Ward 402

by Ronald J. Glasser

  It was almost eleven that night before I had everything on the ward enough under control to be able to return to the doctors’ station. I checked the temperature sheets and began writing a progress report in each chart. Even if there was nothing more to report than “doing well” or “no change,” if McMillan was still angry in the morning, seeing everything up to date would help to soothe him. Scrupulous attention to detail, he insisted, that was the crucial factor in being a good doctor.

  When I finished I called the paging operator to tell her I was going to the on-call room, checked the new admission to make sure the IV was still running well, and left the ward to try to get some rest.

  I don’t think I ever made it through a full night on call for 402 without being waked up at least twice; none of us did. For the most part it was just some little thing gone wrong, like an IV being pulled out, a child spiking a temperature, somebody throwing up, or a morning pre-op order that hadn’t been signed. But it could just as well be a true emergency, and then it wasn’t merely a case of getting up, going to the ward for a few minutes, and getting back to bed. It meant working the rest of the night.

  There wasn’t much point in getting undressed. You just lay down on top of the bed, half-asleep and half-awake, waiting for the phone to ring. If you did manage to fall asleep it was always a fitful kind of thing, easily shattered, and in the morning you woke up almost as tired as you were when you lay down. Inevitably you became a bit hardened and discriminating about what you would get up for and what you wouldn’t, no matter how serious the nurse who called you seemed to think the situation was. With sleep a priority you learned that even in medicine there were things that mattered and things that could wait. You had to be careful though. If someone’s worried enough to call, McMillan said, it’s important enough to get up and check. Most of the interns and even some of the residents thought he was crazy to insist on this but in the main he was right. When you checked you usually found things a little worse than you’d thought.

  The phone rang about three in the morning. I had fallen asleep without turning off the light and I woke with the overhead bulb burning in my eyes.

  It was McMillan. “Sorry,” he said. “We’ve got a new admission.”

  “OK, OK,” I mumbled, sitting up and rubbing my eyes.

  “What is it?”

  “A leukemic.”

  “How old?”

  “Eleven.”

  “Bleeding?” Holding the phone to my ear with one hand, with the other I groped under the bed for my shoes.

  “No, she’s not bleeding,” McMillan said.

  “Fever?”

  “No.”

  “What admission for her?”

  I could feel McMillan hesitate. “First,” he said.

  “What the!—” I couldn’t believe it. “Did you say first?”

  “Yes, first,” he repeated, almost apologetically.

  “Wait a minute, man,” I said. “It’s three in the morning. I’ve been working every other night for almost five weeks. I mean I’m tired. She’s not infected, she’s not bleeding, this is her first admission. Why the hell couldn’t it wait six more hours?”

  “Prader wants her admitted tonight.”

  “But why?”

  “He just wants it that way.”

  “That’s because he’s in bed.”

  “I’ll have coffee for you,” McMillan said to mollify me.

  “I don’t want any coffee, damn it!” I said and slammed down the receiver.

  I walked down the corridor feeling abused. A brand new leukemic. There was no sense bringing her in at three in the morning, even if Prader was head of hematology. She wasn’t bleeding and she wasn’t infected; there was nothing we would be doing at this hour that couldn’t wait until morning. Five or six hours more wouldn’t mean a damn thing. I was sore, my stomach felt queasy, and every step I took down that empty corridor made me angrier.

  I pushed open the first of the ward’s double doors. The ceiling lights were off and the night lights gave barely enough illumination to see across the tiled floor. McMillan was waiting just inside the second door and I almost ran into him. Right off I began complaining when something in his face stopped me.

  “Something wrong?” I asked.

  “No—not really,” he said, pushing his hand through his mop of black hair. “It’s just—she’s really bad. How many leukemics have you taken care of?”

  “Three. Why?”

  “This is my eleventh. They’re all dead,” he said softly. “Every one of them.”

  It was hardly a surprise to me. There was something else on McMillan’s mind, behind what he was saying.

  The lights near the nurses’ station had been turned on, and now I saw a man and woman standing by the desk, looking in our direction.

  “Her parents,” McMillan said. “She’s in the treatment room. Name’s Mary—Mary Berquam. You want to do the physical, or take the history first?”

  “If she’s sick enough to be admitted at three in the morning, she’s sick enough to be examined first.” I let my voice carry so the parents would hear, and know how annoyed I was.

  The treatment room was always bright, but after the muted night lighting on the ward the banks of overhead lamps were dazzling. On the table, barely filling half its length, lay a little girl in her nightgown, her eyes closed, her skin the same lifeless color as the sheet she was lying on.

  Barbara was standing by the cabinets, setting up the examining tray.

  “Is this the new admission?” I asked.

  “That’s her,” she said. “That’s Mary.”

  I looked more closely at the child, at her wasted, exhausted body, and noted the obvious effort it was for her even to breathe.

  “Are you sure?” I said. “This is supposed to be a first admission.”

  “That’s her. Like I said.”

  “But she looks like she’s been sick for months.”

  “She has been.”

