Godplayer

Two

“The patient is ready for you in No. 3 cardiac cath room,” said one of the X-ray technicians. She didn’t come into the office but rather just stuck her head around the door. By the time Dr. Joseph Riggin turned to acknowledge the information, the girl was gone.

With a sigh, Joseph lifted his feet off his desk, tossed the journal he’d been reading onto the bookshelf, and took one last slug of coffee. From a hook behind the door he lifted his lead apron and put it on.

The radiology corridor at 10:30 A.M. reminded Joseph of a sale day at Bloomingdale’s. There were people everywhere waiting in chairs, waiting in lines, and waiting on gurneys. Their faces had a blank, expectant look. Joseph felt an unwelcome sense of boredom. He’d been doing radiology now for fourteen years and he was beginning to admit to himself that the excitement had gone out of it. Every day was like every other day. Nothing unique ever happened anymore. If it hadn’t been for the arrival of the CAT scanner a number of years ago, Joseph wondered if he’d have quit. As he pushed into No. 3, he tried to imagine what he could do if he left clinical radiology. Unfortunately he didn’t have any bright ideas.

The No. 3 cath room was the largest of the five rooms so equipped. It had the newest equipment as well as its own built-in viewer screens. As Joseph entered, he saw that someone else’s X rays had been left up. If he’d told his technicians once, he’d told them a thousand times that he wanted his room cleared of previous films before he did a study. Then, as if that wasn’t enough, Joseph noticed there was no technician.

Joseph felt his blood pressure soar. It was a cardinal rule that no patients were ever to be left unattended, “Dammit,” snarled Joseph under his breath. The patient was lying on the X-ray table, covered by a thin white blanket. He looked about fifteen years old, with a broad face and close-cropped hair. His dark eyes were watching Joseph intently. Next to the table was an IV bottle, and the plastic tube snaked under the blanket.

“Hello,” said Joseph, forcing a smile despite his frustration.

The patient did not stir. As Joseph took the chart, he noticed that the boy’s neck was thick and muscular. Another glance at the boy’s face suggested that this was no ordinary patient. His eyes were abnormally tilted and his tongue, which partially protruded from his lips, was enormous.

“Well, what do we have here?” said Joseph with a wave of uneasiness. He wished the boy would say something or at least look away. Joseph flipped open the chart and read the admitting note.

“Sam Stevens is a twenty-two-year-old muscular Caucasian male institutionalized since age four with undiagnosed mental retardation, who is admitted for definitive work-up and repair of his congenital cardiac abnormality thought to be a septal defect…”

The door to the cath room banged open, and Sally Marcheson breezed in carrying a stack of cassettes. “Hi, Dr. Riggin,” she called.

“Why has this patient been left alone?”

Sally stopped short of the X-ray machine. “Alone?”

“Alone,” repeated Joseph with obvious anger.

“Where’s Gloria? She was supposed…”

“For Christ’s sake, Sally,” shouted Joseph. “Patients are never to be left alone. Can’t you understand that?”

Sally shrugged. “I’ve only been gone fifteen or twenty minutes.”

“And what about all these X rays? Why are they out?”

Sally glanced at the viewers. “I don’t know anything about them. They weren’t here when I left.”

Quickly Sally began pulling the X rays down and stuffing them in the envelope on the countertop. It was someone’s coronary angiogram, and she had no idea whatsoever why the X rays were there.

Still grumbling to himself, Joseph opened a sterile gown and pulled it on. Glancing back at the patient, he saw that the boy had not moved. His eyes still followed him wherever he moved.

With a frightful banging noise, Sally succeeded in loading the cassettes into the machine, then came back to pull off the sterile cover over the cath tray.

While Joseph pulled on rubber gloves, he moved over closer to the patient’s face. “How are you doing, Sam?” For some reason, knowing the boy was retarded made Joseph think he should speak louder than usual. But Sam didn’t respond.

“Do you feel okay, Sam?” called Joseph. “I’m going to have to stick you with a little needle, okay?”

Sam acted as if he were carved from granite.

“I want you to stay very still, okay?” persisted Joseph.

