Authors: Gen LaGreca
“Dr. Lang, this is Tom Bentley. I’m calling about my patient, a thirty-eight-year-old woman who was hit in the back of the head with a baseball five days ago.”
“Yes?”
“After the injury, she developed headaches, sought medical attention, and was treated for migraines. As the week progressed, her headaches worsened. She recently gave birth and has been taking an anticoagulant for a blood clot in her leg. Her husband brought her in tonight because she was becoming harder and harder to arouse. Brain scans show a large subdural bleed in the posterior fossa. She’s falling into a coma.”
“Is her airway clear?” David Lang sat up.
“Yes.”
“Is she intubated?”
“No. She’s been breathing on her own, but her respiration is becoming shallow—”
David heard someone in the background yell, “Arrest!”
“My patient just stopped breathing,” Bentley reported.
“Ventilate her, and give her K-35 in an IV drip to counteract the anticoagulant and restore normal clotting. Take her to the OR. I’m on my way.”
The headpiece on the wall phone in the ER bobbed up and down after Bentley dropped it. David Lang’s beer spilled across the carpet as he rushed to the door.
Bentley joined a wall of uniforms surrounding the almost lifeless woman. A gasping pump forced oxygen into her lungs. Monitors beeped, drawers slammed, voices sounded, wires trembled, and white jackets flew around her bed.
Chapter 3
. . . And the OR
The clatter of conversation in the grand ballroom of the Rutledge Hotel faded when the man on the dais beside Governor Burrow took the podium. Sixty-five years had taken the color but not the thickness from the speaker’s hair. He possessed the intelligent face of a scientist and the expensive clothes of a diplomat. His regal manner suggested a noble purpose, but his eyes seemed to be counting the number of television cameras following him. He was a former surgeon who had become the secretary of the Bureau of Medicine. Because the BOM’s universal health care program, CareFree, was under constant attack by political opponents, the state’s medicine czar was essential to the governor’s bid for reelection. The secretary’s job in the campaign was to defend CareFree. With his crest of white hair and tuxedo-clad trim form, he resembled a tall radio beacon emitting a message.
“Ladies and gentlemen, there are two things in the world that I cherish. One, which I made my former career, is medicine. I studied the glorious human body, discovered its mysteries, and defended it against attack. A doctor is a thinker, an explorer, and a crusader, a testament to the power of science in enriching our lives.
“But medicine is not an end in itself. We must use it to achieve a higher purpose. A proper health care system does just that. It frees medicine from the selfish concerns of business to serve the public. It guarantees care to every person as a right, the way our Founding Fathers guaranteed life and liberty. The other thing I cherish, which embodies this noble ideal, is our new system of medicine, CareFree.”
Waiters watched from the sidelines, ready to serve the first course when the speaker finished.
“Contrary to our opponents’ denials, private medicine has failed. Oh, it gave us dazzling technological advances and a standard of care unmatched in the world. But it failed on moral grounds. Patients had to pay for their care while doctors profited from the sick. The poor suffered the indignity of having to say ‘please’ and ‘thank you’ for someone’s charity. Under CareFree, no one needs to rely on a doctor’s alms, because care is guaranteed to all by law.
“At first the state did not want to manage doctors’ business but merely to pay the bills for special groups like the older folks and the needy. But when the government picked up the tab, patients acted like sweepstakes winners on a shopping spree and providers behaved like retailers whose customers held the key to Fort Knox. The demand for care soared as people sought costly tests for every headache and fancy drugs for every stomachache. And the providers welcomed the increased business with expanded offices, new wings, elaborate equipment, and expensive tests. So there was a problem: People spent more when someone gave them a blank check. The solution was to keep giving the check—no caring person would dispute that—but to fill in the blanks.
“This is why the government had to step in to manage medicine. But did our providers accept the limits placed on them for the public interest? Regrettably, many fought us. To compensate for the lower fees they received for their public patients, the providers hiked the billings to their private patients. This squeezed the private insurance companies that were paying those bills. The insurers reacted by raising their premiums. This continued until the prices got so high that nobody could afford a policy. The problem was worsening. The solution was more management by the state.”
The secretary’s eyes caught the approving nod of Governor Burrow.
“So you see, private insurance also failed, and for the same reason,” the secretary continued with conviction. “The government stepped in to regulate the insurers so that they would act with kindness, not actuarial tables; with sensitivity, not statistics; with the same rates for all; with no one denied a policy; with every condition covered. But did the insurers comply? More concerned with the ticks of their stock than the tears of the needy, they curtailed care and canceled policies faster than we could pass enough laws to stop them.
“The problem became a crisis. The solution was more management by the government. Finally, Governor Burrow, in his ardent compassion for the people, stepped in to save medicine with CareFree.”
Like creatures stalking prey, television cameras covering the event fixed their lenses on the secretary.
“CareFree proudly is concerned not with finance, but with feeling; not with profit, but with pity; not with amount tendered, but with compassion rendered.”
The secretary raised his head, his face imbued with a religious fervor. The governor looked confident that the secretary was the right man for his campaign.
“Our opponents claim that our ideal has been tried before and it failed. However, it was not the
ideal
that failed but the people entrusted with it. If a rocket could soar to Mars but unscrupulous people filled the fuel tank with sand, should we blame the rocket or the saboteurs? Unfortunately, some practitioners have failed in their responsibility to comply with our new program. They break the rules and overload the system with expenses!” He bristled, as if hitting a sore point. “I want to assure all New Yorkers that we will
strictly
enforce our guidelines for the medical profession! Let this be a warning: I will
not
allow malcontents to dump sand into our engine!”
