Do No Harm (2002)

by Gregg Hurwitz

  PBd: Back to the research for a minute; let's not leave that. We learned in our interview in the e-book edition of Minutes to Burn of the kind of intensive research you do. So what was required here?

  Hurwitz: Well, I shadowed in the UCLA Emergency Room on and off for two months, hanging around wherever I could, following doctors into exam rooms and watching procedures. But also going to lunch with them, grabbing a beer after shifts, hearing them bullshit and complain about their cases. Picking up the lingo wasn't hard, since I already had a template from my family, but each field of medicine has its own argot, its own gripes, its own issues with other specialties and departments.

  My time in the ER was really exciting and charged. The worst thing I saw was an anxious intern giving a rectal to a homeless guy. I wasn't sure who was more uncomfortable -- the intern, the patient, or me, the nauseous researcher.

  The ER research was great, but to follow up the continuing care of our alkali-burn victims, I had to get to plastic surgeons, ICU nurses, ophthalmologists, gastroenterologists (this wasn't too difficult, as my father and sister are both GIs), and more.

  To get Horace McCannister right -- the Lab Tech II who takes apart cadavers and distributes their pieces to various departments -- I spent some time with a true Lab Tech II. Visiting over segmented bodies and the whine of a saw was a unique experience.

  PBd: And the police work? The investigative aspects of the book?

  Hurwitz: I had to go about them from two angles. The first was the LAPD. Same drill as always -- make several contacts, and just spend time with them. Talking, drinking, driving around. Hearing them bitch about other stations. Hearing LAPD complain about University Police and vice versa. Asking questions about procedure by the book, and procedure how it really goes down in the field.

  Another angle, which was really fun, was following around a guy I met who does a lot of "unofficial" surveillance and investigative work. For the stunts Ed Pinkerton pulls in the book, I had to learn how guys get things done off the record, out of the system. I developed a relationship with this contact, as I often do. Guys like that don't like to talk, and you have to spend time earning their trust and respect. So by the time they talk -- if they talk -- they usually like you pretty well. And this contact really developed into a good friendship.

  So I could call him up and say, "Let's take a ride over to the UCLA Medical Center. Let's take a stroll through the ambulance bay" -- where Clyde hurls the alkali -- "and tell me what you see." Because more than anything else, writing character is about figuring out how your person thinks, how they view the world. And just walking around town, this friend of mine would notice a gardener wasn't sweaty enough. He'd say, "It's ninety degrees out. That guy's not working. He's certainly not been there all day. What is he doing? Casing the place? Waiting for someone?" He just had an eye for noticing when things and people were out of place. And I started developing it too, just hanging around him. So now I'm tending more paranoid than oblivious.

  PBd: You've opted to go with real settings in the real world for your story -- notably, the UCLA Medical Center. Does using a real setting enforce a kind of discipline in the writing?

  Hurwitz: It absolutely does. It makes the writing harder, and it makes it easier. It makes it harder because you can't fudge it. A lot of the settings in The Tower are fictional -- that's because when I wrote the book, I was in Oxford. So if I set a scene in a restaurant in San Francisco -- guess what? I made up the restaurant. But once I sold The Tower and could devote myself to writing fulltime (and had the resources for research), I strove for greater verisimilitude. I wrote a few drafts of Minutes to Burn before realizing, This isn't working. I have to go to Galapagos. And so I packed up and went to Ecuador for a while.

  Do No Harm was slightly easier because it's set in L.A., where I live, but I still had to get my facts right. I remember being on the phone for the better part of the morning calling around UCLA to get some statistics on the Medical Center -- that it has 29 miles of corridor, covers 3.1 million square feet, and has 57 exits. While this is harder to do than just making up the figures, it also makes my job easier. This is pretty fascinating stuff. It makes for good reading, I hope. The fact that the amount of UCLA Medical Center's square footage is second only to the Pentagon's is pretty damn fascinating. And it rings true because it is true.

