Sometimes, bathed in the glare of operating room lights, Dr. Tom Marchioro wore a surgical cap emblazoned with a sign proclaiming him "The Boss."
Not that anyone ever doubted that the renowned University of Washington surgeon was in charge when it was his patient on the operating table. Marchioro perhaps just decorated his cap to teach his students about confidence, perhaps to reaffirm that quick, informed decisions must be made when wielding surgical instruments on human tissue and bone.
Tomorrow in King County Superior Court, attorneys for Marchioro's widow, Karen, will begin arguing a medical malpractice lawsuit that says the UW didn't measure up in taking care of one its most famous doctors, a pioneer in kidney transplant surgery and a nationally known teacher and researcher.
Recovering from treatment of a heart-surgery wound infection, Marchioro, 66, bled to death in front of his wife after his heart ruptured when he coughed. Scar tissue binding the back of his breast bone, or sternum, to the heart wall literally pulled the organ apart with the movement of his chest. Attorneys will argue that in addition, a tiny piece of surgical wire that had been left in his sternum pierced his heart and contributed to his death.
The suit charges that three UW physicians through negligence caused Marchioro's death on Feb. 5, 1994. The scar tissue and wire fragment should have been removed and better overall care could have prevented complications, the lawsuit contends.
Attorneys for the UW and the three physicians will argue that there was no negligence, that Marchioro received the best care available. They will also argue that Marchioro was indeed "The Boss" in his own case, that he directed most of his own treatment.
The defendants are the UW Medical Center and three of Marchioro's colleagues: Dr. Edward Verrier, chief of cardiothoracic surgery; Dr. Richard Rand, chief of plastic and reconstructive surgery; and Dr. Mika Sinanan, a general surgeon.
Nearly three years of efforts by Karen Marchioro to reach an out-of-court settlement in the case failed. The plaintiff, former chair of the state Democratic Party, asked for $2.6 million. UW officials insist there was no negligence at all.
Now, no one doubts it will be a tough, painful trial for both sides.
"It's a tragedy in all directions," said Dr. Roger Moe, a veteran UW surgeon and friend of Marchioro's and the physicians being sued. "The whole thing is fraught with pain, and nothing is going to change that. Not only has his family lost their loved one, but the department of surgery has lost a highly respected colleague."
Smoking took heavy toll
Thomas Marchioro, a burly, barrel-chested man, was the son of a Butte, Mont., copper miner who worked in the mines himself during high school and college. When he was 17, his mother was injured in an auto accident and died because of botched medical care, according to Karen Marchioro. She said the death was a factor in his decision to go into medicine.
With his quick mind and fierce determination, Marchioro's medical career took off early. After graduating from St. Louis University Medical School and completing four residencies, Marchioro performed some of the earliest kidney and liver transplants, with Dr. Thomas Starzl at the University of Colorado. He and Starzl also did groundbreaking research on how to prevent the body from rejecting transplanted organs.
Marchioro joined the UW Medical School faculty in 1967 and quickly established a reputation as an excellent surgeon and teacher. He performed kidney transplants and surgeries on the lungs, pancreas, liver, gallbladder and just about anything else in the chest and abdomen. He was vice-chairman of the department of surgery. At age 63, he started the UW's lung-transplant program, and only three weeks before his death he was still helping with those operations.
He also smoked heavily for 45 years - from one to four packs of unfiltered Camels a day for about half of that time. Only after a 1989 heart attack was he able to conquer his addiction. But the damage of smoking, naturally high cholesterol, and a weight problem all took a heavy toll on the revered surgeon.
Series of surgeries
In October 1989, Marchioro underwent three-artery bypass surgery at UW Medical Center. He did well for a time, but in 1994 suffered another minor heart attack. He had another bypass on Sept. 15, 1994, this time on five arteries. The next five months were fraught with problems.
By the end of September, one of the bypass arteries had clogged, and a procedure called a balloon angioplasty and the use of blood thinners could not clear the vessel. Marchioro soon needed additional surgery to remove two abdominal hematomas, or knots of blood, stemming from blood-thinner injections.
He developed kidney problems related to X-ray dye used in the attempted artery clearing. And most important to the lawsuit, his sternum, which had been opened for the September bypass, developed a one-eighth inch split and became unstable.
The instability caused a clicking in Marchioro's chest, and pain radiated into his shoulder. The pain interfered with his work in the operating room.
