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Ward 402
A Novel
Ronald J. Glasser
FOR ALL THE ARROWSMITHS
Contents
Foreword
I
1
2
3
4
5
II
6
7
8
9
10
11
12
III
13
14
15
16
17
18
IV
19
20
21
22
23
24
Foreword
THIS IS AS DIFFICULT a time for medicine as it is one of achievement. Despite all the successes a kind of leery feeling parallels the public applause, a suspicion that in making things better some things have been made worse, that in learning more too much has been forgotten.
I finished medical school much the same as any other medical student—eager, confident, sure that a year of internship would be all I needed to put the whole thing together. I was wrong. My internship was not the end I expected it to be, but a wrenching beginning.
It had never occurred to me when I was in school that as a physician there would be anything I’d have to face which was not covered in my classes, anything my professors had not yet worked out, or at least would not have warned us about. Becoming an intern was like passing through a curtain into a world that had never been mentioned, a world I was quite unprepared for.
Ready for hearts and lungs and kidneys, I was confronted with a whole person. In the midst of all the familiar precision, of laboratory values and X-rays, suddenly there were human concerns: grief and heartache, personal problems, economics, distrust, fears, and even anger. So seemingly well turned out, with all of science to draw on, I found myself stumbling; all of us were, with only our own strengths and weaknesses to get us through.
The story I have tried to tell in the following pages is true. Everything actually happened, though the events did not all occur in the same sequence, or in the same hospital, or to the same people; some I witnessed myself, others I heard of. Conversations are as I remember them; those that took place years ago I’ve had, of course, to reconstruct, remembering only the tone; some, especially those of the nurses, I’ve heard so often that by now they all seem to have come from the same person. Names, dates, places have been changed; the characters, in a sense, are fictitious, since each encompasses a number of people I have worked with. The deaths, though, are real; the suffering, the abuses, the misunderstandings—these, too, are real enough. They still go on.
R.J.G.
I
1
OF THE YEAR I spent as an intern at University I can say that all of it was hard but 402 was by far the worst. It was the largest pediatric ward in the hospital. Almost unmanageable in length, it took two nurses’ stations to run, and even then, because of the number of children and the seriousness of their diseases, medications were often given late, specimens went uncollected, and parents of new admissions sometimes had to wait for hours before any of the house staff had a chance to talk to them.
There were two interns assigned to 402 at any one time; during my rotation it was Lang and myself. After a few days we realized the only way we could keep up with everything was to rotate the admissions, he taking one and I the next. With only two of us we had to be on call every other night, which meant being up thirty-six hours at a stretch, sleeping seven or eight, and then beginning another thirty-six hours. The nights we were on we had to take all the admissions ourselves, so that no matter what system we used we were always behind in the morning, always trying to catch up.
In a way I was lucky; I came on 402 late in my internship. To have gone there fresh and scrubbed right out of medical school would have been almost impossible. Of the two doctors who preceded Lang and me and had come on the ward directly after graduating, one asked to have his rotation changed and the other, frazzled and exhausted, came down with mononucleosis and had to leave the program.
By the time it was my turn I was well into the eighth month of my internship. I had already finished my rotations through the newborn and premature intensive care units, the emergency room, and the kidney and cardiac services. With another three months of electives in radiology, hematology, and neurology behind me I felt I was ready for anything. I thought I had seen it all, that there was not a childhood disease or complication I had not already been involved with or read about. I walked onto 402 that first day feeling quite assured there was nothing left to surprise me.
I was soon to learn there was a great deal left to surprise me.
A little before five on the afternoon this account begins, McMillan, the pediatric resident, had admitted a three year old directly from the emergency room. During the year, especially in the late winter months, we saw hundreds of children dehydrated from diarrhea. McMillan must have thought this one was shocky or he wouldn’t have sent him up so quickly.
It was Lang’s turn for an admission. He got a quick history from the mother—a week of poor appetite, fever, vomiting, and finally three days of diarrhea—and then took the patient into the treatment room.
When I had finished what I was doing I went to let Lang know I was going to dinner. The place was a mess. There were discarded needles, IV tubing and alcohol sponges all over the floor. The kid was shrieking, and the nurse and one of the aides were holding him down while Lang was angrily reaching in the drawer for another IV needle. He must already have stuck the child a dozen times, and, to judge from the parts of a surgical cut-down tray scattered on the floor with the rest of the junk, he’d missed a cut-down, too. He looked ready to blow his stack.
“Hold it,” I said. “It’s my night on anyway. I’ll finish up.”
For a moment I thought he was going to ignore me. Interns don’t like giving up; there’s a kind of mystique that makes it hard for you to admit you’ve failed, especially when it’s as simple a matter as starting an IV. Then, too, as interns on the same ward we did have a kind of rivalry going. But Lang had been on the night before, and up for almost all of it with a new diabetic; he was worn out. I guess even his pride couldn’t keep him from wanting to get some sleep, so he finally gave up and let me take over.
