Carlo Conti pushed the heavy oak doors open, stopped, and gazed around the courtroom. David Barnett was seated next to his attorney at the defendant's table. Carlo hadn't seen Barnett since the day of Michael's death, well over a year ago. He was struck by how different the doctor looked; he was smiling--he looked charming. Carlo's memory of Barnett was of a foreboding, sinister man. This contradiction gave him a brief surge of guilt. Should I be doing this? Am I wrong to seek revenge? As he walked toward the front of the room his thoughts went back to Cassie, Marie and Michael. All gone. All dead because of incompetent doctors. He was sure of it. Older memories from his adolescence remained deeply barried for the present. He looked back at Barnett and saw the evil man he remembered. Now his emotion was anger, not guilt. I'm doing the right thing. The Old Testament says, an eye for eye. I deserve vengeance.

The image of David Barnett, lying on Carlo's retinae, stimulated the visual center of his occipital lobe. A micro second later an electric impulse shot down his spine, terminating at his adrenal glands, initiating the release of adrenalin into his circulation. Within seconds a cascade of neurohumoral events took place in Carlo's body. Catecholamines from his adrenals produced an increase in heart rate and blood pressure. His face flushed as veins in his cheeks dilated. His elevated pulse and pressure forced his myocardium to work harder. As blood raced through his coronary arteries, his heart's demand for oxygen increased. Adrenalin activated his sweat glands. Carlo began to perspire.

Unknown to the old man, there were numerous atherosclerotic plaques in his coronary circulation, the worst of these being an eighty-percent narrowing in his left anterior descending artery, a major vessel supplying the front wall of his heart. As his myocardial workload surged, this partial blockage became a critical impedance to blood flow, causing insufficient oxygen supply to a large portion of his left ventricle. Carlo felt uneasy. He had heaviness in the center of his chest and was short of breath. His perspiration turned to a cold sweat. This sequence of events, from his anger to the onset of chest pain, took less than ten seconds.

Approaching the plaintiff's table, Carlo noticed an ache in his left arm. He took a seat. His attorney, John Gallagher, was yet to arrive. Carlo pulled a small cylindrical bottle from his suit pocket and discretely slipped a tiny pill under his tongue. The medication, rapidly absorbed by the soft, moist tissue of his mouth, dilated his blood vessels. Seconds later his chest heaviness was gone. His left arm pain resolved and his blood pressure and heart rate returned toward normal.

A huge black man, a sheriff's deputy, entered from the far side of the courtroom and escorted the jury to their seats. Carlo, hearing activity behind him, turned to see people, five or six, taking seats in the gallery. He didn't recognize anyone; they were all strangers, street people who liked to attend court, mostly to escape to an air conditioned room during the sweltering months of summer or to seek warmth and shelter from snowy, frigid days in the dead of winter.

As Carlo was about to turn from the gallery, his daughter-in-law entered through the rear of the room. Laura walked to the plaintiff's table to say hello. Seeing only two chairs at the table gave her a sense of relief, offering an excuse to sit behind Carlo, rather than next to him. Laura stepped back to the first bench of the gallery, taking a seat directly behind Carlo. A moment later, John Gallagher appeared.

"Hello, Mr. Conti." Carlo turned to greet the attorney. They shook hands as Gallagher took the seat next to him, then turned to say hello to Laura. She silently responded with a smile. After some small talk, the counselor addressed more pertinent issues. "Carlo, I've been pondereing our approach. I think we should put you on the stand first, before your daughter-in-law. "Are you okay with that?"

"Why does it matter?"

Before Gallagher could respond, Judge Franklin Richardson entered the courtroom. "All rise," the bailiff announced. "The Lucas County Court of Common Pleas is now in session, The Honorable Judge Franklin A. Richardson presiding."

The Judge took a seat in the high backed leather chair behind his desk. "The plaintiff's in this case are the survivors of Mr. Michael Conti vs the defendants, doctors Raymondo Tamayo, Thomas Goetsh and David Barnett." He asked Mr. Gallagher whether a medical facility was involved in the suit.

"No, Your Honor. My clients have excused the hospital."

Richardson was surprised. Nearly every malpractice suit he'd presided over involved a hospital. What he didn't know was that Carlo Conti wasn't interested in money--he was out for personal revenge. In his mind, the hospital had nothing to do with his son's death. John Gallagher, on the other hand, being interested in his share of a large financial reward, had tried to convince Carlo to include allegations against Mercy Hospital. Carlo flatly refused. He wanted to get David Barnett, and that was it.

