Lethal Practice (8 page)

“Dr. Garnet, you can’t close emergency!” declared Arnold Pinter, a new and very insecure chief of medicine. Usually he slouched; now he was sitting bolt upright, looking nervously around the table. There were murmurs and nods of agreement from most of the others, but a few weren’t so quick to react. Arnold seemed puzzled by the lack of unanimity.
“Can
he close emergency?” he asked.

“I don’t know,” Sean Carrington said, “but maybe he should.” Sean was chief of surgery and had come straight from the OR, still in greens. He was peering at Arnold over the operating bifocals he used while performing delicate procedures.

“He can’t stop emergencies!” Hector Saswald insisted. As always, he was looking for approval. When it didn’t come, he moved to protect himself from being politically incorrect. “And I want it in the minutes that I said you can’t close,” he declared piously, jabbing his forefinger at me.

“There are no minutes, Sas,” I said.

This seemed to upset him even more than closing the ER.

“What exactly do you hope to achieve?” asked the chief of geriatrics. He was a rather humorless man, though brilliant at assessing mental competence. The doubtful frown on his face made me feel he was checking my capacity to develop even the vestige of a plan.

“Look,” I answered, “we all know how closing beds is crap, dangerous crap. I just had another cardiac go sour because we were playing ICU down here, and I’m not willing to go along anymore. Besides, it’s the goddamn idiots upstairs who need shutting down. They don’t seem to know their budget for carfare let alone for running the hospital. What I’m after is a complete review of the finances of this loony bin and an end to these clowns shutting down care every time they screw up.”

“You can’t do that!” It was Arnold Pinter again. This time his voice cracked. The thought of bucking administration seemed to terrify him.

“One of the real problems, Arnold,” I said, trying to control my impatience with this annoying little man, “is that you allow your guys to fill up the beds with soft admissions who are on fee-for-service plans, and then your department dawdles with those patients as long as the premiums allow because it’s easy money and little work. The nurses let you get away with it because it keeps the hard cases waiting in emergency and out of their hair.” It wasn’t blatant fraud, and it was never picked up on the chart audits that were meant to prevent outright billing abuses. It was simply what could be gotten away with if the chief of medicine was a wimp.

Of course, Arnold started to deny it, but Sean leaned in from the other end of the table and cut him off. “What’s more, Arnold, you’ve got the nerve to let other medical cases pile up in my surgical beds, and I end up canceling admissions for the OR.”

A brief look of fear crossed Arnold’s face as he found himself caught between us—and caught dead to rights. He slumped in his chair, a field mouse within the hawk’s shadow, and began his patented squirming.

“I’ve told you, Sean, many times, that I don’t have the staff,” Arnold said. ‘Ten of my specialists have resigned in the last year, and with the resident cutbacks we have too big a load. I can’t move cases any faster. We’re spread too thin, and it’s going to get worse.”

Good old Arnold, the prince of whine. Maybe he was hoping we wouldn’t expect much of him—certainly nothing hard, if he seemed pathetic enough.

He was wrong. Sean came at him with the keenness of a scalpel edge slicing through bloated flesh. “Look at the stats!” he snapped. “You admit a lot more pneumonias and keep them longer when you’re paid fee-for-service than when it’s by managed care.”

Arnold got a bit white at this shot. He didn’t say it, but his questioning expression asked, Don’t we all have to diddle a few extra bucks when we can? He shrugged, then looked around at the other chiefs and turned his palms up to the heavens. “What do you want, Sean?”

“What I want, my dear Arnold,” Sean said, “is for you to stop running a patient’s stay here as a private pet farm to make money.”

A look of fury flashed across Arnold’s face. He flew out of his seat and stood eye to eye with the muscular surgeon. Fortunately the PA interrupted.

“Dr. Carrington, OR, stat! Dr. Carrington, OR, stat!”

Sean gave Arnold a wicked grin and left without another word.

Arnold slowly recovered his composure and settled back into his chair. I looked at the hostile expressions on the faces of the remaining chiefs, sighed, and said, “You don’t have to do anything. It would be better if we had your support, but I’m putting it to our docs tonight, and they’ll decide. We’ll be the ones who close and who take the heat. Hurst can stop us only if he opens the beds and orders an audit.” I felt even more weary as I realized how alone we were going to be during the long fight ahead. I’d nothing left for diplomacy.

