I looked at another cell. It was the same, perhaps even more grotesque. There was something else that bothered me, something beyond the cellular disorder, and when I switched to still another cell I felt even more strongly there was something important here that I should recognize. It was obviously leukemia, but still—
I had made it a habit to look at all the slides I ordered. I was the only intern who did it regularly. Studying the slides was considered technicians’ work. Indeed, there were those on the house staff who admitted they felt it was a waste of their talents and time to read lab tests. But it seemed to me that with so much of medicine based on laboratory results they were too important to be left to technicians. It took time, but it gave me a sense of what I was up against. Diseases happen on a cellular and subcellular level and I felt better armed when I could see what I was up against. It also made me a kind of expert on blood smears; if any of the other interns got screwy lab results, instead of going to their residents they would use me as an informal consultant.
This one, though, puzzled me. There was something different about it, something I hadn’t seen in other smears, something beyond the cellular disorganization. I was still struggling with the question when McMillan came up behind me.
“What’s wrong?” he asked.
“Take a look,” I said. “It’s from the new admission.”
“Later.”
“Well, anyway, with treatment we can give her at least, I guess, one remission.”
McMillan shook his head.
“What do you mean, no?” I said.
“They don’t want us to treat her.”
“Then why the hell did they bring her here at three in the morning?”
“To die,” McMillan said.
“Hell, they all die. Just like you said. There’s nothing new in that.”
“Yes, I know,” he said wearily. “The point is, they want her to die. They want her to die now.”
The shocking thing, I suppose, is that I wasn’t shocked. We all had our share of difficult parents. With so many children admitted, we were bound to get a few parents who were difficult, but they were never really a problem. A hospital is an imposing place—intimidating is perhaps a better word. Eventually its crisp definitive routines assert authority and even the most hostile parent ends up doing what we want or at least staying out of the way. I couldn’t see why McMillan was so worried.
“Want me to talk to them?” I asked.
He shook his head.
“Sure?”
“No, it’s—”
“Well in that case, let’s get done. The diagnosis is probably lymphocytic leukemia. At least that’s what the smear looks like. No matter what protocol we use, we can probably give her at least—You listening?”
He nodded his head vaguely, his mind obviously on other things.
“You don’t think we can give her one remission?”
“Oh, I suppose we can.”
“Suppose! Jesus! You’re not letting her parents get to you, are you?”
“It’s not a matter of letting them.”
“Why? What can they do?”
“They can keep us from treating her.”
“How?”
“Knowledge,” McMillan said. “Right now her father knows as much about leukemia as you do. Everything. Everything there is to know.”
“He’s not a doctor is he? I mean, Prader would have told us that.”
“No, just the chief tech, head of the hematology lab at Masonic Hospital.”
“Oh.”
“Yeah, oh,” McMillan said glumly.
“What did you say to him?” I asked.
We had had no formal lectures on dealing with parents. Each of us was on his own, and as far as I could see McMillan was one of the best. I’d seen him obtain autopsy permissions when the professors had failed, and I’d heard he had never had a procedure denied or for that matter even questioned. If I wanted to be as successful with parents I had to learn how, and the only way was to watch how others did it and understand their mistakes. If McMillan had screwed up I wanted to know why, even if I had to push him, because it was plain he didn’t want to talk now. But I had learned during my internship that either you found the answers to your concerns as they came up, or the next day they’d be buried and forgotten under a whole new set of concerns.
“Any coffee around?” McMillan said.
I followed him down the corridor to the kitchen. There was a half-filled kettle on the stove. He turned on the burner and I found some instant coffee in one of the cupboards.
“So what did you say?” I asked again.
“The usual—there are drugs to hold her disease in check and more medications being developed every day; there will be weeks, maybe months, when she’ll feel and look normal.” He spooned some coffee into the cups. “You know, the usual line about the medications we have now not being able to cure her but still buying time, so that hopefully in the interval a cure might be found or at least more potent drugs. Meanwhile, we would keep her comfortable. The usual thing.”
“And he didn’t buy it.”
“Oh,” McMillan shrugged, “he’s for keeping her comfortable alright.”
“But?—”
“Not for keeping her alive.”
“Some father! Jesus!”
The water began to boil, and McMillan busied himself filling the cups.
“She’s going to die in any case,” I said. “I mean, why let it get to you?”
