A Case of Need

  I will prescribe regimen 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

  CONTENTS

  MONDAY,

  October 10

  TUESDAY,

  October 11

  WEDNESDAY,

  October 12

  THURSDAY,

  October 13

  FRIDAY—SUNDAY,

  October 14—16

  POSTSCRIPT:

  Monday, October 17

  APPENDICES

  MONDAY

  OCTOBER 10

  ONE

  ALL 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.1 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.2

  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 dx3 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.4 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.

  And they don’t. They just want to bitch, like Conway. It gives them something to do. All surgeons have persecution complexes anyway. Ask the psychiatrists.

  As I went to the phone, I stripped off one rubber glove. 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, I felt like taking him on, but I didn’t. I just said, “You’ve got a malignancy.”

  “I thought so,” Scanlon said as if the whole path work-up had been a waste of time. “Yeah,” I said and hung up. I wanted a cigarette badly. I’d only had one at breakfast, and I usually have two.

  Returning to my table, I saw three specimens were waiting: a kidney, a gallbladder, and an appendix. I started to pull my glove back on when the intercom clicked.

  “Dr. Berry?”

  “Yes?”

  The intercom has a high pickup. You can speak in a normal voice anywhere in the room, and the girl will hear you. They mount the microphone high up, near the ceiling, because the new residents usually rush over and shout into it, not knowing how 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: no calls in the morning. I’m always busy from seven to eleven, six days a week, sometimes seven if one of the staff gets sick. She’s usually very good about it. She didn’t even call when Johnny drove his tricycle into 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 at my hand. The glove was half on. I stripped it off and went back to the phone.

  “Hello?”

  “John?” Her voice was trembling. I hadn’t heard her 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 shoulder and stripped away my other glove. I threw them both in the vinyl-lined wastebasket. “I’ll go see him now,” I said. “You sit tight and don’t worry. It’s probably 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 the peg by the door. Then I went down the hall to Sanderson’s office. Sanderson was chief of the path labs. 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 half frames, “when you know.”

  “I will.”

  He nodded. When I left him, he had opened the file 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 pocket for my car keys, then realized I didn’t know where they were holding Art, so I went to the information desk to call Judith and ask her. The girl at the desk was Sally Planck, a good-natured blonde whose name was the subject of endless jokes among the residents. I phoned Judith and asked where Art was; she didn’t know. It hadn’t occurred to her to ask. 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 research at Harvard, but she stopped when she had her third child. She was usually very calm. The only time I had seen her upset was when George Kovacs had 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 home that 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 she do 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 VOLKSWAGEN out of the doctors’ parking lot, past all the shiny Cadillacs. The big cars are all owned by practicing physicians; pathologists are paid by the hospital and can’t afford all those glistening horses.

  It was 8:45, right in the middle of rush-hour traffic, which in Boston means a life-and-death proposition. Boston has the highest accident rate in the U.S., even higher than Los Angeles, as any EW5 intern can tell you. Or pathologists: we see a lot of automobile trauma at autopsy. They drive like maniacs; like sitting in the EW as the bodies come in, you think there’s a war going on. Judith says it’s because they’re repressed. Art has always said it was because they’re Catholic and think God will look after them as they wander across the double stripe, but Art is a cynic. Once, at a medical party, a surgeon explained how many eye injuries occur from plastic dashboard figurines. People get into
accidents, pitch forward, and have their eyes put out by the six-inch Madonna. It happens a lot; Art thought it was the funniest thing he had ever heard.

  He laughed until he was crying. “Blinded by religion,” he kept saying, doubled over in laughter. “Blinded by religion.”

  The surgeon did plastic stuff, and he didn’t see the humor. I guess because he’d repaired too many punched-out eyesockets. But Art was convulsed.

  Most people at the party were surprised by his laughter; they thought it was excessive and in rather poor taste. I suppose of all the people there I was the only one who understood the significance of 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 we went to medical school together. He’s a bright guy and a skilled doctor, and he believes in what he’s doing. Like most practicing doctors, he tends to be a little too authoritarian, a little too autocratic. He thinks he knows what’s best, and nobody can know that all the time. Maybe he goes overboard, but I can’t really knock him. He serves a very important function. After all, somebody around here has to do the abortions.

  I don’t know exactly when he started. I guess it was right after he finished his gynecology residency. It’s not a particularly difficult operation—a 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 out about it. There was some talk among some of the path residents about Lee; they were getting a lot of D & C’s that were positive. The D & C’s had been ordered for a variety of complaints—menstrual irregularity, pain, mid-period bleeding—but quite a few were showing evidence of pregnancy in the scrapings. I got concerned because the residents were 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 such jokes. They sobered up quickly. Then I went to see Arthur. I found him in the hospital cafeteria. “Art,” I said, “something’s bothering me.” He was in a jovial mood, eating a doughnut and coffee. “Not a gynecological problem, I hope.” He laughed.