His Honor spoke again, "Gentlemen, I see we have a visitor from Detroit, Mr. John Gallagher, representing the plaintiffs, Mr. Carlo Conti. and Mrs. Laura Conti. Mr. Theodore Atkins is legal representative for Dr. Raymondo Tamayo, and Mr. Lawrence Burkhardt is representing doctors Stephen Goetch and David Barnett. Is that correct?"

All three attorney's responded with a, "Yes, Your Honor."

"Mr. Gallagher, Attorney Atkins has asked that his client be crossed examined first, with the intent of possible dismissal. Do you have an objection?"

John Gallagher turned to Carlo and quietly explained what the judge was requesting. Carlo was indifferent. He'd never met either Tamayo or Goetch. "It doesn't matter. I really don't give a shit as long as we nail that bastard Barnett."

Encouraged by his client's vehemence, John Gallagher smiled. "We have no objection, Your Honor."

"You may proceed, Mr. Gallagher."

"Your Honor, I call Dr. Raymondo Tamayo to the stand."

Tamayo, seated next to Atkins, stood and walked to the stand. The doctor was dressed for success: expensive looking charcoal suit, powder blue dress shirt with a white collar, and a beautiful, deep-blue silk tie. His light brown skin contrasted nicely with the silver hair at his temples. As Tamayo took his seat at the witness stand, Barnett saw a bright sparkle from a diamond studded caduceus pin on the doctor's lapel. He was sworn in by the bailiff.

John Gallagher approached. "Dr. Tamayo, you are a cardiologist, is that correct?"

"Yes, it is."

"How long have you been in practice, Doctor?"

"Just over thirty years. All here in Toledo."

"Are you board certified in cardiology?"

"Yes, I am. I'm certified in both internal medicine and cardiovascular disease."

Gallagher continued, "You're familiar with the medical history of Mr. Michael Conti, the deceased, are you not?"

"Somewhat."

"You saw Michael Conti as a patient, didn't you?"

"Yes, I did."

"So, you did know him?"

"A little. I saw him once as a new patient in September 200---------?."

"Why did he consult you?"

"He was having shortness of breath and chest discomfort."

"Did you find these symptoms worrisome?"

"Yes, they were suggestive of coronary artery disease but not diagnostic. There were other diagnosis to consider as well."

"What might those be? What other diagnosis?"

"His cheat pain could have been musculoskeletal pain, inflamation of chest cartilage for instance. Mitral valve prolapse would be another consideration. A  pulmonary emblism could cause both pain and shortness of breath, as could pneumonia. And, as I've noted in his records, he seemed anxious. Anxiety itself can sometimes mimic angina, coronary pain."

That's quite a list, Doctor. How did you investigate these possible diagnosis?"

"My greatest concern was to exclude pulmonary embolism and coronary artery disease, two life threatening conditions. His resting heart rate was low  at fifty-eight beats per minute. That virtually excludes an acute pulmonary embolism. Furthermore, he had no evidence of clotting in his veins, called DVT, deep vein thrombosis, a common source of an embolic clot, a clot that travels through leg veins up to the lungs, which is very dangerous. Coronary disease with angina pectoris cannot be excluded by a physical exam. If I may, I'll dicuss my approach to that diagnosis last."

"Yes, please continue."

Michael Conti's physical examination did not suggest chest wall pain, cartilage pain. His denial of cough or fever made pneumonia unlikely. Ausculatation of his chest was normal, without evidence of infection or mitral valve condition. I ordered a chest x-ray and a white blood cell count, a CBC, to further exclude pneomnia, and an echocardiogram, an ultrasound of the heart, was ordered to exclude mitral valve prolapse, a relatively benign but often bothersome condition."

"Dr. Tamayo, it sounds as though you were quite thorough in your evaluation of these alternative diagnosis. Could you please explain how you investigated Mr. Conti's heart. How did you asses the possibility of his symptoms being cardiac in origin?"

Barnett whispered to his attorney. "Very thorough is an understatement. Tamayo's practice habits are a travesty. A money making machine." Burckhardt nodded to acknowledge. 

Tamayo esoterically continued. "New onset angina pectoris in a young man with no risk factors for CAD, coronary artery disease, would be an unexpected finding, however, that is exactly the diagnosis I investigated most intensely. Mr. Conti had an electrocardiogram, commonly called an EKG, and, as I've previously mentioned, an echocardiodgram, a forty-eight-hour Holter recording, a stress nuclear exam, complete blood work, including a cholesterol fractionation, and, for the sake of completeness, an assessment of his arterial vasculature via a carotid artery Doppler, an ultrasound of his abdominal aorta, and a peripheral arterial exam of his lower extremities.Tamayo, seemingly proud of his testing acumen, finished with a smile. A second later, realizing what he'd said, he regretted mentionining the additional vascular studies. He'd fix that later.

