Michael Crichton - A Case of Need

Joshua Randall, like many surgeons of his period, had a rule that no resident working under him could marry. One resident sneaked off and did; a few months later, Randall discovered what had happened and called a meeting of all his residents. He lined them up in a row and said, “Dr. Jones, please take one step forward.”

The guilty doctor did, trembling slightly.

Randall said, “I understand you have gotten married.” He made it sound like a disease.

“Yes, sir.”

“Before I discharge you from the staff, do you have anything to say in your defense?”

The young doctor thought for a moment, then said, “Yes, sir. I promise I’ll never do it again.”

Randall, according to the story, was so amused by this reply that he kept the resident after all.

After Joshua Randall came Winthrop Randall, the thoracic surgeon. J. D. Randall, Karen’s father, was a heart surgeon, specializing in valvular replacements. I had never met him, but I’d seen him once or twice—a fierce, patriarchal man, with thick white hair and a commanding manner. He was the terror of the surgical residents, who flocked to him for training, but hated him.

His brother, Peter, was an internist with his offices just off the Commons. He was very fashionable, very exclusive, and supposedly quite good, though I had no way of knowing.

J. D. had a son, Karen’s brother, who was in medical school at Harvard. A year ago there was a rumor that the kid was practically flunking out, but nothing recently.

In another town, at another time, it might seem odd that a young boy with such a distinguished medical tradition would choose to try and live it down. But not Boston: in Boston the wealthy old families had long felt only two professions were worthy of one’s attention. One was medicine and the other was law; exceptions were made for the academic life, which was honorable enough so long as one became a professor at Harvard.

But the Randalls were not an academic family, or a legal family. They were a medical family, and any Randall who could, contrived to get himself through medical school and into a house officership [9] Position as an intern or resident, where one is an M.D. but not licensed to practice, and still completing education. at the Mem. Both the medical school and the Mem had, in the past, made allowances for poor grades when it came to the Randalls, but over the years, the family had more than repaid the trust. In medicine, a Randall was a good gamble.

And that was about all I knew about the family, except that they were very wealthy, firmly Episcopal, determinedly public spirited, widely respected, and very powerful.

I would have to find out more.

THREE BLOCKS FROM THE HOSPITAL, I passed through the Combat Zone at the corner of Mass and Columbus avenues. At night it teems with whores, pimps, addicts, and pushers; it got its name because doctors at the City see so many stabbings and shootings from this area they regard it as the location of a limited war. [10] Formerly the most violent area in Boston was Scollay Square, but it was demolished five years ago to make way for government buildings. Some consider that an improvement; some a step backward.

The Boston City itself is an immense complex of buildings sprawling over three city blocks. It has more than 1,350 beds, mostly filled with alcoholics and derelicts. Within the Boston medical establishment, the City is known as the Boston Shitty because of its clientele. But it is considered a good teaching hospital for residents and interns, because one sees there many medical problems one would never see in a more affluent hospital. A good example is scurvy. Few people in modern America contract scurvy. To do so requires general malnutrition and a complete abstinence from fruit for five months. This is so rare that most hospitals see a case every three years; at the Boston City there are a half-dozen each year, usually in the spring months, the “scurvy season.”

There are other examples: severe tuberculosis, tertiary syphilis, gunshot wounds, stabbings, accidents, self-abuse, and personal misfortune. Whatever the category, the City sees more of it, in a more advanced state, than any other hospital in Boston. [11] The frequently bizarre cases mean that every doctor and surgeon has a backlog of strange stories. One surgeon is fond of telling how he was on the Accident Floor—the City’s EW—when two victims of an auto accident were brought in. One man had lost his leg at the knee. The other had massive crush injury to the chest, so bad that the degree of damage could not at first be ascertained from the heavy bleeding. On an X ray of the chest, however, it was seen that one man’s foot and lower leg had been rammed into the second man’s chest, where it was lodged at the time of admission.

THE INTERIOR OF THE CITY HOSPITAL is a maze built by a madman. Endless corridors, above ground and below, connect the dozen separate buildings of the hospital. At every corner, there are large green signs pointing directions, but they don’t help much; it is still hopelessly confusing.

As I cut through the corridors and buildings, I remembered my rotation through the hospital as a resident. Small details came back. The soap: a strange, cheap, peculiar-smelling soap that was used everywhere. The paper bags hung by each sink, one for paper towels, the other for rectal gloves. As an economy, the hospital saved used gloves, cleaned them, and used them again. The little plastic name tags edged in black, blue, and red depending on your service. I had spent a year in this hospital, and during that time I had done several autopsies for the medical examiner.

THERE ARE FOUR MEDICAL SITUATIONS in which the coroner claims jurisdiction and an autopsy is required by law. Every pathology resident knows the list cold:

• If the patient dies under violent or unusual circumstances.

• If the patient is DOA. [12] Dead on arrival at hospital.

• If he dies within twenty-four hours of admission.

• If a patient dies outside the hospital while not under a doctor’s care.

Under any of these circumstances, an autopsy is performed at the City. Like many cities, Boston has no separate police morgue. The second floor of the Mallory Building, the pathology section of the hospital, is given over to the medical examiner’s offices. In routine cases, most of the autopsies are performed by first-year residents from the hospital in which the patient died. For the residents, new to the game and still nervous, a coroner’s autopsy can be a tense business.

You don’t know what poisoning or electrocution looks like, for instance, and you’re worried about missing something important. The solution, passed down from resident to resident, is to do a meticulous PM, to take lots of pictures and notes as you go, and to “save everything,” meaning to keep pieces of tissue from all the gross organs in case there is a court action that requires reexamination of the autopsy findings. Saving everything is, of course, an expensive business. It requires extra jars, extra preservative, and more storage space in the freezers. But it is done without question in police cases.

Yet even with the precautions, you worry. As you do the post, there is always that fear, that dreadful thought at the back of your mind that the prosecution or the defense will demand some piece of information, some crucial bit of evidence either positive or negative, that you cannot supply because you did not consider all the possibilities, all the variables, all the differentials.

FOR SOME LONG-FORGOTTEN REASON, there are two small stone sphinxes just inside the doors of Mallory. Each time I see them, they bother me; somehow sphinxes in a pathology building smack of Egyptian embalming chambers. Or something.