Crichton, Michael - A Case Of Need

By Juan Shaw,2014-05-30 21:48
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Crichton, Michael - A Case Of Need

    I will prescribe regimen for the good of my pa-tients, according to my judgment and ability, andnever do harm to anyone. To please no one will Iprescribe 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. . . .



    There is no moral obligation to conserve DNA.

    Garrett Hardin


    OCTOBER 10



    no exception. He came storming into the path labat 8:30 in the morning, still wearing his green sur-gical gown and cap, and he was furious. WhenConway is mad he clenches his teeth and speaksthrough 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 doestwo open-heart procedures a day, beginning the firstat 6:30. When he shows up in the path lab twohours later, there's only one reason.

    "Stupid clumsy bastard," Conway said. He kickedover a wastebasket. It rolled noisily across the floor.

    "Beat his brains in, his goddamned brains," Conway said, grimacing and staring up at the ceil-ing as if addressing God. God, like the rest of us,

    had heard it before. The same anger, the sameclenched teeth and pounding and profanity. Conway always ran true to form, like the rerun of

    a movie.

    Sometimes his anger was directed against thethoracic man, sometimes against the nurses, some-times 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 anesman. Never. They don't exist. Stupid, shit-eatingbastards, all of them."

    We glanced at each other: this time it wasHerbie. About four times a year the blame fell onHerbie. The rest of the time he and Conway weregood friends. Conway would praise him to the sky, call him the finest anesthesiologist in the country,better than Sonderick at the Brigham, better thanLewis at the Mayo, better than anyone.

    But four times a year, Herbert Landsman was re-sponsible 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 fora man like Conway.

    Because Frank Conway was good, because hewas an eight-percenter, a man with lucky hands, a man with the touch, everyone put up with his tem-per tantrums, his moments of anger and destruc-tiveness. Once he kicked over a path microscopeand did a hundred dollars' worth of damage. Nobody blinked, because Conway was an eight-percenter.

    Of course, there was scuttlebutt in Boston abouthow he kept his percentage, known privately among surgeons as the "Kill rate," down. They saidConway avoided cases with complications. They said Conway avoided jerry cases.1They saidConway never innovated, never tried a new anddangerous procedure. The arguments were, of course, wholly untrue. Conway kept his kill ratelow because he was a superb surgeon. It was as simple as that.

    The fact that he was also a miserable person wasconsidered superfluous.

    "Stupid, stinking bastard," Conway said. Helooked angrily about the room. "Who's on today?"

    "I am," I said. I was the senior pathology staffmember in charge for the day. Everything had to becleared through me. "You want a table?"

    "Yeah. Shit."



    It was a habit of Conway's. He always did hisautopsies on the dead cases in the evening, oftengoing long into the night. It was as if he wanted topunish himself. He never allowed anyone, not evenhis residents, to be present. Some said he criedwhile he did them. Others said he giggled. The factwas that nobody really knew. Except Conway.

    ' Geriatrics.

    "I'll tell the desk," I said. "They'll hold a lockerfor you."

    "Yeah. Shit." He pounded the table. "Mother offour, 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 needthe 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 fac-ing him, and stared at his fingers accusingly, as ifthey had betrayed him. I suppose in a sense they had.

    "Jesus," Conway said. "I should have been a der-matologist. 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 resi-dents, looking very pale, said to me, "Is he alwayslike 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 kindof ritual angry deceleration that he went through ev-ery time he lost a patient. I guess he needed it, butstill most of us in the lab wished he could be like Delong in Dallas, who did crossword puzzles inFrench, or Archer in Chicago, who went out and hada haircut whenever he lost someone.

    Not only did Conway disrupt the lab, he put usbehind. In the mornings, that was particularly bad, because we had to do the surgical specimens andwe were usually behind schedule anyway.

    I turned my back to the window and picked upthe next specimen. We have a high-speed tech-nique in the lab: the pathologists stand beforewaist-high benches and examine the biopsies. A mi-crophone hangs from the ceiling before each of us, and it's controlled by a foot pedal. This leaves yourhands free; whenever you have something to say, you step on the pedal and speak into the mike, re-cording your comments on tape. The secretaries type it up later for the charts.2

    I've been trying to stop smoking for the pastweek, and this specimen helped me: it was a white lump imbedded in a slice of lung. The pink tag at-tached gave the name of the patient; he was down in the OR now with his chest cut open. The sur-geons were waiting for the path dx3before proceed-

    2The files containing the history of treatment of patients in the hospital. Called a "chart" because the bulk of the file consists of daily charts of temperature, blood pressure, pulse and respiration, the so-called "vital signs."