  PBd: Definitely, and it puts you in good company. Someone told me once -- I'm not sure if it's true but it sure sounds good -- that Flaubert actually consulted lunar calendars so that he would know exactly what a character in Madame Bovary was capable of seeing on a given night. But let's talk about points where you and Gustave part company -- pretty intense scenes, the opening of the book, and two that really affected me as I read them, are Clyde's Chapter 12 and Chapter 13. Ghastly stuff, but well and honestly told. What was required of the writer to produce pressurized, violent scenes like those and others that follow?

  Hurwitz: The violence of the book is not glamorized, glorified, or thought up in terms of an action flick -- it's very realistic, and very stark. I strove to make this book as gritty as possible. It's a medical novel, and so I felt a responsibility to make the injuries and the violence progress with scientific precision. And that holds true for Clyde's chapters as well. He's not a drooling, scheming madman petting a white cat -- he's a real, unhinged, pathetic man, as are most people who perpetrate violent crimes. There are very few Ted Bundies out there. One thing I learned in the writing of this book was: the more real the violence, the less over-the-top it is, the greater the impact. And so I kept pulling back the violence, making it less emotional, and it kept ratcheting up the tension of the read.

  One thing I found with Clyde is that I had a real intuitive handle on him and how his mind worked. When I was talking to psychiatrists at the NPI [UCLA's Neuropsychiatric Institute] I was describing Clyde and trying to find some neat DSM-IV classification to fit him into [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition]. Is he schizophrenic? Is he this? Is he that? And an NPI doctor kept gamely trying to help me with this, but then I'd argue with him. "Well, that sounds good, but Clyde's really more like this." And finally, the doc looked at me and said, "Listen, most of our patients don't fit neat classifications, anyway -- the classifications are just there for guidelines. It sounds like you have a real handle on this guy in a way that makes him seem much more like a real patient." And I realized he was right -- my view of Clyde was already intact, and it made it better than picking a classification and working backward to invent character traits.

  PBd: Rodney King makes an appearance, in name, in the novel. You haven't overlooked the fact that L.A. is a very racially aware place, to phrase it politically correctly. Facing that fact is, I'm guessing, again part of the verisimilitude that you're going for here.

  Hurwitz: My goal, when drawing well-rounded characters, is to have them talk the talk and walk the walk. The fact of the matter is, whether cops are racist or not (and most I've met are not), they are rarely politically correct. They don't use delicate language, and they don't shy away from calling it like they see it. And neither do my characters who are police officers.

  PBd: Okay, you asked for this one: "Wow. Sounds like an episode of ER." Only the most popular dramatic show in the history of television. How does someone working this turf bear the tremendous weight of that program? It's not like one can pretend it's not there. And as a follow-up question -- let me get this in here now, because I think it's important -- what do you do when confronted with the facts that ER gets wrong, consistently, and that have become your readership's version of reality.

  Hurwitz: ER is a remarkable show and a remarkable achievement. My novel is a different sort of story, but at the same time, you're right, I couldn't and didn't write the book pretending ER didn't exist. And so I have my characters make a few references to the show -- self-conscious ones -- because the show has become such a part of the zeitgeist that doctors and patients joke about it now, in reality, all the time.


  What is different about Do No Harm is that the primary orientation is not on "life as usual in the ER." It deals with an extraordinary, specific event. And it is, I believe, more character-intensive in certain ways since I don't have the responsibility of fitting plot lines for an entire cast into four twelve-minute segments. Also, the emphasis of my book is primarily ethical, and the ways that an ethical dilemma affects David Spier's character.

  PBd: I get the sense from your book and, of course, from ER, that emergency rooms are not the best models of collegiality. There's a lot of grousing and barking going on a lot of the time. True in reality? This interviewer has, thankfully, not had to spend a lot of time around ERs and hopes not to.

