page 12

"See you soon."

A paying patient? That's always nice. Who doesn't like to operate on one of them? But that was none of Silverstein's business. And besides, in an emergency case I prefer not to know about the patient's payment arrangements. Let me do the case first. If he can pay—what a nice surprise, if not—bad luck. Nothing new. Most of my patients weren't insured or were on Medicaid, which paid peanuts. Paying cases were almost never allowed to reach me; they were filtered and skimmed by our in-house surgical Mafia.

Whatever. An emergency abdominal operation would bring a few thousand bucks, and that was definitely better than the few hundred Medicare would pay. I couldn't complain. I wasn't starving, but who wouldn't want to earn some extra money? It could be compensation for this early wake-up call and another missed breakfast.

I shaved fast, one direction only. I dressed quickly: A pair of khakis, white shirt, blue navy tie with the College of Surgeons' icon. Blazer in same color, cheap--bought at Macy's last year and already frazzling at the sleeves. Heavy black British shoes. A goodbye kiss for Heidi. She opened one sleepy eye. It followed me clumsily as I moved about the darkened room.

"An emergency operation for one of your poor patients?"

I grunted at first and then mumbled to myself. This was not a patient of mine. This was a new case, which was a relief. If I had to go back and perform an emergency operation on someone I'd already operated on, that could be devastating for both them and me! It could have meant I'd made a mistake during a previous surgery. It wasn't the case this time, and for that reason Heidi's black humor succeeded in lightening my mood.

I headed downstairs, gulped a glass of orange juice and stepped into the garage. I looked at my watch—fifteen minutes from bed to car. Not bad. I took a deep breath of the crisp morning air as the automatic garage door swung open.

Page 11

"...Presented yesterday five p.m. to the ER vomiting fresh blood. His blood pressure was low. Responded to a few liters of fluids. GI scoped him, found a large ulcer in the duodenum. It was oozing so they injected it. An hour ago he vomited a pint of clots and his pressure went down to eighty."

I sat up on the edge of the bed and tried to rescue my glasses from the puddle of water that had spread over the table.

The case needed an emergency operation. Silverstein was our best resident. Perhaps even the best surgical resident the hospital had ever seen, or would ever see at the rate it had been going. I respected his intellect and trusted his skills and judgment; I could see and feel the patient over the phone as he explained.

"Hey." Silverstein hesitated for a second.

When I'm deep in thought I have a habit of becoming absolutely motionless. Sometimes, my wife says, I even stop breathing. "Are you with me?"

"Yes," I said, careful not to lose the image forming of this case in my head. I knew if Silverstein saw a problem, there was a problem. In contrast, when our chief resident from the Ivory Coast would tell me that someone needed their belly opened there was a good chance it was something silly like gastroenteritis. I didn't press the panic button until he said the patient is well. "OK, Mike. This guy needs to be done soon. By soon I mean now!"

"That's what I thought Dr. Zohar. I booked the OR; it is ready. Radezki is busy inserting a central line. Blood is on its way. When can we start?"

I did a quick calculation in my head. "I'll be there in forty-five minutes."

"Dr. Zohar, just one more thing you might want to know. The patient's name is Pellegrino. He owns a restaurant close to the hospital; he has good insurance."

"Mike, stop talking so much and work on the guy. We can't operate on a corpse, can we?"

"No," he said with a bit of a chuckle, "we can't."

page 10

An alarm? An instrument malfunctioning? Darkness swallowed my mind and confusion consumed my thoughts. Something was pumping moist sand into my lungs. I popped to the surface like a buoy from the bottom of the dark ocean, cold sweat on my forehead. Only the ringing remained.

It's the phone. I'm in bed. The clock on the radio showed that it was ten after four in the morning. I took a moment to recalibrate my systems before answering the phone. A call that early in the morning could have only meant one thing, so it was worth the extra ring to make sure my head was screwed on right. I took a deep breath before reaching over. Despite my best effort, I still somehow managed to knock over the glass of water on my bedside table as I groped for the receiver.

"Hello?" I said, a hint of irritation spicing my voice.

"Dr. Zohar? Good morning!" It was the cheerful voice of Mike Silverstein, our fourth year resident. A part of me was refreshed by his early morning blast of happiness. The larger part of me figured it had no business anywhere near me at four a.m.

"Morning, Mike." I coughed to shake the grogginess out of my throat. I didn't make much of an effort to be polite about it, either. Why the hell so early again? This is the third stupid call tonight! I detached myself from my wife's warm body and took a deep breath.

"Sorry to wake you up," Mike continued, oblivious to my discomfort. "I have a nice case for you. Are you up? Can I continue?"

I stretched before answering, no doubt filling the phone with a loud primal sounding groan. "Go ahead."

I listened with my eyes closed, my left hand scratching my balls periodically. Years of practice had taught me to produce a mental image of the case under discussion through the voice on the other side. Yes, a case—not a patient yet. He'd only be a patient once we'd had our personal encounter.

"Fifty-five-year-old male. Smoker, drinker. Myocardial infarction two years ago, no congestive failure, no medication—oops, he's on aspirin..."

Chapter 2 Minor Procedure page 9

If want to be on the staff of a hospital, lad, pretend
you're a fool till you're on it.
—Lloyd Roberts, 1853-1920

September 28, 1998

Breathe—come on, breathe. You know how. For God's sake, breathe!

A silent, dry gulp. The mouth opened, but the chest didn't move. Something's jamming. Something is seizing this engine.

I noticed rapid eye movement. Oxygen level in the blood was depleting rapidly. I'll give it another thirty seconds max before the brain goes blank. That is if the lungs don't burst first—an absurd but interesting possibility.