    3 Diagnosis.

    ing 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.

    1 stepped on the floor pedal. "Patient AOfour-five-two-three-three-six. Jo-seph Magnuson, The

    specimen is a section of rightlung, 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.4The 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 centi-meters in diameter. On cut surface, it appears whit-ish 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 masswas benign or malignant, and that was to check itunder the microscope. Quick-freezing the tissue al-lowed a thin section to be rapidly prepared. Nor-mally, to make a microscope slide, you had to dunk

    4Crepitant means it is crackly and filled with air. This is normal.

    your stuff into six or seven baths; it took at least sixhours, 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 seethe lacy network of lung tissue formed into delicatealveolar sacs for exchange of gas between blood andair. The white mass was something else again. I stepped on the floor button. "Micro examination, frozen section. The whitish mass appears composed of undifferentiated paren-chyma cells which have invaded the normal sur-rounding tissue. The cells show many irregular, hyperchromatic nuclei and large numbers of mi-toses. There are some multinucleate giant cells. There is no clearly defined capsule. Impression is primary malignant cancer of the lung. Note markeddegree of anthracosis in surrounding tissue."

    Anthracosis is accumulation of carbon particlesin the lung. Once you gulp carbon down, either as cigarette smoke or city dirt, your body never gets ridof it. It just stays in your lungs.

    The telephone rang. I knew it would be Scanlondown in the OR, wetting his pants because wehadn't gotten back to him in thirty seconds flat. Scanlon is like all surgeons. If he's not cutting, he'snot happy. He hates to stand around and look at the big hole he's chopped in the guy while he waits forthe report. He never stops to think that after hetakes 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 duringthose hours, but biopsies get backed up. There's nothing we can do about itunless they want torisk a misdiagnosis by us.

    And they don't. They just want to bitch, likeConway. It gives them something to do. All sur-geons have persecution complexes anyway. Ask the


    As I went to the phone, I stripped off one rubberglove. My hand was sweaty; I wiped it on the seat of my pants, then picked up the receiver. We are careful about the phone, but just to be safe it gets swabbed with alcohol and Formalin at the end of each day. "Berry speaking."

    "Berry, what's going on up there"?" After Conway, 1 felt like taking him on, but Ididn't. I just said, "You've got a malignancy."

    "I thought so," Scanlon said as if the whole pathwork-up had been a waste of time. "Yeah," I said and hung up. I wanted a cigarette badly. I'd only had one atbreakfast, and I usually have two.

    Returning to my table, I saw three specimenswere waiting: a kidney, a gallbladder, and an appen-dix. I started to pull my glove back on when the in-tercom clicked.

    "Dr. Berry?"


    The intercom has a high pickup. You can speakin a normal voice anywhere in the room, and thegirl will hear you. They mount the microphone highup, near the ceiling, because the new residents usually rush over and shout into it, not knowinghow sensitive it is. That blasts the ears off the girl at the other end.

    "Dr. Berry, your wife is on the telephone."

    I paused. Judith and I have an understanding: nocalls in the morning. I'm always busy from seven to eleven, six days a week, sometimes seven if one ofthe staff gets sick. She's usually very good about it. She didn't even call when Johnny drove his tricycleinto the back of a truck and had to have fifteen stitches in his forehead.

    "All right," I said, "I'll take it." I looked down atmy hand. The glove was half on. I stripped it off and went back to the phone.


    "John?" Her voice was trembling. I hadn't heardher sound that way in years. Not since her father died.

    "What is it?"

    "John, Arthur Lee just called."

    Art Lee was an obstetrician friend of ours; he had been best man at our wedding.

    "What's the problem?"

    "He called here asking for you. He's in trouble."

    "What kind of trouble?" As I spoke, I waved to a

    resident to take my place at the table. We had to

    keep those surgical specimens moving.

