It was cold, bone-chilling cold, and wet, and…dark… eerily dark. Eerily so because it was only 3:45 in the afternoon. Ice, that had formed on the bare lifeless branches of the trees, dripped black moisture onto the mirror-like streets below. The street lights, prematurely on, only added to the scene as they cast long, imposing shadows on buildings and behind cars.
The snow had long since retreated, leaving behind intermittently spaced piles of black soot that just as well could have been coal from the mines just down the road from the tiny house. The wind whistled, then screamed, scratching at the windows, clawing at the walls demanding to be let in. In the distance the howling of wolves was all that pierced the darkness. Such are the winter days in southwestern Ohio.
Scratch that… I wasn’t there. I wasn’t in Ohio. A great way to start a story, but this was not how this one started. In fact, the weather only seemed that way, so dismal, because over the past two months I had been subjected to an “electronic lynching” by the press that could only be described as criminal. This day, I was actually in Beverly Hills, California, and in reality it was 72 degrees and sunny, a perfect day from the standpoint of the weather.
“Dr. Donda West’s death was not the result of an anesthesia or surgery mishap.” That was the Los Angeles County Coroner’s representative speaking with reporters who had assembled on the steps of the coroner’s offices, and he could not have been any clearer than that. The surgeon was not at fault. But no one heard that, at least none of the reporters assembled there. Worse, they never reported it. Here was the most important point of the entire story, the one based on facts and two months of research by the experts in the field, and it never made it to print. That simple fact was ignored in every story to follow, and had not even been considered as an option in every story preceding it. Statements not based in fact were given a life of their own, but the one statement of the experts, the one formulated after two months of research and analysis, got none.
That was my first mistake. When you are innocent you believe the facts will speak for themselves. They don’t. Facts are like bricks used to build a house. The final result is how you stack them, not the bricks themselves.
Nonetheless, I appreciated his candor. For me as a surgeon, the media circus leading up to that statement was my worst nightmare come true. A patient, not under my direct care, had died about 28 hours after surgery. It could have been worse from my perspective – she could have died on the operating room table, in the recovery room, at our surgery center, or within the first 24 hours post-operatively, but she didn’t. She died at home, more than a day later, under the care of her nephew, an experienced nurse with an advanced degree in public health, a doctor.
The conclusion of the Coroner, along with experts from USC, UCLA, and the private pathologist that I had suggested that the family hire to protect their interests, came as no surprise to me. I had been informed of their conclusions a few hours earlier. In fact, as the surgeon of record, I had been in contact with them throughout the entire ordeal. I had tempered my involvement, and my opinions, so as to allow them to do their work, but make no doubt about it: I had my opinions.
My office had been more than forthcoming with the chart and more than one employee at the coroner’s office had commented on how professional and honest we had been. “Dr Adams” Denice Bertone, the nurse in the Coroner’s office had said, “It is such a pleasure working with you. Most physicians must think we’re stupid down here. We get charts and records that have been “doctored-up” all the time. I just want to thank you for being so honest and forthright. I know this was very hard for you.”
She was wrong. The past two months had been a lot worse than hard. It had been pure hell, period. My personal and my professional lives were publicly mutilated by conjecture, falsehoods and innuendo printed in the popular press. My world was being torn down around me and what remained was simply rotting with each passing moment.
As I sat at the desk in my office staring off in the distance in thought, out of the corner of my eye I could see the lights of the telephone blinking. That was nothing new. For the past few weeks they had remained that way from the time we arrived in the office at seven in the morning until everyone had left at end of the day, only to repeat itself tomorrow and tomorrow and tomorrow. Patients were calling to cancel surgeries and request refunds; the media was calling for interviews; and “crazies” were calling… simply to be calling. They demanded to be heard.
The call was from Dr. Louis Pena, the pathologist who had actually performed the autopsy on Donda West, and not one of his administrators or assistants. I sat staring at the walls, when a gentle tapping at my door aroused my attention. Stephanie, my personal assistant, stuck her head around the door. With a slight smile, and a sort of sucking motion from her lips that made an audible snap, she whispered, “It’s the Coroner on line one”.