True to form, Sam didn’t budge. Joseph was about to return his attention to the cath tray when Sam’s tongue once again caught his attention. The protruding portion was cracked and dried. Looking closer, Joseph could see that Sam’s lips weren’t much better off. The boy looked like he’d been wandering around in a desert.

“You a little thirsty, Sam?” queried Joseph.

Joseph glanced up at the IV, noticing that it wasn’t running. With a flick of his wrist he turned it on. No sense in the kid becoming dehydrated.

Joseph stepped over to the cath tray and took the gauze out of the prep dishes.

A high-pitched, inhuman scream shattered the stillness of the cath room. Joseph whirled around, his heart in his mouth.

Sam had thrown off his blanket and was clawing at the arm that had the IV. His feet began to hammer up and down on the X-ray table. A shrill cry still issued from his lips.

Joseph collected himself enough to pull the fluoroscopy unit back away from Sam’s thrashing legs. He reached up and put his hands on Sam’s shoulders to push him back onto the table. Instead Sam grasped Joseph’s arm with such power that Joseph yelped out in pain. Powerless to prevent it, Joseph watched with horror as Sam pulled Joseph’s hand up to his mouth, then sank his teeth into the base of Joseph’s thumb.

It was now Joseph’s turn to scream. He struggled to pull his arm from Sam’s grasp, but the boy was far too strong. In desperation Joseph lifted a foot to the side of the X-ray table and pushed. He stumbled back and fell, pulling Sam on top of him.

Joseph felt Sam release his arm only to feel the boy’s hands close around his throat. Pressure built up inside of his head as the boy squeezed. Desperately he tried to pull Sam’s hands away, but they were like steel. The room began to spin. With a last reserve of strength, Joseph brought his knee up into the boy’s groin.

Almost simultaneously, Sam’s body heaved with a sudden contraction. It was rapidly followed by another and then another. Sam was having a grand mal seizure, and Joseph lay pinned to the floor beneath the heaving, convulsing body.

Sally finally recovered from shock and helped Joseph squirm free. Sam’s eyes had disappeared up inside his head and blood sprayed in a gradually widening circle from his mangled tongue

“Get help,” gasped Joseph as he grasped his own wrist to stem the bleeding. Within the jagged edges of the wound he could see the glistening surface of exposed bone.

Before help arrived, Sam’s wrenching spasms weakened and all but stopped. By the time Joseph realized the boy was not breathing, the medical emergency team arrived. They worked feverishly but to no avail. After fifteen minutes, a reluctant Dr. Joseph Riggin was led away to have his hand sutured while Sally Marcheson removed the misplaced X rays.

As Thomas Kingsley scrubbed, he felt the surge of excitement that always possessed him before an operation. He had known he was born to be a surgeon the first time he’d assisted in the OR as an intern, and it hadn’t been long before his skill had been acknowledged throughout the hospital. Now as Boston Memorial’s foremost cardiovascular surgeon, he had an international reputation.

Rinsing off the suds, Thomas lifted his hands to prevent water from running down his arms. He opened the OR door with his hip. As he did so, he could hear the conversation in the room trail off into awed silence. He accepted a towel from the scrub nurse, Teresa Goldberg. For a second their eyes met above their face masks. Thomas liked Teresa. She had a wonderful body that even the bulky surgical gown she was wearing could not hide. Besides, he could yell at her if need be, knowing she wouldn’t burst into tears. She was also smart enough not only to recognize that Thomas was the best surgeon at the Memorial but to tell him so.

Thomas methodically dried his hands while he checked out the patient’s vital signs. Then, like a general reviewing his troops, he moved around the room, nodding to Phil Baxter, the perfusionist, who stood behind his heart-lung machine. It was primed and humming, ready to take over the job of oxygenating the patient’s blood and pumping it around the body while Thomas did his work.

Next Thomas eyed Terence Halainen, the anesthesiologist.

“Everything is stable,” said Terence, alternately squeezing the breathing bag.

“Good,” said Thomas.

Disposing of the towel, Thomas slipped on the sterile gown held by Teresa. Then he thrust his hands into special brown rubber gloves. As if on cue, Dr. Larry Owen, the senior cardiac surgery fellow, looked up from the operative field.

