The Decision
 | A weak man has doubts before a decision, A strong man has them afterwards. Karl Krau |
12 April 1972
At six AM, the alarm went off. Charlie rolled over and quickly turned it off so as not to disturb his wife. He sat on the edge of the bed for a moment, to orient, before starting the day. God was he tired; only three hours sleep this time. Good, she slept on. He tiptoed to the bathroom, shut the door and went about his morning toilet. Afterward, he gathered clothes from the closet: jeans, flannel shirt and running shoes. Noiselessly, he closed the bedroom door then tiptoed down the carpeted stairs to dress in the library. This was Wednesday and he didn’t have to wear his clinic uniform of white or blue shirt, bow tie, blue blazer, brown slacks with wing-tip shoes and argyle socks. Wednesday was surgery day until one PM then he could escape, assuming no other emergency surgery. He wanted to be alone this afternoon. The last three days had been hectic with only about six hours total sleep. The cases kept coming into the emergency room; too many car accidents on these icy roads. The other surgeon in town, Dr. Anderson, was due back from vacation today so there would be a respite, hopefully, this afternoon.
After 25 years of practice, he could still spout off the latest surgical research. In fact, he maintained an expansive knowledge base of medicine in general, and he enjoyed educating those physicians that did not maintain currency. He could have stayed in a university to teach and to research after completing his training, but both Jean and he felt a small town was best to raise family and interact in the community. In other words, he wanted to be big fish in a small pond rather than small fish in a big pond. At first, he enjoyed being a commander in the medical community, but now his medical troops, trained and accustom to his directions, required little prodding to know exactly what he wanted. He was a General whose troops could respond to any situation. Even the other physicians differed to him; all except that pathologist Joe Black. He was just an alcoholic anyway. Charlie the General, always got his way: the supreme commander of a small, rural, relatively isolated hospital. God only knows he worked hard enough to maintain this medical community as this week had shown.
He checked himself in the hall mirror before exiting the house: tall at six ft four, lean but not emaciated, grey hair with sideburns typical of the period, and a John Kennedy haircut. No jewelry, not even a watch. Jewelry was an encumbrance for surgeons. He had hazel green eyes with sunken cheekbones that made him look streamlined and efficient, which he was. Approaching 55, he still looked young and lithe. He was proud of his stature considering his age. Dr. Charlie Long still had it. After preening in front of the mirror, he rushed out the door as his wife started to stir. He may be a General at the hospital, but at home he was only a Private. He jumped into his 1953 MGTD and sped off to the hospital enjoying the top down despite the weather.
It was only a ten-minute drive, but he used the time to ruminate on the surgical cases for the day. It was a light schedule: only two. The first was to be Ann’s breast biopsy. Normally he would just tell a woman of 32 just to watch a lump like this: it was less than two cm in diameter and soft. He doubted cancer, but her mother died of breast cancer at 56 years of age so, naturally, the daughter was anxious, very anxious. Sometimes it’s okay when anxiety drives the decision to biopsy. He could barely feel the lump, and she did not want to travel to the big city for a mammogram. She had two kids at home. The other case was a garden-variety gall bladder; he chuckled at the memory of her husband dragging her to the clinic because she was breaking wind too much, and the smell was offensive.
The first case, the breast biopsy, could be a simple one, but it still bothered him. Ann was a beautiful young woman and a top-notched school teacher. He felt guilty for the way he treated her last night but rationalized his behavior due to being tired and hungry.