  “But—”

  Barbara shook her head. “Ask her parents,” she said sharply. “The tray’s ready. I’ll be in the drug room if you need me.”

  “Hold it—”

  But she was already out the door. I pushed the tray over to the table.

  “Mary,” I whispered. The child hadn’t moved since I came into the room. “Mary.”

  She turned her head slightly and opened her eyes. She looked so ill, her eyes were so dull and lifeless, I thought surely McMillan must have been mistaken about her never having been admitted before.

  “I’m your doctor,” I said. “I’m going to examine you. It’s not going to hurt. Honest. I just want to listen to your heart and feel your tummy.”

  As weak as she was she still tried to help, bending her arms when she thought she had to, even trying to sit up when I wanted to listen to her chest.

  “No, no,” I said. “It’s OK, honey. Just rest there. I can listen without your moving.”

  She was so obviously uncomfortable I examined her without taking off her gown to avoid any unnecessary movement. Her lungs were clear, her pulses full; her heart sounds, while loud because of her thin chest wall, were normal. I pressed as lightly as I could to feel her stomach, but even that made her grimace. Her liver and spleen literally filled her whole abdomen; I was astonished how big they were. It was impossible to believe that any doctor would let her get that sick without treating her. Surely, I thought, she must have been seen and admitted somewhere before.

  “OK, Mary,” I said. “Just a blood pressure and we’re done.”

  But she had already sunk back into her state of exhausted lethargy. Wrapping the cuff around her arm I began inflating the balloon. As the column of mercury slowly rose in the manometer she groaned. I took the reading and began to unwrap the cuff. It had become stuck and I had to give it a slight tug to pull it off. Without warning, without even opening her eyes, she screamed. I was startled, unnerved.

  “I’m sorry,” I said quickly. “I didn’t—” and sto
pped, with the sudden realization that she had screamed in her sleep.

  Carefully I removed the rest of the cuff. Her arm was so thin I could feel the bone right under the skin. Though I pressed lightly her face flooded with pain.

  “My God!” I said to myself as I left the room to find McMillan.

  No one was in the hallway. The nurses’ station was empty. I went to the admissions area but nobody was there either. Then I saw McMillan’s tall figure coming toward me down the corridor from the little-used conference room. I started to tell him he must have been mistaken about this being Mary’s first admission when he stopped me with a question.

  “How is she?”

  “Sick,” I said.

  He nodded grimly.

  “Not only is she exhausted, wasted, anemic, but she has bone pain. I mean real bone pain. She’s been sick a long time.”

  “I know,” he muttered. “I know.”

  “She must have been treated some place. She had to be. It’s been months at least. The leukemia’s all over her body. Her liver and spleen are gigantic. It’s in her bones. You sure you got the history right?”

  He was about to say something when the hematology technician came off the elevator.

  “She’s in the treatment room,” I said. “I’ll fill out the lab slips later. Just get a smear, white count, and hematocrit now.”

  I looked at McMillan and thought he was nodding in agreement, though he seemed so preoccupied I wondered if he had even heard me.

  “Bone marrow?” the technician asked.

  “Yes, might as well. We’ll—”

  “No,” McMillan said.

  I began to protest.

  “No,” McMillan said again, more determinedly.

  “Look,” I said, “I don’t care when we do it, but that bone marrow is going to have to be done. She’s sick and she’s not going to get any better—if she can get better—until we treat her, and before we can treat her we’ll need a bone marrow. We’re up now, the technician is willing to do it, the patient’s already in the treatment room—”

  I saw I wasn’t getting through to him. “OK,” I said to the technician, who was standing by, “Just the smear, white count, and hematocrit.”

  As she turned to leave I caught sight of Mary’s parents standing in the doorway of the conference room. I had the feeling the Berquams had been standing there in the shadow watching us all the time we were talking. Now the father approached us.

  “Doctor!” he said angrily, blocking the technician’s path.

  “Stay here,” McMillan told me, and went to speak to Berquam.

  I couldn’t hear what they were saying but they were plainly arguing. From the conference room came the sound of Mary’s mother sobbing. Berquam kept shaking his head obstinately, while McMillan as obstinately kept talking.

  “What about it?” the technician said. “I’ve got other work to do.”

  “Go on,” I said. “Just get a sample.”

  “You sure?”

  “Go. Just do it,” I said impatiently. I had no time for goofy parents. Come the morning, we’d need that smear and white count or Prader would be all over my ass and McMillan’s, too, but mostly mine.

  Berquam stared angrily at the technician but let her go by. He listened a while longer to what McMillan was saying and, still shaking his head, he said no! loud enough for me to hear him.

  I heard McMillan say something about at least giving her a chance, but Berquam merely shrugged it off. For a moment I thought Berquam looked more amused than angry, although amused is hardly the right word. Contemptuous is more like it.