“Mr. Campbell is all ready for you,” said Larry, making room for Thomas to approach the OR table. The patient lay with his chest fully opened in preparation for the famous Dr. Kingsley to do a bypass procedure. At Boston Memorial it was customary for the senior resident or fellow to open as well as close such operations.

Thomas stepped up to his position on the patient’s right. As he always did at this point, he slowly reached into the wound and touched the beating heart. The wet surface of his rubber gloves offered no resistance, and he could feel all the mysterious movement in the pulsating organ.

The touch of the beating heart took Thomas’s mind back to his first major case as a resident in thoracic surgery. He had been involved in many operations prior to that, but always as the first assistant, or second assistant, or somewhere down the line of authority. Then a patient named Walter Nazzaro had been admitted to the hospital. Nazzaro had had a massive heart attack and was not expected to live. But he did. Not only did he survive his heart attack, but he survived the rigorous evaluation that the house staff doctors put him through. The results of the work-up were impressive. Everyone wondered how Walter Nazzaro had lived as long as he had. He had occlusive disease in his main left coronary artery, which had been responsible for his heart attack. He also had occlusive disease in his right coronary artery with evidence of an old heart attack. In addition he had mitral and aortic valve disease. Then, as if that weren’t enough, Walter had developed an aneurysm, or a ballooning of the wall, of his left ventricle of his heart as a result of the most recent heart attack. He also had an irregular heart rhythm, high blood pressure, and kidney disease.

Since Walter was such a fund of anatomic and physiologic pathology, he was presented at all the conferences with everyone offering various opinions. The only aspect of his case that everyone agreed upon was the fact that Walter was a walking time bomb. No one wanted to operate except a resident named Thomas Kingsley, who argued that surgery was Walter’s only chance to escape the death sentence. Thomas continued to argue until everyone was sick of hearing him. Finally the chief resident agreed to allow Thomas to do the case.

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 enjoyed 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.”

Thomas still did not say anything, although he nodded at the truth of the comment. As he pulled on his own shirt, he thought of Norman Ballantine, that white-haired, friendly old doc whom everyone loved and applauded. The fact of the matter was that Ballantine probably shouldn’t still be operating, although no one had the nerve to tell him. It was common knowledge in the department that one of the chief thoracic resident’s jobs was to assign himself to all of Ballantine’s cases so that he could help the chief when he blundered. So much for academic medicine, thought Thomas. Ballantine, thanks to the residents, got reasonable results, and his patients and their families worshipped him despite what went on when the patient was anesthetized.

Thomas had to agree with Larry’s comment. He also thought that it would be infinitely more appropriate if he, Dr. Thomas Kingsley, was chief. After all, he did most of the surgery, for God’s sake. It was he, more than any other single person, who had made Boston Memorial the place to have any cardiac surgery. Even Time magazine had said as much.

Yet Thomas did not know if he wanted to be chief any longer. At one time it was all he could think about. It had been one of his driving forces, pushing him on to greater efforts and more personal sacrifice. It had seemed part of a natural progression, and colleagues had started talking about it while he was still a fellow. But that was quite a few years ago, before all the administrative bullshit had reared its ugly head and showed just how much it could interfere in his practice.

Thomas stopped dressing and stared ahead into the distance. He felt an emptiness inside of him. Comprehending that one of his long sought-after goals was potentially no longer attractive was depressing, especially when the goal was finally within his grasp. Maybe there was no place to go… maybe he’d reached his apogee. God, what an awful thought!

“I’m awfully sorry to hear about your wife,” said Larry as he sat down to put on his shoes. “It really is a shame.”

“What do you mean?” asked Thomas, pronouncing each word with deliberate precision. He took immediate offense that a subordinate like Larry would presume to be so familiar.

Larry, oblivious to Thomas’s response, bent to tie his shoes. “I mean about her diabetes and her eye problem. I heard she’s got to have a vitrectomy. That’s terrible.”

“The surgery is not definite,” snapped Thomas.

Hearing the anger in Thomas’s voice, Larry looked up. “I didn’t mean it was necessarily definite,” he managed. “I’m sorry I brought it up. It must be difficult for you. I just hoped that she was okay.”

“My wife is perfectly fine,” said Thomas angrily. “Furthermore, I don’t think that her health is any of your business.”

“I’m sorry.”