  Hurwitz: Let me start to answer that by saying that I had a very idealized view of docs because of my background. I thought they were all ordained from birth, and were models of ethics and care. It was a disillusioning process for me -- in high school and college -- to realize that this wasn't the case. A lot of docs are fantastic. But some are assholes, some are egomaniacs, some are science geeks who couldn't figure out what they wanted to do, so they took pre-med classes and went from there. I was amazed at how much politics plays a role in treatment these days. But then you'll see the one intern or attending go the extra mile, stay an hour-and-a-half after shift to help someone, and your faith is renewed. And it puts your job in perspective. No matter how shitty a day I have, people can't die as a result of it. And it makes clear the tremendous responsibility that every doctor shoulders.

  PBd: Chapter 55 (there are a dozen other good examples) amply demonstrates the kinds of heroic tests a doctor can be put through. Yet we lose sight of that, I think, in part because our own physicians may seem less than heroic at times. On the flip side, as to TV (and I'm not just picking on ER) the sheer onslaught of horrors are met inevitably by a supercharged medical heroism that borders on the cartoonish at times -- if it doesn't actually cross over deep into cartoon territory. So how to find the balance here, especially when you're writing a book that aspires to a wide readership. The "cold, vengeful rage" that David feels for Clyde late in the book, I've got to tell you, I would have felt a lot sooner in his circumstances. But maybe that's why David's a doctor and I'm not.

  Hurwitz: Again, this is where the book gets personal. My father and grandfather set the standard of the ways a doctor must view the world -- I had a personal experience of that worldview. If docs are doing their job well, they do come to view people and interactions differently, through the tint of a different lense. Like cops, like hookers, like anyone else who routinely sees people at the limits of human behavior. David, as a doc, is much more inclined to view Clyde as a man with a sickness than to meditate on whether he's evil. Who cares if he's evil? He's clearly disturbed, clearly ill. Why spend time cultivating a hatred of him? This is not to say doctors are superior morally -- they're just trained to view human behavior more clinically. However, at the point in the text when David feels a "cold, vengeful rage" is when Clyde's violations become extremely personal. And at that point, David's reaction is a more universal one, because Clyde's actions have jarred him out of a physician's mindset.

  PBd: Is Clyde's end inevitable?

  Hurwitz: Tough question. No character's fate is inevitable when you begin writing a book, because then all you'll do is railroad that character to said fate. But if you draw realistic characters, and if you allow them free reign within your prescribed plot, the choices at their disposal narrow until one ending can be said to be more or less organic than another.

  PBd: Clyde escapes, Clyde comes back -- happens all the time in our all-too-real world. We've grown used to it. Further to the verisimilitude theme we've got going here (and this relates to Do No Harm as well as ER) at what point as a novelist does reality leave you feeling defeated -- or does it? It's become cliche to say that anything a writer can think up, wait for just a little while and reality will trump him.

  Hurwitz: This is not the sort of thing that leaves me feeling defeated as a novelist. In fact, I find it sort of invigorating. There's a relationship between art and life -- and a complex one. I don't believe one merely imitates the other. I think they affect each other, while maintaining distinct rules of their own. There is something magical in the fact that legal proceedings from Oscar Wilde to Joseph McCarthy offer suspense, structure, and pacing that is superior to most courtroom thrillers. And then something like September 11 comes along, and everyone's first thought is "How can we write after that?" But that event offered us examples of heroism and patriotism, not to mention cowardice and maliciousness, on a scale that we haven't seen in years. And that, too, will find expression in art.

  PBd: Ever toy with the idea of becoming a doctor yourself?

  Hurwitz: Not recently, much to the chagrin of my Jewish parents. When I was younger it was something I contemplated, in part because severe injuries and blood don't faze me tremendously. I suppose that quirk of mine aids in my career as a novelist as well -- flipping through crime scene photos or standing in on a gory procedure aren't pleasant tasks, but I can handle them. If I were going to be a doc, the ER appeals to me the most -- the fast pace, the constant surprises, the quick fixes. But I think the primary obstacle to a career in medicine is that I like writing novels too damn much.

