In the operating room Doc nodded to the slender figure waiting there, masked and gowned like himself. “Well, Katie, you decided to come watch?”
The woman regarded him with cold green eyes. “After that last performance I decided maybe I’d better.”
“It’s just an appendectomy, nothing can go wrong,” Doc said.
“I don’t expect any problem with the appendectomy. Even you can’t argue with perfectly straightforward pantograph training from Dr. Lerner on something like that. It’s the transplant I’m worried about.”
“Then that makes two of us,” Doc said. “It’s a complex procedure, no two of them anything alike. No robot should try to tackle one.”
“And you’ve been doing your best to block it,” Katie Durham said.
“And I still will, the moment there’s the slightest doubt.”
“Not if I have anything to say,” the woman said.
“Now, Katie, if it comes to that, you don’t,” Doc replied. “Better remember that. In this room I’m the surgeon and you’re the guest. No more. What I decide goes.”
Katie turned away with a sniff as the scrub nurse signaled to Doc to check the positioning of the shiny robot-operator over the draped patient on the table. “Better center it a bit more,” Doc murmured. “No, the other way … fine! Okay, that’s good. Go ahead and activate it.”
With a little shudder the machine came to life. Two flat sensing arms moved across the patient’s exposed abdomen, registering each subtle shift in plane, testing for texture of the skin and thickness of the fatty subcutaneous tissue. Two more metal arms moved up to join the first two, one of them pausing to be loaded with a scalpel by the scrub nurse. That arm moved down in a swift, precise stroke, laying open skin and fatty tissue in a neat three-inch incision in the lower right quadrant of the patient’s abdomen. One by one, pinchers caught the bleeding skin vessels, electrocauterizing them, and then, with incredible swiftness, tying them off with fine gut sutures more quickly and expertly than any human hand could have achieved. With this accomplished, two soft fingerlike probes began separating the muscle layers down to the peritoneum, pausing only to tie off one or two more bleeders as quickly as they appeared.
Watching it, Doc felt a familiar queasy feeling, a sense of sickening dread as the surgical machine moved step by step along in the procedure. The steps were the steps that he would have taken if he had been operating, each accomplished with neat exactitude, but the sensors and probes were not human fingers. They could feel only what they had been programmed to feel, react in their contact with human tissue only as they had been programmed to react, yet there was an appearance of inhuman perfection and finality to the movements that sent chills down Doc’s back. He began perspiring as robot fingers pinched up the peritoneum for a robot scalpel to incise; then two rubber-clad probes entered the peritoneal space, lifting up the membrane so that the incision could be lengthened to the length of the skin incision. Doc watched closely as a long, round-ended sensing probe entered the peritoneal space and began a systematic search for the appendix, drew the cecum and appendix up through the incision for surgical excision and repair.
And as Doc watched, ready to move to the table at the first irregularity, he became aware that Dr. Katie Durham was watching him as well as the robot at the operating table. Doc felt his hands clench and unclench as the machine moved slowly, regularly, flawlessly, from one step to the next. With the appendix removed and the stump cauterized, delicate metal fingers applied a silk purse-string suture around the stump. When one of the sutures tore out in the process, the robot fingers paused, then returned to replace the torn suture before proceeding. Finally, a metal probe pressed in on the stump as the purse-string suture was drawn in, snugly but not too tightly, the amount of tension accurately sensed and controlled by the machine’s complex feedback mechanisms. Next the robot inserted a sensor into the patient’s abdomen, replacing the loop of intestine from which the appendix had been removed to its normal anatomical location.
Almost before it was begun, it seemed, the appendectomy was finished. But the robot-operator was not through. Two more probes now entered the abdomen through the incision, one sensitive to pressure, the other equipped with a light and a lens at its flexible tip. Together they began a delicate exploration of the interior of the abdomen, moving from organ to organ, recording visual and tactile impressions for automatic comparison with images stored in the computer’s memory bank. As the machine proceeded, Doc almost forgot for a moment that it was indeed a machine at work; there was an uncanny illusion that he was watching a slow, meticulous and steady-handed surgeon using metallic grapples to do the work, and he had to shake his head to throw off the inpression.
Then, in the midst of the exploration, the robot stopped dead and a signal light began flashing. The scrub nurse looked up. “Dr. Long? The machine indicates positive findings in the right upper abdomen during its exploration. Will you confirm, please?”
“What does it say it found?”
The nurse read the lines appearing on the robot’s viewing screen. “It says, ‘Hardened mass in right upper quadrant in vicinity of gall bladder.’ Do you want a differential diagnosis?”
“Yes, let’s see what it says.”
Almost instantly the read-out began to change. Doc walked across to peer at the screen. “Yes. Um, hum. Probably gall stones, rule out primary cancer of the gall bladder, rule out common duct obstruction of unknown etiology, rule out … yes, well, it’s got it down all right. Now get that probe out of there so I can see what it is.” Stepping to the table, Doc pushed the sterile probe out of his way, enlarged the incision and then inserted his own gloved hand into the wound while the nurse held a retractor. Finally he withdrew his hand, nodded to the nurse to let the robot proceed, and crossed back to stand beside Dr. Durham. “Gall bladder full of rocks,” he said. “We’d better not fool with them right now, with no history of symptoms. Time enough for that later.”