In January 1994, he asked Sinanan and Rand to treat the problem. On Jan. 25, they fastened metal plates to his sternum to pull it together and stabilize it, and repaired a related hernia near his abdomen. They also removed several wires that had closed his chest in the September heart surgery. But they missed a fragment of one.
In early February, Marchioro's sternum became infected, and on Saturday, Feb. 4, Sinanan and Rand removed the plates, cleared out the infection and left the sternum open to allow the wound to heal without infection.
On Sunday morning, a nurse's aide pushed Marchioro in a wheelchair to an X-ray room, with his wife pushing a wheeled stand carrying intravenous solutions alongside. The top-heavy IV stand tipped over and Tom Marchioro reached out to grab it. Some witnesses will say that may have started a small tear in the heart wall.
Thirty minutes later in bed, Marchioro coughed, pulling the split sternum farther apart. That pulled on the scar tissue, which pulled apart the heart tissue to which it was bound. Marchioro bled to death in minutes.
`Tough decision to sue'
Karen Marchioro was angry from the beginning. She learned that Verrier, the UW's chief heart surgeon, wasn't present for all of his colleague's second bypass surgery - that some of it was performed by a surgical resident in training, though his name was not on the surgery consent form. It is not uncommon for residents to perform less complicated portions of operations without the chief surgeon present.
In depositions taken in the suit, there is conflicting testimony over who first opened Marchioro's chest: Verrier says he did it, but the resident says he did it. Witnesses on both sides say who opened the chest didn't affect the outcome.
Marchioro says she blames the beginnings of her husband's complications on Verrier's absence during part of the surgery and says those problems weren't handled properly. She says in her suit that the other surgeons were also negligent because they didn't consult with Verrier or have a heart surgeon present for the sternum restabilization and the surgery to treat the infection. The surgeons deny the accusations and say Verrier was present for part of the Feb. 4 operation.
"It was a tough, tough decision to sue," Marchioro said last week. "But I had a long time to think about the anger that I had . . . about how someone who had worked so hard (for the UW) had such a series of bad mistakes made on him."
UW attorney William Leedom will argue that Marchioro received excellent care, both in the surgeries and for the complications, which can occur in any heart patient. He will say that Marchioro, an expert chest surgeon, was intimately involved in his own care.
"Dr. Marchioro not only consented to, but specifically sought all of the treatment he received, and hand-selected the specialists who performed the surgeries," the defendants say in court documents. None of the specialists would consent to interviews with The Times.
Expert witnesses for the UW will say that the wire fragment left in the sternum probably did not injure Marchioro's heart. And the attorneys will argue that Marchioro specifically asked the surgeons not to operate deeper than the sternum during the January and February surgeries - that, in effect, he told them not to remove the scar tissue.
"Further dissection into the mediastinum (interior chest) would have risked injury to the heart, to the coronary artery bypass grafts, and certainly would have exposed all these to an active infection," Sinanan said in court documents.
Ron Perey, attorney for Karen Marchioro, will tell the court that there is nothing in Tom Marchioro's medical record documenting his alleged statements about not entering the chest. Such notations are required by hospital and state regulations, he says.
Perey will also cite one medical study saying there is a 15 percent risk of heart rupture when the sternum is left open. He will say the doctors should have removed the scar tissue that pulled Marchioro's heart apart, they should have performed other procedures to stabilize the sternum, or they should have kept Marchioro immobilized in the intensive care unit until his sternum could be closed.
Karen Marchioro, trained as a registered nurse, cannot accept that her husband would have given instructions that would have endangered him. "If he ever had any reservations about (going into his chest) he never told me about them," she said in an interview.
Not an easy job
One of Tom Marchioro's former students and colleagues is Dr. Craig Eddy, now director of trauma services at St. Patrick's Hospital in Missoula, Mont. He fondly remembers Marchioro for his brilliance as a surgeon, for his intellectual integrity and for his strong personality. He does not doubt that his friend would have helped direct his own care.
All of that, he said, helps frame the difficulty of the court case.
"I think it was not an easy task to take care of him. But as doctors we are faced with lots of tasks that aren't easy and we still have to decide how to deliver care," he said.
With obvious pain, he added: "They're going to duke this out in court, try to sort it all out. . . . The tough thing is that it won't bring Tom back."
Warren King's phone message number is 206-464-2247. His e-mail address is: firstname.lastname@example.org