"Mr. Gallagher please call your next witness."
"Your honor, I call Dr. Steven Goetch to the stand."

Steve Goetch presented quite a contrast to the impeccable appearance of Tamayo. He was wearing a tweed sport coat which was a bit too small for his portly midriff. His tie was wrinkled as though he had just pulled it from the bottom of a laundry hamper and his Khaki cotton pants were noticeably casual for the setting. His hair was flattened on one side as though he had just gotten out of bed. He walked to the stand and took his seat.

"Dr. Goetch, you are an emergency room physician is that correct?"

"Yes, that's right, I work in the emergency room at Mercy Hospital."

"And you were the physician in charge the night that Mr. Michael Conti presented with chest pain."

"That's correct."

"Dr. Goetch are you board certified in emergency room medicine?"

"No, I am not. I'm certified in internal medicine."

"You're not board certified?"

"Yes, as I said, I am board certified but not specifically in emergency care medicine. I wasn't officially trained in emergency medicine and therefore can not register for board examination."

"You weren't trained in emergency medicine and yet the hospital allows you to run the E.R.?"

"Mr. Gallagher, I'm fifty-eight years-old. When I went through my residency training in internal medicine, there was no emergency medical training in existence. The very first training program for emergency care in the United States or the world, for that matter, was started at The University of Cincinnati in 1974. I was already in my Internal medicine residency at that time."

Gallagher, caught off guard by Steve's answer, still pushed on. "Could you please explain to the court how you qualify, at this time, to be in such an important position, in charge of a large hospital emergency room, despite your lack of training."

"First of all, I'm not 'in charge' of the department. I'm under the supervision of Dr. Lewis, who is a board certified emergency care physician. Secondly, I began working in emergency rooms shortly after completing my internal medicine residency. I actually have more experience, twenty-six years of experience in emergency care, than any emergency residency graduate in the country. I was doing ER work before ER training existed."

Barnett was pleased with the way things were going. Steve Goetch had just given Tom Gallagher a hard slap, for not doing his homework. Gallagher was angry.

"I understand that, Doctor, but your education as an internist did not give you the preparation that today's ER residencies provide, did it?"

"No!" Now Goetch was getting irritated. He had worked with numerous ER certified docs and had met more than one that didn't know shit about emergency care, especially about working under fire in hectic atmosphere of a busy Emergency Room battle. Steve paused and stared at Gallagher. "Mr. Gallagher, the learning process in medicine is ongoing. It doesn't stop when you leave your residency training. In fact, I believe most physicians would agree, that they learn as much or more about medicine in the early years of practice, than they do in residency training. Textbook medicine and hands-on care, especially emergency care, are two very different things. Furthermore, with regard to the case at hand, as a board certified internist, I am very qualified to deal with chest pain symptoms, heart disease and myocardial infarctions. Probably more qualified than most emergency specialists."

In theory, Barnett agreed with what Goetch was saying. However, he had always been suspect of Steve's EKG reading ability. For some reason, Goetch wasn't very good at interpreting electrocardiograms for acute infarcts. He liked Steve a lot. They had worked together in the emergency room on many occasions and he wanted him to get out of this mess. David's concern for Steve Goetch's medical career was empathetic but misplaced. Barnett didn't know that Carlo Conti had no interest in harming Goetch or Tamayo. He wanted to destroy David, who needed to be more concerned about his own medical future than that of his associates.

Steve Goetch's answers made Gallagher feel small and ill prepared. In light of Steve's disheveled appearance, Gallagher found his responses to be surprisingly pertinent and succinct. He resented the snide nature of the doctor's answers, which made him feel foolish.

Gallagher continued. "So you believe you are as good or better at handling an acute heart attack in an emergency room, than, let's say, some or even most emergency care specialists?"

"What I am saying is that I'm a board certified internist with over twenty-five years of experience in emergency care work, and I feel highly qualified to deal with diagnosing and treating heart attacks."

Barnett was getting concerned about Steve's demeanor. He didn't want him to lose his cool. Gallagher was getting to him.

"I see. Then, Dr. Goetch, can you, in light of your vast experience and expertise in cardiac care, please explain to the jury why Michael Conti died in your emergency room!"

Gallagher's sarcasm was blatant and his question was incredibly confrontational. Goetch sat back in his chair with a stunned look. He turned to Larry Burkhardt with a look of surprise. His attorney, knowing that Michael Conti died in the cardiac catheterization lab, not the emergency room, stood and was about to object. However, he quickly realized that an objection would be passing the buck to his other client, David Barnett. Goetch was doing fine against Gallagher; Barnett was the one he was concerned about. Burkhardt decided to let it pass, and quickly sat down. Turning to David, he said, "I've never worked with John Gallagher but he seems to know what he's doing. Lawyers, including myself, can be real assholes at times. The bottom line is getting the job done."

