{"product_id":"the-procedure-isbn-9780345482822","title":"The Procedure","description":"\"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.\u003cbr\u003e\u003cbr\u003eWith 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. . . .\u003cbr\u003e\u003cbr\u003eDeath 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.\u003cbr\u003e\u003cbr\u003eBlamed 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.\u003cbr\u003e\u003cbr\u003eSmart, 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.Chapter 1\u003cbr\u003e\u003cbr\u003eFive weeks earlier:\u003cbr\u003eTuesday, October 12, 7:00 a.m.\u003cbr\u003e\u003cbr\u003e\u003cbr\u003eThe sight of those tiny human remains spread out before us on the\u003cbr\u003edissecting tray staggered me despite my knowing what to expect. The pink\u003cbr\u003eunspoiled lungs, a maroon heart, the small ocher-colored liver, and a\u003cbr\u003espleen the size of a beet—all gleaming under the overhead light—looked new\u003cbr\u003eenough to hold the promise of a lifetime’s use. But the brain, no bigger\u003cbr\u003ethan my fist, was covered by a thick mesh of crimson streaks. These fanned\u003cbr\u003eout over its surface and obscured the tightly coiled ridges and grooves\u003cbr\u003eunderneath to the point that I couldn’t see their normal beige, gray, and\u003cbr\u003eyellow-white coloration. And the kidneys were so speckled with angry red\u003cbr\u003eblotches that a layperson would have thought someone had spattered them\u003cbr\u003ewith paint.\u003cbr\u003e\u003cbr\u003eFrom the silence of the other physicians and residents in the room, I’d\u003cbr\u003ededuced that everyone was struggling as much as I was to remain clinically\u003cbr\u003edetached. Not even the voice of the presenting pathologist, normally our\u003cbr\u003eguide to at least make scientific sense out of a death, could ever begin\u003cbr\u003eto explain why this child had died. Instead the words simply floated over\u003cbr\u003eme, like a Muzak of medical terminology, and consigned themselves to the\u003cbr\u003eback of my mind.\u003cbr\u003e\u003cbr\u003e“. . . the inflamed meninges, the characteristic pattern of hemorrhagic\u003cbr\u003epetechiae on the surface of the kidneys, and the rapidity of the\u003cbr\u003ecatastrophic process . . .”\u003cbr\u003e\u003cbr\u003eWhen I examined the brain, holding it in the palm of my hand I could\u003cbr\u003ebarely feel its weight through the latex gloves that I’d pulled on in\u003cbr\u003eorder to inspect the specimens.\u003cbr\u003e\u003cbr\u003e“. . . the mother noticed symptoms attributable to an upper respiratory\u003cbr\u003einfection the day before. The baby was irritable, off his food, crying,\u003cbr\u003eand had a mild temperature. She gave him an appropriate dose of\u003cbr\u003eacetaminophen, attempted to keep him hydrated with juice . . .”\u003cbr\u003e\u003cbr\u003eHis name had been Robert Delany, and it was a week ago that his life had\u003cbr\u003eended at eighteen months of age in our emergency department.\u003cbr\u003e\u003cbr\u003e“. . . she telephoned the after-hours number of her health maintenance\u003cbr\u003eorganization, as it was late in the evening, but the HMO’s triage nurse\u003cbr\u003etold her that the child probably only had a cold and could safely wait\u003cbr\u003euntil morning to be seen. Yet the boy continued to cry, his fever remained\u003cbr\u003eelevated at a hundred and three despite the acetaminophen, and after a few\u003cbr\u003ehours the mother once more contacted her clinic. Again she was told that\u003cbr\u003ethe baby most likely had the flu and that she should bring him over only\u003cbr\u003ein the morning. When the mother suggested taking the baby to Emergency\u003cbr\u003ethat night, she was told she could if she wished, but since the illness\u003cbr\u003eseemed minor, payment wouldn’t be preauthorized at any more than the rate\u003cbr\u003eof an office visit. . . .”\u003cbr\u003e\u003cbr\u003eThe balance of the cost, potentially a thousand dollars if a zealous\u003cbr\u003eresident did a battery of tests, they had told her, would not necessarily\u003cbr\u003ebe covered. As a result she delayed several more hours, until the child\u003cbr\u003ehad started to seize. The images of what had happened then, after he\u003cbr\u003earrived in ER, haunted me still.\u003cbr\u003e\u003cbr\u003eWe’d been like giants gathered around his tiny form while his limbs jerked\u003cbr\u003ewith the repetitive rhythm of a grand mal convulsion. He’d had no\u003cbr\u003erespirations, his pressure had been unobtainable, and his heart rate was\u003cbr\u003eslowing into single digits.