Implant

  "Shot down by the senator's staff, eh? And I guess you didn't get your chance to impress Allard either."

  "Hardly. That was some fall he had. Lucky to be in one piece after the way he hit the sidewalk."

  "Right in front of the TV cameras. They've been replaying it all morning on CNN. Too bad."

  Too bad? He'd been there, watching, and hadn't helped. Or didn't he want to admit that?

  "Had some nasty facial lacerations. Chances are he'll be calling you to fix him up."

  "He can save his dime, " Duncan said. "You ought to know by now I don't operate on people who need surgery, only those who want it. By the way, sorry about my outburst yesterday morning. You didn't deserve that." Just like that, Oh, by the way, sorry I damn near gave you a heart attack.

  But relief blotted out his offhandedness. The bunched muscles in her shoulders and the back of her neck began to uncoil.

  "You mean I'm not fired?"

  He laughed. "Hell, no! But I do want to talk to you." His smile faded. "I want to know why a bright, talented young woman like you wants to get involved with the Harold Vincents and Kenneth Allards of the world."

  Oh, God, she thought as she took a deep breath. Here we go.

  '"Somebody's got to, Duncan. They're calling all the shots. But when they want to know what's going on with doctors and medical care, look who they ask, insurance companies, A.M.A officers, public service doctors, VA doctors, whoever's handy."

  Duncan grimaced with distaste. "Or even worse, Samuel Fox."

  Gin nodded. She remembered sitting around with her fellow residents and laughing at Fox's asinine statements during a Donahue appearance a couple of years ago. But he had a knack for PR and had parlayed his alarmist books and press releases into a position of credibility with Congress.

  "Exactly. Congress gets its input from doctors who aren't physicians."

  "Stands to reason," Duncan said. "Real doctors are out in the trenches practicing medicine. They've got too many sick people on their hands to hang around Capitol Hill."

  "Too true. But that's got to change."

  Duncan's jaw jutted at her. "Why?"

  "Because the government's got its sights on health care. The big reform package didn't fly, but that doesn't mean the government's going to go away. It's going to keep inching in, the old salami-slicing method. Nothing's going to stop it."

  Duncan sighed. "Yeah, I know. Don't get me wrong. I'm not opposed to everyone having some sort of coverage. I hate the thought of anyone, especially a child, going untreated. But I loathe the idea of the kakistocracy designing and administering the program, imposing guidelines for medical decisions that should be a matter solely between doctor and patient." His voice took on a TV announcer's tone, "And now, from the people who brought you the House Post Office scandal and the debatable, Health care!" He shook his head. "I don't think so."

  "Doesn't it make sense to standardize medical care and costs across the country?"

  His gaze was hard as steel. "Don't you think we've got enough guidelines already?"

  She thought of old Mrs. Thompson at Lynnbrook Hospital. "Well . . . "

  "What this bill will do is enforce cookbook medicine. The real thrust of all this legislation isn't quality assurance, it's cost control. They'll save a few bucks but the human costs will be huge."

  "It doesn't have to be that way. We," Duncan glanced at the carafe and held up a hand. "Coffee's ready." He lifted the cone from the carafe and placed it in the small chrome sink next to the microwave. Then he filled two thick white diner-style mugs with the fresh, steaming coffee. He handed one to Gin.

  "Now this is coffee. Taste." Gin sniffed, the aroma was fabulous, then sipped. Usually she drank her coffee black with a little sugar. This didn't need sugar. The flavor was so deep, so rich . . .

  "It's . . . " She struggled for words. "It's like I've never had real coffee before. This is amazing."

  Duncan beamed. "It's worth the trouble, isn't it? An anodyne for weltschmerz. I'll grind you up some beans to take home. But use them soon. And if you use a regular drip machine, never, never, leave the pot on a heater. Always decant the coffee immediately into a carafe. Even the best coffee gets bitter when it's overheated."

  "Thanks. I'll remember that." Gin had had no idea Duncan was such a coffee connoisseur. The rituals, the rules . . . it was like a religion. But the result was awfully good.

