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A
dam Williamson was nestled into his Range Rover like a hand in a perfect-fitting, cashmere-lined leather glove. Ludwig van Beethoven's remarkable Ninth Symphony had been playing for the last hundred or so miles, and the astonishing final choir was about to begin. Adam had the volume almost full blast so the sound was as if he were seated in the center of the Berlin Philharmonic Orchestra. As the choir suddenly commenced, Adam sang along in German, his voice drowning out the professional singers. It was so moving that Adam could feel goose pimples spread over his back and down his extremities. It was nearly orgasmic.

With almost precise timing the last few notes of the symphony died away as Adam completed a wide three-hundred-sixty-degree right-hand turn that culminated in a row of toll booths blocking the entrance to the Lincoln Tunnel leading from New Jersey to New York. After paying the toll he entered the tunnel.

A Bach CD was the next selection, and the sounds of the fragile strings and harpsichord were the perfect foil for the brooding drama of Beethoven, and Adam's fingers began to play lightly on the steering wheel in time to the music.

It had been a pleasant drive from Washington, D.C., up to New York City, but Adam was now eager to arrive and eager to carry out his mission. He knew very little about his target, and that was the way he preferred it, a fact that his handlers appreciated. In his current line of work, too much knowledge served only to complicate the issue. All he needed was a name, an address of either work or home, and a few photos. If no photo was available, then a description would suffice. On those missions where there was no photo and only a description, he always allowed himself more time. Adam was not the kind of person who brooked mistakes, so the setup invariably took longer. And this current mission happened to be one of the no-photo types, so he had reserved three full days on the outside chance he might have difficulty with the ID.

The Range Rover emerged from the tunnel into the very heart of midtown Manhattan. Adam had not been back to New York since he'd come home from Iraq. As he headed north up Eighth Avenue, he observed the city dispassionately, which was hardly strange, since in his current persona he viewed everything dispassionately. When he was young, even while in college, he'd come to the big city on numerous occasions with great excitement, at first with his family and then alone, and even on occasion with his fiancée, but now as he drove north along Eighth Avenue with its tawdry shops, it seemed as though it had been in a previous life, and in some respects, it had been. Adam had been a totally different person back then. In fact, he labeled his life as BI and AI, meaning before Iraq and after Iraq.

BI Adam Williamson had been a rather reserved, gentlemanly, quietly intelligent young man with clean-cut good looks who'd fit into his upper-class New England life in an exemplary fashion. He'd gone to a respected boarding school, had learned and respected good manners, and had gone to Harvard, as did his father and his grandfather and back ad infinitum, back to when the
Mayflower
's long boat had scraped ashore in Plymouth, Massachusetts.

The beginning of the interim between BI and AI hadn't been a nativity but rather the horrific event of 9/11, which had jolted Adam's comfortable and predictable world, akin to one of the planets being knocked out of its orbit. At the instant the first plane crashed into the north tower of the World Trade Center, Adam had been brushing his teeth in the Harvard Business School dorm, where he was dutifully learning the ins and outs of business as preparation ultimately to assume control of the family owned financial company.

Against his parents' wishes as well as his law-student fiancée's, Adam insisted on volunteering for the military in a sudden burst of messianic zeal to do his part for America and democracy. As a natural athlete who'd been an all-American lacrosse player as well as a polo devotee, combined with a personality that motivated him to approach everything he did with one hundred percent effort, once in the military, which he'd previously known nothing about, he became fixated on becoming a member of the Special Forces. And in keeping with his personality, even that wasn't enough, and he wasn't satisfied until he became a member of the Delta Force.

Adam had enjoyed the training and reveled in its difficulty, as if the training in and of itself was helping the cause of democracy. But the real thing, meaning actual combat, came as an utter shock, because Adam was far more cerebral than physical. On his second night mission in Iraq, he was forced to kill with a knife another living, breathing human being, and his reaction shocked and shamed him. The experience had triggered a transcendental guilt and sadness, which he hid from his squadmates. To overcome what he construed as a weakness and a failing, he went out of his way on subsequent missions to kill. Over time and with equal horror and relief, he came to accept what he was doing as well as accept that he'd been metamorphosed into a true killing machine with little or no emotional response. It wasn't something he was happy about or proud of. It was just what he thought was expected of him.