    "I don't know," Judith said, "but he's in jail."My first thought was that it was some kind of

    mistake. "Are you sure?"

    "Yes. He just called. John, is it something

    about ---- ?"

    "I don't know," I said. "I don't know any more than you do." I cradled the phone in my shoulderand stripped away my other glove. I threw themboth in the vinyl-lined wastebasket. "I'll go see himnow," I said. "You sit tight and don't worry. It's prob-ably a minor thing. Maybe he was drinking again." "All right," she said in a low voice. "Don't worry," I repeated. "All right."

    "I'll speak to you soon."

    I hung up, untied my apron, and placed it on thepeg by the door. Then I went down the hall to Sanderson's office. Sanderson was chief of the pathlabs. He was very dignified looking; at forty-eight, his hair was just turning gray at the temples. He had a jowly, thoughtful face. He also had as much to fear as I did.

    "Art's in jail," I said.

    He was in the middle of reviewing an autopsy case. He shut the file. "Why?"

    "I don't know. I'm going to see him." "Do you want me to come with you?" "No," I said. "It's better if I go alone."

    Call me, Sanderson said, peering over his halfframes, "when you know."

    "I will."

    He nodded. When I left him, he had opened thefile again, and was reading the case. If he had been upset by the news, he wasn't showing it. But then Sanderson never did.

    In the hospital lobby I reached into my pocketfor my car keys, then realized I didn't know wherethey were holding Art, so I went to the informationdesk to call Judith and ask her. The girl at the deskwas Sally Planck, a good-natured blonde whose name was the subject of endless jokes among theresidents. I phoned Judith and asked where Artwas; she didn't know. It hadn't occurred to her toask. So I called Arthur's wife, Betty, a beautiful and efficient girl with a Ph.D. in biochem from Stanford. Until a few years ago, Betty had done re-search at Harvard, but she stopped when she hadher third child. She was usually very calm. The only time I had seen her upset was when George Kovacshad gotten drunk and urinated all over her patio.

    Betty answered the phone in a state of stony shock. She told me they had Arthur downtown, on Charles Street. He had been arrested in his homethat morning, just as he was leaving for the office. The kids were very upset, and she had kept them home from school that day, and now what did shedo with them? What was she supposed to tell them, for Pete's sake?

    I told her to say it was all a mistake and hung up.

    I drove my Volkswagenout of the doctors' parkinglot, past all the shiny Cadillacs. The big cars areall owned by practicing physicians; pathologistsare paid by the hospital and can't afford all those

    glistening horses.

    It was 8:45, right in the middle of rush-hour traf-fic, which in Boston means a life-and-death proposition. Boston has the highest accident rate in theU.S., even higher than Los Angeles, as any EW5in-tern can tell you. Or pathologists: we see a lot ofautomobile trauma at autopsy. They drive like mani-acs; like

    sitting in the EW as the bodies come in,you think there's a war going on. Judith says it's be-cause they're repressed. Art has always said it wasbecause they're Catholic and think God will lookafter them as they wander across the double stripe,but Art is a cynic. Once, at a medical party, a sur-geon explained how many eye injuries occur fromplastic dashboard figurines. People get into acci-dents, pitch forward, and have their eyes put out by the six-inch Madonna. It happens a lot; Art thoughtit was the funniest thing he had ever heard.

    He laughed until he was crying. "Blinded by reli-gion," he kept saying, doubled over in laughter. "Blinded by religion."

    The surgeon did plastic stuff, and he didn't seethe humor. 1 guess because he'd repaired too many punched-out eyesockets. But Art was convulsed.

    5 Emergency ward.

    Most people at the party were surprised by hislaughter; they thought it was excessive and inrather poor taste. I suppose of all the people thereI was the only one who understood the significanceof this joke to Art. I was also the only one who knew the great strains under which he worked.

    Art is my friend, and he has been ever since wewent to medical school together. He's a bright guy and a skilled doctor, and he believes in what he'sdoing. Like most practicing doctors, he tends to be a little too authoritarian, a little too autocratic. Hethinks he knows what's best, and nobody can knowthat all the time. Maybe he goes overboard, but Ican't really knock him. He serves a very importantfunction. After all, somebody around here has to dothe abortions.