  They sipped in silence for a moment. Gin wandered along the glass wall and admired the koi pool, the rock garden, and the dwarf shrubs that lined it. She continued on, passing his desk. The top right drawer was open. Inside was a glass injection vial filled with a clear amber fluid.

  Something else too. Something metallic, almost like a large trocar . . .

  Suddenly Duncan was beside her, sliding the drawer closed. "You were saying?"

  "Where was I? Well, the point I was trying to make is that if I can get on a committee member's staff, I can see to it that he gets some straight dope on how these guidelines will affect patient care. And if I can influence him even a little, won't it be worth it?"

  Duncan stared at her, slowly shaking his head. "For some time now I've been worrying that you had no direction. I was afraid you were just going to drift, make a career of moonlighting and locum tenens work. Now I almost wish that were the case." Had he actually been thinking about her?

  "Maybe I'll simply devote myself to lexiphania."

  Duncan appeared taken aback. Had she stumped him?

  Lexiphania, the tendency to use obscure and unusual words. The irony would be rich. How wonderful to catch him with a word that described himself.

  Duncan laughed. "Where'd you find that one?"

  "Wasn't easy, believe me."

  "All right. I plead guilty to compulsive grandiloquism, to singlehandedly trying to correct for the entire language's drift into banality." Damn. He did know it.

  She said, "I don't think it's working."

  "More's the pity." He gazed at her, smiling. "Lexiphania . . . that’s wonderful. How can I stay angry at you? But seriously, Gin, you've been trained for a higher sort of work than being legislative aide to some pretentious pinhead pol. I hate to see you wasting your talents."

  For a moment she was struck by how much he sounded like Peter. He'd said almost exactly the same thing when she'd told him she was leaving Louisiana to get involved in medical politics.

  Focusing on Duncan, Gin bit her tongue and thought, I could say the same about your facelifts.

  As if reading her mind he smiled crookedly and said, "Not that I'm one to talk about wasting training." For an instant there was real pain in his eyes. Her heart went out to him.

  "Duncan . . . whatever,"

  He held up the coffee carafe. "Refill?"

  "No, thanks. Can I ask,?"

  "I don't envy you, Gin." Obviously he didn't want to talk about Duncan Lathram. "I wouldn't want to be starting out in medicine today and facing the terrain that's ahead of you."

  "All the more reason to get involved." Why couldn't he see that?

  "But what do you hope to accomplish? What is your goal down there on Capitol Hill?"

  "Fair guidelines. Realistie guidelines we can all live with."

  "Never happen," Duncan said. He sighed. "I hope you know what you're doing, Gin."

  "I've given it a lot of thought."

  "Have you? They're a pretty corrupt bunch, Gin, and,"

  "And I'm so impressionable?"

  "No. It's not that. It's just that, well, as doctors, we're a different breed. Our values are different. We don't speak the same language. We don't walk in the same shoes as other people."

  "That sounds just a little elitist to me." He shrugged.

  "Maybe. But sometimes I think the weight of the life-and-death decisions doctors have to make sets them apart from the rest of humanity. When you've felt someone's life draining through your hands, and you've reeled him back in and sent him home to his family, it does something to you. You've seen things that regular
folk will never see, done things they'll never do, glimpsed them at their most vulnerable, when they're stripped of all their pretenses. You've been master of life and death, and that can't help but change you. It leaves you one step removed from everybody else."

  Gin had run up against this gods-who-walk attitude all through her residency.

  "It's time we ditched the god thing, don't you think? We're not gods, and it's damaging to us and our patients to foster that kind of reverence. We can do extraordinary things, seemingly miraculous things. But we're not gods. We're just people." He was sullen as he sipped his coffee in silence.

  Finally Gin said, "Doesn't look like we'll ever see eye to eye, does it?"

  "No, it doesn't."

  "Can we agree to disagree, then?"

  "I don't suppose I have much choice."

  "You could fire me."

  "I don't want to do that. But don't expect my blessing."

  "I never did." But I want it, dammit. I wish I didn't, but I do. "I don't even know if I'll get the job. But if I do I'll have to adjust my schedule to,"

  "Cassidy can take up the slack. We'll work it out."