Larry Burckhardt turned to Barnett. "Is that standard practice? Sounds excessive." David nearly laughed outloud. "Are you kidding. Tamayo's a jerk, a charlatan. I'd guess he billed Conti for at least four-thousand-dollars for his 'thorough exam', it's ludicrous." Burkhardt skook his head with disgust.

Gallagher, like Barnett, incredulous over the extensive testing ordered by "The Doctor", facetiously commented. "Dr. Tamayo, thats an exhaustive list." Turning to the jury, he smirked, and added, "You surely are dedicted to the cause." 

A few chuckles emanated from the the gallery. David Barnett loved it. Gallagher's subtle sarcasm flew right past Ted Atkins' meager mind.

John Gallagher's sarcasm continued. "Dr. Tamayo, certainly this extensive, thourough testing of your patient, wasn't completed on the day of MIchael Conti's office visit, was it?"

Ray Tamayo, arrogantly oblivious to the attorney's sarcasm, replied, "No, that would be impossible. These examinations were peformed over a period of days."

"I see. So, Mr. Conti returned to see you soon after his initial visit. Yes?" 

Tamayo cringed inside. Realizing he was being set up for a fall, he tersely replied, "Yes, he returned to undergo the studies I've described."

"I see. So you saw Michael Conti again, soon after his first visit?"

Tamayo's mind raced. I'd like to to strangle this prick. Expecting, hoping for an objection, he turned to his attorney with a look of anticipation. Atkins, still seated at the defendants table, head hanging down, chin resting on his chest, had nodded off. (Add description of Atkins age, early dementia, etc at beggining.)


Gallagher quickly jumped back in befor the judge could addreess the sleeping attorney. "Doctor, did you see Mr. Conti when he returned for testing?"

John Gallagher, Carlo Conti, Laura Conti, Steve Goetsch, David Barnett and Larry Burckhardt all knew that Tamayo had left for Cancun the day after Michael Conti's office visit. Despite that knowledge, Ray Tamayo, rather than admitting the obvious, a reasonable occurance for any doctor, wanting to defy gallagher at evry single turn, He foolishly replied, with out explanation, "No. I did not see see Mr. Conti again."   He could hear Atkins snoring.
barnett thinks--maybe ray's not a shrude as I thought--or he's letting his defiance get the the best of him.

"Really! I don't understand, Doctor. If Michael Conti, a young man with symptoms of heart disease, had to return to your office to undergo the extensive testing you've so eloquently outlined, why did you not see him for at least a brief followup visit? Barnett whispered to his attorney."Larry, I love this guy. What a smart ass." Burkhardt replied, "Don't love him too much. He'll be after you pretty soon."

Tamayo,  struggling to maintain a professional demeanor"I saw Mr. Conti on a Friday afternoon. He returned to my office, to undergo the testing I've described. I did not see him because I was on vacation. I was in cancun Mexico. I work long hours and I need.... Gallagher not letting him excuse himself, interupted. Thank you sir. We understand everyones right to take a vacation. on Monday, three days after I saw him."



"And Michael died of an acute myocardial infarction, a heart attack, just one week after your evaluation. Correct?"

"That's correct."

"Do you agree with the diagnosis of myocardial infarction as the cause of death?"

"Yes, after my review of Dr. Barnett's findings, I concured."

"Why didn't you ask Mr. Conti to see you again, for follow up?"

"I performed the necessary tests and told Mr. Conti that I would contact him immediately if there were any abnormalities. Otherwise he was to return to my office in one month."

"Were there any abnormal test results, Doctor?"

Tamayo responded emphatically, "No, there were not."

Gallagher pushed harder, "None!"

The attorney's persistence worried Tamayo. Could Gallagher possibly know about the trashed lab tests? Ray began to sweat. After a brief pause, he responded emphatically. "That's right."

"Could you please review the findings from your exhaustive testing."

Something about the tone of Gallagher's voice reassured Tamayo. He smiled, sat back and relaxed with a sense of relief. He doesn't know a thing about it. Now Tamayo could demonstrate his vast knowledge of cardiology and undeniable dedication to his patients. Responding, he spoke rapidly, his Spanish accent more pronounced. "I performed numerous tests. As I've said, Michael Conti underwent and ee-lectrocardeeo-gram, chest x-ray, nuclear cardiac stress test, echocardee-ogram, forty-eight hour Holter monitor, and the blood profile includee-ng a cholesterol fractionation."

The doctor intentionally omitted three of the tests mentioned previously: Doppler studies of his carotids and lower extremities vessels, and the ultrasound of his abdominal aorta. These tests were grossly abnormal, showing extensive atherosclerosis of every artery visualized. After learning of Michael Conti's demise, Tamayo destroyed all evidence of those studies: the written orders and scheduling, the video recordings, and his dictated interpretations.