Then I realized I knew the symptom; I've witnessed it often enough in dying patients. One moment they're fighting with unexpected determination, the next they drift past the point of no return. I began to register in cold blood every minute detail as his body methodically shut itself down with the grace of a medical Three Mile Island.

The head rolled to one side. The oscillograph's amplitude bounced on the screen, leaving a hysterical pinball's amber trace, the raw score sheet of life performed by the monotonous whine of an electronic beeper. Remarkably steady, an unerring beep-beep-beep said that the heart seemed intent on going on, brain or no brain.

Stunned, I sensed my own heart rhythm merging with the thumping of the heart in the dying form below me. Emotional gravity pulled me down to the abyss. I was being sucked into the last throes of this struggle for life. It was not his life oozing away, but my own.

Then colors exploded before my eyes and the rhythmical electronic pulse was replaced by a chaotic ring.

Page 8

He completed medical school in Heidelberg, and a surgical residency at the Park Hospital long before "New York" was added to its name. For thirty years he was considered the leading local private surgeon, gathering immense influence and wealth. The showpiece of his wealth was an oceanfront mansion and a large boat on the tip of the Island. This was where Dr. Mantzur used to escape each Friday night after a strenuous operating week, far from his dying patients and their anxious families. It was common knowledge among residents that during long weekends and holidays old Mantzur was unavailable. Emergencies, true or otherwise, had to wait until Monday.

The second surgeon in the ruling triumvirate at the New York Park Hospital was Dr. Mahmud Sorki. Sorki, son of a Persian Ayatollah, studied medicine in Iran and trained in surgery at the Park under Mantzur's wings. He married a local Italian nurse and established himself in private practice. A real "cowboy" surgeon, for many years he was considered the "top knife" by the hospital medical community. He, too, became immensely rich.

The third in the triumvirate was Dr. Herb Susman, the only real American in the leading group. He was a half Jew born and bred in Brooklyn. As a graduate of a Caribbean medical school he completed an Internal Medicine residency in the Park where he met and bonded with Sorki. Energetic despite his immense size, Susman became a Clinical Professor of Medicine with two publications on his curriculum vitae.

He and Sorki, both in their late fifties were as close as brothers and socialized together at top Manhattan restaurants and Bahamas casinos, with women in Atlantic City, sharing jokes, loud laughter and a lot of booze. Their old mentor, Mantzur, a widower, did not drink, did not look at women and did not overeat. Always calm, controlled and poker faced, he was the gray eminence of the New York Park and, as I would soon learn, my true nemesis.

Page 7

Two bodies control and limit the power of management. The supreme one, at least in name, is the Board of Trustees, which consists of non-medical dignitaries from the community. The trustees appoint—and fire—the CEO and control his performance. At the Park Hospital only two MDs have voting power on this board: the President and Vice-President of the second controlling body, the Medical Board. The members of this physician-controlled group are elected each year by their fellow hospital physicians. Theoretically, the Medical Board is a democratic body, with a book of bylaws and associated committees and subcommittees elected for various functions.

One of the Board's chief roles is to assess the credentials of physicians who wish to practice in the hospital and to approve the privileges granted to them by the chairpersons of the various departments. The Medical Board represents the highest level of the hospital's quality assurance mechanism and is responsible for maintaining an optimal level of quality care. At the same time, the Medical Board functions as a doctors' union to protect professional and financial interests of the doctors in opposition to hospital administration.

With the authority to appoint, punish, supervise, and protect, the Park's Medical Board is almost omnipotent. It can decapitate or force into resignation a chief of department and even the President himself, which was the fate of Mike Howard's predecessor. In the end, a group of physicians control the Medical Board, the hospital and a large portion of its purse. For many years the domination of the Medical Board at the New York Park rested in the hands of a triumvirate of two surgeons and a physician who had alternated as chairmen and deputies for years.

The oldest was the Vice-Chairman of Surgery, Dr. Joseph Mantzur. In his late sixties and fragile looking, Mantzur was the typical "do-it-all" Brooklyn surgeon. Name it, and he'd do it: general surgery, vascular bypasses and chest operations. Born in Iran, he immigrated to Germany with his aristocratic family before the downfall of the Shah.

If you would like a copy of
Life Means Nothing Behind the Green Wall
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Page 6

No wonder that the New York Monthly listed the Park among the "top ten" hospitals in the greater metropolis.

Although the Park Hospital in this story is purely a concoction of my imagination, there are numerous facilities across the US just like it.

As with any hospital in America, the New York Park is a micro cosmos—a small almost self-contained political and financial system. Although the hospital is formally designated as a "non-profit" institution, the chief ambition of those who govern it is to make it as profitable as possible—and not, of course, for altruistic reasons.

Michael Howard, a lanky Irishman with a small skull impelled over a stooped six foot, seven-inch frame, was the hospital's almighty president. An astute financier and health care administrator, he also served as chairman of the State's Association of Hospital Presidents and was elected by a leading financial journal as the most successful Hospital President in the city. Howard ran the hospital with the help of a small army of Vice-Presidents. The only physician among them was the Senior Vice-President for Medical Affairs, Dr. Albert Farbstein, a late sixty-something internist who was born, raised, educated, trained and promoted in Brooklyn. White haired, balding, bearded, eagle-nosed, and very short, he looked as if he'd jumped straight out of a Nazi propaganda caricature.

As the CEO, Howard held the keys to the hospital's purse, and he knew that the fatter the purse the bigger the bonus to be added to his already high six-figure salary. Naturally, Farbstein also had a financial interest in the well being of the purse. The more doctors and nurses he employed for the money, the more generous Howard would be with him. From any management's perspective a hospital is a business: a large factory that employs doctors and pars-medical staff. A factory that processes patients.