A Case of Need: A Novel
Read A Case of Need: A Novel Online
Authors: Michael Crichton,Jeffery Hudson
Tags: #Literature & Fiction, #Genre Fiction, #Medical, #Mystery; Thriller & Suspense, #Thrillers, #Suspense
A Novel
Michael Crichton
I will prescribe regimens for the good of my patients, according to my judgment and ability, and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art …
—FROM THE HIPPOCRATIC OATH DEMANDED OF THE YOUNG PHYSICIAN ABOUT TO ENTER UPON THE PRACTICE OF HIS PROFESSION.
There is no moral obligation to conserve DNA.
—GARRETT HARDIN
Postscript: Monday, October 17
Appendix I: Delicatessen Pathologists
Appendix III: Battlefields and Barberpoles
Appendix VI: Arguments on Abortion
A Biography of Michael Crichton
October 10
One
A
LL HEART SURGEONS ARE BASTARDS
, and Conway is no exception. He came storming into the path lab at 8:30 in the morning, still wearing his green surgical gown and cap, and he was furious. When Conway is mad he clenches his teeth and speaks through them in a flat monotone. His face turns red, with purple blotches at the temples.
“Morons,” Conway hissed, “goddamned morons.” He pounded the wall with his fist; bottles in the cabinets rattled.
We all knew what was happening. Conway does two open-heart procedures a day, beginning the first at 6:30. When he shows up in the path lab two hours later, there’s only one reason.
“Stupid clumsy bastard,” Conway said. He kicked over a wastebasket. It rolled noisily across the floor.
“Beat his brains in, his goddamned brains,” Conway said, grimacing and staring up at the ceiling as if addressing God. God, like the rest of us, had heard it before. The same anger, the same clenched teeth and pounding and profanity. Conway always ran true to form, like the rerun of a movie.
Sometimes his anger was directed against the thoracic man, sometimes against the nurses, sometimes against the pump technicians. But oddly enough, never against Conway.
“If I live to be a hundred,” Conway hissed through his teeth, “I’ll never find a decent anes man. Never. They don’t exist. Stupid, shit-eating bastards, all of them.”
We glanced at each other: this time it was Herbie. About four times a year the blame fell on Herbie. The rest of the time he and Conway were good friends. Conway would praise him to the sky, call him the finest anesthesiologist in the country, better than Sonderick at the Brigham, better than Lewis at the Mayo, better than anyone.
But four times a year, Herbert Landsman was responsible for a DOT, the surgical slang for a death on the table. In cardiac surgery, it happened a lot: fifteen percent for most surgeons, eight percent for a man like Conway.
Because Frank Conway was good, because he was an eight-percenter, a man with lucky hands, a man with the touch, everyone put up with his temper tantrums, his moments of anger and destructiveness. Once he kicked over a path microscope and did a hundred dollars’ worth of damage. Nobody blinked, because Conway was an eight-percenter.
Of course, there was scuttlebutt in Boston about how he kept his percentage, known privately among surgeons as the “kill rate,” down. They said Conway avoided cases with complications. They said Conway avoided jerry cases.
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They said Conway never innovated, never tried a new and dangerous procedure. The arguments were, of course, wholly untrue. Conway kept his kill rate low because he was a superb surgeon. It was as simple as that.
The fact that he was also a miserable person was considered superfluous.
“Stupid, stinking bastard,” Conway said. He looked angrily about the room. “Who’s on today?”
“I am,” I said. I was the senior pathology staff member in charge for the day. Everything had to be cleared through me. “You want a table?”
“Yeah. Shit.”
“When?”
“Tonight.”
It was a habit of Conway’s. He always did his autopsies on the dead cases in the evening, often going long into the night. It was as if he wanted to punish himself. He never allowed anyone, not even his residents, to be present. Some said he cried while he did them. Others said he giggled. The fact was that nobody really knew. Except Conway.
“I’ll tell the desk,” I said. “They’ll hold a locker for you.”
“Yeah. Shit.” He pounded the table. “Mother of four, that’s what she was.”
“I’ll tell the desk to arrange everything.”
“Arrested before we got into the ventricle. Cold. We massaged for thirty-five minutes, but nothing.
Nothing.
”
“What’s the name?” I said. The desk would need the name.
“McPherson,” Conway said, “Mrs. McPherson.”
He turned to go and paused by the door. He seemed to falter, his body sagging, his shoulders slumping.
“Jesus,” he said, “a mother of four. What the hell am I going to tell him?”
