The Procedure

Chapter 1

Five weeks earlier: Tuesday, October 12, 7:00 a.m.

The sight of those tiny human remains spread out before us on the dissecting tray staggered me despite my knowing what to expect. The pink unspoiled lungs, a maroon heart, the small ocher-colored liver, and a spleen the size of a beet-all gleaming under the overhead light-looked new enough to hold the promise of a lifetime's use. But the brain, no bigger than my fist, was covered by a thick mesh of crimson streaks. These fanned out over its surface and obscured the tightly coiled ridges and grooves underneath to the point that I couldn't see their normal beige, gray, and yellow-white coloration. And the kidneys were so speckled with angry red blotches that a layperson would have thought someone had spattered them with paint.

From the silence of the other physicians and residents in the room, I'd deduced that everyone was struggling as much as I was to remain clinically detached. Not even the voice of the presenting pathologist, normally our guide to at least make scientific sense out of a death, could ever begin to explain why this child had died. Instead the words simply floated over me, like a Muzak of medical terminology, and consigned themselves to the back of my mind.

". . . the inflamed meninges, the characteristic pattern of hemorrhagic petechiae on the surface of the kidneys, and the rapidity of the catastrophic process . . ."

When I examined the brain, holding it in the palm of my hand I could barely feel its weight through the latex gloves that I'd pulled on in order to inspect the specimens.

". . . the mother noticed symptoms attributable to an upper respiratory infection the day before. The baby was irritable, off his food, crying, and had a mild temperature. She gave him an appropriate dose of acetaminophen, attempted to keep him hydrated with juice . . ."

His name had been Robert Delany, and it was a week ago that his life had ended at eighteen months of age in our emergency department.

". . . she telephoned the after-hours number of her health maintenance organization, as it was late in the evening, but the HMO's triage nurse told her that the child probably only had a cold and could safely wait until morning to be seen. Yet the boy continued to cry, his fever remained elevated at a hundred and three despite the acetaminophen, and after a few hours the mother once more contacted her clinic. Again she was told that the baby most likely had the flu and that she should bring him over only in the morning. When the mother suggested taking the baby to Emergency that night, she was told she could if she wished, but since the illness seemed minor, payment wouldn't be preauthorized at any more than the rate of an office visit. . . ."

The balance of the cost, potentially a thousand dollars if a zealous resident did a battery of tests, they had told her, would not necessarily be covered. As a result she delayed several more hours, until the child had started to seize. The images of what had happened then, after he arrived in ER, haunted me still.

We'd been like giants gathered around his tiny form while his limbs jerked with the repetitive rhythm of a grand mal convulsion. He'd had no respirations, his pressure had been unobtainable, and his heart rate was slowing into single digits.

"Bag him!"

"His jaw's clamped shut."

"Anybody got a line?"

His eyes had kept flicking to one side, keeping time with the grotesque dance gripping the rest of him. His skin color, already blue from lack of oxygen, had quickly darkened to purple.

". . . get an IV in his neck . . ."

". . . do a cut-down in his foot . . ."

". . . diazepam up the rectum . . ."

Everyone had been shouting orders, residents had stuck him with needles, nurses probed him with catheters, but he continued to seize. In the end I'd had to grab his pumping right leg, encircle it with my thumb and forefinger to hold it steady, and drive a needle the size of a two-inch nail into the front of his tibia to access his circulation through the marrow within. The steel point had given a lurch as it penetrated the outer layer of bone with a little crunch, but finally I'd gotten a route through which I'd been able to infuse enough medication to make the convulsions stop. But victory had been short-lived. After he'd been intubated, ventilated, and pinked up a bit, what caught my attention was a red rash breaking out below his eyes and spreading over his trunk as I watched.

"Oh, my God!" a resident had muttered, peering over my shoulder. "Meningococcemia!" What he was seeing was also called Waterhouse-Friderichsen syndrome, but by whatever name we gave it, we'd both known immediately what it meant. Meningococcal bacteria were cascading through the bloodstream from infected meninges at the surface of the brain and arriving at the skin. Once there, these microbes produced toxins that attacked the lining of the blood vessels, and it was the subsequent hemorrhagic leaks that led to the red spots. The same process was going on in the vasculature of every vital organ in the boy's body, especially in the kidneys. He could be dead within the hour.

I'd turned him on his side, curled his tiny form into a ball, and held him as a resident pushed yet another two-inch long needle into him, this one between the spines of his third and fourth lumbar vertebrae. Through my hands, which I'd placed on his little back to keep him from moving, I felt the give of the needle tip when it punctured the membrane containing the spinal cord and its surrounding fluid. As the young doctor drew minute samples of this clear liquid into several tubes for testing, it flashed through me how the feel of the child against my arms was so much like that of Brendan, my own infant son. By the time we'd finished the procedure, one of the surgical residents had dissected open a vein in his foot and another had inserted an IV line into his jugular at the neck. We'd then infused a loading dose of ceftriaxone, the indicated antibiotic. With nothing left to be done, I'd stood away from the stretcher and viewed our work. The sight of that poor struggling infant, stuck with tubes, needles, and catheters, had brought me to tears.

Later, once all our efforts had come to nothing and I'd pronounced him dead, I cut each one of these lines off at the skin. My leaving their tips inserted had been in order to verify their position later at autopsy, but I hadn't wanted them protruding from the boy's body, in case the mother asked to see him. I'd then cleaned away the blood, covered the puncture sites with small Band-Aids, and placed a blanket over him. I'd had to concentrate especially hard doing that last simple act. Thoughts of tucking Brendan in kept rushing to mind, and once more I nearly lost the fragile hold I'd had on my own emotions. I'd then gone to tell the mother that her child had died.