    I don't know exactly when he started. I guess itwas right after he finished his gynecology residency. It's not a particularly difficult operationa well-trained nurse can do it with no problem. There's only one

    small catch.

    It's illegal.

    I remember very well when I first found outabout it. There was some talk among some of the path residents about Lee; they were getting a lot ofD & C's that were positive. The D & C's had been ordered for a variety of complaintsmenstrual ir-regularity, pain, mid-period bleedingbut quite afew

    were showing evidence of pregnancy in thescrapings. I got concerned because the residentswere young and loose-mouthed. I told them right

    there in the lab that it wasn't funny, that they could seriously damage a doctor's reputation by suchjokes. They sobered up quickly. Then I went to seeArthur. I found him in the hospital cafeteria. "Art," I said, "something's bothering me."He was in a jovial mood, eating a doughnut andcoffee. "Not a gynecological problem, I hope." He


    "Not exactly. I overheard some of the residentssay that you had a half-dozen pregnancy-positive scrapings in the last month. Have you been noti-fied?"

    Immediately, the hearty manner was gone. "Yes,"

    he said, "I have."

"I just wanted you to know. There might be trou-ble in the tissue committee when these things

    come up, and"

    He shook his head. "No trouble." "Well, you know how it looks." "Yes," he said. "It looks like I'm performing abor-tions."

    His voice was low, almost dead calm. He waslooking directly at me. It gave me a strange feeling. "We'd better have a talk," he said. "Are you freefor a drink about six tonight?" "I guess so."

    "Then meet me in the parking lot. And if you getsome free time this afternoon, why don't you havea look at a case of mine?" "All right," I said, frowning.

    "The name is Suzanne Black. The number isAOtwo-two-one-three-six-five."

    I scribbled the number on a napkin, wonderingwhy he should have remembered it. Doctors re-member a lot about their patients, but rarely thehospital number.

    "Take a good look at this case," Art said, "anddon't mention it to anyone until you talk to me."

    Puzzled, I went back to work in the lab. I was up for an autopsy that day, so I wasn't free until four inthe afternoon. Then I went to the record room andpulled the chart for Suzanne Black. I read it rightthereit

    wasn't very long. She was Dr. Lee's pa-tient, first admitted at age twenty. She was a juniorat a local Boston college. Her CC6was menstrual irregularity. Upon questioning, it was revealed thatshe had recently suffered a bout of German mea-sles, had been very tired afterward, and had been examined by her college doctor for possible mono-nucleosis. She reported irregular spotting approxi-mately every seven to ten days, but no normal flow. This had been going on for the last two months. She was still tired and lethargic.

    Physical examination was essentially normal, ex-cept that she had a mild fever. Blood tests werenormal, though hematocrit7was somewhat low.

    Dr. Lee ordered a D & C to correct her irregular-ity. This was in 1956, before the advent of estrogen

    6 Chief complaint, the term for the medical disorder that brings the pa

    tient to seek treatment.

    7 A test of the amount of hemoglobin, or red cells, in the blood.

    therapy. The D & C was normal; no evidence of tu-mors or pregnancy. The girl seemed to respond well to this treatment. She was followed for the next three months and had normal periods.

    It looked like a straightforward case. Illness or emotional stress can disrupt a woman's biological clock, and throw off her menses; the D & C resetthat clock. I couldn't understand why Art had wanted me to look at it. I checked the path reporton the tissue. It had been done by Dr. Sanderson. The write-up was brief and simple: gross appear-ance normal, micro examination normal.

    I returned the chart and went back to the lab. When I got there, I still couldn't imagine what thepoint of the case was. I wandered around, doingodds and ends, and finally began the work-up on

my autopsy.

    I don't know what made me think of the slide.Like most hospitals, the Lincoln keeps pathslides on file. We save them all; it is possible to go back twenty or thirty years and reexamine the mi-croscopic slides from a patient. They're stored inlong boxes arranged like card catalogs in a library. We had a whole room full of such boxes.

    I went to the appropriate box and found slide 1365. The label gave the case number and Dr. Sanderson's initials. It also said in large letters,

    "D & C."

    I took the slide back to the micro room, wherewe have ten microscopes in a long row. One was

    free; I slipped the slide onto the stage and had alook.