Everyone has bad days during his internship, times not so much when your mind doesn’t work as when your hands just don’t seem to do what they’re told. Mostly it’s because of tiredness, and on 402 we were always tired. Still, even so you can work things out if you’re practiced enough.
I’d had my own trouble with spinal taps, real trouble, so I’d gone down to the morgue and practiced on cadavers until I worked it through. The facility I gained with spinal taps spilled over to starting IVs. I was known to be good at it, even with newborns, and I suppose this was one of the reasons Lang was willing to stop.
“I’m not leaving you much,” he said, taking off his gloves.
In truth there wasn’t much left. He’d destroyed every big vein in the child’s arms and legs, even going so far as to ruin the smaller superficial veins on the back of the hands and feet, not to mention the cut-down site on one leg which he hadn’t even bothered to suture shut. But at least he’d left the patient exhausted, so that when I bent over the table to examine him he hardly moved, much less resisted.
After ten minutes of searching for a vessel I was beginning to think I’d have to do a cut-down on the other leg when I found a
small vein behind the child’s ear. Lang had overlooked it, or thought it was too small to use. I took a tiny scalp needle, and threaded the tip of it down under the skin and finally into the vein, made sure it was working, then taped it down. I had the nurse set up the IV bottle and left the room to write up the orders.
To have been scrupulously correct about ward responsibilities I should have called the resident, McMillan, let him know the difficulty Lang was having and that I’d taken over the patient. But I’d cared for enough dehydrations to know exactly what to do, and once I got the IV going there was no reason to call. If after nine months of pediatric internship you don’t know how to write fluid orders you should quit and do something else. So despite the fact that McMillan should have OK’d my taking over, I decided not to bother him, to do what had to be done, and tell him later.
2
THERE ARE SOME RESIDENTS you would have had to call, if only to keep them from climbing all over you when they found out what you’d done. McMillan wasn’t like that; he let you alone to do your work. If he felt you didn’t know something, or if you told him you were a bit shaky about a procedure or treatment, he’d be right there to show you how to do it. The next time he would watch you do it yourself, and after that you were on your own. If you screwed up, though, if you told him something that wasn’t true, or tried something you were unable to do or knew you’d have trouble handling, he’d nail you to the wall and keep you there the rest of the time you were on the ward with him.
If you didn’t step beyond your ability he was fine—more than fine, he was exceptional. As tough as he could be and as strict as he was, he was liked by everyone—at least we all enjoyed working with him. He was smart, really smart, and he read more than any other resident on the house staff, even those with more seniority. There wasn’t a pediatric or medical journal he didn’t at least scan. If he wasn’t on the wards, or in the clinics, he would be in the library or having an article Xeroxed in the pediatric office. When he didn’t know something he said so, but when he gave advice you knew you could believe him; he didn’t have to show off or guess to maintain his position, the way some of the other residents did. Then, too, he had a way of being cheerful without being irritating, and candid without being cruel, though his concern for excellence did make him seem distant at times.
McMillan had been my resident six months before, when I was on kidney service. I certainly didn’t know much, and working with transplants and all their complications made my inexperience even more obvious and me more nervous, so that I really leaned on him. But it was what happened right at the beginning of my rotation with him that made me realize how tenacious he could be, and concerned.
I had come on the kidney service a day or two after McMillan, so in a sense we both inherited Kerry at the same time. Inherited is the right word, because the child had been passed on from one set of interns and residents to the next. His hospital chart ran to over nine volumes. Most of us considered him to be a kind of medical and surgical triumph, but we also agreed he was almost impossible to care for. With no kidneys and more than half of his small bowel removed Kerry was always ill; even when things were relatively stable there were at least ten or twelve things to watch for or to check on. We were always waking him up to draw a blood sample, or check his blood pressure, or do an EKG, yet things still got out of hand and his hospital course went from one crisis to another.
With all the testing and blood-drawing it was understandable that the child might be difficult to handle, but that didn’t make it any easier to work with him. All kids tend to get freaky when they’ve been hospitalized a long time, but Kerry was almost unapproachable. Off and on he’d been hospitalized for twenty-two of his forty-seven months, and he showed it. He was not only miserable physically, he was sullen and resentful, and no wonder. By the time McMillan and I got to him he had already gone through a complete kidney transplant, its rejection, months of post-operative care, chronic dialysis, infections, and two cardiac arrests. Now he was back in the hospital again to get ready for a second transplant.
You just couldn’t fool him any more, and that made taking care of him all the harder. Everything had been used on him and used again until they no longer worked, all the ploys and the cute little phrases, all the explanations you rely on to get through difficult and unpleasant times, the lies and pleasant deceits you get used to hiding behind and having people accept. Kerry would have none of them. He was not yet four years old but he was as knowledgeable about hospital methods and procedures as any adult. He knew that mornings meant he would be stuck, that trips off the ward to the labs and X-ray meant pain, and that a doctor, no matter how concerned or kind, always did something to him. He would glare at you as if demanding to know why, and while he no longer screamed you knew that even though he held out his arm to let you get a blood sample you only got it because you were bigger than he was. And if you failed, if you hooked a machine up wrong, missed a vein, or made any kind of mistake, he’d be on you, yelling for another doctor who “knows how to do it.” It was unnerving in a child of his size. He knew how to make it tough for us; and refusing to take his medicine, vomiting up his food, soiling his bed, or pulling out his IVs didn’t help to endear him to anyone.