There was an uncomfortable silence as Larry quickly finished with his shoes. Thomas tied his tie and splashed on Yves St. Laurent cologne with rapid, irritated motions.

“Where did you hear this rumor?” asked Thomas.

“From a pathology resident,” said Larry. “Robert Seibert.”

Larry closed his locker and told Thomas he’d be in the recovery room if he was needed.

Thomas ran a comb through his hair, trying to calm down. It just wasn’t his day. Everyone seemed intent on upsetting him. The idea that his wife’s ill health was a topic of idle conversation among the resident staff seemed inexplicably galling. It was also humiliating.

Placing the comb back in his locker, Thomas noticed a small plastic container. Feeling a rising inner tension and the stirrings of a headache, he flipped open the lid of the bottle. Snapping one of the scored yellow tablets in two, he popped the half into his mouth. Hesitant, he then popped in the other half as well. After all, he deserved it.

The tablets tasted bitter, and he needed a drink from the fountain to wash them down. But almost immediately he felt relief from his growing anxiety.

The Friday afternoon cardiac surgery conference was held in the Turner surgical teaching room diagonally across the hall from the surgical intensive care unit. It had been donated by the wife of a Mr. J. P. Turner, who’d died in the late nineteen-thirties, and the decor had an Art Deco flavor. The room provided seating for sixty, half the medical school class size in 1939. In the front there was a raised podium, a dusty blackboard, an overhead rack of ancient anatomy charts, and a standing skeleton.

It had been at Dr. Norman Ballantine’s insistence that the Friday meeting be held in the Turner teaching room because it was close to the ward, and, as Dr. Ballantine put it, “It is the patients that it’s all about.” But the small group of a dozen or so looked lost among the sea of empty seats and distinctly uncomfortable behind the spartanly designed desks.

“I think we should get the meeting under way,” called Dr. Ballantine over the hum of conversation. The people took their seats. Present at the meeting were six of the eight cardiac surgeons on staff, including Ballantine, Sherman, and Kingsley, as well as various other doctors and administrators, and a relatively new addition, Rodney Stoddard, philosopher.

Thomas watched Rodney Stoddard sit down. He looked like he was in his late twenties despite the fact that he was mostly bald and his remaining hair was such a light color that it was difficult to see it. He wore thin wire-rimmed glasses and an expression of constant self-satisfaction. To Thomas it seemed as if the man were saying, “Ask me about your problem because I know the answer.”

Stoddard had been hired at the university’s insistence. Until recently doctors were committed to trying to save all their patients. But now, with the advent of such expensive and complicated procedures as open-heart surgery, transplants, and artificial organs, hospitals had to pick and choose to whom to give these life-saving operations. For the time being, these techniques were limited by extraordinary costs and by the space available in the sophisticated units needed for aftercare. In general the teaching staff tended to favor patients with multisystemic disease, who did not always do well, while private physicians such as Thomas leaned toward otherwise healthy, productive members of society.

Looking at Rodney, Thomas allowed an ironic smile to steal across his face. He wondered just how self-confident Rodney would feel if he held a man’s heart in his hand. That was a time for decision, not discussion. As far as Thomas was concerned, Rodney’s presence at the meeting was one more indication of the bureaucratic soup in which medicine was drowning.

“Before we start,” said Dr. Ballantine, extending his arms with hands spread out as if to quiet a crowd, “I want to be sure that everyone has seen the article in this week’s Time magazine rating the Boston Memorial as the center for cardiac bypass surgery. I think we deserve it, and I want to thank each and every one of you for helping us reach this position.” Ballantine clapped, followed by George and a smattering of others.

Thomas, who’d sat near the door in case he was called to the recovery room, glowered. Ballantine and the other doctors were taking credit for something that was due largely to Thomas and to a lesser extent to two other private surgeons who happened to be absent. When he had gone into surgery, Thomas thought he would avoid the bullshit that surrounded most other professions. It was going to be him and the patient against disease! But as Thomas looked around the room, he realized that almost everyone at the meeting could interfere with his work because of one aggravating problem-the limited number of cardiac surgical beds and associated OR time. The Memorial had become so famous that it seemed as if everyone wanted to have their bypass there. People literally had to wait in line. Especially in Thomas’s practice. He had been limited to nineteen OR slots a week and he had a backlog of more than a month.