  Gin felt a trickle of warmth, seeping through her. This was a blessing of sorts, wasn't it? If not, it would have to do.

  "Thank you, Duncan. I didn't expect,"

  "I want to keep you nearby . . . where I can keep an eye on you."

  The warm trickle became a chill. What was that supposed to mean?

  "Just don't let us down, Gin," he said, his blue eyes burning into hers. "Don't betray us." He held her locked in his gaze a moment longer, then turned away.

  "I'm glad we had this talk, Gin. The first of many, I hope. I'm sure you've got some dictation to catch up on."

  "Yes. Sure. I'll see you later."

  "Be sure to let me know as soon as you hear from Marsden. As for me, I'm off to the links." He pulled out a key ring and matter-of-factly locked his top drawer. "Surgery tomorrow at eight."

  Idly wondering why he bothered locking the drawer, Gin waved and left him.

  This was turning out to be one strange day.

  6

  GIN.

  EASY NOW, OLIVER SAID SOFTLY, WATCHING OVER HER shoulder, coaching her.

  "That's it. Just go easy . . . easy . . . " Gin hadn't felt like being alone this afternoon. No word from Marsden's office, or from Gerry, so she'd arranged to spend a couple of hours in Oliver's lab practicing her implant-filling technique. She'd learn and get paid for it.

  She smelled garlic on his breath and wondered what he'd had for lunch.

  Nothing low cal, she was sure. Oliver had a weakness for Italian food and didn't seem to care what effect it had on his waistline. Probably linguine and clam sauce, don't spare the garlic, Better forget Oliver's dietary indiscretions. She needed to concentrate on what she was doing.

  Gin had the 26-gauge needle of a tuberculin syringe inserted in the end of one of Oliver's medium-size membranous implants and was injecting it with normal saline. Had this been for real, she'd be working under sterile conditions and filling the implant with Oliver's "secret sauce." Staring through the magnifying lens centered in the round head of the fluorescent examination lamp, she watched the half-inch-long tubular membrane swell and stretch. Like filling the world's tiniest water balloon.

  "It's full now," Oliver said. "Feel that back pressure?" She hadn't felt any until now, which was why half a dozen membranes lay ruptured on the side of the tray. But this time she did feel a hint of resistance on the plunger.

  "Believe it or not, I think I do."

  "Swell! Now it's time for the zapper." Gin repressed a smile as she reached for the cautery handle. Did anyone else on earth still say swell? Oliver had to be the last.

  He was a bit of an enigma. Didn't seem to have much of a life outside his lab. No wife or family. No significant other that she knew of.

  He'd had the staff over to his house for a dinner party one night and Gin had felt she knew less about him afterward than before.

  '"Okay," she said. "I'm ready."

  "You know what to do. Just take your time" Gin had seen Oliver do this a hundred times but had never got this far. She readied the flattened tip of the cautery unit in position near the puncture site, slowly withdrew the needle, then stepped on the round power pedal near her left foot. A tiny blue spark arced from the tip to the implant, searing and coagulating the protein membrane around the puncture.

  She watched through the magnifying lens, waiting for a telltale bead of fluid to form, signaling the need for another zap. But the membrane remained dry. She'd sealed the opening.

  Success. Finally. A tiny triumph. Hardly made up for the fiasco in Marsden's officer Monday or Allard's accident this morning, but right now she'd take anything.

  Gin looked up and found Oliver's round face grinning at her.

  "It's going to be swell having someone else around who can fill these things. I'm sick to death of it."

  "Why don't you just hire an assistant or two to help with the scut work?"

  "There's really not all that much to be done at this stage of the studies. And I'd like to limit the number of people who know what we're working with."

  "And just what are we working with?"

  "Secret sauce."

  "Oliver, come on. Don't you think I have a right to know."

  He thought a moment. "All right. Fair enough. But keep it under your hat. This solution is not patentable, so I don't want anyone stealing my thunder by beating me to market with it."

  "Mum's the word," she said.

