A Case of Need: A Novel (9 page)

It takes a certain kind of man to assume this burden, to set his sights on such a distant goal. By the time he is ready to begin surgery on his own, he has become another person, almost a new breed, estranged by his experience and his dedication from other men. In a sense, that is part of the training: surgeons are lonely men.

I thought of this as I looked down through the glass-overhead viewing booth into OR 9. The booth was built into the ceiling, allowing you a good view of the entire room, the staff, and the procedure. Students and residents often sat up here and watched. There was a microphone in the OR, so that you heard everything—the clink of instruments, the rhythmic hiss of the respirator, the quiet voices—and there was a button you could press to talk to the people below. Otherwise they could not hear you.

I had come to this room after going to J. D. Randall’s office. I had wanted to see the chart on Karen, but Randall’s secretary said she didn’t have it. J. D. had it, and J. D. was in surgery now. That had surprised me. I had thought he would have taken the day off, considering. But apparently it had not entered his mind.

The secretary said the operation was probably almost over, but one look through the glass told me it was not. The chest of the patient was still open and the heart was still incised; they had not even begun suturing. There I was not going to interrupt them; I’d have to come back later and try and get the chart.

But I stayed a moment to watch. There is something compelling about open-heart surgery, something fantastic and fabulous, a mixture of dream and nightmare, all come true. There were sixteen people in the room below me, including four surgeons. Everyone was moving, working, checking in smooth, coordinated movements, like a kind of ballet, like a surrealistic ballet. The patient, draped in green, was dwarfed by the heart-lung machine alongside him, a giant complex as large as an automobile, shining steel, with smoothly moving cylinders and wheels.

At the head of the patient was the anesthetist, surrounded by equipment. There were several nurses, two pump technicians who monitored the dials and gauges on the machine, nurses, orderlies, and the surgeons. I tried to tell which was Randall, but I could not; in their gowns and masks, they all looked the same, impersonal, interchangeable. That was not true, of course. One of those four men had responsibility for everything, for the conduct of all sixteen workers present. And responsibility for the seventeenth person in that room, the man whose heart was stopped.

In one corner, displayed on a television, was the electrocardiogram. The normal EKG is a briskly bouncing line, with spikes for every heartbeat, every wave of electrical energy that fires the heart muscle. This one was flat: just a meaningless squiggle. That meant that according to one major criterion of medicine, the patient was dead. I looked at the pink lungs through the open chest; they were not moving. The patient was not breathing.

The machine did all that for him. It pumped his blood, oxygenated it, removed the carbon dioxide. In its present form, the machine had been in use for about ten years.

The people below me did not seem in awe of the machine or the surgical procedure. They worked matter-of-factly at their jobs. I suppose that was one reason why it all seemed so fantastic.

I watched for five minutes without realizing the time. Then I left. Outside, in the corridor, two residents slouched in a doorway, still wearing their caps with their masks hanging loosely around their necks. They were eating doughnuts and coffee, and laughing about a blind date.

¹
See
Appendix III: Battlefields and Barberpoles
.

R
OGER WHITING, M.D
., lived near the hospital in a third-floor walk-up on the sleazy side of Beacon Hill, where they dump the garbage from Louisburg Square. His wife answered the door. She was a plain girl, about seven months’ pregnant. She looked worried.

“What do you want?”

“I’d like to talk to your husband. My name’s Berry. I’m a pathologist at the Lincoln.”

She gave me a hard suspicious glance. “My husband is trying to sleep. He’s been on call for the last two days, and he’s tired. He’s trying to sleep.”

“It’s very important.”

A slim young man in white ducks appeared behind her. He looked more than tired; he looked exhausted and afraid. He said, “What is it?”

“I’d like to talk to you about Karen Randall.”

“I’ve been over it,” he said, “a dozen times. Talk to Dr. Carr about it.”

“I did.”

Whiting ran his hands through his hair, then said to his wife, “It’s O.K., honey. Get me some coffee, would you?” He turned to me. “Want some coffee?”

“Please,” I said.