“While George passes out the schedule for next week,” said Dr. Ballantine, extending a stack of stapled papers to George, “I’d like to recap this week.”

He droned on as Thomas turned his attention to the schedule. His own patients were scheduled by his nurse, who collated the necessary information and got it over to Ballantine’s secretary, who typed it up. It contained a capsule medical history of each patient, a listing of significant diagnostic data, and an explanation of the need for surgery. The idea was that everyone at the conference would go over each patient and make sure that the operation was needed or advisable. But in reality it rarely happened, except if you missed the meeting. Once when Thomas had been absent, the anesthesiology department had canceled several of his cases, resulting in a row no one was likely to forget. Thomas continued reviewing the sheets until Ballantine mentioned something about deaths. Thomas looked up.

“Unfortunately there were two surgical deaths this week,” said Dr. Ballantine. “The first was a case on the teaching service, Albert Bigelow, an eighty-two-year-old gentleman who could not be weaned from the pump after a double-valve replacement. He’d been scheduled as an emergency. Is there word on the autopsy yet, George?”

“Not yet,” said George. “I must point out that Mr. Bigelow was a very sick cookie. His alcoholism had seriously affected his liver. We knew we were taking a risk going to surgery. You win some and you lose some.”

There was a silence. Thomas commented sarcastically to himself that Mr. Bigelow’s untimely demise had prompted a stimulating discussion. The galling part was that it was this kind of patient that was keeping Thomas’s patients waiting.

Ballantine glanced around, and when no one spoke he continued: “The second death was a patient of mine, Mr. Wilkinson. He died last night. He was autopsied this morning.”

Thomas saw Ballantine look over at George, who shook his head almost imperceptibly.

Ballantine cleared his throat and said that both cases would be discussed at the next death conference.

Thomas wondered at the silent communication. It brought to mind the weird comment George had made up in the lounge. Thomas shook his head.

Something was going on between Ballantine and George, and Thomas felt a twinge of uneasiness. Ballantine had a unique position in the medical center. As chief of cardiac surgery, he held an endowed chair with the university and was paid a salary. But Ballantine also had a private practice. Ballantine was a holdover from the past, bridging as he did the full-time salaried men like George and the private staff, like Thomas. Of late Thomas had begun to think that Ballantine, whose skills were obviously on the decline, was beginning to favor the prestige of being a professor over the rewards of private practice. If that were true, it could cause trouble by upsetting the balance between the full-time staff and the private physicians, which in the past had always tilted toward the latter.

“Now, if everyone will turn to the last page of the handout,” said Dr. Ballantine, “I’d like to point out that there has been a major scheduling change.”

There was a simultaneous rustle as everyone flipped the pages. Thomas did the same, placing the papers on the arm of his chair. He did not like the sound of a major scheduling change.

The last page was divided vertically into four columns, representing the four rooms used for open-heart surgery. Horizontally the page was divided into the five days of the work week. Within each box were the names of the surgeons scheduled for that day. OR No. 18 was Thomas’s room. As the fastest and busiest surgeon, he was assigned four cases on each day except Friday when he had three because of the conference. The first thing Thomas checked when he looked at the page was OR No. 18. His eyes widened in disbelief. The schedule suggested that he’d been cut to three cases a day, Monday through Thursday. He’d lost four slots!

“The university has authorized us to hire another full-time attending for the teaching service,” Dr. Ballantine was saying proudly, “and we have started a search for a pediatric cardiac surgeon. This, of course, is a major advance for the department. In preparation for this new situation, we are expanding the teaching service by an additional four cases per week.”

“Dr. Ballantine,” began Thomas, carefully controlling himself. “It appears from the schedule that all four additional teaching slots are being taken from my allotted time. Am I to assume that is just for next week?”

“No,” said Dr. Ballantine. “The schedule you see will hold until further notice.”

Thomas breathed out slowly before speaking. “I must object. I hardly think it’s fair that I should be the sole person to give up OR time.”

“The fact of the matter is that you have been controlling about forty percent of the OR time,” said George. “And this is a teaching hospital.”

“I participate in teaching,” snapped Thomas.