  STAT, SALINE, CBC: ER TERMS DEFINED

  Why do the characters on ER say "stat" all the time? Why the constant demand for saline? "Pulseox" -- huh? And just what is a CBC? Melissa Hurwitz, M.D. (the author's sister), offers some quick definitions of terms you've heard dozens of times on TV, and also terms that are specific to the medical scenes in Do No Harm. You can easily navigate between this glossary and the text of the novel with a click of a hyperlink.

  "blood pressure had just hit sixty": a healthy blood pressure. In this scene, it indicates that the patient has been helped by fluid and blood resuscitation, along with draining of the blood from around the heart.

  CBC: The complete blood count (CBC) measures the number of red and white blood cells, the total amount of hemoglobin in the blood, and other vital aspects of blood.

  crepitance: gas/air that has escaped from the lungs and has become lodged in the subcutaneous tissues, just beneath the skin. A faint crackling sound or sensation is appreciated when fingers are run over the skin.

  cyanotic: displaying bluish or purple skin or mucosal color; caused by poor oxygen supply to tissues.

  EKG: electrocardiogram, also referred to as ECG. A method of demonstrating the electrical activity of the heart. Circular adhesive patches attached to electrical leads are placed externally on the chest wall and other locations on the patient's body. The results, seen on a monitor or strip of paper from the EKG machine, show the heart's rate and rhythm.

  erythematous: redness of the skin caused by congestion and dilatation of the capillaries.

  etomidate and rocuronium: standard medications used to sedate and paralyze a patient prior to intubation.

  "heart rate = 140": the heart rate is a key vital sign. It is usually assessed along with blood pressure, respiratory rate, and oxygenation saturation. A normal resting heart rate in adults is between 50-70 beats per minute. An elevated heart rate indicates pain, anxiety, fear, fever, or decreased intravascular (within the veins) volume.

  Decreased intravascular volume: indicates that there is not enough volume (i.e., blood) in the patient's blood vessels to get enough oxygen to the patient's tissues and organs. The body compensates by having the heart beat faster.

  o-two saturation: refers to how well one is breathing and getting oxygen to tissues and organs. Normal saturation is 100%.

  patency: openness, extent of being unblocked.

  pericardial tamponade: occurs when blood fills the sac around the heart, impeding the heart's ability to beat properly and pump blood to the body.

  pH strips: placed on the skin to determine whether a contaminant is basic or acidic. The nature of the contaminant affects assessment and treatment of injuries.

  "pul
seox", or pulse oximeter: is a device used to measure oxygenation saturation (see "o-two saturation"; a small sensor is typically attached to the patient's finger.

  rapid infuser: a machine that quickly transfuses blood.

  retractions: the skin of the chest pulls in upon inspiration, indicating difficulty breathing.

  saline: the standard fluid used for volume resuscitation. If someone has had significant bleeding, lost volume must be replaced. While waiting for blood products to arrive, intravascular volume can be quickly expanded with saline.

  stat: from the Latin, statim, meaning: "Immediately!"

  stridorous: a loud, harsh respiration, usually upon inspiration (inhalation); caused by swelling of the upper airway.

  substernal: beneath the sternum.

  supraclavicular: above the collar bone.

  tension pneumothorax: A collapse of the lung caused by a puncture of the lung. Air escapes and fills the space around the lung, compressing it. The lung cannot expand during inspiration because it is being pressed on by the air that now surrounds it. This was accurately depicted in David O. Russell's film of the Gulf War, Three Kings (1999). When Mark Wahlberg's character, Sergeant First Class Troy Barlow, had a tension pneumothorax and had a needle inserted into his chest with a valve to relieve pressure by releasing the air.

  Melissa Hurwitz, M.D., is a Fellow in Pediatric Gastroenterology at Packard Children's Hospital at Stanford University.