    I saw it immediately.

    The tissue was a uterine scraping, all right. Itshowed a rather normal endometrium in the prolif-erative phase, but the stain stopped me. This slidehad been stained with Zenker-Formalin stain, giving everything a brilliant blue or green color. It was a rather unusual stain, employed for special diagnos-tic problems.

    For routine work, the Hematoxylin-Eosin stain isused, producing pink and purple colors. Almost ev-ery tissue slice is stained with H & E, and if this is not the case, the reasons for the unusual stain arenoted in the pathological summary.

    But Dr. Sanderson had not mentioned that the slide was Zenker-Formalin.

    The obvious conclusion was that the slides had been switched. I looked at the handwriting on thelabel. It was Sanderson's, no doubt about it. Whathad happened?

    Almost immediately, other possibilities came to mind. Sanderson had forgotten to note in his reportthat an unusual stain was used. Or two sections were made, one H & E, the other Zenker-Formalin, and only the Zenker was saved. Or that there had been some legitimate mixup.

    None of these alternatives was particularly con-vincing. I thought about it and waited impatiently until six that evening, when I met Art in the park-ing lot and got into his car. He wanted to go someplace away from the hospital to talk. As he drove, he said, "Read the case?" "Yes," I said. "Very interesting." "You checked the section?" "Yes. Was it the original?" "You mean, was it a scraping from Suzanne

    Black? No."

    "You should have been more careful. The stain was different. That kind of thing can get you intotrouble. Where did the slide come from?"

    Art smiled thinly. "A biological supply house.'Slide of normal endometrial scraping.' "

    "And who made the switch?"

    "Sanderson. We were new to the game, in thosedays. It was his idea to put in a phony slide and write it up as normal. Now, of course, we're muchmore refined. Every time Sanderson gets a normal scraping, he makes up a few extra slides and keepsthem around."

    "I don't understand," I said. "You mean Sanderson is in this with you?"

    "Yes," Art said. "He has been for several years." Sanderson was a very wise, very kind, and very

    proper man.

    "You see," Art said, "that whole chart is a lie. The girl was twenty, all right. And she had German measles. And she had menstrual irregularity, too, but the reason was she was pregnant. She had been knocked up on a football weekend by a guy she said she loved and was going to marry, but she wantedto finish college first, and a baby would get in the

    way. Furthermore, she managed to get measles dur-ing the first trimester. She wasn't a terribly brightgirl, but she was bright enough to know what itmeant when you got measles. She was very worriedwhen she came to see me. She hemmed and hawed for a while, and then blurted it all out and asked foran abortion.

    "I was pretty horrified. I was fresh from my res-idency, and I still had a little starry idealism in me. She was in a terrible fix; she was a wreck and actedas if the world had collapsed around her. I guessin a way it had. All she could see was her problem as a college dropout, the unwed mother of a possi- bly deformed child. She was a nice enough girl, andI felt sorry for her, but I said no. I sympathized withher, feeling rotten inside, but I explained that my hands were tied.

    "So then she asked me if it was a dangerous op-eration, to have an abortion. At first I thought she was planning to try it on herself, so I said it was. Then she said she knew of a man in the North Endwho would do it for two hundred dollars. He hadbeen a medical orderly in the Marines, or some- thing. And she said that if I wouldn't do it for her, she'd go to this man. And she walked out of my of-fice."

    He sighed and shook his head as he drove.

    "I went home that night feeling like hell. I hatedher: I hated her for intruding on my new practice, for intruding on my neatly planned life. I hated herfor the pressure she was putting on me. I couldn't

    sleep; I kept thinking all night. I had a vision of her going to a smelly back room somewhere andmeeting a leering little guy who would letch herand maybe even manage to kill her. I thought aboutmy own wife and our year-old baby, and how happyit could all be. I thought about the amateur abor-tions I'd seen as an intern, when the girls came inbleeding and foaming at three in the morning. Andlet's face it, I thought about the sweats I'd had incollege. Once with Betty, we sat around for sixweeks waiting for her period. I knew perfectly wellthat anybody can get pregnant by accident. It's nothard, and it shouldn't be a crime."

    I smoked a cigarette and said nothing."So I got up in the middle of the night andfought it out with six

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