The Patient Was…

The patient was a 70-year old man whose medical history was as complicated any I have ever encountered. Hospitalized multiple times earlier in his adult life for undiagnosed conditions, he had even undergone multiple exploratory operations to determine the cause of unexplained symptoms. On one occasion, emergency responders to a roadside site where he had been found had pronounced him dead, only to have him awaken in the ambulance.

One thing that was clearly diagnosed, however, was severe coronary artery disease. Every major blood vessel supplying blood to his heart was markedly narrowed, with blood flow severely impaired. Despite maximum tolerated medications, he suffered from repeated bouts of angina pectoris, chest pains due to heart muscle inadequately supplied with blood.

An attempt at coronary bypass surgery, where new blood vessels are implanted into diseased ones beyond the sites of blockage, was a failure. Even in the hands of a pioneering surgeon in this type of operation, there simply were not enough disease-free sites where new blood vessels could be attached.

Despite the severe blockages in his coronary arteries and the repeated bouts of angina pectoris signally limited blood flow to his heart muscle, he had not actually sustained a heart attack where heart muscle was irrevocably damaged. Somehow, enough blood trickled through tiny pathways to keep his heart muscle alive, albeit hurting.

But on a morning in early autumn, when he was supervising a construction site, he developed chest pain once again. Being so accustomed to such episodes, he merely sat down to rest a bit. The pain eased a bit, he finished his work, and then went on to another construction site where he was supposed to check on progress. His chest pain returned, but he continued to supervise some workers and, in fact, tried to help them move some building materials. In so doing, he fell and injured himself somehow.

The pain in his chest grew more severe, he became short of breath, sweaty, and slightly nauseated. An ambulance was summoned, and he was brought to the hospital, where tests revealed that he had, in fact, suffered an actual heart attack with permanent damage to a part of his heart muscle. He recovered, but was left weaker than before and unable to return to any sort of meaningful work.

Because he lost the ability to work and was forced to retire, issues of financial compensation arose. Was Workers Compensation to be the only recompense? Was there corporate liability as well? If so, which construction company would be responsible? If both were responsible, how would liability be apportioned?

The issues went to court. It was not a jury trial. The action was brought before a special judge who adjudicated such work-related injuries and illnesses.

As his cardiologist, I was asked to testify not only to the nature and degree of his cardiac disability, but when his heart attack had occurred. Were his symptoms at the first construction site the beginning of the inevitable heart attack or were they just an episode of angina pectoris like those he suffered so often before? Did the heart attack begin at the second construction site or was it already underway when he exerted himself at that location? And what was the contribution of the injury he sustained while helping the workmen move building materials?

There were multiple lawyers present, representing the building companies, the insurers, and the patient and his family. The medical testimony was crucial to assigning liability and compensation. I was, as is customary in court proceedings, asked about my credentials, and I went through my education, my specialty training and board certification, military experience, research activities, and medical school faculty appointments and teaching roles.

I had just begun to explain how heart attacks do not represent an event of a single moment but evolve over a period of time, when the judge interrupted.

“I want to go off the record,” he said, instructing the court reporter to stop transcribing the proceedings.

“Doctor,” he said, bending over the bench toward the witness box, “I have a question for you.”

Everybody in the courtroom, the patient, his family, the lawyers, were all very interested, leaning forward, wondering what was about to happen. And I was concerned that I had said or done something that was inappropriate.

“Doctor,” the judge said, “can you help my daughter get into medical school?”

Nobody in the courtroom seemed to know whether to laugh, sigh, or sit in silence. The judge was looking at me intently. He seriously seemed to want an answer.

What do you say in such a situation?

“Your honor,” I said, “if it please the court, I take the fifth!”