May. 23rd, 2008

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After lunch, we're let into the courtroom for the start of the actual trial. The first witness is the plaintiff, Miss T, a young woman now 30 years old. We learn the details of her case.

In April of 2002 she was in a car wreck. She was turning from SR 509 onto SR 518 when Frank t-boned her car. She was headed southbound on the large freeway there (you can see about ten cars in the exit ramp) turning left to get onto the other freeway headed east. I'm very familiar with this interchange; I live near it and I drive on it, through it, or under it two or three times a week. The north-south freeway is how I get to Seattle; the east-west one leads to the major shopping center, the Southcenter Mall Complex of Tukwila. This interchange is the end of SR 518 and has traffic lights controlling it. I can completely understand how this accident happened. But we've been told to accept that the accident happened and that Frank was responsible. It's how much responsibility Frank has we're to assess.

She talks about the accident, what she doesn't remember, what happened afterward. She was cut out of the car, she says, but she only knows that because she was told so afterward.

I'm going to be brutal in my assessment of her. She said she was "so freaked out" by the screaming and frenetic activity of Harborview Trauma Center, by the fact that her gurney was left in the hospital hallway because they were out of beds and she could hear the other patients moaning and screaming, that she checked herself out of the hospital only a few hours after the accident. She did so even though, she testifies, she could not feel her legs below the waist, could not feel her arms below the shoulders. The hospital would not allow her to leave unless she could do so under her own power, so she "sort-of scooted out of there" on a pair of crutches.

I have my doubts about these claims because I don't know if you have enough proprioception at that point to stay upright even with crutches. I think she was completely stupid to try that. I don't care how bad it was: you listen to the doc and follow his advice. What she did was stupid.

There follows a long litany of agonies and various medical procedures. The agonies go on for months as she describes her slow recovery to walking. The standout point is that all of her diagnosis and therapy was carried out by the same doctor, a Doc L, whom we'll later meet. She never sought a second opinion, never saw a physical therapist, an orthopedist, or even consulted a psychologist for her depression. We don't learn about this guy's qualifications to treat her at this time; all we learn is that he was recommended to her after the accident, once by someone at her church. She makes the case that she's serious about her rehabilitation, does her exercises regularly, goes to the gym for two hours every day five to seven days a week. She talks about being on the "diathermy" machine. What the hell is a diathermy machine? She fumbles, saying she can't explain it. She says over and over again that she doesn't have the medical training necessary to even remember all the words.

When my stomach started to bug me, I read up on it so much I corrected my physician on one point (she kept referring to my pyloric valve; it's my esophogeal valve that has the problem).

Man, if there's a lesson in here for me, it's never move anywhere where I don't have a support network. It bugs me no end that she has little real understanding of what's going on.

That gives Koenig his in on cross-examination. He walks her through a series of questions about how she managed to find and keep work full time, go back to school, complete four quarters of college, get her degree as a paralegal, and find work, eventually ending up at the law firm she's currently at. He establishes that despite her injuries she apparently has a very ordinary and normal career path, with nothing in it to indicate that she has suffered any major impairment.

I really feel sorry for the poor woman, I do. She looks so sad during her testimony, and when she's sitting next to her lawyer at the plaintiff's table. There's not much more I can say about her other than that. I'm having a "shit happens" moment here, and really, our question will ultimately come down to, how much is Frank on the hook for Miss T's shit?

In this building, the Regional Justice Center, downstairs in the law library, there is an entire rack of books with collections of questions that a lawyer should have on hand when interviewing a person of certain expertise or experience. I picked one up at random, once, and opened to a page on how to walk the maintainer of a piece of large carpentry machinery (like a lathe or bandsaw) through a series of questions to determine whether or not the machine was maintained and operated properly. As I'm listening to both lawyers question Miss T, I realize that many of them are using sequences of questions out of a book exactly like that one. I'll recognize this later when the doctors are interviewed.

Koenig asks her to repeat her diagnosis. "It was too medical," says Miss T. "I don't have the training to repeat or even pronounce it." Wait, you don't know what your problem is called? After six years? Koenig randomly tosses in the word "ridiculopathy," which sounds ridiculous, but we never get a definition for it. Koenig clearly knows his stuff, and Landry's face reflects unhappiness with the progress being made.

While we're there, a few law students sneak in and sit in the back of the pews. Who knew first year law students were so gosh-darned cute? They're like little puppies.

There's also an annoying 50kHz hum in the courtroom, and the lighting does nobody any favors at all. The hermetic, sealed nature of the courtroom makes knowing the passage of time difficult.

The court reporter is a gorgeous big woman who smiles a lot and types a gazillion miles a minute on a customized keyboard that attaches via a USB cable to her laptop. She sits with her back to the jury most of the time.
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I was never a terribly big fan of Aahz & Skeeve the way some were. My main exposure to them was the comic book series illustrated by Phil Foglio, which were screamingly funny, but when I tried to read the actual novels they fell kinda flat for me.

Still, he was a big figure and he did write a dozen of the best comic books I'd ever read. I met him once, a really nice guy. Another reminder of our mortality clicks away...
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I got there early, only to be told that the actual trial won't resume for another hour or so. Some maneuvering going on backstage. I take out the laptop and start to get up-to-date, or at least try.