Adam turned right at Columbus Circle, and the Bach Brandenburg Concertos seemed so apropos with the sudden appearance of Central Park, with its lacy, budding trees providing a welcome relief from the hard, angular, and mostly concrete city. Adam's route was to take him along Central Park South all the way to Madison Avenue where he'd turn north. At that point, it was a matter of going around the block to arrive at his destination, the Hotel Pierre, a New York City landmark from the Gilded Age.

The Pierre had been the hotel Adam had stayed in ever since he'd visited the city as a small child, all the way up to and including when he was in business school. On this trip, he'd insisted on staying there, to his handler's chagrin. His primary handler, in particular, had tried to get him to stay in some less vigilant surroundings and where he'd have his Range Rover instantly at his disposal. But Adam had insisted. He was curious if he'd feel any nostalgia. He didn't think he would. It was as if his experiences in Iraq, particularly the covert missions, has sucked all the emotion out of him from both witnessing and participating in the kind of atrocities that before Iraq, BI, he couldn't have ever imagined. And most disturbing of all, he'd come to enjoy what he was doing, even the killing.

His Iraq experience came to a disastrous conclusion. It happened during an ill-fated covert action that went horribly wrong. He and the rest of his team had ended up being decimated by misdirected friendly fire, which he and his colleagues had called in. Although he'd not been killed, as were his squadmates, Adam had had a leg broken and had been rendered unconscious. In such a vulnerable state, he'd been taken hostage by the very people he and his team had been sent to kill or capture.

Despite supposed preparatory training as a POW, Adam was unprepared for his ordeal as a captive. He leg was never appropriately attended to and was a source of constant pain. But worse, he was tortured by repeated episodes during which he was certain he was about to be shot or beheaded.

Although it had been explained to him as a common psychological response called the Stockholm syndrome, he was shocked when it happened to him. After several months, he began to identify with his captors and their twisted ideology. He'd even made a tape that was shown on Al Jazeera satellite TV in which he lauded the insurgents' cause and cast aspersions on the United States' motives for the Iraq intervention. His mind had been so twisted that when his release was eventually brokered by an FBI negotiator for the secret exchange of a number of insurgent detainees, he didn't know whether to rejoice or bewail his release and ultimate repatriation. Intuitively, he'd known he could never return to his former life; it was simply out of the question.

Adam turned left on 61st Street, and halfway down the block pulled over to the Pierre's entrance marquee. The doorman tipped his hat and opened the Range Rover's door. “Checking in, sir?”

Adam merely nodded as he climbed out of the car. Following the doorman to the car's rear, Adam insisted on taking the tennis bag, which contained the tools of his trade, the moment the doorman opened the hatchback. The small overnight bag he allowed to be carried for him.

“Will you be needing your vehicle this evening?” the doorman asked as he held open the hotel's door.

Adam nodded again.

“Fine, I'll keep it right here at the door,” the doorman said as he gestured toward the registration desk.

Directions weren't necessary for Adam, as the lobby had barely changed over the twenty or so years he had intermittently stayed at the hotel. Pausing at the flower-bedecked center table in the middle of the carpet, Adam let his eyes take in the familiar surroundings, including the raised sitting area to the right and mostly nineteenth-century English furniture. As he'd expected, he didn't feel anything. The scene evoked no emotion whatsoever. It was like his memories were of someone else's life.

The check-in was dispatched with commendable speed, after which the receptionist called for a porter, saying, “Hector, this is Mr. Bramford from Connecticut. Would you show him to his room? By the way, Mr. Bramford, we've given you a very nice park view.”

Bramford was one of the several identities Adam carried on this particular mission, along with all the associated documentation. His handlers in Washington ran a discreet risk-management/security firm with branches in major cities around the world, and Adam worked for them for special operations as an independent contractor. The clients for the current mission, all former lawyers and politicians, had contacts in the highest levels of government, so obtaining the identities had been relatively simple.

“This way, Mr. Bramford,” Hector said, pointing toward the elevators.

The interior of the elevator was unique in regard to its French style, and Adam remembered it the moment he stepped in. Its frivolousness as well as its cleanliness stood in such sharp juxtaposition to his war experience that he marveled it could exist on the same planet as Iraq. And as he rose up in the fussy décor, the sheer contrast of the total situation made him think back to his release from captivity. At that time, he'd been picked up in the scrubby, battle-scarred desert dressed only in a soiled pair of boxer shorts and limping on a deformed leg.

