The woman—slender, with a narrow face and eyes still shielded by her hat—withdrew her left hand and passed over an envelope. Her calmness and the coldness in her voice brought a knot of fear to Marcia’s chest. She stared down at the envelope, which she now held.
“Go ahead,” the woman urged. “Open it.”
Marcia fumbled the envelope open and withdrew two cards, each three inches square. On one, carefully printed with some sort of marker, was the unadorned block letter R. On the other was a T.
“What is this? What is this all about?”
She stumbled backward toward the Mercedes, the letters and envelope still reflexively clutched in her hand.
Before her, the woman calmly withdrew a pistol from her coat pocket, its muzzle extended several inches by a silencer.
“My God, no!” Marcia cried. “Don’t do this! I have money. Lots of money. I’ll give you whatever you want.”
“This won’t hurt as much as it should,” the woman said, firing from six feet away into the center of Marcia’s chest.
The CEO was reeling backward when a second shot, fired almost from the hip, caught her squarely in the throat.
The woman slid the silenced pistol back into her pocket and turned toward the door.
“Sleep tight,” she whispered.
CHAPTER 1
DRAINED.”
“Wiped.”
“Fried.”
“Burnt.”
“Oh, that’s a good one.”
“Okay, whose turn is it?”
“Dr. Cameron’s.”
“Hell no, lass. Not me. I just did tuckered out.”
“Then it’s Dr. Grant’s turn.”
From his position across the operating table from his partner, Will Grant surveyed the three nurses and, finally, the anesthesiologist.
“You sure?” he asked.
“It’s you, all right,” the scrub nurse said.
“I can’t think of any more.”
“Well, you damn well better, laddie,” Cameron said, his Highland brogue as dense as it had been when he moved to the States a decade and a half ago. “Give me a sponge on a stick, please, would you, Mary? Thank ye. Now, Will, today’s word was your idea. ’Twould be a travesty for you to lose the whole shibickie and end up buyin’ the beers for this motley crew.”
Before he could reply, Will yawned widely enough to displace his paper surgical mask off his nose.
“Seems like I should have picked some word other than exhausted,” he said as the laughter died down. He turned his head to allow the circulating nurse to reposition his mask. “But it was the only one I could think of.”
“No surprise there,” Cameron said. “We should allow Dr. Will Grant as a legal answer to this one because, laddie, you define the term. I couldn’t believe it when I heard you were covering again tonight.”
“Four days of alimony.”
“What?”
“Every extra call night I take from you guys translates into four days of alimony paid—more if I get a case.”
“Which you almost always do. Well, we’re getting ready to close. Sir Will, my trusty assistant, do you have any reasons why we shouldn’t go ahead and sew up this lucky bugger?”
“Stomachs R Us,” Will said. “You did a really nice job getting that tumor out, Gordo.”
“You forgot to add ‘as always.’ ”
“As always. How about prostrate?”
“Debbie did that already,” the circulating nurse said. “I’ve been keeping track. Fatigued, winded, frazzled, rundown, wilted, sagging, flagging, weary, sucking wind, tired, overtired, dog tired, dead tired, worn-out, prostrate, whipped, spent, leaden, pooped, too pooped to pop, baked, enfeebled, haggard, drained, tuckered out, plumb tuckered out, wiped, fried, and burnt. You only have until the last clip is in.”
Will flexed his neck muscles, which after a three-and-a-half-hour case felt as if someone had injected them with Krazy Glue. It was only a slight exaggeration to say that the last time he hadn’t been some form of exhausted was eighteen years ago when, at twenty-three, he started medical school. Med school, internship, surgical residency, vascular fellowship—he often wondered whether if he had known, really known, about the call schedules, and the interminable hours in the OR, and the early-morning emergencies, and the office practice, and the continuing-education responsibilities, and the staff meetings, and the mushrooming malpractice premiums, and the ambulance chasers, and the diminishing financial returns brought about by managed care, and ultimately the divorce and supplementary nights on duty to make ends meet, would he do it all again the same way. The answer, as always, was yes . . . except, of course, for the managed care part.
“Last clip coming down, laddie,” Cameron announced, lowering the final surgical clip dramatically toward the incision.
“Petered out,” Will blurted at the last possible second.
Silence held sway as those in OR 3 polled one another.
“We’ll give it to you, Will boy,” Cameron said finally, “as long as you assure us your answer isn’t merely a description of your sex life.”
