The Procedure by Peter ClementThe Procedure by Peter Clement

The Procedure

byPeter Clement

Paperback | May 29, 2001

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"Heartpounding suspense," hailed Entertainment Weekly of Peter Clement's first medical thriller, Lethal Practice. Now the former ER physician has done it again--combining his technical expertise with a page-burning plot to create a chillingly plausible novel of suspense.

With authentic detail and a surgeon's precision, Clement captures the tense, electrifying atmosphere of a big city hospital turned into a flash point. For in Fatal Medicine, one threat is more dangerous than contagion: the threat of human beings deciding who should live and who should die. . . .

Death is a daily, sometimes hourly, occurrence at St. Vincent's Hospital in Buffalo, New York. Now, in his pressure cooker career, Dr. Earl Garnet has broken the cardinal rule of modern medicine: he publicly blames a powerful HMO for practicing "no-fault murder" in the death of an eighteen-month-old baby. The HMO swiftly strikes back, igniting a debilitating boycott of the hospital. But after several accidents nearly cost patients their lives, the true bloodletting begins. A doctor is found sprawled out in the parking lot, his throat cut ear to ear.

Blamed for instigating the chaos, Earl Garnet knows that he faces more than a deadly power play. The doctor may have uncovered a conspiracy reaching from the halls of one of the nation's most influential HMOs to a small, experimental clinic in Mexico, where yet another of his patients went for treatment and disappeared. To find answers, Garnet must wade deep into the murky, surreal workings of today's health care industry.

Smart, tough, crackling with suspense, and vivid in its hospital setting, this visionary novel instantly places Peter Clement in the distinguished company of Michael Palmer and Robin Cook. Make no mistake: The Procedure is the work of a first-rate physician and an absolutely brilliant storyteller.
Peter Clement, M.D., is a physician who headed an emergency room at a major metropolitan hospital and now maintains a private practice. He is also the author of Lethal Practice and Death Rounds. He is married to a physician and has two sons.
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Title:The ProcedureFormat:PaperbackProduct dimensions:388 pages, 8.5 × 5.5 × 0.75 inShipping dimensions:8.5 × 5.5 × 0.75 inPublished:May 29, 2001Publisher:Random House Publishing GroupLanguage:English

The following ISBNs are associated with this title:

