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, there’s 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, “I’ll never find a decent anes man. Never. They don’t 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. [1] Geriatrics. 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. “Who’s 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 Conway’s. 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.

“I’ll tell the desk,” I said. “They’ll hold a locker for you.”

“Yeah. Shit.” He pounded the table. “Mother of four, that’s what she was.”

“I’ll tell the desk to arrange everything.”

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

“What’s 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 didn’t 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 it’s 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. [2] The files containing the history of treatment of patients in the hospital. Called a “chart” because the bulk of the file consists of daily charts of temperature, blood pressure, pulse and respiration, the so-called “vital signs.”

I’ve 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 [3] Diagnosis. before proceeding further with the operation. If this was a benign tumor, they’d simply remove one lobe of his lung. If it was malignant, they’d take the whole lung and all his lymph nodes.

I stepped on the floor pedal. “Patient AO—four-five-two-three-three-six. Joseph Magnuson, The specimen is a section of right lung, upper lobe, measuring”—I took my foot off the pedal and measured it—“five centimeters by seven point five centimeters. The lung tissue is pale pink in color and crepitant. [4] Crepitant means it is crackly and filled with air. This is normal. 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, measuring”—I measured the lump—“approximately 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.”