Gallagher went on. "Doctor, please tell us what happened."

Goetch took a deep breath to relax and responded with mechanical, curt sentences. "Michael Conti was brought to the hospital emergency room by his wife. He had symptoms of chest heaviness. He had pain in his left arm. He was diaphoretic."

"Please excuse me, Dr. Goetch. What does 'diaphoretic' mean?"

"It means he was perspiring. He was sweating. It was a straight forward case of unstable angina versus acute myocardial infarction.

"Doctor, could you please explain to the jury what those two conditions are."

"I'd be glad to. Angina implies that a person's chest pain id due to coronary artery narrowings. Unstable angina refers to a condition in which the chest pain or angina symptoms are of new onset or have recently become more frequent, and / or more severe in nature. Unstable angina often precedes an acute heart attack."

"And Dr. Goetch, what is an 'MI'?"

"MI is short for myocardial infarction. A heart attack. If a coronary narrowing progresses to a complete closure, a one hundred percent blockage of an artery, it cuts off blood flow to the heart muscle, the myocardium. The heart muscle is damaged or in medical terms, 'infarcted', hence the term 'myocardial infarction'."

"I thank you for your succinct explanation."

Goetch subtly smirked and thought, Yeah, right. I'm sure you're grateful.

"Dr. Goetch, "Is it easy to distinguish between angina, unstable angina, and a heart attack or infarction?"

"It is usually easy to tell the two apart but, on occasion, it can be difficult."

"And in Mr. Conti's case, what was your impression? What diagnosis did you make in reference to his chest pain?"

Barnett hoped Goetch would choose his words carefully. It sounded like Gallagher knew where he was going with this. Despite previously appearing to be uninformed, he now seemed quite prepared. He had obviously done his homework on heart attacks, and David sensed that he was going to trap Goetch in a contradiction.

Steve Goetch continued. "Michael Conti's presentation and diagnosis was problematic for a few reasons."

"And what were those reasons, Doctor?"

"His symptoms sounded very much like an acute myocardial infarction, a heart attack, however, he was only thirty-eight years old and, as we have already heard in great detail, he had no apparent risk factors for heart disease. I've seen heart attacks in men his age, even younger, but they usually had factors such as hypertension, high cholesterol or diabetes. Most of them were heavy smokers."

Gallagher, after hearing Steve's anonymous reference to Ray Tamayo's exhaustive review of risk factors, used the opportunity to take a jab at Tamayo. "Yes, we've already heard of Michael Conti's lack of risk factors during Dr. Tamayo's extensive, yet elegant, discourse." A few laughs echoed through the courtroom. "Please go on, Doctor. You said there were a 'few reasons' for the difficult diagnoses. What other reasons were there?"

"I took a thorough history from both Michael Conti and his wife. Michael was an avid runner, an exercise enthusiast, and he had never smoked." Goetch paused and looked around the courtroom. His eyes met with Laura Conti's, still seated on the front bench directly behind her father-in-law. "I was informed by Mrs. Conti, that her husband had just gone through a very thorough cardiac testing regimen by Dr. Tamayo. To the best of her knowledge, all of Michael's examinations were normal. That, of course, made the presence of underlying coronary artery disease less tenable, thereby, making the diagnosis of unstable angina or myocardial infarction less likely. In addition, and very importantly, Mr. Conti's initial electrocardiogram in the emergency room was completely normal."

"Very nicely done, Doctor."

To Goetch, the attorney's comment reeked of sarcasm, and in some sense, suggested that Steve was lying.

"What was your diagnosis when you saw the normal EKG?"

Barnett took a deep breath and waited for Steve's response. This could be trouble, he thought.

Goetch continued, "My impression was the same. The diagnoses was still unstable angina versus myocardial infarction." David sighed with relief. His friend had given the right answer.

"Please tell me how an electrocardiogram can be 'completely normal' in a patient, who we now know, was in the throes of a soon to be fatal heart attack?"

Fortunately for David, Dr. Goetch was feeling better, more confident about his presentation. "It's rare but possible. If the heart attack is 'hyper acute', meaning in an extremely early phase, the electrocardiogram may not show any abnormalities. I've seen this a few times over past years."

The normal EKG findings were of no benefit to Gallagher's case. He opted to ignore it. "What did you do next doctor, after seeing the normal electrocardiogram?"

"I initiated treatment for unstable angina with an order for testing to exclude or 'rule out' an infarction."

"And what was the treatment you administered to Mr. Conti?"