“It’s this simple,” I continued, my voice getting harder. “We’re doing it. You can consider this meeting formal notification. I’m not here to negotiate with you.”

There wasn’t much left to say. Arnold looked deflated, and the rest of them seemed either resigned to my decision or relieved that I’d taken responsibility for it myself. No one had even mentioned Kingsly. Obviously, the hospital gossip about his murder hadn’t reached these upper echelons yet. As they rose to leave, I was left wondering if one of them could be the murderer. Each knew the hospital, but so did a few hundred others. Yet I had my hunch, and if Watts found what I was afraid he would find at the postmortem, then by tonight Bufort’s hunt for the killer could be narrowed to about thirty people.

The funny look on Fernandez’s face earlier came to mind. It still puzzled me. I thought about him now only because he had declined to come to the meeting, telling Carole that the bed cuts didn’t affect him much, so he didn’t need to attend.

* * * *

“Will your surgeons support us, Sean?”

Carrington and I were having coffee together in the surgeons’ lounge. It was two
P
.
M
., and I’d arranged to meet him there when he was between cases again. He looked relaxed and at home stretched out on a couch, still in his greens with a surgical mask hanging loosely on his chest. He’d been operating since he left my meeting.

“I think so,” he replied. “A few will be worried about the damage to their incomes, but I haven’t heard any other bright ideas to save us from Hurst and his cuts, and in the long run, that will cost them a lot more.”

Half of the major surgery done in the hospital came from emergency. Obviously, our closure would affect the incomes of his departmental members. Even in this room, a few of the other surgeons who’d been reading newspapers had put them down and were leaning forward to try to hear our conversation.

“In any case,” Sean added, “I’ll support you, and I’ll talk to the others.” He stretched, sat up, and leaned closer to my chair. In a near whisper, he asked, “What’s this I hear about Kingsly being murdered?”

“How’d you find out?”

“It’s all over the hospital—rumors, cops beginning to poke around. How come you didn’t tell me?”

“Those same cops told me to keep my mouth shut.”

“Well, now that it’s no longer a secret, you can open your mouth.”

We had another cup of coffee while I told him what I knew. Again, I omitted that Bufort had singled me out for special attention. Not knowing why he’d done so was making me increasingly uneasy, and I wasn’t going to fuel any rumors about myself. I had just finished the story when a nurse stuck her head into the room and called over to a gray-haired woman in greens, “Your case is ready. Doctor.”

“Sean, is that Phoebe Saunderson, the gynecologist?” I asked as the middle-aged woman left the lounge.

“Yep.”

“I thought she’d retired from practice years ago.”

He shook his head. “Became the VP medical of a hospital in the east end of Buffalo. After five years she asked to come back to St. Paul’s.”

“And she can still operate?”

“Sure.”

“After being away from it for five years?”

“Absolutely. She had to work like crazy to catch up on all the new drugs and the latest in reproductive endocrinology, but apart from a few new techniques and instruments, cutting is cutting. Once you’re a surgeon and know how to operate, it’s like riding a bicycle—you never really lose the technique.”

The same nurse who had summoned Dr. Saunderson now poked her head through the door and called Sean.

“You know,” he said as he got up, “I bet even old Hurst could still wield a pretty mean scalpel.”

My meeting at five that evening with my own staff was brief. By five-fifteen we decided, nearly unanimously, to withdraw our services and shut down emergency in twenty-four hours if the closed beds weren’t immediately reopened. I suggested we should consider issuing a press release warning of our hazardous overcrowding in the ER. It would condemn the administration for its irresponsible action and request that patients use other emergency facilities until we could make our own department safe. I said I was going to sleep on the wording of the press release and we’d take it up tomorrow. Then I explained that I would warn our sister hospitals, since our closing would increase their loads. In spite of the added burden to the other ERs, I expected we’d get support from their staffs. Finally somebody would be doing something. I’d inform MAS what we were up to. They would have no choice but to continue diverting ambulances to other institutions.

