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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!”