“We understand that,” said Ballantine. “You’re not to take this personally. It is plainly a matter of more equitable distribution of OR time.”

“I’m already over a month behind on my patient schedule,” said Thomas. “There isn’t that kind of demand for teaching cases. There aren’t enough patients to fill the current teaching slots.”

“Don’t worry,” said George. “We’ll find the cases.”

Thomas knew what the real issue was. George, and most of the others, were jealous of the number of cases Thomas did and how much money Thomas earned. He felt like getting up and punching George right in the face. Glancing around the room, Thomas noticed that the rest of the doctors were suddenly busy with their notes, papers, or other belongings. He could not count on any of the people present to back him up.

“What we all have to understand,” said Dr. Ballantine, “is that we are all part of the university system. And teaching is a major goal. If you feel pressure from some of your private patients, you could take them to other institutions.”

Thomas’s anger and frustration made it hard for him to think clearly. He knew, in fact everybody knew, that he could not just pick up and go to another hospital. Cardiac surgery required a trained and experienced team. Thomas had helped build the system at the Memorial, and he depended on the structure.

Priscilla Grenier spoke up, saying they might be able to add an additional OR room if they got an appropriation for another heart-lung machine and perfusionist to run it.

“That’s a thought,” responded Dr. Ballantine. “Thomas, perhaps you’d be willing to chair an ad hoc committee to look into the advisability of such expansion.”

Thomas thanked Dr. Ballantine, struggling to keep his sarcasm to a minimum. He said that with his current workload it was not possible to accept Ballantine’s offer immediately, but that he’d think about it. At the moment he had to worry about putting off patients who might die before they had OR time. Patients with a ninety-nine-percent chance of living long, productive lives if they did not find their OR time sacrificed to some sclerotic wino whom the teaching service wished to experiment on!

On that note the meeting was adjourned.

Struggling to keep his temper under control, Thomas went up to Ballantine. George had, of course, beat Thomas to the podium, but Thomas interrupted.

“Could I speak to you for a moment?” asked Thomas.

“Of course,” said Dr. Ballantine.

“Alone,” said Thomas succinctly.

“I was heading over to the ICU anyway,” said George amiably. “I’ll be in my office if you need me.” George gave Thomas a pat on the shoulder before leaving.

To Thomas, Ballantine was the Hollywood image of the physician, with his soft white hair combed back from a deeply lined but tanned and handsome face. The only feature that somewhat marred the overall effect were the ears. By anyone’s standards they were large. Right now Thomas felt like grabbing and shaking them.

“Now, Thomas,” said Dr. Ballantine quickly. “I don’t want you getting paranoid about all this. You have to understand that the university has been putting pressure on me to delegate more OR time to teaching, especially with the Time article. That kind of publicity is doing wonders for the endowment program. And as George pointed out, you have been controlling a disproportionate amount of hours. I’m sorry you had to learn about it like this, but…”

“But what?” asked Thomas.

“You are in private practice,” said Dr. Ballantine. “Now if you’d agree to come full-time, I can guarantee a full professorship and…”

“My title as Assistant Clinical Professor is fine with me,” said Thomas. Suddenly he understood. The new schedule was another attempt at pressuring him into giving up his private practice.

“Thomas, you do know that the chief of cardiac surgery who follows me will have to be full-time.”

“So I’m to look at this cut in my OR time as a fait accompli,” said Thomas, ignoring Ballantine’s implications.

“I’m afraid so, Thomas. Unless we get another OR, but, as you know, that takes time.”

Abruptly Thomas turned to go.

“You’ll think about coming aboard full-time, won’t you?” called Dr. Ballantine.

“I’ll consider it,” said Thomas, knowing he was lying.

Thomas left the teaching room and started down the stairs. At the first landing he stopped. Gripping the handrail and closing his eyes as tightly as possible, he let his body shake with sheer anger. It was only for a moment. Then he straightened up. He was back in control. After all, he was a rational individual, and he’d been up against bureaucratic nonsense long enough to deal with it. He’d suspected that Ballantine and George were up to something. Now he knew. But Thomas wondered if that were all. Maybe it was something more than the OR schedule change because he still had the anxious feeling something else was going on that he should know about.