Even now, a week after the boy's death, I could still visualize the horrible expression I'd seen on her face during the instant she looked up when I entered the room where she was waiting. In that second of exchange, before I'd spoken a word, the light flowed out of her eyes and her face collapsed from a rigid mask of hope into a fluid swirl of agony and grief.

Later, as I'd supported her, she stood over the already whitening corpse of her child. "Can I hold him?" she asked. The nurses looked appalled. I'd swallowed my own alarm, lifted the tiny bundle off the stretcher, and handed it to her.

". . . Dr. Garnet, is there anything you wish to add to the presentation of this case, before pronouncing whether the death was expected or unexpected, avoidable or unavoidable?" The pathologist's question pulled my thoughts back to the present.

It took a few seconds longer before I could collect myself enough to speak. There were specific lessons I wanted the residents to take from this, but I wasn't sure how much of what I was thinking I should reveal. "I think we have to talk about what happened prior to the infant's admission to Emergency," I began. "In particular, if the mother hadn't been put off by her HMO, her instincts about the child being sick enough to warrant a visit to ER might have gotten him here sufficiently early that we could have saved him."

"What did the HMO representatives say when they learned of the child's death?" asked a young woman across the table from me. She was planning a career in ER and was doing a rotation in my department. "I presume you told them."

"Oh, I told them all right, but they'd covered themselves legally. Notice what their triage nurse said to the child's mother. She could take him into ER if she thought he was seriously ill, but if the visit wasn't justified, they probably wouldn't cover the cost of any tests. It's a variant of what HMOs always claim-'We don't withhold care; we withhold payment'-and by so doing they make the choice of whether to come into ER rest with the patient, or as was the case here, with the parent. According to this usual spiel of theirs, the delay was then her doing. Reminding her of company policy regarding trivial visits, and their refusing to preauthorize payment of costly tests, was simply standard procedure, not a violation of any law. The fact that she second-guessed her initial impulse to get the child help after hearing the reminder made it her responsibility, not theirs. And legally, they're right. Of course they are very sorry the baby died, and his visit will be covered, they were quick to tell me, since he was obviously quite ill."

Only the first-year rookies let out exclamations of disgust and surprise. Everyone else in the room was well used to how the deadly game for profit was played. "But that's wrong," one of the newcomers said. "They gave her medical advice not to come in. They have to be legally accountable."

"A lot of lawmakers agree with you, but not the law as it stands," I replied, watching the incredulity grow in his eyes. "In 1998 the so-called patients' rights bill that would have redressed that very issue was defeated. And watch out, all of you, while you're in ER, that you don't get caught by another dodge that these companies use, or you yourself will be left paying for the consequences of their decisions to withhold payment."

The resident looked alarmed. "How could that be?"

"If they refuse to cover an admission or a treatment of someone in ER, and you go along with that decision, despite your better judgment, you are liable for damages, even though they aren't."

"But that's crazy," another innocent exclaimed.

"That's reality," I snapped, "and in particular watch out for the HMO this poor woman belonged to. They're a new outfit in town called Brama Health Care, but they've been operating on the West Coast for decades and know every trick in the book about how to discourage people from going to the hospital yet still remain within the law. In fact, they're the ones who first pleaded the 'We withhold payment, not care' defense, thereby rendering it the industry's battle cry whenever a case goes wrong. Now they're bringing all that expertise to the East, and according to the junk mail they keep bombarding us with, they intend to be the first HMO to have a presence in all fifty states plus the District of Columbia. So wherever you plan to practice, you'll be crossing swords with them, and since the lawyers for Brama are the best in the business, I think every resident here with a desire to make ER a career should listen to them argue a case in court, because then you'll know what you're up against. Remember, their standard line means that it's up to you or me as doctors to know what to do medically, regardless of what any triage officer says they will or will not pay for. 'Those statements are simply policy guidelines, not medical decisions,' I've heard them claim, and the judges agree with them."

In previous years my sole duties as a teacher were to arm the residents against the wily ways of a disease like meningococcemia. These days the curriculum included instruction against the perils of managed care.

"You mean what Brama Health Care did to this baby will go unpunished?" someone else asked.

He was answered with silence.

The pathologist cleared his throat and tried to wrap up the meeting. "Dr. Garnet, would you care to give us your pronouncement on the case?"

Death Rounds always ended with a judgment on whether we could have prevented the patient in question from dying. It was the ultimate point of the exercise-to identify what we did right, and to temper our skills by learning from our failures.

I hesitated before answering, glancing over the young faces of the residents turned toward me.

"Dr. Garnet?"

I looked back at the organs on the table. "Okay, here's what I think. If we look at the case simply from the time the child arrived in ER, the death, tragically, was expected and unavoidable."

Immediately there was a murmur of agreement, followed by a rustle of movement and a scraping of chairs as everyone began preparing to leave. "However," I added, raising my voice above the noise, "we can't in all conscience ignore what happened in the prehospital phase of this child's illness." I waited a few seconds until the room grew quiet again, then continued. "Had the mother not been intimidated by Brama Health Care and brought her son in earlier, the death might have been prevented."

"So that's your ruling? You're calling this a preventable death?" the pathologist asked, his forehead creasing. "That's really not the domain of these rounds, to comment on prehospital events-"

"Then let's make it our domain," I shot back, staring at the remains of little Robert Delany. I felt a surge of fury against the likes of Brama and the new world of medicine that they and their kind had created. A world where a decision to withhold care to maximize profit could cause injury and death, and yet by law no one was accountable. "In fact, I know exactly what we should label this death, and every death like it. No-fault murder!"
Excerpted from The Procedure by Peter Clement. Excerpted by permission of Fawcett, a division of Random House, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.