\u003cbr\u003e\u003cbr\u003e“Bag him!”\u003cbr\u003e\u003cbr\u003e“His jaw’s clamped shut.”\u003cbr\u003e\u003cbr\u003e“Anybody got a line?”\u003cbr\u003e\u003cbr\u003eHis eyes had kept flicking to one side, keeping time with the grotesque\u003cbr\u003edance gripping the rest of him. His skin color, already blue from lack of\u003cbr\u003eoxygen, had quickly darkened to purple.\u003cbr\u003e\u003cbr\u003e“. . . get an IV in his neck . . .”\u003cbr\u003e\u003cbr\u003e“. . . do a cut-down in his foot . . .”\u003cbr\u003e\u003cbr\u003e“. . . diazepam up the rectum . . .”\u003cbr\u003e\u003cbr\u003eEveryone had been shouting orders, residents had stuck him with needles,\u003cbr\u003enurses probed him with catheters, but he continued to seize. In the end\u003cbr\u003eI’d had to grab his pumping right leg, encircle it with my thumb and\u003cbr\u003eforefinger to hold it steady, and drive a needle the size of a two-inch\u003cbr\u003enail into the front of his tibia to access his circulation through the\u003cbr\u003emarrow within. The steel point had given a lurch as it penetrated the\u003cbr\u003eouter layer of bone with a little crunch, but finally I’d gotten a route\u003cbr\u003ethrough which I’d been able to infuse enough medication to make the\u003cbr\u003econvulsions stop. But victory had been short-lived. After he’d been\u003cbr\u003eintubated, ventilated, and pinked up a bit, what caught my attention was a\u003cbr\u003ered rash breaking out below his eyes and spreading over his trunk as I\u003cbr\u003ewatched.\u003cbr\u003e\u003cbr\u003e“Oh, my God!” a resident had muttered, peering over my shoulder.\u003cbr\u003e“Meningococcemia!” What he was seeing was also called\u003cbr\u003eWaterhouse-Friderichsen syndrome, but by whatever name we gave it, we’d\u003cbr\u003eboth known immediately what it meant. Meningococcal bacteria were\u003cbr\u003ecascading through the bloodstream from infected meninges at the surface of\u003cbr\u003ethe brain and arriving at the skin. Once there, these microbes produced\u003cbr\u003etoxins that attacked the lining of the blood vessels, and it was the\u003cbr\u003esubsequent hemorrhagic leaks that led to the red spots. The same process\u003cbr\u003ewas going on in the vasculature of every vital organ in the boy’s body,\u003cbr\u003eespecially in the kidneys. He could be dead within the hour.\u003cbr\u003e\u003cbr\u003eI’d turned him on his side, curled his tiny form into a ball, and held him\u003cbr\u003eas a resident pushed yet another two-inch long needle into him, this one\u003cbr\u003ebetween the spines of his third and fourth lumbar vertebrae. Through my\u003cbr\u003ehands, which I’d placed on his little back to keep him from moving, I felt\u003cbr\u003ethe give of the needle tip when it punctured the membrane containing the\u003cbr\u003espinal cord and its surrounding fluid. As the young doctor drew minute\u003cbr\u003esamples of this clear liquid into several tubes for testing, it flashed\u003cbr\u003ethrough me how the feel of the child against my arms was so much like that\u003cbr\u003eof Brendan, my own infant son. By the time we’d finished the procedure,\u003cbr\u003eone of the surgical residents had dissected open a vein in his foot and\u003cbr\u003eanother had inserted an IV line into his jugular at the neck. We’d then\u003cbr\u003einfused a loading dose of ceftriaxone, the indicated antibiotic. With\u003cbr\u003enothing left to be done, I’d stood away from the stretcher and viewed our\u003cbr\u003ework. The sight of that poor struggling infant, stuck with tubes, needles,\u003cbr\u003eand catheters, had brought\u003cbr\u003eme to tears.\u003cbr\u003e\u003cbr\u003eLater, once all our efforts had come to nothing and I’d pronounced him\u003cbr\u003edead, I cut each one of these lines off at the skin. My leaving their tips\u003cbr\u003einserted had been in order to verify their position later at autopsy, but\u003cbr\u003eI hadn’t wanted them protruding from the boy’s body, in case the mother\u003cbr\u003easked to see him. I’d then cleaned away the blood, covered the puncture\u003cbr\u003esites with small Band-Aids, and placed a blanket over him. I’d had to\u003cbr\u003econcentrate especially hard doing that last simple act. Thoughts of\u003cbr\u003etucking Brendan in kept rushing to mind, and once more I nearly lost the\u003cbr\u003efragile hold I’d had on my own emotions. I’d then gone to tell the mother\u003cbr\u003ethat her child had died.