Robin Cook: Godplayer

Robert stepped back to his desk and picked up his phone.

“Autopsy!” Joan whispered, alarmed. “I didn’t bargain on an autopsy. I’m not sure I’m up for that.”

“It might be worthwhile,” said Cassi innocently, as if watching an autopsy was something people did for amusement. “During my time as a pathology resident, Robert and I became interested in a series of cases that we’ve labeled SSD, for sudden surgical death. What we found was a group of cardiac surgery patients who had died less than a week after their operations even though most had been doing well and who, on autopsy, had no anatomical cause of death. A few might be understandable, but counting what turned up in the records for the last ten years, we found seventeen. The case Robert is going to autopsy now could make eighteen.”

Robert returned from the phone saying Jerry Donovan would be right down and offered his guests coffee. Before they had a chance to drink it, Jerry arrived on the run. The first thing he did was give Cassi a hug. Joan was impressed. Cassi seemed to be on friendly terms with everyone. Then he slapped Robert on the shoulder and said, “Hey, man, thanks for the call.”

Robert winced at the impact of the blow and forced a smile.

To Joan, Jerry was dressed like the usual house officer. His white jacket, rumpled and soiled, hung askew due to the weight of an overstuffed black notebook in the right pocket. His pants were spotted with a line of bloodstains across the thighs. Next to Robert, Jerry looked like a floor sweeper in a meat-packing house.

“Jerry went to the same medical school as Robert and I,” explained Cassi. “Only he was an upper classman.”

“A distinction that is still painfully obvious,” kidded Jerry.

“Let’s go,” said Robert. “I’ve had one of the autopsy rooms on hold long enough.”

Robert left first, followed by Joan. Jerry stepped aside for Cassi, then caught up to her.

“You’ll never guess who I had the pleasure of watching do his thing last night,” said Jerry as they skirted the microscope table.

“I wouldn’t even try,” said Cassi, expecting some off-color humor.

“Your husband! Dr. Thomas Kingsley.”

“Really?” said Cassi. “What was a medicine man like you doing in the OR?”

“I wasn’t,” said Jerry. “I was on the surgical floor trying to resuscitate the patient we’re going to autopsy. Your husband responded to the code. I was impressed. I don’t think I’ve ever seen such decisiveness. He ripped this guy’s chest open and gave open-heart massage right on the bed. It blew my mind. Tell me, is your husband that impressive at home?”

Cassi shot Jerry a harsh glance. If that comment had come from anybody but Jerry, she probably would have snapped back. But she expected off-color humor and there it was. So why make an issue? She decided to let it drop.

Ignoring Cassi’s less-than-positive reaction, Jerry continued: “The thing that impressed me was not the actual cutting open of the guy’s chest but rather the decision to do it in the first place. It’s so goddamn irreversible. It’s a decision I don’t know how anybody could make. I agonize over whether or not to start a patient on antibiotics.”

“Surgeons get used to that sort of thing,” said Cassi. “That kind of decision making becomes a tonic. In a sense they enjoy it.”

“Enjoy it?” echoed Jerry with disbelief. “That’s pretty hard to believe, but I suppose they must; otherwise we wouldn’t have any surgeons. Maybe the biggest difference between an internist and a surgeon is the ability to make irreversible decisions.”

Entering the autopsy room, Robert donned a black rubber apron and rubber gloves. The others grouped around the pale corpse whose chest still gaped open. The edges of the wound had darkened and dried. Except for an endotracheal tube that stuck rudely out of the mouth, the patient’s face looked serene. The eyes were thankfully closed.

“Ten to one it was a pulmonary embolism,” said Jerry confidently.

“I’ll put a dollar on that,” said Robert, positioning a microphone which hung from the ceiling at a convenient height. It was operated by a foot pedal. “You told me yourself the patient initially had been very cyanotic. I don’t think we’re going to find an embolism. In fact, if my hunch is correct, we’re not going to find anything.”

As Robert began his examination, he started dictating into the mike. “This is a well-developed, well-nourished Caucasian male weighing approximately one hundred sixty-five pounds and measuring seventy inches in length who appears to be of the stated age of forty-two…”

As Robert went on to describe the other visible evidence of Bruce Wilkinson’s surgery, Joan stared at Cassi, who was placidly sipping her coffee. Joan looked down at her own cup. The idea of drinking it made her stomach turn.

“Have all these SSD cases been the same?” asked Joan, trying not to look at the table where Robert was arranging scalpels, scissors, and bone clippers in preparation of opening and eviscerating the corpse.

Cassi shook her head. “No. Some have been cyanotic like this case, some seemed to have died from cardiac arrest, some from respiratory failure, and some from convulsions.”

Robert began the usual Y-shaped autopsy incision, starting high on the shoulder and connecting with the open-chest incision. Joan could hear the blade scrape across the underlying bony structures.

“What about the kind of surgery?” asked Joan. She heard ribs crack and closed her eyes.

“They’ve all had open-heart surgery but not necessarily for the same condition. We’ve checked anesthesia, duration of pump time, whether or not hypothermia was used. There were no correlations. That’s been the frustrating part.”

“Well, why are you trying to relate them?”

“That’s a good question,” said Cassi. “It has to do with the mentality of a pathologist. After you’ve done an autopsy, it’s very unsatisfying not to have a definitive cause of death. And when you have a series of such cases, it’s demoralizing. Solving the puzzle is what makes pathology rewarding.”

Involuntarily Joan’s eyes stole a quick glance at the table. Bruce Wilkinson appeared as if he’d been unzipped. The skin and subcutaneous structures of the chest and thorax had been folded back like the leaves of a gigantic book. Joan felt herself swaying.

“The knowledge is important,” Cassi went on, unaware of Joan’s difficulties. “It can have a direct benefit to future patients if some preventable cause is discovered. And in this situation, we’ve noticed an alarming trend. The initial patients seemed to have been older and much sicker. In fact, most were in irreversible coma. Lately though, the patients have been under fifty and generally healthier, like Mr. Wilkinson here. Joan, what’s the matter?” Cassi had turned and finally noticed that her friend seemed about to faint.

“I’m going to wait outside,” said Joan. She turned and started for the door, but Cassi caught her arm.

“Are you all right?” asked Cassi.

“I’ll be fine,” said Joan. “I just need to sit down.” She fled through the stainless steel door.

Cassi was about to follow when Robert called for her to look at something. He pointed at a quarter-sized contusion on the surface of the heart.

“What do you think of that?” asked Robert.

“Probably from the resuscitation attempt,” said Cassi.

“At least we agree on that,” said Robert as he directed his attention back to the respiratory system and the larynx. Deftly he opened the breathing passages. “No obstruction of any sort. If there had been, that would have explained the deep cyanosis.”

Jerry grunted and said, “Goin’ to be pulmonary embolism. I’m sure of it.”