He thought to himself as he drove through town. “What will I do if the frozen section shows cancer? I trained at the greatest surgical center, John Hopkins Medical Center in Baltimore, where the great Halsted did his pioneer work at the turn of the 20th century.” Halsted was the first to show that breast cancer could be cured by surgery, but the procedure was extensive: remove the breast and all tissue down to the ribs and then remove as many lymph nodes from the armpit as possible. Cure rates as high as 50% documented. “Yes, I will do a Halsted; I trained that way. This new young Dr. Anderson leaves the chest wall muscles and doesn’t remove all the lymph nodes from the armpit. He calls it a ‘modified radical mastectomy’.” Charlie snorted, but a truck horn blasted behind the little sports car just then and startled him. He swerved and almost drove off the road. The truck passed. Its driver gave a dirty look and mouthed something. Charlie waved with three fingers, like the Pope’s salute, and then went back to his thoughts. “But until studies show this new procedure is better, I’ll stay with the time-tested way. After all, Halsted recognized how breast cancer spread: first to the armpit nodes then through out the body. It made sense to remove the source and then follow potential spread areas. Since local recurrence is about five percent, removing the muscles seems like a good idea. After all, it is better to be cured than cancerous no matter what the procedure!” He geared down and slowed to a stop at the first light on his route. A shop keeper was sweeping the sidewalk in front of a store and waved. Charlie waved back with his Papal salute, let out the clutch and sped away. He remembered the last American College of Surgeons meeting, where that young whippersnapper, Bernard Fisher, implored surgeons to involve their patients in a study comparing mastectomy to just remove a quarter of the breast that contained the tumor. He even had the audacity to call the procedure a quadratectomy. Fisher claimed the Scots and Finns were doing quadratectomies since the late forties with results equal to the Halsted procedure. He even referenced that wild Englishman, Baldwin, who was just removing the part of the breast segment that contained tumor. No, this would not do. “I’m a surgeon, I know what’s best.” He almost shouted. “Halsted would roll over in his grave!”
He continued this self-talk, enjoying listening to an expert and the way he could think out a problem: “Are we plastic surgeons or real surgeons?” He scoffed again as he continued “All these approaches are just fads. Even when I was in training, there were fads: that super-Halsted procedure where they removed the neck nodes and breastplate. It was no better than the Halsted.” Then, he remembered another gimmick and laughed out loud. “That crazy female radiation doctor down at M.D. Anderson Tumor Institute just radiated the tumor. Didn’t last long and, after the initial report, there was no further mention of primary treatment with radiation. Those surgeons down there must have tarred and feathered her.” A car passed in the other direction and the driver looked at him as if puzzled. Apparently others could see him talking to himself. He concentrated on his driving now. Downtown was mostly deserted this early in the morning, but it still required him to pay attention. He pulled up to another light and while waiting another thought occurred. He started mumbling again. “We now have Medicare. The government isn’t going to pay for experimentation. Besides, we have to be aware of those ambulance chasing lawyers. Any procedure that is not the standard of care leaves a surgeon vulnerable.” He rationalized, as if he were giving a younger physician a lecture. No, if she needed it, he would do a radical mastectomy. “This is crazy, she isn’t going to have cancer and all I’ll have to do is a simple biopsy.” He stated out loud again only this time with finality on the subject and floored the accelerator to make the little MG speed into the hospital parking lot. At the entrance to the lot was a sign that said 15 MPH, this was his territory now and he could go as fast as he wanted. Almost on two wheels, the speedy little sports car turned into his reserved spot.
****
“Good morning, Ann! Well, you are the first patient this morning, and if all goes well we should have you out of here tomorrow morning.” He tried to atone for his curtness of the night before. “You will not be too ‘with it’ until tonight, but I’ll talk to Bob right after the surgery. I’ll talk to you tomorrow morning before you leave. Do you have any further questions?”
“Yes, if it doesn’t go well?” She asked in a soft voice as if she didn’t want to upset him. Then meekly added: “How long will I be here?”
“Probably seven to ten days.” He started the sentence with a short, nervous laugh. “But, let’s cross that bridge if and when we have to.” With that, he turned and left.
At 7:25 AM, Dr. Long entered the men’s dressing room to change into his surgical scrubs. Everything was right on schedule. Good, maybe I can take a nap this afternoon, he thought as he opened his locker. After changing, he walked into the surgical lounge. Two nurses were drinking coffee. He was annoyed; they should have been preparing his patient.
