Michael Crichton - A Case of Need

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, theres 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, Ill never find a decent anes man. Never. They dont 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. 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. Whos 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 Conways. 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.

Ill tell the desk, I said. Theyll hold a locker for you.

Yeah. Shit. He pounded the table. Mother of four, thats what she was.

Ill tell the desk to arrange everything.

Arrested before we got into the ventricle. Cold. We massaged for thirty-five minutes, but nothing. Nothing.

Whats 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 didnt 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 its 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.

Ive 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 before proceeding further with the operation. If this was a benign tumor, theyd simply remove one lobe of his lung. If it was malignant, theyd take the whole lung and all his lymph nodes.

I stepped on the floor pedal. Patient AOfour-five-two-three-three-six. Joseph Magnuson, The specimen is a section of right lung, upper lobe, measuringI took my foot off the pedal and measured itfive centimeters by seven point five centimeters. The lung tissue is pale pink in color and crepitant. 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, measuringI measured the lumpapproximately 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 couldnt 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 didnt 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.