"Mr. Conti was given sublingual nitroglycerin and one aspirin orally. He was instructed to chew the aspirin before swallowing. An IV was started in his arm and treatment was started with an IV nitroglycerin drip, IV heparin and a single dose of IV morphine."

Gallagher's next question confirmed that he had definitely done his homework on the contemporary standard for treatment for an acute myocardial infarction. "Dr. Goetch, the treatment you've described is for unstable angina, isn't it?"

"That's correct."

"If Mr. Conti were, in fact, having a full blown heart attack, 'an infarction' this wouldn't be the correct treatment, would it?

Goetch was getting angry. "It sure would!"

"But doctor, doesn't the standard for care for a heart attack include more than what you've described? David was impressed with, and concerned about Gallagher's medical knowledge.

"Current treatment includes exactly what I have described, along with other treatment if indicated; either thrombolytic therapy or urgent PTCA, percutaneous coronary angioplasty--commonly called 'balloon treatment'."

"Thrombolytic. Could you please explain what that is?"

"Thrombolytic therapy was introduced in the early 1980's and has revolutionized the treatment of heart attacks. It's known by the general public as 'clot busting' or 'clot dissolving' medicine."

"And urgent angioplasty. Doctor, what is that?"

"Angioplasty is an alternative to thrombolytics. If a cardiac catheterization lab is immediately available, the patient can be taken to the cath laboratory for an angioplasty or 'balloon treatment' to open the blocked artery. This procedure is more definitive than thrombolytics but it can produce delays in treatment related to the time required to access a lab, including time to organize the necessary personnel. Time is of the utmost importance in treating an acute MI."

"Dr. Goetch, are you qualified to perform an angioplasty or 'balloon treatment'?"

"Certainly not. That requires a cardiologist."

"Then are you qualified to prescribe thrombolytic therapy, as a non-cardiologist?"

"Yes, I am."

"You are?"

"That's right!"

"Dr. Goetch, are you sure of that? Michael Conti presented to you on the evening of _________. Isn't it true that Mercy Hospital's emergency room policy in _______________ required patient's to be seen by a cardiologist before treatment with thrombolytics could be initiated?"

Goetch paused as he realized his mistake. Barnett shook his head. He couldn't believe the shit Gallagher knew about this case. Goetch finally answered. "Well, yes. I'd forgotten that. That policy was dropped a few months after Mr. Conti's hospitalization."

Gallagher was elated. "You forgot! So Doctor, in Mr. Conti's case, in 19_________,if you had diagnosed an acute myocardial infarction or 'heart attack', you would have needed a cardiologist present to deliver the treatment that you yourself have described as revolutionary. Is that correct?"

Goetch felt trapped. He had a brief urge walk out and go home. His head drooped. His anxiety was obvious as he stumbled through an answer. "Yes, at that time. Yes, yes, that's correct. You're right."

Barnett couldn't believe it. Goetch was losing it over some half-assed policy that no longer existed.

"Doctor, when did it become apparent that Michael Conti, was in fact suffering an acute myocardial infarction and not the less severe condition called unstable angina?"

"When I saw his repeat electrocardiogram. There were new changes on his EKG, suggesting that he was in the early stages of an acute infarction."

"So, as policy dictated, did you call a cardiologist?"

The question made David feel ashamed. Even though Michael Conti's fate was sealed by his severe, irreversible coronary disease, David had always felt badly about arriving late to the emergency room. In reality, his presence made no difference. There was nothing anybody could have done to save Michael Conti.

Steve Goetch went on. "Mr. Gallagher, hospital policy requires an immediate call to the patient's primary doctor if a critical condition exists."

"And who did you call?"

"I asked Mrs. Conti who their family doctor was. She informed me that they didn't have one. I was actually quite surprised by that."

"Why were you surprised?"

"Well, I see many people without a family doctor but they're usually of lower income status, no health insurance, etc. It appeared to me that the Conti's were successful people. I was told Mr. Conti was an auto executive. It just seemed unusual, that's all--unusual to not have a primary physician."

"So, there was no doctor to call?"

"Well, yes there was. Mrs. Conti informed me of her husband's recent visit to a cardiologist, Dr. Ramondo Tayamo. I instructed the nursing staff to call Dr. Tamayo immediately."

"And did Dr. Tamayo respond?"

"No. We reached his answering service. They informed us that he was out of the country."

Gallagher responded facetiously. Taking another shot at Tamayo. "Yes, Dr. Goetch, we've all heard Dr. Tamayo's exquisite explanation on that." More laughter rang through the courtroom. "What did you do then, Dr. Goetch; since you needed a cardiologist?"

"I called Dr. David Barnett."

(Add or precede with judges fatique--gives Gallagher one las t question after wkich courtwill be dismissed.)