He held his hands up, surgeon-style, palms facing him, and stared at his fingers accusingly, as if they had betrayed him. I suppose in a sense they had.
“Jesus,” Conway said. “I should have been a dermatologist. Nobody ever dies on a dermatologist.”
Then he kicked the door open and left the lab.
WHEN WE WERE ALONE
, one of the first-year residents, looking very pale, said to me, “Is he always like that?”
“Yes,” I said. “Always.”
I turned away, looking out at the rush-hour traffic moving slowly through the October drizzle. It would have been easier to feel sympathy for Conway if I didn’t know that his act was purely for himself, a kind of ritual angry deceleration that he went through every time he lost a patient. I guess he needed it, but still most of us in the lab wished he could be like Delong in Dallas, who did crossword puzzles in French, or Archer in Chicago, who went out and had a haircut whenever he lost someone.
Not only did Conway disrupt the lab, he put us behind. In the mornings, that was particularly bad, because we had to do the surgical specimens and we were usually behind schedule anyway.
I turned my back to the window and picked up the next specimen. We have a high-speed technique in the lab: the pathologists stand before waist-high benches and examine the biopsies. A microphone hangs from the ceiling before each of us, and it’s controlled by a foot pedal. This leaves your hands free; whenever you have something to say, you step on the pedal and speak into the mike, recording your comments on tape. The secretaries type it up later for the charts.
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I’ve been trying to stop smoking for the past week, and this specimen helped me: it was a white lump imbedded in a slice of lung. The pink tag attached gave the name of the patient; he was down in the OR now with his chest cut open. The surgeons were waiting for the path dx
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before proceeding further with the operation. If this was a benign tumor, they’d simply remove one lobe of his lung. If it was malignant, they’d take the whole lung and all his lymph nodes.
I stepped on the floor pedal.
“Patient AO—four-five-two-three-three-six. Joseph Magnuson. The specimen is a section of right lung, upper lobe, measuring”—I took my foot off the pedal and measured it—“five centimeters by seven point five centimeters. The lung tissue is pale pink in color and crepitant.
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The pleural surface is smooth and glistening, with no evidence of fibrous material or adhesions. There is some hemorrhage. Within the parenchyma is an irregular mass, white in color, measuring”—
I measured the lump—“approximately two centimeters in diameter. On cut surface, it appears whitish and hard. There is no apparent fibrous capsule, and there is some distortion of surrounding tissue structure. Gross impression … cancer of the lung, suggestive of malignancy, question mark metastatic. Period, signed, John Berry.”
I cut a slice of the white lump and quick-froze it. There was only one way to be certain if the mass was benign or malignant, and that was to check it under the microscope. Quick-freezing the tissue allowed a thin section to be rapidly prepared. Normally, to make a microscope slide, you had to dunk your stuff into six or seven baths; it took at least six hours, sometimes days. The surgeons couldn’t wait.
When the tissue was frozen hard, I cranked out a section with the microtome, stained the slice, and took it to the microscope. I didn’t even need to go to high dry: under the low-power objective, I could see the lacy network of lung tissue formed into delicate alveolar sacs for exchange of gas between blood and air. The white mass was something else again.
I stepped on the floor button.
“Micro examination, frozen section. The whitish mass appears composed of undifferentiated parenchyma cells which have invaded the normal surrounding tissue. The cells show many irregular, hyperchromatic nuclei and large numbers of mitoses. There are some multinucleate giant cells. There is no clearly defined capsule. Impression is primary malignant cancer of the lung. Note marked degree of anthracosis in surrounding tissue.”
Anthracosis is accumulation of carbon particles in the lung. Once you gulp carbon down, either as cigarette smoke or city dirt, your body never gets rid of it. It just stays in your lungs.
The telephone rang. I knew it would be Scanlon down in the OR, wetting his pants because we hadn’t gotten back to him in thirty seconds flat. Scanlon is like all surgeons. If he’s not cutting, he’s not happy. He hates to stand around and look at the big hole he’s chopped in the guy while he waits for the report. He never stops to think that after he takes a biopsy and drops it into a steel dish, an orderly has to bring it all the way from the surgical wing to the path labs before we can look at it. Scanlon also doesn’t figure that there are eleven other operating rooms in the hospital, all going like hell between seven and eleven in the morning. We have four residents and pathologists at work during those hours, but biopsies get backed up. There’s nothing we can do about it—unless they want to risk a misdiagnosis by us.