Michael Crichton - A Case of Need

“Four months, supposedly.”

“Four months? And you can’t tell from the uterus?”

“Murph—”

“Yeah, sure, it could be done at four months,” he said. “Won’t stand up in a courtroom or anything, but yeah. Could be done.”

“Can you do it?”

“That’s all we got in this lab,” he said. “Steroid assays. What’ve you got?”

I didn’t understand; I shook my head.

“Blood or urine. Which?”

“Oh. Blood.” I reached into my pocket and drew out a test tube of blood I had collected at the autopsy. I’d asked Weston if it was O.K., and he said he didn’t care.

Sometimes rather bitter arguments break out over who needs the next dead baby most for their studies.

Murph took the tube and held it to the light. He flicked it with his finger. “Need two cc’s,” he said. “Plenty here. No problem.”

“When will you let me know?”

“Two days. Assay takes forty-eight hours. This is post blood?”

“Yes. I was afraid the hormones might be denatured or something…”

Murph sighed. “How little we remember. Only proteins can be denatured, and steroids are not proteins, right? This’ll be easy. See, the normal rabbit test is chorionic gonadotrophin in urine. But in this lab we’re geared to measure that, or progesterone, or any of a number of other eleven-beta hydroxylated compounds. In pregnancy, progesterone levels increase ten times. Estriol levels increase a thousand times. We can measure a jump like that, no sweat.” He glanced at his technicians. “Even in this lab.”

One of the technicians took up the challenge. “I used to be accurate,” she said, “before I got frostbite on my fingers.”

“Excuses, excuses,” Murphy grinned. He turned back to me and picked up the tube of blood. “This’ll be easy. We’ll just pop it onto the old fractionating column and let it perk through,” he said. “Maybe we’ll do two independent aliquots, just in case one gets fouled up. Who’s it from?”

“What?”

He waved the test tube in front of me impatiently. “Whose blood?”

“Oh. Just a case,” I said, shrugging.

“A four-month pregnancy and you can’t be sure? John boy, not leveling with your old buddy, your old bridge opponent.”

“It might be better,” I said, “if I told you afterward.”

“O.K., O.K. Far from me to pry. Your own way, but you will tell me?”

“Promise.”

“A pathologist’s promise,” he said, standing up, “rings of the eternal.”

THE LAST TIME ANYONE COUNTED, there were 25,000 named diseases of man, and cures for 5,000 of them. Yet it remains the dream of every young doctor to discover a new disease. That is the fastest and surest way to gain prominence within the medical profession. Practically speaking, it is much better to discover a new disease than to find a cure for an old one; your cure will be tested, disputed, and argued over for years, while a new disease is readily and rapidly accepted.

Lewis Carr, while still an intern, hit the jackpot: he found a new disease. It was pretty rare—a hereditary dysgammaglobulinemia affecting the beta-fraction which he found in a family of four—but that was not important. The important thing was that Lewis discovered it, described it, and published his results in the New England Journal of Medicine.

Six years later he was made clinical professor at the Mem. There was never any question he would be; simply a matter of waiting until somebody on the staff retired and vacated an office.

Carr had a good office in terms of status at the Mem; it was perfect for a young hotshot internist. For one thing, it was cramped and made even worse by the stacks of journals, texts, and research papers scattered all around. For another, it was dirty and old, tucked away in an obscure corner of the Calder Building, near the kidney research unit. And for the finishing touch, amid the squalor and mess sat a beautiful secretary, looking sexy, efficient, and wholly unapproachable: a nonfunctional beauty to contrast with the functional ugliness of the office.

“Dr. Carr is making rounds,” she said without smiling. “He asked for you to wait inside.”

I went in and took a seat, after removing a stack of back issues of the American Journal of Experimental Biology from the chair. A few moments later, Carr arrived. He wore a white lab coat, open at the front (a clinical professor would never button his lab coat) and a stethoscope around his neck. His shirt collar was frayed (clinical professors aren’t paid much), but his black shoes gleamed (clinical professors are careful about things that really count). As usual, his manner was very cool, very collected, very political.

Unkind souls said Carr was more than political, that he shamelessly sucked up to the senior staff men. But many people resented his swift success and his confident manner. Carr had a round and childlike face; his cheeks were smooth and ruddy. He had an engaging boyish grin that went over very well with the female patients. He gave me that grin now.

“Hi, John.” He shut the door to his outer office and sat down behind his desk. I could barely see him over the stacked journals. He removed the stethoscope from his neck, folded it, and slipped it into his pocket. Then he looked at me.

I guess it’s inevitable. Any practicing doctor who faces you from behind a desk gets a certain manner, a thoughtful-probing-inquisitive air which is unsettling if there’s nothing wrong with you. Lewis Carr got that way now.

“You want to know about Karen Randall,” he said, as if reporting a serious finding.

“Right.”

“For personal reasons.”

“Right.”

“And anything I tell you goes no further?”

“Right.”

“O.K.,” he said. “I’ll tell you. I wasn’t present, but I have followed things closely.”

I knew that he would have. Lewis Carr followed everything at the Mem closely; he knew more local gossip than any of the nurses. He gathered his knowledge reflexively, the way some other people breathed air.

“The girl presented in the outpatient ward at four this morning. She was moribund on arrival; when they sent a stretcher out to the car she was delirious. Her trouble was frank vaginal hemorrhage. She had a temperature of 102, dry skin with decreased turgor, shortness of breath, a racing pulse, and low blood pressure. She complained of thirst.” [20] Thirst is an important symptom in shock. For unknown reasons, it appears only in severe shock due to fluid loss, and is regarded as an ominous sign.

Carr took a deep breath. “The intern looked at her and ordered a cross match so they could start a transfusion. He drew a syringe for a count and crit [21] White count and hematocrit. and rapidly injected a liter of D 5. [22] Five percent dextrose in water, used to replace lost fluid volume. He also attempted to locate the source of the hemorrhage but he could not, so he gave her oxytocin to clamp down the uterus and slow bleeding, and packed the vagina as a temporary measure. Then he found out who the girl was from the mother and shit in his pants. He panicked. He called in a resident. He started the blood. And he gave her a good dose of prophylactic penicillin. Unfortunately, he did this without consulting her chart or asking the mother about allergic reactions.”

“She was hypersensitive.” [23] Penicillin reactions occur in 9–10 percent of normal patients.

“Severely,” Carr said. “Ten minutes after giving the penicillin i.m. [24] Intramuscularly. the girl went into choking spasms and appeared unable to breathe despite a patent airway. By now the chart was down from the record room, and the intern realized what he had done. So he administered a milligram of epinephrine i.m. When there was no response, he went to a slow IV, benadryl, cortisone, and aminophylline. They put her on positive pressure oxygen. But she became cyanotic, [25] Blue. convulsive, and died within twenty minutes.”