A disturbing stillness fell on the room, most quickly on the doctors in the audience. They sat frozen, their eyes darting nervously. The governor’s smile faded, and panic covered the secretary’s face. Sensing that a change in course was needed to avoid crashing his rocket, the secretary quickly scanned his mind for a remedy. He noticed that the waiters had placed a glass of champagne before each person, so he picked up his and smiled.
“But let us return to our purpose,” he said, his tone lighter. “Let us toast that which ended centuries of misery, transforming human existence from pain, suffering, and early death to health, happiness, and long life. A toast to modern medicine.”
He raised his glass high and waited for the guests to follow suit.
“And a toast to the man who harnessed medicine to serve the public, the man who will be reelected in November. A toast to Governor Malcolm Burrow!”
Eight hundred gulps reverberated through the room.
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David Lang’s car hit the bridge to Manhattan with a loud thump, but his foot did not lighten on the gas pedal. The procedure would be a normal event of his life—he was called, he came, he worked, he left—except for one thing: This time he was angry.
A hot fuse of disturbing facts burned through his mind. Fact one: Bentley said the hemorrhage was subdural, below the dura, one of the layers of tissue between the skull and brain. David expected such a bleed to be from a vein, which flowed more slowly than an artery, providing time for diagnosis and treatment. Bentley said that the patient had sought medical attention prior to her emergency. Why did the problem remain undetected for days after the patient had seen her doctor? Fact two: The brain was sending warning signals with the worsening headaches. A blow to the head followed by progressively severe headaches, he thought, was a neon advertisement of trouble early on. Why had this symptom been preposterously misdiagnosed as migraines? And why had a scan apparently been delayed until so much blood and pressure mounted that the brain became a kettle about to blow its lid? Fact three: The patient was taking an anticoagulant, a blood thinner, for treatment of a clot in her leg. She had just given birth, and because pregnancy can worsen varicose veins and thrombosis, anticoagulants are sometimes prescribed. But any medical student knows that people taking blood thinners run a higher risk of hemorrhage after injury because their blood can fail to clot normally. Why was the anticoagulant apparently continued after the head injury and onset of headaches while the possibility of hemorrhage was ignored? He swore aloud; the prospect of senseless death was increasing the pressure on his own brain.
Was Bentley the doctor who had treated the woman earlier in the week? With general practitioners pressured by CareFree to reduce referrals to specialists, patients increasingly flooded the ER, where they could see such doctors more easily. Bentley was the neurosurgery resident on call that week in the ER, and he had referred to the woman as “my patient.” Had Bentley examined her earlier and sent her home to take blood thinners, with a subdural bleed? He swore again.
Stop it!
he ordered himself as he reached Manhattan. He ran a red light and headed west.
The air in the windowless waiting room of Riverview Hospital was hot and stale. Ten-year-old Billy Miller thought it was the stink of the hospital that made him sick to his stomach. A tall man in blue clothing, Dr. Bentley, was talking to his father. The doctor said that Eileen, his mother, was very sick, that her brain was bleeding, that a Dr. Lang was coming to operate. Billy could not take his eyes off the man’s face, waiting, hoping . . . but Dr. Bentley did not smile. Billy wondered why he had played baseball outside their brownstone after his mother had told him not to, after she had warned him that someone could get hurt. He wondered why she was falling asleep so much and wasn’t herself that week. Was it because his baseball had hit her that she was sick? Billy’s father and older sister sat holding hands, but the boy remained by himself.
A door swung open in the operating room where Eileen Miller lay unconscious. The scrub nurse raised her eyebrows when Dr. Lang rushed in wearing street clothes. His eyes hit the shaved head on the operating table and the brain scans on the view box, and then he gasped.
“Get me gloves!”
“I’ll have these instruments laid out in a few minutes while you change and scrub, Doctor,” said the scrub nurse.
“We don’t have a few minutes!”
“I need to insert this catheter,” said the circulating nurse, trying to move around him.
“Forget that!” he said.
“I’ll tape these tubes down,” said the anesthesiologist, trying to get at the patient.
“Not now,” said David, as the nurses threw a sterile gown over street clothes and sterile gloves over unwashed hands.
Someone managed to place a mask and cap on him. Soon the buzz of a high-speed drill and the smell of scorched tissue hit the air.
David had no time to question Tom Bentley, who was assisting him, because pieces of Eileen Miller’s brain were about to explode. Clumped blood from the hemorrhage pushed structures in the brain, causing pressure to rise. David ordered drugs to reduce the swelling while trying desperately to contain the brain tissue in the skull, to remove the mottled clumps of blood, and to find the source of the bleed in a sea of red.
The brain David faced was raging. Spewing and clumping blood buried the normal pale color, gentle pulse, and delicate landscape of vessels and nerves. Somewhere near the red deluge was the center that controlled Eileen’s circulation and breathing. How much time would David have before the red menace reached the command post of the brain and began pushing and shoving critical areas? The threat haunted him. He evacuated the purple blotches at an alarming pace, with vital structures a hair’s width from flying instruments. Could David find the source of the bleed and stop it in time? How much good brain would be lost on the battlefield? And what would remain of Eileen Miller, wife and mother?
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Aromas of cognac and coffee laced the air of the grand ballroom after the meal. The crystal chandeliers cast a jaundiced glow on Governor Malcolm Burrow, rising from the dais to speak. His hair was neither black nor white but a tangle of the two, as if undecided between youth and old age. With thin legs and a paunch, he was both slim and chubby. His mouth smiled while his eyes drooped, his face seemingly unable to choose a mood. He wore cuff links handcrafted by an Iroquois descendant and a digital watch from a New York manufacturer. Malcolm Burrow was said to be all things to all people, an impression that he seemed to encourage, especially with an election looming. Television cameras followed him to the podium as the band played “Back Mack,” a tune created for his campaign.