  4

  I HAD DEALT WITH parents of leukemics before, not as many as McMillan, certainly, but enough to feel that they all behaved about the same. They tried to be helpful, were aware of our efforts and duly appreciative of what we were doing. Even through the last few admissions they acted as if everything was going along alright, and death was not a certainty—only to fall apart at the end and cry so bitterly, when we came to tell them their child was dead, that we could not help wondering if they had ever realized their children were mortally ill. Yet they continued to act deferential towards us, and even contrite.

  Berquam was different. He wasn’t listening to McMillan, much less agreeing with him; he wasn’t asking, he was telling. McMillan was cool, waiting for his chance to say something, then trying again, but it was plain he wasn’t getting anywhere. For a moment I thought of trying to help, but then I decided to keep out of the argument, it would probably only make things worse. Anyway, no matter what happened, Mary still had to be taken care of, a chart had to be made up and the lab work signed for; a complete physical still had to be completed, orders written, and a problem list made out.

  Somebody had to do all this and I was the one. A resident like McMillan had time to argue, and Prader and the other professors sitting at home or in their labs had time to decide when to admit or when not to admit, but that was because there were others to do the work that had to be done. Like that smear and white count. In the morning I would be the one who was responsible for anything medical that hadn’t been done.

  I found Barbara in the back, near the narcotics cabinet, drawing up the four A.M. medications. I asked her if she could get Mary into a room.

  “Why not?” she said, without looking up.

  “You sore about something?” I asked.

  “No, it’s just that every now and then a parent—”

  “Or parents.”

  “Yeah, parents.” Barbara sounded disgusted. “Anyway, I’ll get her into a bed.”

  As I walked back to the doctors’ station I noticed that Berquam and McMillan were still at it. Exhausted, with that sick rubbery feeling of having been up too long coming over me, I sank into a chair. It was too late to think of going back to sleep, so I pulled a new chart out of the rack, put my feet on the desk and began writing Mary’s work-up. If it had been earlier I would merely have written a quick admissions note and the orders, and finished the work-up the next morning before blood rounds, but now I thought I might just as well get the whole thing over and done with while I was at it.

  Leaving the first page open for McMillan’s history, I began the second page with Mary’s physical examination: the huge liver and spleen, the bone pain, the generalized wasting away, the large lymph nodes, the way she had tried to help, her pale mucous membranes and anemic skin. At the bottom of the page I scribbled my impressions—“acute lymphocytic leukemia”—then turned to the orange order-sheet. For the most part the orders were routine: vital signs every two hours for the first day; diet as tolerated; weight every day; chest film, urinalysis, and urine culture. After the order for the white count, smear, and differential, I wrote “done,” so the nurses wouldn’t make the technician come back up again. Under medications I left the space blank, and signed both sheets.

  The medications would be a problem. They always were. We had protocols for new leukemics. Once the diagnosis was made and the base-line blood studies drawn, the patient was put under one of four different treatment regimes which were selected at random. The protocols were as much a matter of research as they were of treatment, although in truth the only thing that leukemic research had bought, with its new techniques and its ever increasing armamentarium of stronger and stronger drugs, was time.

  Nobody really knew which combination of drugs, or in what dosages and what order, gave the best results. Under a national program, Prader and other hematology professors across the country had set up the protocols to find out. Some of the combinations were tough on the kids, for a time making them sicker than they were with their leukemia. But, as Prader said, there was no choice. No one yet knew what treatment regime was best, and if a few weeks of severe iatrogenic illness for the patient advanced our knowledge, proved us right, or meant a longer remission, that was the price that had to be paid. Prader was pretty hard-nosed about it. He was hard-nosed about everything, but staying with the protocols was his first priority. “Stick w
ith the study,” he demanded. “No matter how you may feel about it, there’s no other way to get the information.”

  If I’d heard him say it once I must have heard him say it a dozen times. That was another reason I was so annoyed when McMillan told me that Prader had instructed Mary’s parents to bring the child in at such an unlikely hour. We wouldn’t be able to put her on the protocol study until morning anyway; the protocol cards and treatment numbers were unavailable at night. To keep things from getting fouled up Prader kept them locked in his lab. For that matter, treatment of a newly-diagnosed leukemic had never been an emergency that couldn’t wait a few hours.

  So I left the medication space blank and was going into the problem list on the next page when Barbara walked in.

  “The lab tech sent this up,” she said, handing me a slide. “She’s rechecking the white cell count. She said the differential will take a while yet.”

  “Thanks,” I said. “If anyone wants me I’ll be in the back looking at this.”

  It didn’t take a hematologist to read that slide. It was all there, brilliantly stained for anyone to see. The whole microscopic field was filled edge to edge with wild misshapen cells. I moved the slide to look at another field. It was the same; I flipped the objective to a higher magnification so I could focus on the cells themselves.

  At a 400 magnification a single white cell just about fills a whole microscopic field. I expected to see something text-bookish, like the photomicrographs in the hematology journals. Not these. They were the worst I had ever seen. All the subcellular order was gone. The nucleus, stained a crazy, almost shocking blue, was twisted around, rolling in and over on itself. What should have been a homogeneously highly-stained cytoplasm was green and ugly, filled with holes and great clumps of blackish-purple material.