“I’m sorry Dr. Long, but we have a delay. It seems that the anesthesiologist isn’t here yet.” One of the nurses blurted, sensing his annoyance.
“What’s the trouble?” Not again, he thought. Ever since they contracted with the anesthesiology group that covers four regional hospitals the service has not been good.
“Seems that Dr. Adams is late, that’s all I know.” She fired back defensively.
Inside he was fuming, but he wasn’t ready to show it…yet. Dr. Adams was the female anesthesiologist. She had been late two or three times before. Seems she just couldn’t get her kids organized in the morning. He had little tolerance for female doctors, especially female anesthesiologists.
“Get a nurse anesthetist now and let’s get going.”
“We can’t. The nurse anesthetist is in on Dr. Anderson’s case.”
He tried to remain calm but it was a struggle as he turned and went to the head surgical nurse’s office. “What’s the hold up, Nancy?’ he implored with agitation in his voice.
“I called Dr. Adam’s home. She left on time, so it must be delay by construction on the pass. She should be here soon.” She nervously replied.
“Is the pathologist here yet?”
“No, that’s why I think there is a delay due to road work.” Nancy was glad she had an excuse, any excuse.
He walked back to the lounge. There was nothing to do but wait. He sat for a few minutes watching television, but he couldn’t concentrate. He went back to Nancy.
“Who’s the pathologist today?”
“I’ll call Sue and check.” She picked up the phone as she spoke. Having worked with him, she knew it would not be good if Dr. Long stayed agitated. She got the answer fast, but still paused before telling him. She also knew the relationship he had with the pathologist. “It’s Dr. Black.” Her voice broke as she spoke.
By now, he had all the bad news he could take. He marched out of the surgical area and quickly stepped across the hospital to the administrator’s office, and without being announced, entered. “Matt, I thought we got rid of Black.” he declared without preamble.
“I’m just as surprised as you that Dr. Black is here today, but I turned all of our files on him over to the Board of Medicine last week. The Board told me they would handle the case now and we were not to remove Dr. Black from staff privileges until they completed the investigation.”
“Call the Board now and see what they are doing in this case.”
Matt’s hand shook as he made the call. He hated this, but he had to keep the surgeons happy, particularly this one. Luckily, the Board investigator responded, after all, it wasn’t even eight AM yet. The explanation, passed on to Dr. Long, was, despite their concern about Dr. Black, there was no evidence to suspend his license. The Board, at their monthly meeting next week, would review his case. Until then, Dr. Black was under no restriction. Matt added: “The only thing we can do is have the Chief of Staff meet him at the door and tell him his privileges are temporarily suspended. Even then, he could sue us for…”
“Yeah, I know.” Dr. Long interrupted. The Chief of Staff might not agree to bar Dr. Black. These days, doctors were suing for constraint of trade when being sanctioned. No one wanted to get into that fight. Besides, even if successfully barred, they still needed a pathologist today. Dr. Long wasn’t about to accept another delay. The only thing to do was continue with today’s surgical cases. Before leaving the office, he made it clear to Matt that there better be disposition of the Black case soon.
By the time he got back to the surgical suite and changed into clean scrubs, Dr. Adams had arrived and she had the patient anesthetized. She didn’t want to face the surgeon’s bluster either.
“Call pathology and make sure the pathologist is there and ready.” Dr. Long commanded as he scrubbed hands and arms to go into the operating room. He was comfortable now; once the operation started, he was in charge. As his emotions calmed, he started to re-evaluate the situation. This was no time to react. Actually, Black had been a good pathologist before he became a drunk. Maybe he would be sober today. Things would be all right, just kept a cool head.
Dr. Adams greeted him as he backed through the operating room doors: “Sorry about the delay. They blocked traffic for 30 minutes on the pass. I’ll sure be glad when the freeway is done.”