Barnett couldn't resist another comment to his attorney."Numerous tests. Typical for Tamayo. He ordered thousands of dollars' worth of studies for his own profit and probably didn't even lay a stethoscope on the guy's chest."

Burkhardt murmered something about a Tamayo being a quack.

Gallagher spoke, repeating his question for the third time. "And, as you've said, all of these tests were normal?"

Tamayo, anxiously recalled trashing many results. His pulse raced. "Si. . . I mean, yes. That is correct."

"Dr. Tamayo, isn't it true that you left town for a two week vacation just one day after Michael Conti's office visit."

"Yes, that's true."

"I believe you were in Cancun, Mexico."

"Yes, I was."

"And Michael Conti's unfortunate death preceded your return, didn't it?"

"Yes, it did."

"Then could you please explain to the court how you intended to notify Mr. Conti. How you intended to 'immediately' notify Mr. Conti, as you said, of any abnormal test results, if you weren't even in the city or the country for that matter."

Tamayo kept a straight face as he boldly lied. "I reviewed nearly all of the studies before I left on vacation."

Gallagher pounded away for the fourth time, nearly shouting. "And we are to believe that every study you performed was entirely normal?"

Attorney Atkins, on the verge of dozing off in his seat, awoke in response to Gallaghers --------. "Objection, Your Honor. Dr. Tamayo has answered this question three times."

"Objection sustained. Move on, Counselor."

John Gallagher replied, "Yes, Your Honor", and thought, Whatever the fuck you say, your highness.  "Doctor, you said you reviewed 'nearly all' of the studies. Which tests were not reviewed?"

Tamayo, the weekend of Michael Conti's office visit, having been absorbed with planning his vacation, had ignored his office work for days and hadn't  reviewed any of Michael Conti's test results. He blatantly lied again. "I personally reviewed Michael Conti's electrocardiogram, cardiac stress test and echocardiogram. The only remaining test, a forty-eight hour Holter recording, was not available until it was returned to my office three days later. Likewise, his lab results, his blood work, was not reported for a few days."

Gallagher paused, mentally reviewing the list of examinations Tamayo had mentioned earlier. "Doctor, what about the vascular studies you performed. I believe there were three, carotid, aorta and lower extremities. Correct?"

"Yes, that's correct. My mistake. I was thinking of a different patient. Mr. Conti did not undergo those tests."

Gallager jumped on the 'mistake'. "I see, so your memory is failing you, sir?"

Tamayo glared at Atkins as if to say, Wake up and object you old fool. Atkins, oblivious, simply stared back at his client. Tamayo had to respond. "No, Mr. Gallagher, my memory is excellent. I see many patients, sometimes as many as fifty-a-day. It was an honest mistake."

Barnett whispered to Burkhardt, "He's lying. I've seen Tamayo's standard work up on quite a few of his patients. He always does a Carotid Doppler, aortic ultrasound and peripheral vascular study. For him, it's routine. It generates big bucks." Burkhardt responded with a subtle shake of his head.

Gallagher let it go. "Doctor, since you were in Cancu at the time of this testing, how did you intend to check the results--the results of Michael Conti's Holter study and laboratory work, his blood tests?"

"I have a very competent physician's assistant, Mr. Todd Dagy. He's worked with me for years. Whenever I leave town, Todd reviews all of my patient's pending test results. He calls me religiously with any significant findings."

The response pleased Gallagher. He smiled and forged ahead. "So, Doctor, your physician's assistant is not an M.D., is he?"

"No, he's not."

"Yet you trust him to decide what is, as you said, 'significant'?"

Exasperated, Tamayo replied with a loud, emphatic, "That's correct, Mr. Gallagher! My assistant is well trained, intelligent and very experienced. I trust him implicitly with his review of test results."

* * *

Years ago, when Todd Dagy was first hired, he was dedicated to his career, worked hard to educate himself and put in long hours learning to interpret a myriad of cardiovascular tests. He was, as Tamayo said: well trained, intelligent and experienced. Unfortunately, over time, things changed. The truth was that Tamayo's physician's assistant ignored most test results when his boss was out of town. It had been years since Todd had called Tamayo to report abnormal test results or patient's problems. Todd resented the doctor for leaving him alone in the office--alone with mountains of cardiac studies in need of interpretation, and scores of undictated charts. Even though Tamayo had cancelled all routine office visits during his absence, Todd Dagy remained responsible for the care of unscheduled patients who required immediate attention, many of whom were critically ill and in need of care that was beyond the training and abilities of a PA. Todd was apprehensive about the game of legal jeopardy Tamayo was playing by leaving a physician's assistant in charge; recklessly exposing Todd and himself to potentially ruinous malpractice suits.