Within hours, he'd been airlifted to Germany where his leg was rebroken and reset, and he began treatment for what was called a post-traumatic stress disorder variant. Under the psychiatrist's guidance, Adam made considerable strides in dealing with his anxiety, his inability to concentrate, his joylessness, and his difficulty sleeping. He had had less success with generating any interest whatsoever in returning to any semblance of his former life, which included resurrecting his relationships with his family, his family's business, his fiancée, or Harvard Business School. He also had had no success in adjusting to the loss of the camaraderie of his Delta Force colleagues and the unique and addictive risk of making a kill.

Adam's psychiatrist had become frustrated by what she considered Adam's lack of progress, until she suggested a new strategy: namely, for Adam to embrace what he'd been morphed into from his military experience rather than attempting to suppress or ignore it. It was even she, as an Alexandria, Virginia, resident, who had introduced Adam to the founder and CEO of Risk Control and Security Solutions, which was extremely receptive to the combination of his Special Forces training and his experience of having been a POW. To protect his identity, they worked out an employment relationship, which didn't show up on their books. In return, they paid him extremely well.

The Pierre elevator reached the correct floor. Hector allowed Adam to disembark first, then pushed ahead to open the door to Adam's room. He gave Adam a rapid tour of the room, including how to navigate the hotel's simple entertainment systems and the location of the minibar. Then he backed out of the room, obsequiously clutching Adam's tip.

For a few minutes, Adam stood in front of the window that gave out onto Central Park. The most apparent object was the skating rink, brightly illuminated in the center of the park's mostly dark expanse. He then turned back into the room. He took his tennis bag from his shoulder and unzipped it. Inside was a selection of favorite firearms, carefully wrapped in towels and tape. He took each out, unwrapped them, and checked to make sure they were all in the same working order as they had been when he had packed them. When he was satisfied that his arsenal was unscathed by the drive, he pulled out a single sheet of paper from an inner zipped pocket. On it was the target's name, a brief and probably useless description, and the rather odd address of the Office of the Chief Medical Examiner of the City of New York.

I
t doesn't look good,” Dr. Tom Flanagan said. “It doesn't look good at all.”

Dr. Tom Flanagan was one of eight intensivists employed by University Hospital at great cost to supervise care in the intensive-care unit, or ICU. He was either there at the unit or on call 24/7. He was speaking to Dr. Marlene Ravelo, who was board-certified in internal medicine and infectious disease and who ran the University Hospital department of infectious disease.

“Unfortunately, I agree,” Dr. Ravelo said.

They were standing at the foot of Ramona Torres's bed in a special isolation cubicle off the main ICU room.

On the right side of the bed was Dr. Raymond Grady, a pulmonologist. He was busy adjusting her positive-pressure ventilating machine in an attempt to give adequate volume. It was becoming difficult. He glanced at the readout for the central venous pressure and the other one for the pulmonary wedge pressure. “We're not ventilating her very well,” he called across the bed to Dr. Phyllis Bohrman, the cardiologist consult they'd called. She was watching the ECG on another monitor. Next to her was the chief resident in medicine, Marvin Poole.

“It's pretty clear why,” Dr. Bohrman said. “Look at that last chest X-ray. The lungs are full of fluid.”

“Let's look on the bright side,” Dr. Flanagan said. “We're getting a lot more practice handling sepsis with septic shock than usual with these Angels Healthcare patients.”

“That's true,” Dr. Ravelo agreed. “But it would be nice to save one of them now and then.”

“We can't be faulted. Having had a liposuction, this individual's surgical site infection covered a significant percentage of her body's surface area.”

“Let's not forget what I believe is necrotizing pneumonia,” Dr. Ravelo said.

“Do you think the pneumonia is a result of seeding by her surgical-site infection, or do you think it is primary—I mean, isn't primary staph pneumonia rather rare?”

“It is, but the time interval seems strange. Weren't we told the pulmonary symptoms preceded the symptoms of cellulitis?”

“That was what was on the record.”

“It's very strange, especially considering last night's case was so similar, although the surgical-site infection was so much smaller.”

“Okay, guys and girls,” Dr. Flanagan called out. “Pulmonary function is heading south to Antarctica, cardiac function is going in the same direction so that the blood pressure is in the basement. There's no longer any urinary output, so that tells us what's happening in the kidneys, and the liver is not doing what it should be doing. Thank you all for your hard work, but we've clearly lost the battle.”

Dr. Flanagan and Dr. Ravelo turned and walked back to the central desk, where they got Ramona Torres's chart to write their final notes.