“Are you sure that’s what it is?”
“Sure, I felt them.”
“But you still have to consider the other possibilities that the machine listed.”
“Oh, it’s possible to have a tumor or obstruction of some sort in addition to the stones, but the stones are there.”
“Then the machine wasn’t overreacting?” Katie Durham said. “That’s been a common charge, you know, that the machine can’t distinguish fine dividing lines of diagnosis and therefore produces unwieldy lists of possible diagnosis that the doctor then has to wade through later.”
“Well, I guess this machine did just about right,” Doc said reluctantly. “Except that we wouldn’t have gotten an upper abdomen exploration if a surgeon had been doing it — too small an incision, too hard on the patient. The best he would have done would have been a laparoscopy, just putting a light in there to look; so I guess you’re one up on us there.”
“You also have to admit that this has been as smooth as silk,” Katie said. “Not a flaw, not a false move. We really didn’t need to use an operating room at all. One of the robot tables like the Davies group has been using on dogs would have kept it all in a perfectly enclosed operating box, no chance for contaminated surgical fields, no need for scrub nurses or assistants. That robot has eight pairs of sensor-arms it can use, all at the same time, if necessary.”
“Sure, I know,” Doc acknowledged. “Everything but human judgment.”
“But the pantograph even programs in a simulation of that.”
“And that’s just what it is … a simulation,” Doc rejoined. “Unfortunately, some cases just plain require the real thing. Like this heart transplant patient coming. You’ve been trying to schedule a robot transplant case for months, right?”
“Years,” Katie Durham said quietly. ‘The first one ever tried. But there’s got to be a start sometime.”
“Well, you just watch. See for yourself how far off the mark the machine goes on that one before I have to step in.” And with that, Doc turned and s
talked back into the scrub room to strip off his gown and mask and rescrub. There was no longer any doubt in his mind now that the time for dissembling was past. With Katie Durham monitoring his every move in the next case, the fat was really in the fire.
IV
Later on, Doc knew, it would be perfectly clear to any objective observer that he had never had the slightest intention of allowing a robot-operator to carry out a cardiac transplant on a patient under his care, but at the time he gave every appearance of finally acquiescing to the procedure that Hospital Administration had been pressuring him to permit and monitor these many months past. With the steady, almost catastrophic, decrease in newly trained physicians and other medical personnel in recent years, all the government Hospitals were deeply committed to ever-increasing computerization of all medical services. Diagnosis had become almost completely computerized as much as ten years previously, and many of the medical specialties were rapidly following the same path, as fewer and fewer trained physicians were available to provide care, and the few that were left were increasingly occupied with monitoring the computerized services, acting as overseers and computer consultants rather than physicians.
Surgery, by far the most technically demanding of all the specialties, had naturally resisted computerization the longest. As little as ten years before, expert surgeons had insisted flatly that programming robots to do even the most simple surgery could never be accomplished. Too much, they said, depended on the skilled fingers and refined surgical judgment that no machine could ever emulate — and they might have been right except for the development of Hunyadi’s neuropantograph and the whole new approach to direct, one-to-one surgeon-to-computer programming system the neuropantograph made possible.
The neuropantograph, of course, changed the whole picture. With its use the surgeon, in effect, programmed the robot-operator’s computer directly by what he did or did not do at the operating table. In a sense, the surgeon’s entire surgical performance at every level was captured in molecular miniature in the colloidal gel of the pantograph’s activated Hunyadi tubes, and thence transferred directly to the memory circuits of the computer in usable form. In theory, by repetitive neuropantographic scan of the same surgeon doing the same kind of procedure multitudes of different times, the number of surgical eventualities that the computer could be programmed to face and act upon would be increased exponentially until, in the end, the risk that the computer might encounter a problem or complication it could not handle was reduced to the point of the negligible.
Even this risk, however, could theoretically be minimized by having human surgeons stand in and monitor computer-handled cases. At first only the simplest procedures had been attempted, but as the robot-operators proved themselves in the operating room, more and more complex procedures were being programmed and run. Now there were those enthusiasts from Health Control and Hospital Administration — including Dr. Katie Durham, administrator of Hospital No. 7 — who optimistically contended that there was no surgical procedure too complex or too demanding that a robot-operator could not be programmed to handle it; and there were surgeons like Dr. John Long who used every resource at their command to prove that there were types of difficult surgery that the robot-operators could not manage, now or ever. Today was the first attempt to allow a robot-operator to perform a cardiac transplant from beginning to end, and Doc’s responsibility was clear-cut. As the “teaching surgeon” whose neuropantographs had been used to program the robot’s computer, he was assigned to monitor the surgery, to detect any errors or misjudgments that might occur, and, ultimately, to bail the patient out if anything went wrong.
