The Saga of Bill Carter, Part 1

Editor's Note: The following short series involves a case in which the author was involved.

Part 1: Falling Off the Edge of the World

William Carter is a primary care physician from Lancaster County, PA. His story will horrify you.

Dr. Carter has practiced primary care deep in the Amish country of central PA for nearly 30 years. His practice was successful and he has never been sued for malpractice. Dr. Carter is a pillar of the community; his children are popular students and his family is well known and beloved by their friends and neighbors.

In December 2008, Bill’s 14 year old son Connor blew out his knee playing sports. The week before Christmas, Connor underwent an ACL repair and had a rocky post-op course. Connor came home from the hospital complaining of severe pain in the knee. He didn’t sleep at all his first night home despite the oxycodone and non-steroidals and promethazine that had been prescribed by the orthopedic surgeon. Bill became concerned about Connor – his son was an athlete and had a very high threshold for pain. Why was Connor so uncomfortable?

Bill called the orthopedic surgeon and described the knee. It was swollen and tender, but the staples were intact, it wasn’t hot or bleeding and he was neurovascularly stable – it looked like a typical post-op knee. The surgeon was concerned, but was scheduled to be in the OR all day and asked Bill to bring Connor to the office first thing the next day. Bill agreed and uneasily left his suffering son to attend to his own office practice.

While at his office, Bill related Connor’s complications to his office staff. A patient that Bill had treated for many years suggested that Connor might benefit from a fentanyl transdermal patch that she had left over from her own surgery. Bill’s friend and patient gave him the patch for Connor to use and Bill accepted the fentanyl and returned to caring for the citizens of Lancaster County.

That night, Connor seemed worse – his knee was throbbing and he couldn’t get comfortable. Bill placed the fentanyl patch on Connor at 10pm and checked up on him at midnight, surprised to find Connor more comfortable and actually looking forward to getting some sleep. Bill felt relieved and said good-night to his son.

The next morning, Connor was dead.

Bill found his son apneic, initiated CPR by the twinkling lights of the Christmas tree and accompanied him to Lancaster General Hospital, where he was pronounced in the ER. For four hours that day all Bill could scream or say was "I killed him!" to anyone that came near him. An autopsy was performed and since his mother couldn’t bear the thought of her son lying in the cold ground, Connor’s body was cremated.

Dr. Carter, his wife Barbara and the rest of their family spent the next few weeks sleep-walking through the cold bones and days and black, starless nights of winter. Christmas came and went and needn’t have bothered. The Carter’s found small reasons to get out of bed in the morning; they clung to each other and somehow they survived (lived is too definitive a word) moment-by-moment, supported by the community and their friends.

Bill was tortured with the fear that his provision of the fentanyl patch may have contributed to Connor’s death. He turned to his faith and prayer, asking unanswerable and terrifying and timeless questions. Only a parent that has lost a child can begin to understand the anguish and sorrow that the Carter’s endured (and still endure) and no one can begin to understand the wretched, unique heartache and torment that enveloped Bill Carter every minute. Despair was always only a photograph or whispered word away.

Several weeks into 2009, Dr. Carter was notified that the district attorney of Lancaster County was bringing criminal charges of narcotics trafficking (diversion) and manslaughter against him.