Introduction

Dr. Michael Esposito’s breakout novel stunningly illuminates the world of medicine and malpractice law in a way that fiction never could. Locked In is an intelligent, fast-paced thriller of deceit, greed, and murder set in Tampa’s medical and legal community. Dr. John Armstrong, a respected Tampa radiologist, lives a privileged life built on a crumbling foundation. Cal Burton, his college roommate, is Tampa’s premier medical malpractice attorney. The two men form a group to defraud insurance companies in medical malpractice cases. Initially their scheme is successful but greed pushes them too far. Unbeknownst to Armstrong, the group begins to use their patients as pawns in their malpractice game. Armstrong discovers their plot and attempts to break free. Before he can, the group sets him up for one final case. His battle to free himself without losing it all leads to thrilling climax. Locked In is a must read that will keep the reader up turning pages. Dr. Esposito describes a shocking look at the practice of radiology. His characters and imagery transport the reader beyond the pages and into a terrifying world of medicine gone awry. Locked In clearly positions Dr. Esposito as one of America’s premier writers of medical thrillers.

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Excerpt

The hallway was so long and curved he could not see the end. John wondered if he was headed in the right direction, but as he approached the end of the hallway, a sign pointed the way to the morgue. He followed the sign and in moments he was at Wolfe’s office.

Armstrong grabbed the handle on the door, turned the knob cautiously and pushed the door open. The room was brightly lit in contrast to the hall, and he had to squint. The office was much larger and older than his. There were yellowed, dusty pathology posters covering the faded walls. Wolfe was in the far end of the room looking through a microscope when Armstrong entered. Wolfe gave him a half-hearted smile, or at least he turned up the corner of his mouth which John knew was ominous.

Wolfe stood up and motioned for John to follow him. They entered the autopsy room and Wolfe told Kurt he could take a ten-minute break.

“I want you to have a look at something here, John. I think it’s important.” Wolfe adjusted the microscope to the abnormal area.

John bent down and adjusted the lenses so his eyes could focus on the image below. He saw what appeared to be an arterial wall with plaque within it. “I haven’t looked at one of these in many years, Bill. It appears to me that he had fairly significant atherosclerosis, because there’s calcification in the vessel wall. Am I correct?”

“Right on the money, John. You’re wasting your talents in radiology. You should come down to where the money is - pathology.”

“I don’t like to deal with dead people.”

“We don’t only deal with dead people. We make all the diagnoses in the hospital.”

Wolfe was proud of the fact he was a pathologist. He enjoyed assisting in making many of the diagnoses in the hospital, and his skill allowed for rapid treatment in many cases. An equivocal or erroneous pathology report would delay treatment or result in the wrong treatment for the patient. He was very diligent about keeping up with the latest literature and studying things he was not sure of.

“Take a look at the vessel wall.”

John turned the knob on the side of the microscope and scanned through the slide. He examined the vessel wall and noticed there was an unusual pattern of markings along the outside wall. He was unsure what it meant, but he believed it was what Wolfe wanted him to see. “I see some kind of irregularity along the vessel wall. There appear to be areas of indentation or impression at regularly spaced intervals.” John stood up, straightened his lanky frame from the microscope and looked at Wolfe. Wolfe was staring back at him with a blank expression.

“That’s what I wanted you to see. What do you think of it?”

Armstrong thought about the markings, but didn’t come up with any solution. He was not used to looking at anything under a microscope and was unsure of the meaning. He wondered what kind of biological event could cause such a regular pattern of deformity or striation on a vessel wall.

“Could that be fibromuscular dysplasia, with areas of muscular hypertrophy alternating with areas where the muscle is atrophied?” John asked.

“Think again, my friend. Think of something iatrogenic.” Wolfe watched Armstrong’s eyebrows raise. “Those are marks from a hemostat. Norman placed a hemostat on the basilar artery,” Wolfe said.

Armstrong’s stomach lurched. “How do you think that happened?”

Wolfe looked away. “You probably don’t want to hear what I am about to say. I can’t prove it. To prove what I’m accusing someone of is very difficult.”

Armstrong knew what Wolfe was about to say, but was not sure he wanted to hear it. How would this affect them? They were both nearly as guilty of the same crime. They had agreed to send this man to surgery. Surgery may or may not have been indicated, but in pushing the case they had allowed Carmichael to be in the hands of Norman, who was unscrupulous and immoral.

“Well, let me show you the gross pictures of the cerebellum and then the microscopic margins.” Wolfe walked over to his desk and turned the computer monitor towards John. The screen showed images of Mr. Carmichael’s sectioned brain on a cine-loop. In the left cerebellar hemisphere there was a four centimeter wedge shaped piece of brain removed. “This is the surgical cavity created by Norman. You can see how well defined the margins are.” Wolfe pointed with his pen. “It’s in the shape of a triangle. That is not a natural occurring cavity. Of course, we know that. Because he submitted the section for review.”

Armstrong studied the pictures. He had not often seen gross anatomy pictures of this portion of the brain, but recognized it well from the MRI, which detailed magnificently.

“The lesion only involved the peripheral two-thirds of the cerebellum. How did he get near the basilar artery?” he asked.

