by Robin Cook
On the day of surgery, Thomas, who had been working with an experimental method of aiding cardiac function, inserted a helium-driven counterpulsation balloon into Walter’s aorta. Anticipating trouble with Walter’s left ventricle, Thomas wanted to be prepared. Only after the operation had begun did the reality of the situation dawn on him. Excitement had changed to anxiety as Thomas began to follow the plan he had outlined in his mind. He would never forget the sensation he experienced when he stopped Walter’s heart and held the quivering mass of sick muscle in his mind. At that moment he knew it was in his power to restore life. Refusing to consider the possibility of failure, Thomas first performed a bypass, an experimental procedure in those days. Then he excised the ballooned area of Walter’s heart, oversewing the defect with rows of heavy silk. Finally, he replaced both the mitral and aortic valves.
The instant the repair was complete, Thomas tried to take Walter from the heart-lung machine. By this time, unknown to Thomas, a significant audience had gathered. There was a murmur of sadness when it was obvious that Walter’s heart did not have the strength to pump the blood. Undaunted, Thomas started the counterpulsation device he had positioned before the operation.
He would always remember his elation when Walter’s heart responded. Not only was Walter taken off the heart-lung machine, but three hours later in the recovery room even the counterpulsation assist was no longer needed. Thomas felt as if he had created life. The excitement was like a fix. For months afterward he was carried away by open-heart surgery. Reaching in, touching the heart, defying death with his own two hands-it was like playing God. Soon he found he became deeply depressed without the excitement of several such operations a week. When he went into practice he scheduled one, two, three such procedures a day. His reputation was so great that there was an endless stream of patients. As long as the hospital allowed him sufficient time in the OR, Thomas was supremely happy. But if another department or the boys in full-time academic medicine attempted to cut back his operating hours, Thomas became as tense and angry as an addict deprived of his daily drug. He needed to operate in order to survive. He needed to feel Godlike in order not to consider himself a failure. He needed the awed approval of other people, the unquestioning approval that was in Larry Owen’s eyes this moment as he asked, “Have you decided if you’re going to do a double or triple bypass?”
The question brought Thomas back to the present.
“It’s a good exposure,” said Thomas, appreciating Larry’s work. “We might as well do three provided you got enough saphenous vein.”
“More than enough,” said Larry with enthusiasm. Prior to opening the chest, Larry had carefully removed a length of vein from Mr. Campbell’s leg.
“All right,” said Thomas with authority. “Let’s get this show on the road. Is the pump ready?”
“All ready,” said Phil Baxter, checking his dials and gauges.
“Forceps and scalpel,” said Thomas.
Swiftly but without haste, Thomas began to work. Within minutes the patient was on the heart-lung machine. Thomas’s operative technique was deliberate and without wasted motion. His knowledge of the anatomy was encyclopedic, as was his sense of feel for the tissue. He handled sutures with an economy of precise motion that was a joy for the aspiring surgeons to watch. Every stitch was perfectly placed. He’d done so many bypass procedures, he could almost function by rote, but the excitement of working on the heart never failed to stir him.
When he was through and convinced the bypasses were all sound and there was no excessive bleeding, Thomas stepped back from the table and snapped off his gloves.
“I trust you’ll be able to put back the chest wall the way you found it, Larry,” said Kingsley, turning to leave. “I’ll be available if there is any trouble.” As he left, he heard an audible sigh of appreciation from the residents.
Outside the operating room, the corridor was jammed with people. At that time of day, midafternoon, most of the thirty-six operating rooms were still occupied. Patients, either going to or coming from their surgery, were wheeled through on gurneys, sometimes with teams of people in attendance. Thomas moved among the crowd, occasionally hearing his name whispered.
As he passed the clock outside of central supply, he realized that he’d done Mr. Campbell in less than one hour. In fact, he’d done three bypass cases that day in the time it took most surgeons to do one or two at best.
Thomas told himself that he could have scheduled another operation although he recognized this was not true. The reason he had scheduled only three cases was the bothersome new rule that all surgeons attend Friday afternoon cardiac surgical conference, a relatively recent creation of the chief of the department, Dr. Norman Ballantine. Thomas went, not because he was ordered to do so, but because it had become the ad hoc admitting committee for the department of cardiac surgery. Thomas tried not to think about the situation, because whenever he did so, it made him furious.
“Dr. Kingsley,” called a harsh voice, interrupting Thomas’s thoughts.
Priscilla Grenier, the overbearing director of the OR, was waving a pen at him. Thomas gave her credit for being a hard worker and putting in long hours. It was no picnic keeping the thirty-six operating rooms at the Boston Memorial working smoothly. Yet he could not tolerate it when she insinuated herself in his affairs, something that she seemed eager to do. She always had some order or instruction.
“Dr. Kingsley,” called Priscilla. “Mr. Campbell’s daughter is in the waiting room, and you should go down and see her before you change.” Without waiting for a reply, Priscilla turned back to her desk.
With difficulty, Thomas contained his annoyance and continued down the hall without acknowledging the comment. Some of the euphoria he had felt in the OR left him. Lately he found the pleasure in each surgical success increasingly fleeting.