\u003cbr\u003e\u003cbr\u003eEven now, a week after the boy’s death, I could still visualize the\u003cbr\u003ehorrible expression I’d seen on her face during the\u003cbr\u003einstant she looked up when I entered the room where she\u003cbr\u003ewas waiting. In that second of exchange, before I’d spoken a word, the\u003cbr\u003elight flowed out of her eyes and her face collapsed from a rigid mask of\u003cbr\u003ehope into a fluid swirl of agony and grief.\u003cbr\u003e\u003cbr\u003eLater, as I’d supported her, she stood over the already whitening corpse\u003cbr\u003eof her child. “Can I hold him?” she asked. The nurses looked appalled. I’d\u003cbr\u003eswallowed my own alarm, lifted the tiny bundle off the stretcher, and\u003cbr\u003ehanded it to her.\u003cbr\u003e\u003cbr\u003e“. . . Dr. Garnet, is there anything you wish to add to the presentation\u003cbr\u003eof this case, before pronouncing whether the death was expected or\u003cbr\u003eunexpected, avoidable or unavoidable?” The pathologist’s question pulled\u003cbr\u003emy thoughts back to the present.\u003cbr\u003e\u003cbr\u003eIt took a few seconds longer before I could collect myself enough to\u003cbr\u003espeak. There were specific lessons I wanted the residents to take from\u003cbr\u003ethis, but I wasn’t sure how much of what I was thinking I should reveal.\u003cbr\u003e“I think we have to talk about what happened prior to the infant’s\u003cbr\u003eadmission to Emergency,” I began. “In particular, if the mother hadn’t\u003cbr\u003ebeen put off by her HMO, her instincts about the child being sick enough\u003cbr\u003eto warrant a visit to ER might have gotten him here sufficiently early\u003cbr\u003ethat we could have saved him.”\u003cbr\u003e\u003cbr\u003e“What did the HMO representatives say when they learned of the child’s\u003cbr\u003edeath?” asked a young woman across the table from me. She was planning a\u003cbr\u003ecareer in ER and was doing a rotation in my department. “I presume you\u003cbr\u003etold them.”\u003cbr\u003e\u003cbr\u003e“Oh, I told them all right, but they’d covered themselves legally. Notice\u003cbr\u003ewhat their triage nurse said to the child’s mother. She could take him\u003cbr\u003einto ER if she thought he was seriously ill, but if the visit wasn’t\u003cbr\u003ejustified, they probably wouldn’t cover the cost of any tests. It’s a\u003cbr\u003evariant of what HMOs always claim—‘We don’t withhold care; we withhold\u003cbr\u003epayment’—and by so doing they make the choice of whether to come into ER\u003cbr\u003erest with the patient, or as was the case here, with the parent. According\u003cbr\u003eto this usual spiel of theirs, the delay was then her doing. Reminding her\u003cbr\u003eof company policy regarding trivial visits, and their refusing to\u003cbr\u003epreauthorize payment of costly tests, was simply standard procedure, not a\u003cbr\u003eviolation of any law. The fact that she second-guessed her initial impulse\u003cbr\u003eto get the child help after hearing the reminder made it her\u003cbr\u003eresponsibility, not theirs. And legally, they’re right. Of course they are\u003cbr\u003every sorry the baby died, and his visit will be covered, they were quick\u003cbr\u003eto tell me, since he was obviously quite ill.”\u003cbr\u003e\u003cbr\u003eOnly the first-year rookies let out exclamations of disgust and surprise.\u003cbr\u003eEveryone else in the room was well used to how the deadly game for profit\u003cbr\u003ewas played. “But that’s wrong,” one of the newcomers said. “They gave her\u003cbr\u003emedical advice not to come in. They have to be legally accountable.”\u003cbr\u003e\u003cbr\u003e“A lot of lawmakers agree with you, but not the law as it stands,” I\u003cbr\u003ereplied, watching the incredulity grow in his eyes. “In 1998 the so-called\u003cbr\u003epatients’ rights bill that would have redressed that very issue was\u003cbr\u003edefeated. And watch out, all of you, while you’re in ER, that you don’t\u003cbr\u003eget caught by another dodge that these companies use, or you yourself will\u003cbr\u003ebe left paying for the consequences of their decisions to withhold\u003cbr\u003epayment.”\u003cbr\u003e\u003cbr\u003eThe resident looked alarmed. “How could that be?”\u003cbr\u003e\u003cbr\u003e“If they refuse to cover an admission or a treatment of someone in ER, and\u003cbr\u003eyou go along with that decision, despite your better judgment, you are\u003cbr\u003eliable for damages, even though they aren’t.”\u003cbr\u003e\u003cbr\u003e“But that’s crazy,” another innocent exclaimed.