Fredrickston Surgical Associates was a four-person group headquartered in the Medical Arts Building, a block away from Fredrickston General Hospital, a fully designated trauma center thirty miles southwest of Boston. The four surgeons rotated call with three others, although in any given seven-day stretch, Will would take on one or even two nights in addition to his own. Today, Tuesday, he finished seeing patients in the office, then trudged back to the hospital through the raw, gray afternoon. Douglas Cannon and Susan Hollister met him for sign-out rounds outside the surgical intensive care unit. Cannon, now in his late sixties, was the patriarch of the practice, if not the entire hospital. He was as stiff in his manner and speech as he was in his posture, and to the best of Will’s knowledge, no one had ever mentioned his telling a joke. Still, the man was universally beloved and respected for his dignity, his skill in the operating room, and his ability to teach residents and other physicians.
“Weren’t you just on call, Will?” he asked.
“That was two nights ago, and it was incredibly quiet. Steve Schwaitzberg wants to chaperone some sort of overnight with one of his kids’ class.”
“Is he going to pay you back with a night?” Cannon pressed.
Whether it was his liberal politics and interests, his relaxed dress and manner with the patients, or his inability to keep his marriage together, Will sensed that he had for some time been Cannon’s least favorite of the three younger associates. Still, the two of them had always been on decent terms, although there was invariably some tension when the subject of Will’s extra call nights came up.
“He probably will pay me back,” Will said, knowing, as doubtless did his senior partner, that the truth was being stretched.
“Don’t you see the twins on Tuesdays?” Susan asked.
As reserved and conservative as Gordon Cameron was flamboyant, Susan had preceded Will into the practice by two years. A competent surgeon, she was quite slender and attractive in a bookish way, but to the best of Will’s knowledge had never been married. For several years she had been dating a businessman—at least, according to her she was. Will had never met the man, nor had Gordo. And from time to time Cameron would speculate that Susan’s businessman was, in fact, a businesswoman. Regardless, Susan had gone from being reserved and somewhat distant from Will before his divorce to being a concerned friend, worrying about his health, his children, and even his social life. One of the rare times Will had allowed himself to be fixed up was with a former Wellesley College roommate of Susan’s. Had he taken years of acting lessons, he still couldn’t possibly have been less himself than he was that night.
“I’m just not ready,” he reported to Susan after the spiritless evening. “We didn’t have anything in common. She was a human being.”
“I do have the kids, yes,” he said, “but tonight’s our regular night at the soup kitchen, so I’ll just take call from there
until I bring them home. Speaking of the Open Hearth,” he added, determined to divert the subject from his taking too much call, “we’re always looking for volunteers to serve.”
“When I resign from the symphony board, I just might take you up on your invitation,” Cannon replied sincerely.
“Me, too,” Susan added with more sparkle.
“I didn’t know you were on the symphony board,” Will said.
“I’m planning on being on it someday.”
“All right,” Cameron said, “let’s get on with this. Will, it’s a good thing you enjoy your work, because you certainly do a heck of a lot of it.”
Doug Cannon had seven patients in the hospital. Susan and Will three apiece, Gordon Cameron, who had already gone home, two, including the case he and Will had done earlier in the day. The trio that included Steve Schwaitzberg had another five. Schwaitzberg had signed his three out over the lunch hour, and the other two would do so by phone. Twenty patients in all—a load by modern standards. Insurance restrictions had seen to it that most of them had received their preop evaluations as outpatients and had been operated on before they had even seen their room or met the nurses who were going to be their caregivers. The moment after their surgery was completed, they were beginning to be primed for discharge. Actuarial tables compiled by the managed care and insurance industries had demonstrated that such policies saved money without causing a significant rise in postop complications. Will’s experience with his own and many other practices had shown that a good number of patients would gladly beg to differ with those statistics.
At Susan’s urging they saw Doug Cannon’s group first. He would never complain about his workload or diminishing physical capabilities, but the three younger members of the group had each seen evidence that layers were peeling off his stamina and abilities in the OR, and they sought to protect him in any way they could. All went well until the last of Cannon’s patients, a sixty-three-year-old diabetic man whose gall bladder Cannon had removed the morning before.
“So, Mr. Garfield,” Cannon said, checking the four small incisions he had made into the man’s abdominal cavity, and nodding approval of the way they looked, “is your wife on her way here to get you?”
“She just called from the parking garage, I shouldn’t worry,” Garfield said.
“Good, good. And the nurses have given you my discharge instructions? Good.”
Will didn’t like anything about what he was seeing and hearing. Stuart Garfield was doing his very best to mask it, and maybe he didn’t even realize it was happening, but he was experiencing some shortness of breath. Susan nodded minutely that she had noticed the same thing. The managed care companies decreed that a night in the hospital or less was to be the standard of care for the laparoscopic removal of a gall bladder, and Cannon did not consider the man’s diabetes to be reason to argue for more. And it wouldn’t have been except for the distension of the veins along the man’s neck, and the slight bluish cast to his lips—both subtle signs of trouble.