During the appendectomy done previously, Doc had been content to let things go as they would. Thousands of robot appendectomies had been performed by now, and the monitoring doctor only rarely needed to intervene. But for this case he had his full surgical team on hand, scrubbed and gowned in the operating room, ready at a moment’s notice. Dr. Katie Durham stayed back from the group, watching closely but remaining discreetly out of the way. As the robot-operator began the procedure, Doc kept a careful eye on the anesthetist, checked the robot-operator’s continual monitoring of the patient’s heart rate, electrocardiogram, and electroencephalogram. The machine made the customary incision, opening the patient’s chest widely and tying off bleeding vessels before proceeding. As it moved into the chest with three of its sensor-arms, Doc said, “Hold it. There’s too much seepage there. We’ve got to get those bleeders.” He stepped to the table, tied off two or three small bleeding vessels before allowing the robot to proceed. Moments later he interrupted it again. “This has got to move faster, this patient’s heart is about used up, and it’s going to be fibrillating if we don’t get moving. This machine had better get the bypass ready fast or this patient is going to be in trouble.”
The machine responded hesitatingly, placing the clamps and arranging the tubes in preparation for switching the patient’s circulation to the heart-lung bypass machine. Then, rather than making the switch to machine circulation, the robot hesitated again, then placed electrodes to monitor the heart’s natural but irregular rhythm. A moment later two additional sensorarms moved to resettle the bypass clamps again. The operating room fell dead silent as the robot moved placidly, methodically, delaying the bypass switch as it rechecked the electrocardiograph-monitoring leads. As the apprehension increased, Doc looked over his shoulder at Dr. Durham. Then he said, “Sorry, Katie, but I’m cutting this thing out and going in myself.”
“What’s the trouble?” Katie asked sharply.
“The machine’s obviously confused. It senses the irregular conduction and anticipates that the heart will be fibrillating at any moment, but it can’t seem to complete the bypass. It can’t decide which to do first, stand by to defibrillate the heart or take the bull by the horns.”
“Can’t it handle the defibrillation and the bypass both at the same time?”
“It should be able to, but it’s not doing it. I don’t dare wait any longer; I’m taking over.”
“Doctor, you’re making a mistake. There’s no urgency. The bypass connections are all ready any second they’re needed — ”
“I’m still not taking a chance.” Doc brushed her objections aside and nodded to the nurse to inactivate the robot. With his team moving to the table, Doc quickly made the bypass connection that the robot-operator had started. Then, with the patient’s circulation controlled by the heart-lung machine, he shocked the aging and damaged heart into inactivity. The replacement heart in its perfusion bath was readied, and the people around the table lapsed into a tense silence as Doc moved ahead with the procedure.
“Dr. Long,” Katie Durham’s voice was tight with anger. “You could perfectly well have let that robot go on.”
“Sorry, but I’m the one who had to decide, and I decided no dice.”
“That may be, but I’m not blind. Any confusion on the part of that robot was programmed into it, and you were the one the programming came from.”
“This patient could have been dead before the robot made up its mind to complete the bypass. It should have moved fast and without delay. That’s a fundamental judgment.”
“So you say,” Dr. Durham said. “Well, you’re going to have to say it to the Committee, I’m afraid, when I make my report.”
“Whatever you say,” Doc said sharply. “I’m busy now.”
“Then let me see you in my office when you’re through.”
Doc sighed as the woman left the operating room, closing the door quietly behind her. He had known it would come sooner or later, it had been inevitable from the beginning, but now that he actually faced it he could not put aside the apprehension in his mind. He had been fighting the system from within as stealthily and subtly as he knew how, but now at last the fight was out in the open. And in that kind of fight, he feared, Dr. Katie Durham held all the trumps.
V
The sign on the door said HOSPITAL ADMINISTRATION, and below it: KATHERINE DU
RHAM, M.D. Beneath the name was the single word PRIVATE.
At the secretary’s nod Doc opened the door and stepped into a large, simply furnished office. The room was bright and airy, with large windows looking out across the city from their thirty-fourth-story vantage point. Now mid-afternoon sunlight was slanting across the city, throwing the mile upon mile of high-rise offices and residential complexes into sharp relief, bristling like dragons’ teeth. At a desk near the windows Dr. Katie Durham stood up, smiling. “Come in, John, and relax,” she said pleasantly. “Sorry about earlier. I’m afraid I lost my temper. Bad move, I’m told. I seem to be doing it more and more these days.”
She was a small, striking woman with auburn hair swept severely back from her forehead, wide-set green eyes that could look inviting or frigid depending on the circumstances, and with finely chiseled features that held a freshness that belied her thirty-six years. In the operating room her trim figure had been lost in the bulky surgical gown, but now it was set off to advantage in the blue and white uniform with the white physician’s jacket she wore.
Doc smiled and sat down across the desk from her. “I probably wasn’t the soul of politeness myself,” he said, “but that’s the way it is with surgeons. Cardiac transplants just naturally make me nervous. But that’s not why you wanted to see me.”
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