“Well, that’s the question. There was no reason to get near the basilar artery. I didn’t do the frozen section on this case, but Dr. Carlton did. He told Norman the tissue he saw appeared to be nonmalignant. The section he sent was consistent with infarct.”

Armstrong’s heightened nerves sensed there may have been a conspiracy. “I thought you were going to read the case.”

“I got caught up in grand rounds and got here late. I keep wondering if I had shown up earlier, whether Carmichael would still be alive.”

“Bill, I have questioned many things, too. I don’t blame you for something Norman did. Remember, I’m the one that got the whole Carmichael case rolling. I have more than enough blame on myself already.”

“Thank you, John. I’ve been feeling terrible lately. Obviously that won’t make everything right, but maybe it will help me get on the correct path.” He smiled. He almost felt sorry for John, who was unaware of who and what he was up against. “Anyway, Norman resected more tissue even though Carlton told him it was benign.”

“But there was no need for him to resect any more tissue,” Armstrong said.

“Exactly. But it still didn’t explain how he gained access to the basilar artery. I assumed there was no way he could have after viewing the gross sections. We did not section the cerebellum any further since we had the surgical specimen. However, I went back and examined the gross brain. There’s an incision from the apex of the triangular-shaped cavity towards the basilar artery. The incision is complete and separates the lateral portion of the cerebellum from the medial portion. Superiorly it is still intact, so the brain appeared to be uninjured or unaffected. However, I was able to slip a surgical instrument through this crevice. The tip of the hemostat was where the basilar artery would have been if I did not remove it.”

“So, what you’re saying is, Norman made an incision through the normal brain substance just to get to the basilar artery?” Armstrong started pacing the room. Oh my God. Norman had deliberately clamped the only blood vessel supplying blood flow to Carmichael’s brain.

John Armstrong realized he had reached a new low. He had made many mistakes over the past year, but the most egregious was manipulating the films on Mr. Carmichael. If this were made public he would be in jail for a long time, and that thought terrified him. He could not survive being caged like an animal.

John tried to examine the situation logically, resigned to the fact that he was in serious trouble now. The changes he had made in Carmichael’s case were no longer important. They were no longer documented, since most of the films were somehow missing from the patient’s jacket. The only evidence that he had changed anything was on the optical disk which he thought he had erased. But the disk was missing from the storage room. Norman probably had the disk, which would not matter unless Norman planned to blackmail him.

John saw a scenario where a man had died and he had read the case as possibly being a tumor. It was not really a miss. However, the tumor had turned out to be an infarct, and it was iffy as to whether the surgery was indicated. Carmichael may have had cerebellar symptoms and would have needed surgery even if it were an infarct. That would have depended on his clinical presentation, which would be determined by Norman’s note and testimony. Every which way John turned, Norman stood holding the key to his future.

Armstrong could see himself being sued for a large amount of money in this case if someone played the cards correctly. Norman assured him the family would not be litigious toward him, but toward the anesthesiologist. The family was “informed” that the anesthesiologist had made some mistakes in surgery, which caused a severe hypotensive episode and a large stroke. Norman had told the family there was no need for Mr. Carmichael to die. The anesthesiologist should have known better than to allow him to operate when he had such severe carotid disease. The carotid stenosis could have been fixed under local anesthetic or even with a radiological procedure, and Carmichael would have lived. The anesthesiologists were incompetent in this case.

Armstrong could not believe how hard Norman had come down on the anesthesiologist, but it exonerated himself and Wolfe.

“How sure are you those marks are from a hemostat?” Armstrong asked, his mouth dry.

“I could show you the photos I made with the high-powered microscope, which show the actual striations. If I wanted to, I could pull the surgical instruments from Norman’s tray and analyze the contour of each hemostat. I could tell you exactly which hemostat caused this injury.”

“You’re saying he clamped the basilar artery and basically killed this man.” Armstrong was tired of beating around the bush. He and Wolfe had something in common. They were both screwed by Norman and were in over their heads. “What are you going to do with the information?”

Wolfe shrugged. “I don’t know. I can’t go to the police because Norman will implicate us, and then we are just as guilty as he is.”

Armstrong paced the worn linoleum floor, staring blankly, grappling with impotent anger. “If you do nothing, then you have to falsify your autopsy report and say he died of a stroke, which he did,” Armstrong told Wolfe, trying to get him to agree.

Wolfe took a deep breath and looked at him. “Technically, you’re correct. Mr. Carmichael did die of a stroke. The etiology was decreased perfusion to his brain. But that’s the same as saying somebody who gets shot in the head died because their brain was swelling and not because the bullet caused the injury. There are extenuating circumstances in this case that neither one of us wants to face.” His voice trailed off. “I think we both have blood on our hands.” view abbreviated excerpt only...

Discussion Questions

From the author:

1. The day Carmichael went to surgery, Wolfe was giving grand rounds. Was he late back to work on purpose. Was it all part of a setup?

2. Armstrong attempted to prevent Emily from having surgery but Norman changed plans. Did Norman plan the outcome of the surgery or did it happen by chance? Was he also trying to set up Wolfe?

3. At what point in the the novel did you figure out the ending? Thinking back, did you see the hints which could have led you to the conclusion?

4. Was Armstrong really a bad guy or was he a guy trying to hold together a bad situation?

Weblinks

»	Publisher's Book Info
»	Author Mike Esposito's web site

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