ISBN - 10:0345482824

ISBN - 13:9780345482822

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Chapter 1Five weeks earlier:Tuesday, October 12, 7:00 a.m.The sight of those tiny human remains spread out before us on thedissecting tray staggered me despite my knowing what to expect. The pinkunspoiled lungs, a maroon heart, the small ocher-colored liver, and aspleen the size of a beet—all gleaming under the overhead light—looked newenough to hold the promise of a lifetime’s use. But the brain, no biggerthan my fist, was covered by a thick mesh of crimson streaks. These fannedout over its surface and obscured the tightly coiled ridges and groovesunderneath to the point that I couldn’t see their normal beige, gray, andyellow-white coloration. And the kidneys were so speckled with angry redblotches that a layperson would have thought someone had spattered themwith paint.From the silence of the other physicians and residents in the room, I’ddeduced that everyone was struggling as much as I was to remain clinicallydetached. Not even the voice of the presenting pathologist, normally ourguide to at least make scientific sense out of a death, could ever beginto explain why this child had died. Instead the words simply floated overme, like a Muzak of medical terminology, and consigned themselves to theback of my mind.“. . . the inflamed meninges, the characteristic pattern of hemorrhagicpetechiae on the surface of the kidneys, and the rapidity of thecatastrophic process . . .”When I examined the brain, holding it in the palm of my hand I couldbarely feel its weight through the latex gloves that I’d pulled on inorder to inspect the specimens.“. . . the mother noticed symptoms attributable to an upper respiratoryinfection the day before. The baby was irritable, off his food, crying,and had a mild temperature. She gave him an appropriate dose ofacetaminophen, attempted to keep him hydrated with juice . . .”His name had been Robert Delany, and it was a week ago that his life hadended at eighteen months of age in our emergency department.“. . . she telephoned the after-hours number of her health maintenanceorganization, as it was late in the evening, but the HMO’s triage nursetold her that the child probably only had a cold and could safely waituntil morning to be seen. Yet the boy continued to cry, his fever remainedelevated at a hundred and three despite the acetaminophen, and after a fewhours the mother once more contacted her clinic. Again she was told thatthe baby most likely had the flu and that she should bring him over onlyin the morning. When the mother suggested taking the baby to Emergencythat night, she was told she could if she wished, but since the illnessseemed minor, payment wouldn’t be preauthorized at any more than the rateof an office visit. . . .”The balance of the cost, potentially a thousand dollars if a zealousresident did a battery of tests, they had told her, would not necessarilybe covered. As a result she delayed several more hours, until the childhad started to seize. The images of what had happened then, after hearrived in ER, haunted me still.We’d been like giants gathered around his tiny form while his limbs jerkedwith the repetitive rhythm of a grand mal convulsion. He’d had norespirations, his pressure had been unobtainable, and his heart rate wasslowing 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 grotesquedance gripping the rest of him. His skin color, already blue from lack ofoxygen, 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 endI’d had to grab his pumping right leg, encircle it with my thumb andforefinger to hold it steady, and drive a needle the size of a two-inchnail into the front of his tibia to access his circulation through themarrow within. The steel point had given a lurch as it penetrated theouter layer of bone with a little crunch, but finally I’d gotten a routethrough which I’d been able to infuse enough medication to make theconvulsions stop. But victory had been short-lived. After he’d beenintubated, ventilated, and pinked up a bit, what caught my attention was ared rash breaking out below his eyes and spreading over his trunk as Iwatched.“Oh, my God!” a resident had muttered, peering over my shoulder.“Meningococcemia!” What he was seeing was also calledWaterhouse-Friderichsen syndrome, but by whatever name we gave it, we’dboth known immediately what it meant. Meningococcal bacteria werecascading through the bloodstream from infected meninges at the surface ofthe brain and arriving at the skin. Once there, these microbes producedtoxins that attacked the lining of the blood vessels, and it was thesubsequent hemorrhagic leaks that led to the red spots. The same processwas 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 himas a resident pushed yet another two-inch long needle into him, this onebetween the spines of his third and fourth lumbar vertebrae. Through myhands, which I’d placed on his little back to keep him from moving, I feltthe give of the needle tip when it punctured the membrane containing thespinal cord and its surrounding fluid. As the young doctor drew minutesamples of this clear liquid into several tubes for testing, it flashedthrough me how the feel of the child against my arms was so much like thatof 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 andanother had inserted an IV line into his jugular at the neck. We’d theninfused a loading dose of ceftriaxone, the indicated antibiotic. Withnothing left to be done, I’d stood away from the stretcher and viewed ourwork. The sight of that poor struggling infant, stuck with tubes, needles,and catheters, had broughtme to tears.Later, once all our efforts had come to nothing and I’d pronounced himdead, I cut each one of these lines off at the skin. My leaving their tipsinserted had been in order to verify their position later at autopsy, butI hadn’t wanted them protruding from the boy’s body, in case the motherasked to see him. I’d then cleaned away the blood, covered the puncturesites with small Band-Aids, and placed a blanket over him. I’d had toconcentrate especially hard doing that last simple act. Thoughts oftucking Brendan in kept rushing to mind, and once more I nearly lost thefragile hold I’d had on my own emotions. I’d then gone to tell the motherthat her child had died.Even now, a week after the boy’s death, I could still visualize thehorrible expression I’d seen on her face during theinstant she looked up when I entered the room where shewas waiting. In that second of exchange, before I’d spoken a word, thelight flowed out of her eyes and her face collapsed from a rigid mask ofhope into a fluid swirl of agony and grief.Later, as I’d supported her, she stood over the already whitening corpseof her child. “Can I hold him?” she asked. The nurses looked appalled. I’dswallowed my own alarm, lifted the tiny bundle off the stretcher, andhanded it to her.