suctioned his airway to remove secretions. We administered Lasix and dopamine to counter supraventricular tachycardia and atrial fibrillation caused by the stress to his heart. I also administered Pavulon, a curare derivative, in order to facilitate an intubation that would allow us to administer pure oxygen to reduce BP. It was at this point we decided to go in to relieve the intracranial pressure and extract the invasive object, so I administered sodium pentathol to anesthetize him and reduce his brain metabolism, and performed an emergency craniotomy.”

“All this time Mr. Donahue was unconscious?”

“Yes.”

“How long did he remain unconscious?”

Dr. Ryan looked at the jury once again. “Mr. Donahue remained unconscious for almost six months.”

“In a coma.”

“In a coma. Correct.”

“Please describe the surgery, Doctor.”

“Objection, irrelevant and prejudicial.” Chambers's interruption was clearly an irritant to the jury.

“I can understand counsel not wanting the jury to know the ordeal his clients' conduct put Mr. Donahue through,” Tollison argued, “but it is proof of what he has suffered.”

Judge Powell nodded. “Overruled.”

“Doctor?”

“As I said, we opted for surgery to relieve the subdural hematomas and to remove the object that had pierced the skull. We shaved the head and made an incision in the scalp so it could be peeled back to expose the portion of skull we needed to remove. In this case that portion was approximately the left forehead, about here.” Ryan pointed. “Once the skull was exposed, we drilled four small holes at the corners of the portion we wanted to remove, then cut out the rectangle with a cranial saw. In Mr. Donahue's case, we removed a section of bone the size of a playing card.”

The room was hushed, as if the surgery were still in progress. “Then what?” Tollison asked.

“I cut through the dura—the protective membrane around the brain—to see what was going on. There was a great deal of bleeding, so I cauterized as many of the bleeders as I could, then sucked out the clotted blood that was causing pressure, being careful to extract as little brain tissue as possible.

“After we relieved the hematomas and stopped the obvious sources of bleeding, I extracted the foreign object, then waited to see if further bleeding would result. When it did, I blocked as many bleeders as I could find and removed such skull fragments and other debris as I could without doing further damage. At that point, I did nothing further beyond an exploratory peek at the invasive injury, because we had not yet run tests showing the extent of the problems in there, and because you don't invade the mid-brain unless you have to. Since it was quite possible I would have to go back in once the tests were run, we put a temporary cover over the portion of the brain we had exposed, replaced the flap of scalp, and bandaged him up, doing everything possible to avoid infection.”

Tollison reached into his briefcase. “I show you an object marked Plaintiff's Exhibit Two. Can you identify it?”

“That's the object that pierced Mr. Donahue's skull.”

“What is it, if you know?”

A slight smile stretched his lips. “A knitting needle. With accompanying fibers of bright red yarn.”

“Thank you. Move that it be admitted.”

Judge Powell nodded.

“Is the damage to Mr. Donahue's brain still causing him problems, Doctor?”

Ryan nodded. “A great many of them.”

“Will some of these problems persist for the rest of his life?”

“Very definitely.”

Tollison glanced at the jury. When they seemed suitably entranced, he moved on. “After the emergency craniotomy, did you make a further examination of the injury?”

“Yes. We performed both a CAT scan and a PET scan.”

“Those are methods of assessing brain damage?”

“Yes. The PET scan—positron emission tomography—measures glucose metabolism to indicate which portions of the brain are most active. A radioactive isotope—usually, fluorine eighteen—is administered intravenously and tracked by a machine, which detects the gamma rays emitted as the isotope decays. Emission reflects activity at that point, and lack of emission indicates damage of some sort. The CAT scan, or computerized axial tomography, is a more static reading, a rotating X ray that generates a picture based on the varying rates of absorption of radiation by portions of the brain with different densities.”

“These tests are the basis for your testimony as to what damage was done to Mr. Donahue's brain in the SurfAir crash?”

“Yes.”

“Thank you, Doctor. So tell us. What exactly
did
happen to Mr. Donahue's brain in the crash? And please keep in mind that none of us are physicians, so we're going to need some explanation of the fancy terms.”