The sad truth was Todd Dagy detested Dr. Tamayo. The only reason he stayed under his employ was because of the salary he could demand--a salary he dearly needed to provide for his wife and three children. Few PA's who would accept the burden and liability of running a cardiology practice in a physician's absence, and Tamayo was well aware of that. Todd Dagy was generously compensated for accepting such responsibility.

* * *

John Gallagher pursued the issue. "Doctor, as you've said, your assistant is not an M.D., and he's certainly not a cardiologist."

"No he isn't, but also, as I've said, he has many years' experience in my office, as well as on hospital cardiac wards. I trust his abilities and judgment without reservation." Tamayo instantly regretted mentioning in-patient cardiac wards.

"Your PA works in the hospital as well as the office? Does Mr. Dagy see Coronary Care patients for you?"

Tamayo could have kicked himself. Once more, he'd have to lie his way out. "Yes, he does. Todd occasionally sees hospital patients in the morning, especially if I'm tied up doing something else, such as working in the cath lab or if I'm across town at another hospital. However, Mr. Gallagher, I always follow-up on each of my patients later in the day. In addition, Mr. Dagy consistently calls me for my opinion and consent if he needs to order medications or other treatments. When I return to the hospital, I review and cosign all of his notes. It's a good system for the patients. They're seen twice a day, instead of once, and I'm made aware of any developing problems early in the day, rather than the afternoon or evening."

David Barnett turned to his attorney. "He's lying again." Tamayo often skipped hospital rounds, leaving Todd Dagy alone to care for critically ill patients. Most of the hospital's cardiology staff, and certainly all of the coronary care nurses were aware of Tamayo's illicit practice habits. Todd Dagy was disgusted by it, but because of his financial needs, he was helpless, or at least shamefully reluctant, to report Tamayo's behavior to the hospital administration.

Most of Mercy Hospital's nursing staff had either directly experienced or had heard reports of Ray Tamayo's hair trigger temper and frightening, vindictive nature. To date, none had mustered the courage to report his lax inpatient attendance to the Director of Nursing or hospital administration. Their fear of Tamayo's retribution, including possible physical harm, kept them quiet.

* * *

Medicare rules clearly state that the primary physician must see his or her hospital inpatients on a daily basis. There is no accommodation made for substitution by a physician's assistant. Furthermore, if a physician submits charges for an inpatient visit he never made, he's committing Medicare fraud. Had the doctor been reported, he, at a minimum, would have his hospital privileges revoked, or at a maximum, would be heavily fined by Medicare and possibly prosecuted.

* * *

John Gallagher, reluctantly accepting the doctor's eloquent (discourse--explanation-etc)regarding Todd Dagy's responsibilities, moved forward with a question on Michael Conti's test results. "Doctor, what were the findings on Michael Conti's Holter and blood lab results, as reported by your assistant?" 

Tamayo produced more fabrications. "Mr. Conti's Holter monitor and lab results were perfectly normal. His Holter showed a normal heart rhythym for the entire forty-eight hours of recording. The doctor followed with his most egregious lie of all. "Actually, his cholesterol was better than average for his age."

"Well, Dr. Tamayo, I must admit, as an attorney and not a physician, I don't quite understand this sequence of events. Could you please explain to me and the court, how a thirty-eight year-old man can have the extensive cardiac testing you've described, with entirely normal results and then fall victim to a massive, fatal myocardial infarction one week later?"

The doctor repositioned himself in his chair, straightened his back and sat up tall. His face changed from a look of contempt to a deceptive grin. Barnett knew what was coming. It was what Tamayo had been waiting for. David figured the doctor had prepared  an (eloquent) response to this anticipated question. Tamayo sat silently for a moment. His grin changed to a smile of self-content.

Gallagher spoke again, more emphatically than before. "Doctor, please help me with this."

"I'd be delighted, Mr. Gallagher." Tamayo's demeanor exuded an air of importance without overt arrogance. He looked dignified, polished. Sitting even higher, he folded his hands across one knee and began an unexpectedly charming oration. "Despite the tremendous advances made in the field of cardiology over the past twenty to thirty years, we must still, we as physicians, must still put our faith in testing procedures that are not one-hundred- percent accurate. All diagnostic tests in medicine suffer from some degree of fallibility. And so it is with the studies I've described."

As Ray Tamayo continued, his Spanish accent became stronger. He was on stage and he loved it. Incredibly, Gallagher didn't interrupt the doctor's (absurd) discourse. Instead, he let his adversary go on and on, hoping he would at some point, contradict himself, giving Gallagher more ammunition for the fight. Tamayo continued.