“Thanks”, I said… but she did not move. I rolled my eyes, “I’ll let you know what he says.” With that she was gone and I turned to pick up the receiver, “Dr. Adams”.
“Oh, Hi Dr. Adams, this is Dr Pena.”
“Hey, how are you?”
“Fine, thank you…Well… I have very good news for you. Ed Winters is about to announce the conclusions of the Coroner to the press, and we wanted you to hear it from us. The team has concluded that Ms. West’s death is certainly not the result of surgical or anesthesia error. I know that comes as a relief. And I just wanted to thank you again for being professional.”
“Thank you” I said… “Is Winters going to say that…That specifically the cause of her death was not surgical error?” At that point it really did matter to me what he said. Without solid information on the case, the press, lead by TMZ, had decided the story lie in personal attacks on me. The facts would give me the opportunity, as a physician, to defend myself and my reputation.
Incidentally, that was my second mistake: being a doctor. As a physician, I am not afforded the same protections as other citizens when my reputation is challenged. Both Federal and State confidentiality laws prevent me from a public airing of details, but allows clients and the media to make virtually any statement they want regardless of its validity. So long as someone said it, it can be repeated and printed. Worse yet, if you are also considered a public figure like me, assailants get away with making false public statements under the guise of stimulating conversation in a public forum. Regardless of the facts, I have to defend statements made by others, not the truth.
“I can’t say for sure exactly what he’s going to say” Pena offered “…but…if that helps and I can get to him, he might include something like that, but I make no promises. I just wanted you to hear it from us.”
“What’s the official cause of death?” I asked.
“I don’t think anyone can really say. There are a number of possibilities.”
“There are a number of possibilities?” I thought. “What does that mean? I hated pathology (as a student), and that is why. I hated people who always hedged their bets. Radiologists were like that also. I understood their argument, they were looking at shadows, but a pathologist had tissue in front of him; maybe not live tissue, but at the very least, the real thing.”
“I think it was aspiration,” I offered quickly. My first opportunity in two months to say what I believed was not going to be denied. “I think they fed her, gave her narcotics, and then put her in bed with the head of the bed flat to sleep. So she’s sleeping, got narcotics on board that suppress her gag reflex, aspirates her stomach contents, and a few minutes later her heart stops. She dies from respiratory arrest, plain and simple.”
“Well… yes… you’re right… I think it’s fair to say that that scenario is as plausible as any of the others… maybe more.”
“Hmm…well, thanks again for the call,” I said. “Good bye”.
Stephanie was back in the office before the indicator light on the phone went out. “Well?” she asked.
“Well what?” I joked. This time she rolled her eyes… “He said their evaluation shows that ‘neither surgery nor anesthesia errors were the cause of Donda West’s death’.”
“That’s good, right?” she asked.
“That’s very good… But the fact remains, we still have all these patients who have cancelled; there’s no money coming in… and in fact, I’m reimbursing all the surgeries we had scheduled for November and December (our busiest months). It’s not going to be a great holiday…I don’t know if the center can survive this. It’ll take us six months to a year just to get people to start considering coming back. And I can bet you that you won’t read any of it in any paper, or hear about it on the news. None of these people are now going to say: “Oh, never mind, we were wrong; it wasn’t the doctor.”
They didn’t, but the coroner made his opinion known: The Los Angeles County Coroner, in his capacity as the final authority in the matter, filed a complaint with the Nursing Board of the State of California: figure 1. In his complaint, the coroner (along with the other experts) clearly specified who he thought was negligent in the death of Donda West. But you didn’t read that anywhere either. The question is why?
Understand, however, “this is not a story about Donda West”. Physician-patient privilege will remain intact. Her death serves only as a catalyst for the action that follows.
I will document the things I have to say. There will be no hearsay here. For many of the participants that will be painful and embarrassing. For others it will expose their hypocrisy and demonstrate their evil. Some will even feel remorse, though there will be those who continue to deny the truth in the face of overwhelming data. These people are sick and deserve our compassion.