“Do you think we should have done anything differently?” Dr. Ravelo asked as they took seats side by side.

Dr. Flanagan shook his head. “We followed the newer protocol to a T, so I don't think so. Hell, we gave her everything we've got, including the activated protein C and corticosteroids. Equally as important, you changed the antibiotics the instant we knew we were again dealing with MRSA, so we can be confident we had the right cocktail. And remember her APACHE II score was off the charts when she arrived, so we didn't have much to work with.”

“Why can't we get Angels hospitals to send these patients sooner?”

“That's a damn good question. What I'm guessing is these patients' infections develop just too damn quickly postsurgery. I mean, this woman was operated on just this morning at seven-thirty a.m. In her chart, it says the first nonspecific symptoms started a little after four p.m. That's one hell of a rapid course.”

“With all the nasty toxins potentially at staphylococcus's disposal, it's understandable. I'd be willing to put some money on this patient's bug to have the Panton-Valentine leukocidin, or PVL, gene.”

“Does it surprise you that the Angels hospitals are having so many MRSA cases?” Dr. Flanagan asked.

“Yes and no. Staph is the most common surgical site pathogen, and whereas MRSA comprised only two percent back in the nineteen seventies, today it is sixty percent and rising all the time.”

“Actually, what bothers me most about these cases is the whole specialty hospital dilemma. They don't have the resources for this kind of case, and they have to outsource it. In fact, in one specialty hospital, I think it was also an orthopedic hospital, a patient had a heart attack. And you know how they dealt with it?”

“No.”

“They called nine-one-one.”

“You are kidding!” Dr. Ravelo blurted in total disbelief.

“They didn't have any doctors on duty. Can you believe it?”

“Did the patient survive?”

“I don't think so.”

“That's a travesty.”

“I agree, but what can you do? Are you aware of the specialty hospital debate in general?”

“I know a little about it, I suppose. It's one of the advantages of being in academic medicine. We don't have to get so involved in various private-sector squabbles.”

“I would not be so sure. It might eventually influence our salaries. The biggest problem most people see in these private specialty hospitals is that they are only interested in the cream of the patients: i.e., the healthy, well-insured who come in to have a quick procedure and then are out. It's really a moneymaking machine, because they get paid the same as the university gets paid, but because they don't have ICUs like ours or an ER like ours, which are not moneymakers, their costs are significantly less.”

“I heard the government had a moratorium against them for a while. Was that the reason?”

“No,” Dr. Flanagan said. “The government was against them for a time, actually from late 2003 to late 2006, because the specialty hospitals involve some level of physician ownership to guarantee a continual flow of patients. There is an existing ban in Medicare law for physicians to refer patients to medical service organizations in which they have ownership interest, like imaging centers or clinical laboratories or the like. But there is a loophole as far as a whole hospital is concerned. Ownership in that situation was not banned because it was thought that in a whole hospital, there would be little risk of a conflict of interest.”

“But a specialty hospital is not a whole hospital!” Dr. Ravelo said indignantly. “They only do a very limited number of services.”

“Exactly! Yet it is by claiming they are a whole hospital that they are taking advantage of the loophole.”

“Why was the moratorium lifted then?”

“I haven't the foggiest idea. There were a number of hearings on the issue in which all these points were clearly raised. Most people familiar with the debate, who'd either attended the hearings or read about them, thought for sure the moratorium should be sustained and actually strengthened because the existing moratorium was only against new specialty hospitals getting Medicare provider numbers, which are necessary for reimbursement.”

“What happened?”

“Suddenly, the moratorium was lifted with little explanation. My guess is that it was a behind-the-scenes lobby competition, with the lobbyists from the AMA pitted against the lobbyists for the AHA, or American Hospital Association, and the FAH, or Federation of American Hospitals. I guess the doctors spent more money than the hospital admin groups.”

“That's awful. Everything comes down to money. I'm embarrassed for our profession.”

“Well, it's not all bad. Patients generally like specialty hospitals, and for routine procedures, they are certainly more comfortable.”

“Maybe we should ask Ramona Torres,” Dr. Ravelo said. “Maybe she'd have an opinion about which is best: a specialty hospital and its comforts or a truly full-service hospital. If she'd been here from the start, from our statistics, she would have had a significantly higher chance of surviving her infection.”

“Good point,” Dr. Flanagan said. “A very good point.”