  "I'm sure I can trust you," he murmured as if he'd just now realized it.

  He removed his thick, horn-rimmed glasses as he sat down next to her.

  He began to talk, rapidly, as if someone had opened a valve. Gin realized he must have been dying to expound on his secret sauce.

  "Are you familiar with the work done by the Department of Cell and Structural Biology in the University of Manchester in England?"

  "No. Not a bit."

  "Not many clinicians are. Okay then, how about fetal surgery? Have you seen any of that?"

  "Some down in Tulane. It wasn't part of the internal medicine rotation, obviously, but I picked up some information by osmosis."

  "Good. Then you know that a fetus can have surgery in utero and be born months later completely scar free."

  "Yes, I remember a couple of OB residents talking about that. This high-risk baby they'd delivered had had a mass removed from its abdominal wall at about sixteen weeks' gestation and was born without a trace of an incision."

  "Exactly. But the surgery has to be performed during the first five months. Any procedure done later leaves a scar just as it would on an adult. Cellular biologists have wondered about it for years. What's happening in there? What's different? What prevents the usual excess amount of collagen from being laid down and forming the scars we all know so well? The folks at the University of Manchester came up with the answer a few years ago."

  Gin snapped her fingers. She remembered something . . . where had she seen it? "Some sort of growth factor, wasn't it?"

  Oliver clapped his hands. "Excellent! Transforming growth factor beta, to be precise. They identified three types of the growth factor, and found that the third, beta type 3, falls off sharply at the end of the second trimester of pregnancy. The type-three molecule, I call it beta-3 for short, has been synthesized since then and that's the key ingredient in the secret sauce."

  "So that's the secret behind Duncan's incredible results."

  ''Uh-uh," Oliver said, wagging a finger. "Duncan has the eyes and the hands that do the remodeling. Even without a drop of beta-3 his patients would have minimal scarring. All I've done is find a way to gild the lily."

  "But why the implants? Couldn't he just coat the incisions with beta-3?"

  "No. You need it in the final phase of healing. Remember the three stages of wound repair, inflammation, proliferas ion, and remodeling? Beta-3 does its work in stage three where scar t
issue forms to replace granulation tissue. At suturing time, beta-3 would accomplish nothing. You need a means of delayed release. I was, slaving away, testing antidepressants on rats in Skinner boxes as a psychopharmacologist at GEM Pharm during the day, and at night working in my home on a continuous delivery system for medication. Norplant was the hot topic then, but the Norplant implants have to be removed after five years. I thought I could improve on that, develop an implant that would deliver its medication in a metered dose for five years, maybe longer, and then dissolve. Great idea, no?"

  "I take it that didn't happen."

  "Not completely. I developed a soft, flexible, crystal-protein matrix that would indeed dissolve without a trace. However, it was nonpermeable. Wouldn't allow a drop of anything on one side to pass through to the other, until it dissolved, and then it would dump its entire contents into the surrounding tissues. I'd come up with nothing more than a very elaborate and expensive way of giving someone an injection. I was terribly discouraged."

  "And then along came Duncan."

  "Right. After his . . . well, after he left vascular surgery, I heard about Manchester's results with transforming growth factor beta type 3 and saw how my imperfect slow-delivery membrane might be perfect for delivering something else. The FDA approved us for clinical trials and the results have been astounding."

  Gin had seen patients on postsurgical follow-up visits and only with a magnifying glass was it possible to tell they'd had surgery. Suddenly Gin was struck by the enormous potential for Oliver's implants.

  "But plastic surgery is just icing on the cake," she said. "Think of what you could do in general surgery."

  Oliver was nodding excitedly. "Of course. The implants would-have the most value in trauma cases, but they'll become routine in procedures like hysterectomies and appendectomies. A few weeks post-op you could wear your bikini, heck, you could even go to a nude beach if you wished, and no one would even guess you'd had surgery."

  Gin's hand strayed to the front of her blouse. Through the fabric she could feel the upper end of the thick, numb, puckered ridge of scar that ran the length of her abdomen.

  Duncan's scar.