At first Thomas thought he’d ignore Priscilla, change into his suit, then stop in to see Mr. Campbell’s daughter. However, the fact remained that he felt obligated to remain in his scrub clothes until Mr. Campbell had reached the recovery room, just in case there were unforeseen complications.
Banging open the door to the surgical lounge with his hand, Thomas stopped at the coat rack and rummaged for a long white coat to put over his scrub clothes. As he pulled it on, he thought about the unnecessary frustrations he was forced to endure. The quality of the nurses had definitely gone down. And Priscilla Grenier! It seemed like only yesterday that people like her knew their place. And compulsory Friday afternoon conferences… God!
In a distracted state, Thomas walked down to the waiting room. This was a relatively new addition to the hospital, which had been created out of an old storeroom. As the number of bypass procedures done by the department had soared, it was decided that there should be a special room close by where family members could stay until their loved ones were out of the OR. It had been the brainchild of one of the assistant administrators and turned out to be a gold mine for public relations.
When Thomas entered the room, which was tastefully decorated with pale blue walls and white trim, his attention was caught by an emotional outburst in the corner.
“Why, why?” shouted a small, distraught woman.
“There, there,” said Dr. George Sherman, trying to calm the sobbing woman. “I’m sure they did all they could to save Sam. We knew his heart was not normal. It could have happened at any time.”
“But he’d been happy at the home. We should have let him be. Why did I let you talk me into bringing him here. You told me there was some risk if you operated. You never told me there was a risk during the catheterization. Oh God.”
The woman’s tears overwhelmed her. She began to sag, and Dr. Sherman reached out to catch her arm.
Thomas rushed over to George’s side and helped support the woman. He exchanged glances with George, who rolled his eyes at the outburst. As a member of the full-time cardiac staff, Thomas did not have a high regard for Dr. George Sherman, but under the circumstances
he felt obligated to lend a hand. Together they sat the bereaved mother down. She buried her face in her hands, her hunched-over shoulders jerking as she continued to sob.
“Her son arrested down in X ray during a catheterization,” whispered George. “He was badly retarded and had physical problems as well.”
Before Thomas could respond, a priest and another man, who was apparently the woman’s husband, arrived. They all embraced, which seemed to give the woman renewed strength. Together they hurriedly left the room.
George straightened up. It was obvious that the situation had unnerved him. Thomas felt like repeating the woman’s question about why the child had been taken from the institution where he’d apparently been happy, but he didn’t have the heart.
“What a way to make a living,” said George self-consciously as he left the room.
Thomas scanned the faces of the people remaining. They were looking at him with a mixture of empathy and fear. All of them had family members currently undergoing surgery, and such a scene was extremely disquieting. Thomas looked for Campbell’s daughter. She was sitting by the window, pale and expectant, arms on her knees, hands clasped. Thomas walked over to her and looked down. He’d seen her once before in his office and knew her name was Laura. She was a handsome woman, probably about thirty, with fine light brown hair pulled back from her forehead in a long ponytail.
“The case went fine,” he said gently.
In response, Laura leaped to her feet and threw herself at Thomas, pressing herself against him and flinging her arms around his neck. “Thank you,” she said, bursting into tears. “Thank you.”
Thomas stood stiffly, absorbing the display of emotion. Her outburst had taken him by complete surprise. He realized that other people were watching and tried to disengage himself, but Laura refused to let go. Thomas remembered that after his first open-heart success, Mr. Nazzaro’s family had been equally hysterical in their thanks. At that time Thomas had shared their happiness. The whole family had hugged him and Thomas had hugged them back. He could sense the respect and gratitude they felt toward him. It had been an unbelievably heady experience, and Thomas recalled the event with strong nostalgia. Now he knew his reactions were more complicated. He often did three to five cases a day. More often than not he knew little or nothing about his patients save for their preoperative physiological data. Mr. Campbell was a good example.
“I wish there was something I could do for you,” whispered Laura, her arms still tightly wrapped around Thomas’s neck. “Anything.”
Thomas looked down at the curve of her buttocks, accentuated by the silk dress that hugged her form. Disturbingly he could feel her thighs pressed against his own, and he knew he had to get away.
Reaching up, he detached Laura’s encircling arms.
“You’ll be able to talk with your father in the morning,” said Thomas.
She nodded, suddenly embarrassed by her behavior.
Thomas left her and walked from the waiting room with a feeling of anxiety that he did not understand. He wondered if it was fatigue, although he had not felt tired earlier even though he’d been up a good portion of the previous night on an emergency operation. Returning the white coat to the rack, he tried to shrug off his mood.
Before going into the lounge, Thomas paid a visit to the recovery room. His two previous cases, Victor Marlborough and Gwendolen Hasbruck, were stable and doing predictably well, but as he looked down at their faces he felt his anxiety increase. He wouldn’t have recognized them in a crowd although he’d held their hearts in his hand just hours before.