\u003cbr\u003e\u003cbr\u003e“That’s reality,” I snapped, “and in particular watch out for the HMO this\u003cbr\u003epoor woman belonged to. They’re a new outfit in town called Brama Health\u003cbr\u003eCare, but they’ve been operating on the West Coast for decades and know\u003cbr\u003eevery trick in the book about how to discourage people from going to the\u003cbr\u003ehospital yet still remain within the law. In fact, they’re the ones who\u003cbr\u003efirst pleaded the ‘We withhold payment, not care’ defense, thereby\u003cbr\u003erendering it the industry’s battle cry whenever a case goes wrong. Now\u003cbr\u003ethey’re bringing all that expertise to the East, and according to the junk\u003cbr\u003email they keep bombarding us with, they intend to be the first HMO to have\u003cbr\u003ea presence in all fifty states plus the District of Columbia. So wherever\u003cbr\u003eyou plan to practice, you’ll be crossing swords with them, and since the\u003cbr\u003elawyers for Brama are the best in the business, I think every resident\u003cbr\u003ehere with a desire to make ER a career should listen to them argue a case\u003cbr\u003ein court, because then you’ll know what you’re up against. Remember, their\u003cbr\u003estandard line means that it’s up to you or me as doctors to know what to\u003cbr\u003edo medically, regardless of what any triage officer says they will or will\u003cbr\u003enot pay for. ‘Those statements are simply policy guidelines, not medical\u003cbr\u003edecisions,’ I’ve heard them claim, and the judges agree with them.”\u003cbr\u003e\u003cbr\u003eIn previous years my sole duties as a teacher were to arm the residents\u003cbr\u003eagainst the wily ways of a disease like meningococcemia. These days the\u003cbr\u003ecurriculum included instruction against the perils of managed care.\u003cbr\u003e\u003cbr\u003e“You mean what Brama Health Care did to this baby will go unpunished?”\u003cbr\u003esomeone else asked.\u003cbr\u003e\u003cbr\u003eHe was answered with silence.\u003cbr\u003e\u003cbr\u003eThe pathologist cleared his throat and tried to wrap up the meeting. “Dr.\u003cbr\u003eGarnet, would you care to give us your pronouncement on the case?”\u003cbr\u003e\u003cbr\u003eDeath Rounds always ended with a judgment on whether we could have\u003cbr\u003eprevented the patient in question from dying. It was the ultimate point of\u003cbr\u003ethe exercise—to identify what we did right, and to temper our skills by\u003cbr\u003elearning from our failures.\u003cbr\u003e\u003cbr\u003eI hesitated before answering, glancing over the young faces of the\u003cbr\u003eresidents turned toward me.\u003cbr\u003e\u003cbr\u003e“Dr. Garnet?”\u003cbr\u003e\u003cbr\u003eI looked back at the organs on the table. “Okay, here’s\u003cbr\u003ewhat I think. If we look at the case simply from the time the\u003cbr\u003echild arrived in ER, the death, tragically, was expected and\u003cbr\u003eunavoidable.”\u003cbr\u003e\u003cbr\u003eImmediately there was a murmur of agreement, followed by a rustle of\u003cbr\u003emovement and a scraping of chairs as everyone began preparing to leave.\u003cbr\u003e“However,” I added, raising my voice above the noise, “we can’t in all\u003cbr\u003econscience ignore what happened in the prehospital phase of this child’s\u003cbr\u003eillness.” I waited a few seconds until the room grew quiet again, then\u003cbr\u003econtinued. “Had the mother not been intimidated by Brama Health Care and\u003cbr\u003ebrought her son in earlier, the death might have been prevented.”\u003cbr\u003e\u003cbr\u003e“So that’s your ruling? You’re calling this a preventable death?” the\u003cbr\u003epathologist asked, his forehead creasing. “That’s really not the domain of\u003cbr\u003ethese rounds, to comment on prehospital events—”\u003cbr\u003e\u003cbr\u003e“Then let’s make it our domain,” I shot back, staring at the remains of\u003cbr\u003elittle Robert Delany. I felt a surge of fury against the likes of Brama\u003cbr\u003eand the new world of medicine that they and their kind had created. A\u003cbr\u003eworld where a decision to withhold care to maximize profit could cause\u003cbr\u003einjury and death, and yet by law no one was accountable. “In fact, I know\u003cbr\u003eexactly what we should label this death, and every death like it. No-fault\u003cbr\u003emurder!”","brand":"Fawcett","offers":[{"title":"Default Title","offer_id":46304261374181,"sku":"NP9780345482822","price":19.0,"currency_code":"USD","in_stock":false}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/1842\/7735\/files\/9780345482822.jpg?v=1767741088","url":"https:\/\/k12savings.com\/es\/products\/the-procedure-isbn-9780345482822","provider":"K12savings","version":"1.0","type":"link"}