I like the other jurors. And that's the problem. The only people who actually show up for jury duty are those who are nice, responsible people with stable enough lives that they can take a week off. They're a wide bunch, including your classic pony-tailed software geek, the young auto mechanic, the strong responsible woman, and the professional jazz mixer who still slips into speaking jive now and then. All nifty people assembled for a common purpose, and all of them worth being part of my monkeysphere.

I learned from the bailiff that the case that's so far gone through 200 potential jurors looking for 13 (the one I mentioned earlier that I did not get into) is a medical malpractice case where the patient died. The testimony is expected to last four to six weeks even before deliberations. Finding that many people willing to be sequestered for so long is apparently very hard.

This morning we hear from three people. The first is the EMT who was first on the scene of the accident. He looks like a firefighter: big tanned white guy, buzz cut, muscles everywhere. He doesn't remember this one specifically, and I don't hold that against him. He must see one of these a week, and it's been six years since this particular crash. (Odd, though; he uses the term "accident," which I thought was no longer in favor. Accident investigators always say "crash" to avoid the laying or absolution of blame.) His only duty today is to read the report aloud and assert that that's his handwriting and his signature and as far as he knows he has no reason to doubt the report's veracity. It recites evidence of surface injury, how the patient was "extricated" (cut out of the car), no broken limbs, and all vital signs were normal. She scored on 2 out of 3 response criteria. She could answer questions, but was disoriented about what had happened or where she was. He says, "Yes, sir," a lot to the lawyers.

Mr. Landry, of course, goes to the severity of the accident, pointing out that she was given a critical care ambulance (rather than a transport ambulance) and driven to our level-1 trauma center. Koenig goes into signs of well-being on Miss T's part.

Landry tries to get Underhill's report entered as evidence. Koenig objects on the grounds that it's hearsay and without foundation. The jury does a small doubletake and Judge Prochnau admits it into evidence.

The next two people up are her sister, and her mother. They're hard to tell apart: her sister, despite being close to Miss T's age, has not been kind to the passage of time or vice versa: she looks closer to her mother's age. She has awful hair. All three are that hardy mix of Kansas and Norway that seems to occupy the Upper West of Washington. She has three sons, that might explain it. But then what do we say about Omaha?

We get the same litany of injuries contrasted with prior vivaciousness. Descriptions of her dancing, water-skiing, and sports counterpoint her current incapacity, an inability to lift heavy things, to walk far, to run at all. Koenig tries to trap the mother in a deceit about when Miss T went back to work full time, but I think it falls flat. I'm willing to forgive the mother's memory as fallible about whether it was three months or six before Miss T went back to work full time five years ago. I can't remember the exact months I started working at a variety of employers prior to my current, after all. The mother talks about how Miss T can't sit still for long periods of time without having to stretch out her neck, how she suffers headaches constantly, how she can't lie down without carefully calculating how she'll do that.

We also get other details about her hardship: psychologically freaked out by the prospect of driving now, she can't go camping anymore with the hard ground, she can't sit or lie down without giving the movement some thought. Koenig asks a very critical question: if she's so depressed, has she ever sought psychological treatment, counseling, or therapy? The answer is "No." Her mother testifies that Miss T "lost her bubby personality." She doesn't know when Miss T started to see Doc L, and she doesn't believe that Miss T ever went to anyone but Doc L.

I write in my notes, "Dammit, there's a timeline. There are dates, documents. Why the Hell doesn't the jury have access to this stuff already?" The bandwidth of a jury trial is painfully low. I supposed there's something to be said for the slow, deliberate process.

We break for lunch. At lunch, I have an insight about something Koenig said during voir dire, a nasty bit of work that laid the seeds for his side of the argument. That guy is playing within the rules, but man is that dirty. He made sure that we, the jurors, could sit still for two hour stretches at a time. That we were fit to sit on the jury. Miss T has sat in her plaintiff's seat the whole time, seemingly contradicting her own mother's statements. She doesn't fidgit, she doesn't rearrange herself. She just sits, quietly. She didn't even pick up on that while her mother was testifying.

Dude.

I still have an open mind. It's amazing to me how well the jury system really works, at least for me and from my point of view. I still want to know if the treatment administered was justified, and if so, is it helping. I know that no matter what decision I help render, if I get to help render it, someone's life will be burdened horribly for a long, long time to come. I want to make the right choice. Cases like this, where no matter what happens someone will hurt, just suck. I can't think of a better system, actually, but this one is just brutal to everyone concerned.
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The afternoon session sits us all down with the big guy: Doc L, the doctor treating Miss T. He introduces himself as a Doctor of Osteopathic Medicine and Surgery (D.O.), with a 41-year practice. He talks to us of diatheramy and sclerotherapy, and I have to confess that I'm feeling bamboozled. I'm trying hard, and so far succeeding, in not looking this stuff up, in not "forming my own opinions" about the procedures he's describing, but instead taking what's said in the courtroom at face value. I know in this era that there's a gigaton of data about this kind of thing. I could ask Orac: he's a font of data about woo. Is sclerotherapy woo-ey? I have this fretful feeling that it is. That there's no real scientific evidence to back it up. I don't know, and it infuriates my network-born instincts that I'm not allowed to know.