We sat in the living room. The apartment was small, the furniture cheap and rickety. But I felt at home: it had been only a few years since I had done my own internship. I knew all about the money problems, the stresses, the hellish hours, and the slop work you had to do. I knew about the irritating calls from nurses in the middle of the night, asking you to okay another aspirin for patient Jones. I knew how you could drag yourself out of bed to see a patient and how you could, in the small hours of the morning, make a mistake. I had nearly killed an old man with heart failure when I was an intern. With three hours of sleep during the last two days, you could do anything and not give a damn.

“I know you’re tired,” I said. “I won’t stay long.”

“No, no,” he said very earnestly. “Anything I can do to help. I mean, now …”

The wife came in with two cups of coffee. She looked at me angrily. The coffee was weak.

“My questions,” I said, “have to do with the girl when she first arrived. Were you in the ward?”

“No. I was trying to sleep. They called me.”

“What time was this?”

“Almost exactly four.”

“Describe what happened.”

“I was sleeping in my clothes, in that little room just off the OPD. I wasn’t asleep long when they called me; I’d just gotten through putting another IV into a lady who pulls them out. She says she doesn’t, but she does.” He sighed. “Anyway, when they called me, I was bleary as hell. I got up and dunked my head in cold water, then toweled off. When I got to the ward, they were bringing the girl in on a stretcher.”

“Was she conscious?”

“Yes, but disoriented. She was pale, and she’d lost a lot of blood. She was feverish and delirious. We couldn’t get a good temperature because she kept gnashing her teeth, so we figured it was about 102 and got to work on the cross-matching.”

“What else was done?”

“The nurses got a blanket over her and propped her feet up with shock blocks.
¹
Then I examined the lesion. It was very clearly vaginal hemorrhage and we diagnosed it as miscarriage.”

“About the bleeding,” I said, “was there any discharge accompanying it?”

He shook his head. “Just blood.”

“No tissue? No signs of a placenta?”

“No. But she’d been bleeding for a long time. Her clothes …” He looked across the room, seeing it again in his mind. “Her clothes were very heavy. The nurses had trouble getting them off.”

“During this time, did the girl say anything coherent?”

“Not really. She was mumbling every once in a while. Something about an old man, I think. Her old man, or an old man. But it wasn’t clear, and nobody was really paying any attention.”

“Did she say anything else?”

He shook his head. “Just when they were cutting her clothes off her. She would try to pull them back. Once she said ‘You can’t do this to me.’ And then later she said, ‘Where am I?’ But that was just delirious talk. She wasn’t really coherent.”

“What did you do about the bleeding?”

“I tried to localize it. It was hard, and things were pretty rushed. And we couldn’t angle the lights down properly. Finally I decided to pack it with gauze pads and concentrate on getting her blood volume back up.”

“Where was Mrs. Randall during all this?”

“She waited by the door. She seemed all right until we had to tell her what had happened. Then she went to pieces. Just went to pieces.”

“What about Karen’s records? Had she ever been admitted to the hospital before?”

“I didn’t see her chart,” he said, “until … later. They had to be pulled from the record room. But she had been in before. Papp smears every year since she was fifteen. Usual blood tests from her twice-yearly physicals. She was well looked after medically, as you might expect.”

“Was there anything unusual in her past history? Besides the hypersensitivity, I mean.”

He gave a sad smile. “Isn’t that enough?”

For a fleeting moment I was angry with him. He was soaking in self-pity, despite his natural fright. But I wanted to tell him he’d better get used to the idea of people dying in front of him, lots of people. And he’d better get used to the idea that he could make a mistake, because they happened. Sometimes the mistakes were balder than others, but it was just degree. I wanted to tell him if he’d asked Mrs. Randall about Karen’s hypersensitivity, and she’d said the girl was O.K., that Whiting would have been free and clear. The girl would still have died, of course, but Whiting would be clear. His mistake was not killing Karen Randall; it was not asking permission first.

I thought about saying this, but I didn’t.

“Any indication in the chart of psychiatric problems?” I asked.

“No.”

“Nothing unusual at all?”

“No.” Then he frowned. “Wait a minute. There was one strange thing. A complete set of skull films were ordered about six months ago.”