"An EKG for instance, may be entirely normal just hours or even minutes before a fatal heart attack. The resting ee-lectrocardiogram is most useful for determining past events, not future events. A Holter monitor may show twenty-four or forty-eight hours of totally normal heart rhythm, even in the presence of severe, underlying coronary artery disease. Echocardiograms give us a beautiful picture of the heart muscle and cardiac valves but they cannot visualize the arteries themselves. The only means of truly "seeing" the coronary vessels is through an invasive test known as a coronary angiogram or cardiac catheterization. This entails insertion of a plastic catheter within the arterial system, followed by injection of x-ray contrast into the arteries themselves. This test is expensive, entails a definite degree of risk and is certainly not indicated in all patients with chest pain. Likewise, in view of Mr. Michael Conti's test results, a cardiac catheterization was not indicated, and, in fact, would have exposed him to unnecessary risk."

Exasperated, John Gallagher, having had enough of Tamayo's nonsense, cleared his throat in preparation to halt the doctor's (-----) Tamayo beat him to the punch. 

"The most accurate, safe, non-invasive test available for the assessment of coronary artery status, is a stress nuclear examination. This test is very safe, does not require the insertion of a catheter into the body, and is without a doubt the best procedure available to (assess) a patient for coronary artery disease without subjecting him or her to the potential risks of a cardiac cath. This is the very test that I performed on Mr. Conti. However, Mr. Gallagher, in response to your specific question . . . "

Gallagher sucessfully interupted. "Doctor, please get to the point and answer my question. Tell me why your patient suddenly died a short time following your very extensive examination, which included, as you've stated, numerous normal test results."

"I'm doing my best, sir. It's difficult to explain medical technology in lay terms. I want the jury to understand."

"Your Honor, I'd like to treat Dr. Tamayo as a hostile witness."

Judge Richardson nodded with approval. "You may. Please, get on with this."

Gallagher's voice rose. "Doctor, none of us are fooled by your intellectual presentation. Answer my question in brief, succinct terms."

Tamayo, ignoring the attorney's demand, turned to the jury and continued. "I performed a stress nuclear test on Mr. Conti. However, this test, like most, is not infallible. As I've stated previously, all scientific studies have a degree of error or inaccuracy. Medical tests in particular are subject to problems related to the prevalence of any disease within the population studied. That is to say that the predictive value of the test is often directly related to the probability of the disease being present in the patient being studied."

"Your Honor! This witness is either deaf or delusional."

Barnett loved it. This must be how Tamayo talks to his patients. He snows them with charm and pseudo intellect while robbing them blind.

Gallagher was flabbergasted, his frustration visible to both judge and jury. He couldn't believe Tamayo's audacity. He shouted, "Dr. Tamayo! Answer my question!"John Gallagher was beyond perplexed. His voice rose. "Doctor, please get to the point! You say you want to clarify your position with the jury, while in fact, you are only confusing them further. I want you to . . . ."Ted Atkins stood and voiced an objection. "Your honor, Mr. Gallagher has posed a difficult question and Dr. Tamayo is doing his very best to answer it. The councilor's continued interruptions are inappropriate." Frank Richardson looked at Gallagher. "Objection sustained. Mr. Gallagher, please allow the doctor to continue."


The doctor, taken by surprise by the outburst, flinched. His eyes opened wide as he repositioned himself in his chair, and crossed his arms in defiance.

"Years ago, a statistician by the name of Baye, put forth a theorem which nicely explains the pitfalls inherent in a test such as a nuclear cardiac stress study."

Gallagher smirked, rolled his eyes and wisely, or so he thought, allowed Tamyo to complete his dissertation, assuming the doctor's arrogace would bury him. let the doctor carry on with his diversion. Frank Richardson,  amused by the visiting attoney's frustration, remained mute.

"If the test is performed on a population of patients with a known low incidence of heart disease, such as a group of young women, the study will show an unusually high incidence of 'false positives'. These are tests that appear to be abnormal, while in fact, the patient has no coronary problem. On the other hand, it the study population has a high probability of coronary disease, such as a group of elderly, male smokers, the test has a much better predictive value but a higher incidence of 'false negative' results. That is to say, a test which looks normal when the patient does have significant coronary atherosclerosis."



Gallagher could not understand the judge's obvious prejudice against him. He turned his back to the bench and to Tamayo, contemplating his next move. It's because I'm an outsider. He thought. Imported from Michigan. I'm not a Buckeye and the judge resents it. Turning back to face Tamayo, he spoke with a loud, blatant tone of sarcasm. "Please do proceed, doctor".  (move this paragraph)

Tamayo, feeling he held the judge's sympathy, sat back and relaxed. He spoke with more animation, gesturing with his hands to intentionally irritate Gallagher. Barnett couldn't believe it. Tamayo's arrogance was astounding.

