Michael Crichton - A Case of Need

Now, of course, surgeons are not barbers, or vice versa. But the barbers retain the symbol of their old trade—the red-and-white-striped pole which represents the bloody white dressings of the battlefield.

But if surgeons no longer give haircuts, they still accompany armies. Wars gives them vast experience in treating trauma, wounds, crush injuries, and burns. War also allows innovation; most of the techniques now common to plastic or reconstructive surgery were developed during World War II.

All this does not necessarily make surgeons either prowar or antipeace. But the historical background of their craft does give them a somewhat different outlook from other doctors.

DOCTORS LOVE ABBREVIATIONS, and probably no other major profession has so many. Abbreviations serve an important time-saving function, but there seems to be an additional purpose. Abbreviations are a code, a secret and impenetrable language, the cabalistic symbols of medical society.

For instance: “The PMI, corresponding to the LBCD, was located in the 5th ICS two centimeters lateral to the MCL.” Nothing could be more mysterious to an outsider than that sentence.

X is the most important letter of the alphabet in medicine, because of its common use in abbreviations. Use ranges from the straightforward “Polio x3” for three polio vaccinations, to “Discharged to Ward X,” a common euphemism for the morgue. But there are many others: dx is diagnosis; px, prognosis; Rx, therapy; sx, symptoms; hx, history; mx, metastases; fx, fractures.

Letter abbreviations are particularly favored in cardiology, with its endless usage of LVH, RVF, AS, MR to describe heart conditions, but other specialties have their own.

On occasion, abbreviations are used to make comments which one would not want to write out in full. This is because any patient’s hospital record is a legal document which may be called into court; doctors must therefore be careful what they say, and a whole vocabulary and series of abbreviations have sprung up. For instance, a patient is not demented, but “disoriented” or “severely confused”; a patient does not lie, but “confabulates”; a patient is not stupid, but “obtunded.” Among surgeons, a favorite expression to discharge a patient who is malingering is SHA, meaning “Ship his ass out of here.” And in pediatrics is perhaps the most unusual abbreviation of all, FLK, which means “Funny-looking kid.”

EVERYBODY KNOWS DOCTORS WEAR WHITE UNIFORMS, and nobody, not even the doctors, knows why. Certainly the “whites,” as they are called, are distinctive, but they serve no real purpose. They are not even traditional.

In the court of Louis XIV, for example, all physicians wore black: long, black, imposing robes which were as striking and awe-inspiring in their day as shining whites are now.

Modern arguments for whites usually invoke sterility and cleanliness. Doctors wear white because it is a “clean” color. Hospitals are painted white for the same reason. This sounds quite reasonable until one sees a grubby intern who has been on duty for thirty-six consecutive hours, has slept twice in his clothes, and has ministered to dozens of patients. His whites are creased, wrinkled, dirty, and no doubt covered with bacteria.

Surgeons give it all away. The epitome of aseptic conditions, of germ-free living, is found in the operating room. Yet few OR’s are white, and the surgeons themselves do not wear white clothing. They wear green, or blue, or sometimes gray.

So one must consider the medical “whites” as a uniform, with no more logic to the color than the designation of blue for a navy uniform or green for an army uniform. The analogy is closer than the casual observer might expect, for the medical uniform designates rank as well as service. A doctor can walk into a ward and can tell you the rank of everyone on the ward team. He can tell you who is the resident, who the intern, who the medical student, who the male orderly. He does this by reading small cues, just as a military man reads stripes and shoulder insignias. It comes down to questions like: Is the man carrying a stethoscope? Does he have one notebook in his pocket or two? File cards held by a metal clip? Is he carrying a black bag?

The process may even be extended to indicate the specialty of a doctor. Neurologists, for example, are readily identified by the three or four straight pins stuck through their left jacket lapels.

THERE ARE GENERALLY CONSIDERED to be six arguments for abortion, and six counterarguments. The first argument considers the law and anthropology. It can be shown that many societies routinely practice abortion and infanticide without parental guilt or destruction of the moral fiber of the society. Usually examples are drawn from marginal societies, living in a harsh environment, such as the African Pygmies or Bushmen of the Kalahari. Or from societies which place a great premium on sons and kill off excess female infants. But the same argument has used the example of Japan, now the sixth-largest nation in the world and one of the most highly industrialized.

The reverse argument states that Western society has little in common with either Pygmies or the Japanese, and that what is right and acceptable for them is not necessarily so for us.

Legal arguments are related to this. It can be shown that modern abortion laws did not always exist; they evolved over many centuries, in response to a variety of factors. Proponents of abortion claim that modern laws are arbitrary, foolish, and irrelevant. They argue for a legal system which accurately reflects the mores and the technology of the present, not of the past.

The reverse argument points out that old laws are not necessarily bad laws and that to change them thoughtlessly invites uncertainty and flux in an already uncertain world. A less sophisticated form of the argument opposes abortion simply because it is illegal. Until recently, many otherwise thoughtful doctors felt comfortable taking this position. Now, however, abortion is being debated in many circles, and such a simplistic view is untenable.

The second argument concerns abortion as a form of birth control. Proponents regard abortion on demand as a highly effective form of birth control and point to its success in Japan, Hungary, Czechoslovakia, and elsewhere. Proponents see no essential difference between preventing a conception and halting a process which has not yet resulted in a fully viable infant. (These same people see no difference between the rhythm method and the pill, since the intention of both practices is identical.) In essence, the argument claims that “it’s the thought that counts.”

Those who disagree draw a line between prevention and correction. They believe that once conception has occurred, the fetus has rights and cannot be killed. This viewpoint is held by many who favor conventional birth-control measures, and for these people, the problem of what to do if birth control fails—as it does in a certain percentage of cases—is troublesome.

The third argument considers social and psychiatric factors. It has variants.

The first states that the physical and mental health of the mother always takes precedence over that of the unborn child. The mother, and her already existing family, may suffer emotionally and financially by the birth of another infant, and therefore, in such cases the birth should be prevented.

The second states that it is immoral and criminal to bring into the world an unwanted child. It states that, in our increasingly complex society, the proper rearing of a child is a time-consuming and expensive process demanding maternal attention and paternal financial support for education. If a family cannot provide this, they do a grave disservice to the child. The obvious extreme case is that of the unwed mother, who is frequently unprepared to rear an infant, either emotionally or financially.