Initially, the younger physicians were reluctant to go along with the plan. Not having the established reputations or financial security of the older doctors, they balked at putting their jobs at risk.

“You guys can walk out of here and probably find a new position by tomorrow night,” one of them said pointedly. “We don’t have your options.”

But then I explained about Arnold Pinter’s “pet farms” and excessive lengths of stays upstairs.

“Do the math!” I said. “We admit twenty-five fee-for-service patients a day to medicine, on average. I doubt they all really need to come in, but even if they do, our length-of-stay data show we keep each of them, again on average, two days longer than a managed-care patient with the same diagnosis. That’s sixty beds. Two times thirty. By getting internal medicine off its ass, and these soft admissions out two days earlier. Hurst could close fifty beds and we’d never miss them. And that was just one department. Cut length of stay in the rest of the hospital, maybe we’d have our beds, and he’d have his budget.”

As I talked, it all seemed so logical, I suddenly wondered why he hadn’t done it this way himself. It would have taken a lot longer and been a lot more work, but it wouldn’t have caused the chaos we were in now. And if I could figure out a way to balance the books that wasn’t disruptive, so could he. Whatever else he was. Hurst wasn’t stupid. So what was so urgent about cutting costs that he had to put patients at risk for it? And if something else that important to him
was
at stake, how hard would he resist backing off?

At least the rest of my department seemed persuaded by the logic of what we were about to impose on him. As I looked around the table, I could see they were talking to one another more freely now, nodding approval, and clearly excited by our chances of winning. All except Kradic. He seemed nervous. He obviously didn’t agree, yet for the moment he kept silent. I wondered if he’d heard how angry I was at him for having left too early this morning.

Just then Jones entered the room. Research must be finished for the day, I thought sarcastically. She was tall, thirty-something, and wore her red hair in a ponytail. This evening she was dressed in a green track suit that matched her eyes. Cute, until you got to know her. She mumbled something about traffic and took a seat, but the slight flush still in her cheeks made me suspect she’d gone for her daily run rather than be on time for our meeting. Not wanting to rekindle our fight on the phone, I ignored her and again glanced around the table. “Any more comments?” I asked.

There were no takers. We voted. Secret ballot.

I collected the papers. One against. (Kradic?) One abstention. (Jones?) The rest were in favor of closing down.

Before I could adjourn, there were a few questions about Kingsly. While most of those present had heard the rumors that he’d been murdered, no one seemed aware yet that he’d been killed with a cardiac needle. But they’d all been told I’d discovered it was homicide, and they wanted to know more. My explanation that the police had instructed me not to talk about the case was met with catcalls, a few raspberries. So much for respect for the chief of the ER.

We were starting to leave when I saw Popovitch take Kradic’s elbow, say a few words into his ear, and then walk away. Kradic caught my eye, quickly looked down, and shuffled out the door. I don’t know what Popovitch had said, but from the stunned look on Kradic’s face I was pretty sure he’d be staying for sign-out rounds.

I looked across the table at Jones and my resentment from this morning rekindled. I was undecided whether to confront her now or continue to ignore her. I must have had a pretty unpleasant expression on my face, because when she glanced up and saw me watching her, I could have sworn she turned pale.

* * * *

The speed of rumor and the reaction from Hurst were equally swift. His page for me arrived at five-twenty.

“What have you done?” he shrieked as soon as I picked up the phone on Carole’s desk.

I didn’t bother putting it to my ear. Carole started to muffle her giggles.

“Exactly what you heard.” I was trying to speak into the mouthpiece and keep the earphone as far away as I could. It wasn’t far enough.

“I’ll have all of you suspended immediately!”

Obviously I was up against a tactical genius. “We’ve just done that for you.” Then I hung up fast ... before Carole and I laughed ourselves to tears.

* * * *

I’d dropped in on Watts again to see if I could get a preliminary on Kingsly’s postmortem. Instead, I found him still gloved and garbed in protective gown, mask, and cap. He was stooped over Kingsly’s freshly opened and eviscerated corpse with a pile of broken and bent cardiac needles strewn about in the body cavity. Even for this place it was a sight. Watts was too involved to notice my arrival.