“. . . Dr. Garnet, is there anything you wish to add to the presentationof this case, before pronouncing whether the death was expected orunexpected, avoidable or unavoidable?” The pathologist’s question pulledmy thoughts back to the present.It took a few seconds longer before I could collect myself enough tospeak. There were specific lessons I wanted the residents to take fromthis, 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’sadmission to Emergency,” I began. “In particular, if the mother hadn’tbeen put off by her HMO, her instincts about the child being sick enoughto warrant a visit to ER might have gotten him here sufficiently earlythat we could have saved him.”“What did the HMO representatives say when they learned of the child’sdeath?” asked a young woman across the table from me. She was planning acareer in ER and was doing a rotation in my department. “I presume youtold them.”“Oh, I told them all right, but they’d covered themselves legally. Noticewhat their triage nurse said to the child’s mother. She could take himinto ER if she thought he was seriously ill, but if the visit wasn’tjustified, they probably wouldn’t cover the cost of any tests. It’s avariant of what HMOs always claim—‘We don’t withhold care; we withholdpayment’—and by so doing they make the choice of whether to come into ERrest with the patient, or as was the case here, with the parent. Accordingto this usual spiel of theirs, the delay was then her doing. Reminding herof company policy regarding trivial visits, and their refusing topreauthorize payment of costly tests, was simply standard procedure, not aviolation of any law. The fact that she second-guessed her initial impulseto get the child help after hearing the reminder made it herresponsibility, not theirs. And legally, they’re right. Of course they arevery sorry the baby died, and his visit will be covered, they were quickto 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 profitwas played. “But that’s wrong,” one of the newcomers said. “They gave hermedical 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,” Ireplied, watching the incredulity grow in his eyes. “In 1998 the so-calledpatients’ rights bill that would have redressed that very issue wasdefeated. And watch out, all of you, while you’re in ER, that you don’tget caught by another dodge that these companies use, or you yourself willbe left paying for the consequences of their decisions to withholdpayment.”The resident looked alarmed. “How could that be?”“If they refuse to cover an admission or a treatment of someone in ER, andyou go along with that decision, despite your better judgment, you areliable 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 thispoor woman belonged to. They’re a new outfit in town called Brama HealthCare, but they’ve been operating on the West Coast for decades and knowevery trick in the book about how to discourage people from going to thehospital yet still remain within the law. In fact, they’re the ones whofirst pleaded the ‘We withhold payment, not care’ defense, therebyrendering it the industry’s battle cry whenever a case goes wrong. Nowthey’re bringing all that expertise to the East, and according to the junkmail they keep bombarding us with, they intend to be the first HMO to havea presence in all fifty states plus the District of Columbia. So whereveryou plan to practice, you’ll be crossing swords with them, and since thelawyers for Brama are the best in the business, I think every residenthere with a desire to make ER a career should listen to them argue a casein court, because then you’ll know what you’re up against. Remember, theirstandard line means that it’s up to you or me as doctors to know what todo medically, regardless of what any triage officer says they will or willnot pay for. ‘Those statements are simply policy guidelines, not medicaldecisions,’ I’ve heard them claim, and the judges agree with them.”In previous years my sole duties as a teacher were to arm the residentsagainst the wily ways of a disease like meningococcemia. These days thecurriculum 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 haveprevented the patient in question from dying. It was the ultimate point ofthe exercise—to identify what we did right, and to temper our skills bylearning from our failures.I hesitated before answering, glancing over the young faces of theresidents turned toward me.“Dr. Garnet?”I looked back at the organs on the table. “Okay, here’swhat I think. If we look at the case simply from the time thechild arrived in ER, the death, tragically, was expected andunavoidable.”Immediately there was a murmur of agreement, followed by a rustle ofmovement and a scraping of chairs as everyone began preparing to leave.“However,” I added, raising my voice above the noise, “we can’t in allconscience ignore what happened in the prehospital phase of this child’sillness.” I waited a few seconds until the room grew quiet again, thencontinued. “Had the mother not been intimidated by Brama Health Care andbrought her son in earlier, the death might have been prevented.”“So that’s your ruling? You’re calling this a preventable death?” thepathologist asked, his forehead creasing. “That’s really not the domain ofthese rounds, to comment on prehospital events—”“Then let’s make it our domain,” I shot back, staring at the remains oflittle Robert Delany. I felt a surge of fury against the likes of Bramaand the new world of medicine that they and their kind had created. Aworld where a decision to withhold care to maximize profit could causeinjury and death, and yet by law no one was accountable. “In fact, I knowexactly what we should label this death, and every death like it. No-faultmurder!”