Doc L talks about how his practice is "everything from dandruff to fallen arches." Cute. Sounds practiced. Uses the word "allopathic." Well, score one for him. "A Doctor of Osteopathic Medicine and Surgery is a full doctor. We are not limited. Not like them." We'll learn who Doc L believes is "them" shortly.

Landry goes on for some time, making the case with Doc L that Miss T was benefiting from his therapy. A line of questioning straight out of one of those textbooks. My discomfort is that there's no corroboration. No physical therapy was ordered, no neurology studies, nothing. It's all about the ligaments, which he asserts can only be healed primarily by an irritation technique: he introduces a foreign substance ("sterilized dextrose" or "cod liver oil"-- the last makes the woo-meter tick hard!) and that causes the ligament to grow defensive tissue to protect it against the substance. He makes the comment that skin grafts and bone grafts work the same way-- an assertion I would contest. Introducing growing tissue and spanning the gap sufficient to encourage growth is different from irritating the tissue to encourage defensive growth. Doc L says he looked at the head CT scans, skeletal X-rays, and abdominal ultrasound, but asserts (and I underlined "asserts") that none of them can tell you about ligament failure. (He later admits, under cross-examination, that he never actually saw the films, only the radiologist's reports.) The only way to do tissue density of ligaments is to assess the turgor with a needle; no visualization technique will give you an insight into the status of strained ligaments.

This therapy is his life's mission: it worked for his father, and his mother, and he went into osteopathic medicine to bring this technique to the world. The woo meter goes up another tick.

But he does say that he didn't start this procedure until two years after the accident. Instead, he concentrated on the traditional sports medicine treatments: pain relievers, muscle relaxants, ice, massage to break up swelling and move blood in and out of the injured portion, physical therapy of the injured parts to restore range of motion. He testifies that Miss T is "hypermoble," meaning she has more elastin than collagen in her ligaments, and so has less protection against this kind of soft-tissue damage.

He makes an interesting case against the current three-point seat belt, recommending a four-point instead, although he admits he doesn't have one. We get a show-and-tell, with a full-sized plastic model of the spine ("Gave 'em a bit of a start at the security checkpoint" -- really? Like they don't have personal injury cases come through here constantly?) as Doc L points to where the ligaments are, what the injections are like, and so forth. As he twists and bends the model spine, several members of the jury tense visibly.

I wrote in my notes, "Are there any EBM [evidence-based medicine - Elf] studies that back it up? Double blind, placebo, that sort of thing?" A few lines later I write, "Koenig delivers!" Because he does. His first line of attack upon standing up is a 2007 meta-study concluding that all the studies to date have shown no conclusive evidence that the procedure works at all. The doctor says he's not surprised: it depends upon the skill of the practitioner, and the substance used. My problem with his response is that the same is true of surgery, but if this procedure is fifty years old good grief you would think the docs would have figured out what works and what doesn't? Woo meter plus one. He goes on to diss the "other" members of his profession: chiropractors on the one hand-- "We have significant disagreement about what really goes wrong with the spine"-- and orthopedic specialists on the other-- "They're surgeons. That's what they do. Surgeons love to do surgery. ... I am not a fan of surgery, nor would I recommend it. In this case, I mean." Woo meter climbs once more.

Koenig then goes on to attack a different aspect of practice: the doctor's use of his own hand as an instrument of diagnosis, specifically his use of turgor. I find this a weak line of attack: the hand is a perfectly valid tool, and an experienced hand with a needle is probably better than a machine for determining the turgor of at least some conditions.

Koenig's last line of attack is to the documentation, specifically that his own objective assessments of Miss T's conditions do not match her subjective assessments. Doc L isn't surprised: he might see full range of motion but she might continue to report pain. And indeed, her reports do show "full range of motion" and "within normal limits."

Landry gets back and talks about the procedure. It's painful. No patient would go through it unless they absolutely have to. I write in my note, "What an evolutionary mess we are." A minute later Doc L mirrors my sentiment theologically: "I don't know why our Creator would create us so messed up. To make such marvels as our body, and then not give this one important part of us the ability to heal." His final point is that all of his treatments have been necessary and reasonable for the injuries she has sustained as a result of the auto accident.

The jury gets to ask its questions. Someone asks the obvious: even with the sclerotherapy can Miss T expect to see restoration to full health? Doc L answers no, of course not. But she will see significant improvement and that's what's important. He wants to try and restore her limbs to their pre-injury state, he says. He says he has no reason to believe that Miss T is a "malingerer" or is "being untruthful" about her subjective state.

After that, we're all free to go on our own recognizance.

I'm reminded of a quote I read once:
Cardiac physicians are fitness freaks. They exercise and eat right. They know the consequences of a heart attack. Oncologists, in contrast, are usually eat-drink-and-be merry types. They know the consequences of cancer. They'd rather have a heart attack.
I don't know why my brain thinks that's relevant right now, but I wrote it down.

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Elf Sternberg

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