Of course, Mr. Gallagher. It would be my pleasure to proceed. Mr. Conti, being a male at age thirty-eight, fell between the two theoretical test groups I have described; that is, the young female population versus the elderly male population. In Michael Conti's case, the tests accuracy was less than optimal. His stress nuclear study had both a ten to fifteen percent chance of a false positive result, as well as, most importantly, a ten to fifteen percent incidence of a false negative result. It is my contention that Mr. Conti fell into this unfortunate but well described category of patients who have a totally normal stress nuclear test despite having of severe, underlying coronary artery disease as later discovered at his cardiac cathetherization. In some sense, and I have some hesitation to say this, he was simply unlucky. He had only a ten percent chance of his stress test showing a falsely normal result, but that is precisely what happened."

The word 'unlucky', caught Carlo Conti's attention. To him, Tamayo's discourse was an excuse for missing an obvious diagnosis. The doctor's assertion of Michael having bad luck hacked him off.

Burkhardt turned to his client. "David, does this all make sense?"

"Yes, it does. Tamayo may be greedy and unethical but he's not stupid.

To startle Tamayo, Gallagher took a quick step toward the witness stand. He turned to face the jury, hiding his face from Judge Richardson, and, with blatant sarcasm, smiled, rolled his eyes and spoke. "Doctor Tamayo, I'm sure the jury appreciates your detailed and eloquent review of medical statistics." A few chuckles came from the stand. He turned back to Tamayo. "Doctor, I have a few more questions. Michael Conti, as you've described, had severe coronary artery disease, very severe arterial blockages for a man his age."

Tamayo nodded. Gallagher went on. "You've stated that Michael was a non-smoker and an avid exercise enthusiast. Furthermore, you told us that his blood cholesterol levels were surprisingly normal, I think your words were, 'Better than average'. In light of this, do you have any idea why Michael Conti had such severe hardening of the arteries at his young age?"

The doctor smiled. Gallagher, anticipating another exhaustive dissertation, quickly cut him off, asking, actually demanding him to get to the point. Attorney Atkins was just about to object when Richardson deftly waved him off with a subtle motion of his hand. Atkins sat down without complaint.
Similar to Gallagher, the judge was getting fed up with the doctor's ceaseless commentary. "Doctor Tamayo, I can feel Mr. Gallagher's frustration. It would behoove you to be succinct and brief with your responses. Do you understand?"

Tamayo, offended by Richardson's command, sat in thought for a moment. Who the fuck does this guy think he is. A mere judge, telling me what to do? He tersely answered. "Yes, your honor. I understand very well."

Tamayo continued with comments on genetic factors and cholesterol sub-particles as, to date, poorly understood causes of coronary artery disease. He ended by saying it wasn't the first time he'd seen a young male with such severe, premature coronary artery disease in the absence of identifiable risk factors.

Gallagher accepted the answer without question. Barnett, on the other hand, wasn't satisfied. He'd never personally seen Michael Conti's cholesterol results. (Knowing the stress of an acute heart attack, along with the intravenous fluids and medications Michael was given in the cath lab, precluded David's evaluation of his patient's cholesterol levels .) Barnett was suspicious of Tamayo's description of Michael's cholesterol as being '. . . surprisingly good. Better than average'.)

John Gallagher continued, "I have one final question doctor. As you've so elegantly explained, a nuclear cardiac stress test is not infallible. Likewise, despite the myriad of normal test results you've described, you have acknowledged that Michael Conti's symptoms were, in your own words, 'Highly suggestive of coronary artery disease'. Knowing that, why did you discharge Mr. Conti from your office without pursuing more definitive testing, such as a cardiac catheterization?"

Tamayo, having anticipated this question, was fully prepared to respond. "Very good question, Mr. Gallagher. As I've said, cardiac catheterization does entail some very serious risk--risk that should not be taken lightly."

Barnett whispered to Burkhardt. "Tamayo's full 'a shit it. He's grossly exaggerating the risks and the jury'sa  eating it up. In a man Conti's age, the chance of a serious cath complications; such as a stroke, heart attack or death, is well under one in one-thousand. Catheterizations are remarkably safe and yield invaluable information." Burkhardt nodded to confirm his understanding.

Tamayo proceeded with his response. "The most serious complications are stroke, catheter induced myocardial infarction, and the ultimate complication, death. The risk of each of these devastating events must always be weighed against the potential benefits of rushing into a catheterization procedure."

Gallagher balked at Tamayo's insinuation of needlessly 'rushing' into a dangerous procedure. Approaching the witness stand, he placed both hands on the rail directly in front of the doctor.

Tamayo flinched and leaned back, away from the attorney. Gallagher smiled. I finally have him. And he know's it. 