“Did you see the films?”

“No. I just read the radiologist’s dx.”

“And what was that?”

“Normal. No pathology.”

“Why were the films taken?”

“It didn’t say.”

“Was she in an accident of some kind? A fall, or an auto accident?”

“Not that I know of.”

“Who ordered the films?”

“Probably Dr. Randall. Peter Randall, that is. He was her doctor.”

“And you don’t know why the X rays were taken?”

“No.”

“But there must be a reason,” I said.

“Yes,” he said, but he didn’t seem very interested. He stared moodily at his coffee, then sipped it. Finally he said, “I hope they take that abortionist and screw him to the wall. Whatever he gets, he deserves worse.”

I stood. The boy was under stress and almost on the verge of tears. All he could see was a promising medical career jeopardized because he had made a mistake with the daughter of a prominent physician. In his anger and frustration and self-pity, he, too, was looking for a goat. And he needed one worse than most.

“Are you planning to settle in Boston?” I asked.

“I was,” he said with a wry look.

W
HEN I LEFT THE INTERN
I called Lewis Carr. I wanted to see Karen Randall’s chart more than ever. I had to find out about those X rays.

“Lew,” I said, “I’m going to need your help again.”

“Oh?” He sounded thrilled by the prospect.

“Yes. I’ve got to get her chart. It’s imperative.”

“I thought we went over that.”

“Yes, but something new has come up. This thing is getting crazier by the minute. Why were X rays ordered—”

“I’m sorry,” Carr said. “I can’t help you.”

“Lew, even if Randall does have the chart, he can’t keep—”

“I’m sorry, John. I’m going to be tied up here for the rest of the day and most of tomorrow. I’m just not going to have time.”

He was speaking formally, a man counting his words, repeating the sentences over to himself before speaking them aloud.

“What happened? Randall get to you and button your mouth?”

“I feel,” Carr said, “that the case should be left in the hands of those best equipped to deal with it. I’m not, and I don’t think other doctors are, either.”

I knew what he was saying and what he meant. Art Lee used to laugh about the elaborate way doctors back out of things, leaving behind a spoor of double-talk. Art called it The Pilate Maneuver.

“O.K.,” I said, “if that’s the way you feel.”

I hung up.

In a way, I should have expected it. Lewis Carr always played the game, following all the rules just like a good boy. That was the way he always had been, and the way he always would be.

¹
Shock blocks are simply wooden blocks used to elevate the legs in cases of shock, helping to get blood to the head.

M
Y ROUTE FROM WHITING
to the medical school took me past the Lincoln Hospital. Standing out in front near the taxi stand was Frank Conway, hunched over, his hands in his pockets, looking down at the pavement. Something about his stance conveyed sadness and a deep, dulling fatigue. I pulled over to the curb.

“Need a ride?”

“I’m going to Children’s,” he said. He seemed surprised that I had stopped. Conway and I aren’t close friends. He is a fine doctor but not pleasant as a man. His first two wives had divorced him, the second after only six months.

“Children’s is on the way,” I said.

It wasn’t, but I’d take him anyway. I wanted to talk to him. He got in and I pulled out into traffic.

“What takes you to Children’s?” I said.

“Conference. They have a congenital CPC once a week. You?”

“Just a visit,” I said. “Lunch with a friend.”

He nodded and sat back. Conway was young, only thirty-five. He had breezed through his residencies, working under the best men in the country. Now he was better than any of them, or so it was said. You couldn’t be sure about a man like Conway: he was one of the few doctors who become so famous so fast that they take on some aspects of politicians and movie stars; they acquire blindly loyal fans and blindly antagonistic critics; one either loves them or loathes them. Physically, Conway was a commanding presence, a stocky, powerful man with gray-flecked hair and deep, piercing blue eyes.

“I wanted to apologize,” Conway said, “about this morning. I didn’t mean to blow up that way.”

“It’s O.K.”

“I have to apologize to Herbie. I said some things …”

“He’ll understand.”

“I feel like hell,” Conway said. “But when you watch a patient just collapse under you, just fall apart before your very eyes … You don’t know how it is.