Everyone discussed the freeway while preparations got under way. It was usual to discuss mundane issues during surgery. He was not prone to small talk and usually let others carry the conversation. It was like going to the barber and trying to talk about current issues; he was always glad when it was over.
He probed the breast with his fingers. At first, he could not find the lump. Had it disappeared? He was just getting ready to declare it gone when his index finger rolled over unusual tissue. A three centimeter incision over the tissue exposed the area and blunt dissection with Kelley forceps revealed a one centimeter mass. This could be fibrocystic, he thought, as his fingers delivered it to the opening. Deep down, that’s what he hoped as he removed the mass with some fatty tissue and plopped it into a sterile basin. An aide took the basin and rushed out the door toward the pathology lab. There was nothing to do now but wait for the path report. In the meantime, he examined the exposed breast tissue for any other abnormality.
“What’s taking so long?” Charles boomed into the intercom after what seemed like a long delay.
“Tell them to hold on to their god damn horses.” Joe Black yelled back.
“Well?” asked Charlie after a few more minutes. He wasn’t going to take this passive aggressive behavior from this pathologist.
Again, silence. The whole operating crew listened, hoping for an answer, but all they could hear was a chair squeaking in the background through the intercom.
Finally the pathologist announced, in a calm, but firm, even insolent voice: “The specimen is too hard to read with a frozen section. We’ll have to wait for the permanents.”
Dr. Long was silent at first and then sighed so that all could hear it, before speaking at the intercom. “Joe, I have this patient on the table under general anesthesia and I need an answer now. We can’t wake her up and wait a couple of days for you. Give me an answer.”
As if reading something out of a textbook, Dr. Black shot back his answer. “Okay, the cells are distorted and swollen beyond recognition. There are knife artifacts as well as freezing artifacts. These specimens are inconclusive.”
After a long pause, Dr. Long calmly replied: “Joe, come down here now, and let’s talk.” With that announcement, he broke sterility and started to walk out the room.
Dr. Adams and the surgical team were baffled, so she asked to his departing back: “What do I do, wake her up?”
“Just wait.” was the command.
Charlie paced in the surgical office until Joe showed up. He was fuming with rage and unsure he could control it. Everything was going wrong today, and he had no time for this. Besides, a competent pathologist would have given him an answer. This insubordination was unacceptable, especially from a drunk.
The door opened and the little pathologist walked through it with his head down, then turned and slowly closed it. Charlie could see his chest heave as he took a deep breath, paused, and then turned around. For some reason, this behavior made him angrier.
Then Joe changed completely. With head up, he walked directly into Charlie’s zone of comfort, so close that he wanted to back away. Charlie could feel the warmth in his breath and the faint odor of alcohol as he spoke.
“I cannot tell what it is. It may be cancer and it may not.” The pathologist pronounced with conviction.
Charlie reeled initially by this bold and brazen approach. He was not use to being challenged, but he could not accept the answer either. “What the hell am I suppose to do?” he countered.
“Wait. I understand they are doing biopsies at the University then waiting a few days for the final path report to do definitive surgery if needed. That way the patient knows what to expect.” Joe had the upper hand now and backed away as if dismissing the problem.
“That’s ridiculous! We use halothane for anesthesia and the risk of chemical hepatitis increases the more it’s used. Lawyers would sue our ass off if we waited and she got hepatitis!” Charlie blurted out, lost for any other logical retort.
“Charles, that’s the way it is.” Joe countered with finality.
Charlie hastily turned and headed for the door, dismissing the pathologist with a wave. As he re-scrubbed, he was thinking what to do. Already they were over an hour into this case. If it is cancer and I delay, she will have to suffer further anxiety and risk of hepatitis. If I operate now, and it isn’t cancer, she will suffer needlessly. I must decide. God damm that drunk! I’ll get him!
He made his decision as he backed into the room with sterile hands and arms held high.