"Doctor Tamayo, you've mentioned the various potential complications associated with heart catheterization. However, you've not discussed the frequency of such events, the incidence correlated with, what you called, 'devastating complications'. How about it, Doctor? How often do these bad things happen?"

Larry Burkhardt spoke to David. "Gallagher's trapped him. The infamous Dr.Tamayo, has used cath complications as an excuse to ignore an important diagnostic study on his patient. If those complications are as rare as you've said, David, Tamayo's concern about risk becomes moot. Since he was going out of town, he should have, at least, referred Michael Conti to another cardiologist. Michael's death, seven days later, proves the point."

Tamayo stared at the jury for a long, pensive moment before turning to face Gallagher. "Michael Conti's symptoms were not severe, definitely not disabling, and the diagnoses of coronary disease, in my opinion, was less likely than I initially thought."

Gallagher jumped in. "You're saying you changed your mind, Doctor?"

"Yes. After seeing the patient's normal test results, especially his normal stress test, I concluded he did not have angina pectoris."

"Angina pectoris? Please explain that term to the jury."

("Angina is the medical term for chest discomfort or pain resulting from herat disease, so called hardening of the arteries, the coronary arteries.")

"But you've explained, in great detail, how the tests you performed, especially nuclear stress tests, are not infallible. In your own words, they have a proven incidence of 'false negative results'. Meaning, once again as you've said, 'the test can look normal', when in fact, the patient has significant heart problems. Didn't that concern you, Dr. Tamayo?"

Ray Tamayo was beyond mere irritation. He was pissed off. Fuckin' attorneys, he thought.
They have no clue about the long hours, exhausting work and life and death issues a cardiologist deals with. I should tell this prick to shuve it up his ass.The doctor took a deep breath, mentally reviewed his plan and proceeded with another diversional discourse. "There certainly are many conditions that could cause mild chest discomfort and shortness of breath as Mr. Conti described. Furthermore, in this era of medical insurance capitation, rampant malpractice suits, and sky rocketing national health costs, a doctor must always carefully assess the cost--benefit ratio along with procedural risk before  with any expensive or dangerous diagnostic investigation."

Barnett wanted to vomit. he lened toward his attorney. "Larry, this charlatan is back tracking. He's using health care costs as a defense for his negligence. He ordered thousand's of dollars of office testing and ignored the most important procedure because it inconvenienced his schedule. It's nauseating.

Tamayo's pontification continued. "Mr. Gallagher, in light of Mr. Conti's relatively mild symptoms and normal test results, I felt that it would be prudent to not burden him with unnecessary risk and financial expense. Therefore, I deferred a cardiac catheterization until I could observe his response to the medical treatment I prescribed. I gave Mr. Conti a prescription for nitroglycerin along with very specific instructions to go to the emergency room if his pain recurred. He was instructed to take one aspirin tablet a day. In addition, given the possibility that that his pain was musculoskeletal in origin, I advised him to try a brief course of over-the-counter anti-inflammatories. I believe my treatment decisions are medically sound, justified and readily defensible."

Tamayo, to everyone's relief, stopped talking. Gallagher was tired and exasperated. Knowing his client'ss, Carlo's, only concern was to punish david barnett, he reluctantly caved on tamayo. "Your Honor, I have no further questions here."

Judge Richardson, likewise disgusted with Tamayo's verbose arrogance, addressed Attorney Atkins."Mr. Atkins, do you have any questions for your client?"

"Your Honor, I believe Dr. Tamayo's testimony clears him of any wrong doing in this case. I request that he be dismissed from these proceedings."

The( judg) turned back to John Gallagher. "Mr. Gallagher?"

"Your Honor, I'd like to speak with my client."

"Go ahead."

Gallagher walked to Carlo's side and asked if he had any objection to dismissing Dr. Tamayo. Still angry over Tamayo's reference to Michael's 'bad luck', Carlo Conti reluctantly agreed to dismiss. He whispered in Gallagher's ear. "Screw that spic. He's an asshole but he's not the one I'm after."

"Your Honor, we agree to dismiss Dr. Tamayo without prejudice."

Frank Richardson turned to the doctor, still seated at the witness stand. "Dr. Tamayo, you are dismissed from these proceedings for the time being. I must remind you that you could be called for further testimony. You may leave."

Tamayo, snubbing the judge, didn't say a word. He stood, straightened his coat and tie, and slowly stepped from the stand. He strode out as though he were a Nobel Laureate leaving the podium. Once again, David saw a sparkle of light reflecting from Tamayo's diamond studded caduceus pin. He wasn't  surprised to see Tamayo pull off a dismissal. Raymondo Tamayo was the most charismatic, conniving, deceitful human being David Barnett had ever known.