Feeling distracted and irritated by the forced camaraderie of the recovery room, Thomas retreated to the surgical lounge. He didn’t particularly care for the taste of coffee, but he poured himself a cup and took it over to one of the overstuffed leather armchairs in the far corner. The living section of the Boston Globe was on the floor, and he picked it up, more as a defense than for what it contained. Thomas didn’t feel like being trapped into small talk with any of the OR personnel. But the ploy didn’t work.
“Thanks for the help in the waiting room.”
Thomas lowered the paper and looked up into the broad face of George Sherman. He had a heavy beard, and by that time in the afternoon it appeared as if he’d forgotten to shave that morning. He was a stocky, athletic-looking man an inch or two shorter than Thomas’s six feet, but his thick, curly hair made him look the same height. He had already changed back to his street clothes, which included a wrinkled blue button-down shirt that appeared as if it had never felt the flat surface of an iron, a striped tie, and a corduroy jacket somewhat threadbare on the elbows.
George Sherman was one of the few unmarried surgeons. What put him in a unique class was that at age forty he’d never been married. The other bachelors were either separated or divorced. And George was a particular favorite among the younger nurses. They loved to tease him about his errant bachelor’s life, offering help in various ways. George’s intelligence and humor took all this in stride, and he milked it for all it was worth. Thomas found it all exceedingly irritating.
“The poor woman was pretty upset,” said Thomas. Once again he had to refrain from making some comment concerning the advisability of bringing such a case into the hospital. Instead he raised his paper.
“It was an unexpected complication,” said George, undeterred. “I understand that good-looking chick in the waiting room was your patient’s daughter.”
Thomas slowly lowered his paper again.
“I didn’t notice she was particularly attractive,” Thomas said shortly.
“Then how about sharing her name and phone number?” said George with a chuckle. When Thomas failed to respond, George tactfully changed the subject. “Did you hear that one of Ballantine’s patients arrested and died during the night?”
“I was aware of it,” said Thomas.
“The guy was an admitted homosexual,” said George.
“That I didn’t know,” said Thomas with disinterest. “I also didn’t know that the presence or absence of homosexuality was part of a routine cardiac surgical work-up.”
“It should be,” said George.
“And why do you think so?” asked Thomas.
“You’ll find out,” said George, raising an eyebrow. “Tomorrow in Grand Rounds.”
“I can’t wait,” said Thomas.
“See you in conference this afternoon, sport,” said George, giving Thomas a playful thump on the shoulder.
Thomas watched the man saunter away from him. It annoyed him to be touched and pummeled like that. It seemed so juvenile. While he watched, George joined a group of residents and scrub nurses slumped over several chairs near the window. Laughter and raised voices drifted across the room. The truth was that Thomas could not stand George Sherman. He was convinced George was a man bent on accumulating the trappings of success to cover a basic mediocrity in surgical skill. It was all too familiar to Thomas. One of the seemingly inadvertent evils of the academic medical center was that appointments were more political than anything else. And George was political. He was quick-witted, a good conversationalist, and socialized easily. Most important, he thrived within the bureaucratic committee system of hospital politics. He’d learned early that for success it was more important to study Machiavelli than Halstead.
Thomas knew that the root of the problem was an antagonism between the doctors on the teaching staff like himself, who had private practices and earned their incomes by billing their patients, and the doctors like George Sherman, who were full-time employees of the medical school and received salaries instead of fees for service. The private doctors had substantially higher incomes and more freedom. They did not have to submit to a higher authority. The full-time doctors had more impressive titles and easier schedules, but there was always someone over them to tell them what to do.
The hospital was caught in the middle. It liked the high census and money brought in by the private doctors, and, at the same time, it enj
oyed the credibility and status of being part of the university medical school.
“Campbell’s chest is closed,” said Larry, interrupting Thomas’s thoughts. “The residents are closing the skin. All signs are stable and normal.”
Tossing the newspaper aside, Thomas got up from the chair and followed Larry toward the dressing room. As he passed behind George, Thomas could hear him talking about forming some kind of new teaching committee. It never stopped! Nor did the pressure that George, as head of the teaching service, and Ballantine, as head of the department, applied to Thomas, trying to convince him to give up his practice and join the full-time staff. They tried to entice him by offering him a full professorship, and although there’d been a time when that might have interested Thomas, now it held no appeal whatsoever. He’d keep his practice, his autonomy, his income, and his sanity. Thomas knew if he went fulltime it would only be a matter of time before he was told who he could and who he could not operate on. Before long he’d be assigned ridiculous cases like the poor mentally retarded kid in the cath room.
Tense and angry, Thomas went into the dressing area and opened his locker. As he pulled off his scrub clothes and tossed them into the hamper, he recalled Laura Campbell’s pliant body pressed against his own. It was a welcome and pleasant image and had the effect of mollifying his frazzled nerves. Ever since he’d left the OR, his pleasure in operating had dissipated, leaving him increasingly tense.
“As usual, you did a superb job today,” said Larry, noting Thomas’s grim face and hoping to please him.
Thomas didn’t respond. In the past he would have loved such a compliment, but now it didn’t seem to make any difference.
“It’s too bad that people can’t appreciate the details,” said Larry, buttoning his shirt. “They’d have a totally different idea of surgery if they did. They’d also be more careful who they let operate on them.”