“Can you explain the disease to the jury, Dr. Kord?” I ask.
“Of course. Acute myelocytic leukemia, or AML, is a disease that strikes two age groups, the first being young adults ranging in age from twenty to thirty, and the second being older people, usually above the age of seventy. Whites get AML more than nonwhites, and for some unknown reason, people of Jewish ancestry get the disease more than others. Men get it more than women. For the most part, the cause of the disease is unknown.
“The body manufactures its blood in the bone marrow, and this is where AML strikes. The white blood cells, which are the ones in charge of fighting infection, become malignant in acute leukemia and the white cell count often rises to one hundred times normal. When this happens, the red blood cells are suppressed, leaving the patient pale, weak and anemic. As the white cells grow uncontrollably, they also choke off the normal production of platelets, the third type of cell found in bone marrow. This leads to easy bruising, bleeding and headaches. When Donny Ray first came to my office, he complained of dizziness, shortness of breath, fatigue, fever and flu-like symptoms.”
When Kord and I were practicing last week, I asked him to refer to him as Donny Ray, not as Mr. Black or patient this or that.
“And what did you do?” I ask. This is easy, I tell myself.
“I ran a routine diagnostic procedure known as a bone marrow aspiration.”
“Can you explain this to the jury?”
“Sure. With Donny Ray, the test was done in his hip bone. I placed him on his stomach, deadened a small area of skin, made a tiny opening, then inserted a large needle. The needle actually has two parts, the outer part is a hollow tube, and inside it is a solid tube. After the needle was inserted into the bone marrow, the solid tube was removed and an empty suction tube was attached to the opening of the needle. This acts sort of like a syringe, and I extracted a small amount of liquid bone marrow. After the bone marrow was aspirated, or removed, we ran the usual tests by measuring the white and red blood cells. There was no doubt he had acute leukemia.”
“What does this test cost?” I ask.
“Around a thousand dollars.”
“And how did Donny Ray pay for it?”
“When he first came to the office, he filled out the normal forms and said he was covered under a medical policy issued by Great Benefit Life Insurance Company. My staff checked with Great Benefit, and verified that such a policy did in fact exist. I proceeded with the treatment.”
I hand him copies of the documents relevant to this, and he identifies them.
“Did you get paid by Great Benefit?”
“No. We were notified by the company that the claim was being denied for several reasons. Six months later the bill was written off. Mrs. Black has been paying fifty dollars a month.”
“How did you treat Donny Ray?”
“By what we call induction therapy. He entered the hospital and I placed a catheter into a large vein under his collarbone. The first induction of chemotherapy was with a drug called ara-C, which goes into the body for twenty-four hours a day, seven straight days. A second drug called idarubicin was also given during the first three days. It’s called ‘red death’ because of its red color and its extreme effect of wiping out the cells in the bone marrow. He was given Allopurinol, an anti-gout agent, because gout is common when large numbers of blood cells are killed. He received intensive intravenous fluids to flush the by-products out of his kidneys. He was given antibiotics and anti-fungus treatments because he was susceptible to infection. He was given a drug called amphotericin B, which is a treatment for funguses. This is a very toxic drug, and it ran his temperature to 104. It also caused uncontrolled shaking, and that’s why amphotericin B is known as ‘shake and bake.’ In spite of this, he handled it well, with a very positive attitude for a very sick young man.
“The theory behind intensive induction therapy is to kill every cell in the bone marrow and hopefully create an environment where normal cells can grow back faster than leukemic cells.”
“Does this happen?”
“For a short period of time. But we treat every patient with the knowledge that the leukemia will reappear, unless of course the patient undergoes bone marrow transplantation.”
“Can you explain to the jury, Dr. Kord, how you perform a bone marrow transplant?”
“Certainly. It’s not a terribly complicated procedure. After the patient goes through the chemotherapy I just described, and if he or she is lucky enough to find a donor whose match is close enough genetically, then we extract the marrow from the donor and infuse through an intravenous tube to the recipient. The idea is to transfer from one patient to another an entire population of bone marrow cells.”
“Was Ron Black a suitable donor for Donny Ray?”
“Absolutely. He’s an identical twin, and they’re the easiest. We ran tests on both men, and the transplant would’ve been easy. It would’ve worked.”
Drummond jumps to his feet. “Objection. Speculation. The doctor can’t testify as to whether or not the transplant would’ve worked.”
“Overruled. Save it for cross-examination.”
I ask a few more questions about the procedure, and while Kord answers I pay attention to the jurors. They’re listening and following closely, but it’s time to wrap this up.
“Do you recall approximately when you were ready to perform the transplant?”
He looks at his notes, but he knows the answers. “August of ’91. About eighteen months ago.”
“Would such a transplant increase the likelihood of surviving acute leukemia?”
“Certainly.”
“By how much?”
“Eighty to ninety percent.”
“And the chances of surviving without a transplant?”
“Zero.”
“I tender the witness.”
It’s after twelve, and time for lunch. Kipler adjourns us until one-thirty. Deck volunteers to fetch deli sandwiches, and Kord and I prep for the next round. He’s savoring the idea of sparring with Drummond.
I’ll never know how many medical consultants Drummond employed to prepare for trial. He’s not obligated to disclose this. He has only one expert listed as a potential witness. Dr. Kord has repeatedly assured me that bone marrow transplantation is now so widely accepted as the preferred means of treatment that no one but a quack would claim otherwise. He’s given me dozens of articles and papers, even books, to support our position that this is simply the best way to treat acute leukemia.
Evidently, Drummond discovered pretty much the same thing. He’s not a doctor, and he’s asserting a weak position, so he doesn’t quarrel too much with Kord. The skirmish is brief. His main point is that very few acute leukemia patients receive bone marrow transplants compared with those who don’t. Less than five percent, Kord says, but only because it’s hard to find a donor. Nationwide, about seven thousand transplants occur each year.
Those lucky enough to find a donor have a much greater chance of living. Donny Ray was a lucky one. He had a donor.
Kord looks almost disappointed when Drummond surrenders after a few quick questions. I have no redirect, and Kord is excused.
The next moment is very tense because I’m about to announce which corporate executive I want to testify. Drummond asked me this morning, and I said I hadn’t made up my mind. He complained to Kipler, who said I didn’t have to reveal it until I was ready. They’re sequestered in a witness room down the hall, just waiting, and fuming.