Nonchalantly Will sidled over to the bedside, slipped his stethoscope into his ears, and listened through the back to the base of the man’s lungs. Rales, the crackling sounds made by fluid filling the small air sacs, were most definitely present. Stuart Garfield was in early heart failure—a potentially serious condition in any patient, but even more so in a diabetic who, with little warning, perhaps by the time he and his wife had reached the highway, could be in full-blown pulmonary edema—a life- threatening emergency. Will motioned Cannon over to the doorway. There was no easy way to present the findings, and with a physician as forthright and honorable as Cannon, it wasn’t smart to try.
“Doug, he’s in some congestive heart failure,” Will whispered. “Neck veins distended, rales at both bases, a little blue around the gills.”
Cannon sagged visibly, crossed to the bedside to listen, then returned to the doorway.
“I knew I shouldn’t have been rushing him out,” he said, shaking his head in dismay.
“Listen, don’t be hard on yourself. We’re making rounds together. This sort of thing is why we do it. The pressure’s on all of us now all the time. They tell you that the average surgeon gets his gall bladder patients out of the hospital on the first postop day, or even the day of the procedure. You know darn well that if you keep yours an extra day or two, you’re going to be down on the HMOs’ list. They don’t ignore these things.”
“Just the same,” Cannon said wearily, “thanks for saving my bacon.” He returned to his patient. “Mr. Garfield, I’m going to wait for your wife to get up here, then we have to talk.”
“I’ve never seen him so glum,” Susan said as they headed off to see the first of her patients.
As the sole woman in the group, Susan had proclaimed herself the mother hen, dedicated to keeping Gordo’s weight under control, seeing that Will got enough sleep and met someone special, and insisting that Doug Cannon cut back on his many obligations.
“We more or less grew up with the problems of managed care,” Will said. “Doug’s had to adapt to them. He gets sort of wistful when he talks about the days when you simply diagnosed a surgical problem in a patient and cut it out.”
“Ah, yes, the good old days before one-size-fits-all medicine. My mom is embroiled in a battle with her HMO right now. She’s got huge fibroids and her GYN wants to do a hysterectomy. The evaluators at her HMO say the procedure is unnecessary. What’s more, they performed their magnificent evaluation of her over the phone. No one from her HMO has ever laid eyes or hands on her, but they’re the ones making the decision.”
“I’m not a doctor, but I play one on the phone.”
“Exactly. So Mom has pain every time she takes a step, and her doctor says the fibroids would make it impossible for him to feel a malignancy if one was there.”
“She still in Montana?”
“Forever.”
“And you never had any desire to go back there?”
“How can I know I exist if I can’t see myself in store windows when I walk down the street?” Susan’s dark eyes smiled. “Besides, what do I have in common with Demi Moore and all of those other big-name transplants from Hollywood?”
“You should bring your mom’s case up at the Society meeting Thursday night.”
“Um . . . the truth is, I hadn’t decided if I was going to go. Will, I appreciate your enthusiasm for the Hippocrates Society, really I do, but after almost a year of going, I just haven’t gotten caught up in it. I’m definitely upset with managed care companies’ policies and regulations, and all they’re doing to the way we practice, but I just haven’t been able to get as . . . as fired up as the rest of you, even with my mom’s recent problems. You know me. I’m pretty reserved about most things—not shy, like some people think, but not that outspoken either. And excuse me for saying so, but you people are fanatics.”
Will laughed.
“Hey, now, I wouldn’t go that far. Listen, we need every body we can get at these meetings. There were over a hundred docs there last time. The papers are really starting to take notice.”
“Will, I’m on two committees in the hospital and a couple at church. The people on the desk at my gym don’t know who I am. I’m afraid my boyfriend may be headed there, too.”
“I understand. Just do your best. I may tell your mom’s story anyway.”
“You have my permission.”
“These companies have ripped the heart out of medicine, Susan. They have to be stopped.”
“You just be careful not to rile them up too much. You wouldn’t be the first doctor they’ve squashed.”
“I’d like to see them try,” Will said.
This is a work of fiction. The names, characters, organizations, and incidents portrayed in this novel are the product of the author’s imagination or are used fictitiously. Any resemblance to actual persons or organizations is entirely coincidental.
FATAL
A Bantam Book
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Bantam hardcover edition published May 2002
Bantam mass market edition / October 2003
Published by Bantam Dell
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Copyright © 2002 by Michael Palmer
Library of Congress Catalog Card Number: 2002018460
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