McMillan, though, went out of his way to spend time with Kerry and to talk to his parents who seemed as worn down by his behavior as we were. But as the resident on the service he didn’t have to struggle with the kid every day. I did, and no matter what else happened or even how I felt, Kerry was always there waiting for me. I got to the point where I dreaded having to make morning work-rounds. Then just when I was getting as freaky taking care of him as he was to take care of, a kidney became available. It was with a feeling of relief that I watched him being wheeled to the operating room for another transplant.
He came back to the ward alert and active but with his eyes tightly closed. We tried to get him to open them but he refused, and when we checked with the recovery room they said he hadn’t opened his eyes up there either, not even when the anesthesia was first wearing off. I thought he was just being his usual obnoxious self, but despite our coaxing and threats he kept his eyes tightly shut, his lips sealed in grim, almost desperate, determination. I suppose he knew that if he opened his eyes everything would be back the way it was before.
As the days passed with no change I became worried about the possibility of Kerry’s condition becoming chronic. I told McMillan we had to get those eyes open even if it meant taping back the lids. He didn’t like the idea. He was afraid that if we used force Kerry might simply refuse to see; then we wouldn’t only have an obstinate kid on our hands, we’d have a case of hysterical blindness.
I was embarrassed that I hadn’t thought of this possibility. The truth was that I just wanted to get his eyes open and the whole thing over and done with. As an intern, with so much to do, you tend to look for immediate solutions, but I could see that it would have been a bad mistake to force Kerry’s eyes open. McMillan consoled me by saying he might have been tempted to do the same thing if he hadn’t happened to come across an article on hysterical blindness. I accepted his support gladly, although I knew he wasn’t the sort who just stumbled across important facts. He’d probably researched the whole damn thing the first time he saw Kerry with his eyes closed. In any case, it was plain the patient wasn’t going to cooperate; each day the depths of his self-imposed darkness increased. What I and everyone else on the ward had at first thought to be another of his obstinate pranks was settling into a behavior pattern.
It was really spooky to see him sitting propped up in bed blindly, even cheerfully feeling across the cover for a toy he’d dropped or a half-eaten piece of candy. He seemed happy. His thin face, so long drawn into a grim suspicious scowl, had relaxed and taken on a playful elfishness that made him for the first time look like the little boy he was.
McMillan talked to a few of the psychiatric residents, but they hadn’t much to offer. Finally we sent in a formal psychiatric consultation requ
est. The staff psychiatrist came by and agreed that something had to be done and mumbled about reassurance and reality testing, but when McMillan pushed for a program he had to admit that he really had nothing to offer.
We tried everything, even going so far as sedating Kerry, putting him to sleep and standing by his bedside when he woke up, in the hope of catching him with his eyes open. It was no good; he awoke with his eyes as tightly closed as when he went to sleep. It began to look rather hopeless and I found myself drifting to other patients and concerns that I could do something about. Not McMillan though. I’d catch him at all times of the day standing by Kerry’s bed, watching the child move through his own self-imposed darkness. How he came to do what he did is still beyond me. It must be the stuff miracles are made of.
One night—it was a little before midnight—he woke Kerry up, talked to him and played with him for a while to make sure he was fully awake, then put a small kitten on the bed. I wasn’t there at the time, but the next day Barbara, the RN working nights, told me what happened. When the kitten began to move, she said, Kerry suddenly stopped everything and literally held his breath. Then tentatively he reached out to where the kitten was stumbling across the bed covers, and finally touched it. The effect was electric; Kerry gasped and almost jumped out of bed.
“It’s a kitten,” McMillan explained, and Kerry, trembling, began to stroke the soft warm fur. It was too much for him; he simply had to look. Forgetting everything, the hospital, the pain, the fears, he opened his eyes.
I suppose it shows something of the distance I’ve come if I admit that when Barbara told me what had happened, my first thought was it was pretty slick of McMillan.
3
WHEN I FINALLY DID call McMillan to let him know I had taken over Lang’s patient he got on me more than I thought he should have. He grilled me about what I had done and how I had done it, and then made me get him Lang’s number at home. I suppose he was right to be angry. After all, he had sent an almost shocky child up from the ER and Lang’s fiddling had added two hours to the kid’s dehydration. I didn’t feel he was angry so much about my taking over without letting him know, as he was about Lang’s going so long without asking for help, but he was sore enough for me to keep my feelings to myself and just give him the number. Poor Lang, I thought as I hung up, he’s in for it.
Ward 402 Page 1