At the time, I thought I meant it. I had sat through enough conferences on kids with malignant tumors, massive congenital defects, and degenerative neurological diseases—conferences called to see what could be done about additional correctable defects like pyloric stenosis or ureteral reflux—to know that no matter what was decided the doomed were going to die.
“After all,” I said, “I mean it’s their kid.”
McMillan handed me the steaming cup, but his hand shook and some of the coffee spilled on my pants.
“Oh, for Chrissake,” I swore, “what’s the matter with you?”
“We’ll talk about it in the morning,” McMillan said. And when I started to object, he added coldly, “I said in the morning.”
When I returned to the ward I was surprised to learn the Berquams were still around, in the conference room.
Barbara was in the nurses’ station, charting. “They’re waiting for you,” she said.
“Oh shit,” I said. “Not at this hour.”
“You know Dr. Prader’s procedure. Parents are to stay on the ward until the intern takes a history.”
“That’s during the day,” I said. “In case you haven’t noticed it’s five o’clock in the morning.”
5
BEFORE I LEFT THE ward to go back to the on-call room, I checked the IV on the child McMillan had admitted earlier and then out of habit or compulsiveness looked in quickly on Mary. I didn’t bother waking her, just watched her breathing, and checked the vital-signs chart pasted on the wall above her bed. Her heart rate, respirations, and temperature ran in three straight lines across the chart—no dips, no peaks. She didn’t move and when I looked closer, it seemed as if she was hardly breathing. I think now that I should have tried to wake her—but it was late and I told myself I really wanted to let her rest a while.
It was almost six by the time I got back to the interns’ room and into the shower. Hopefully the shower would keep me going until after morning rounds and from then on coffee and knowing I’d be able to sleep that night would get me through the rest of the day. After I had bathed, I lay down.
I must have fallen asleep because the next thing I knew the phone was ringing.
Mary was in trouble.
“What are her vital signs doing,” I said. I was getting dressed even while the nurse was checking. I didn’t run back to the ward. I had done that earlier in the year—the new intern racing down the hallway to save a life—but all I’d accomplished was getting to the ward out of breath and nauseat
ed. So I walked quickly—but I walked. With seizures you have time.
All the lights were on in the ward and McMillan without his lab coat, his shirt sleeves rolled up, was coming out of Mary’s room. “I stopped them,” he said before I could ask. The orderly was rolling the emergency cart past him into the room.
“What lab tests have you got on her?” he asked.
“Just a smear and urinalysis.”
“Better get a blood culture. Did you order any electrolytes?”
I shook my head.
“Better draw some now—Barbara’s setting up for a spinal tap.”
“Meningitis?”
“No—I don’t think so—she doesn’t have a fever—probably’s leukemic infiltrates in her brain. It could be meningitis, though. Better start an IV too, just in case.”
The RN float, who’d come up to the ward to help, stuck her head out of Mary’s room. “She’s seizing again.”
McMillan looked at me. There was a moment of hesitation, then we both hurried into the room. The huge overhead lights were on. The curtain that usually separated the bed from the rest of the room was pulled back. Mary lay naked on her back in the middle of the bed, her body rigid and trembling.
Even as we watched, she seemed to contract for a moment, and then with a visible shudder, her eyes widening, she stretched full length, her head and feet pressing downward into the bed so that her back lifted off the frame. Her body arched higher and higher until it seemed as if her spine must break. Foam welled from her mouth. Then she shrieked and collapsed back onto the bed. McMillan took a vial of Amytal off the cart, cracked it open and drew it into a syringe. Meanwhile, I’d already found a vein and using my hand as a tourniquet held her arm steady as he jabbed the needle into her arm up into her vein, then pushed the plunger carefully a quarter way down the barrel. Even while the medicine was flooding her body I felt her arm begin to twitch. I tightened my grip. We were both leaning over her, our heads almost touching as McMillan injected a few more cc’s.
“She’s going again,” I cautioned.
“That’s almost sixty milligrams,” he said.
I was having trouble keeping her arm down while he injected more of the medication. It was no use. She was going.
“Paraldehyde,” McMillan called to the nurse as he pulled the needle out of Mary’s arm.
We gave her the paraldehyde rectally; all of it, over ten cc’s. She was half way into her seizure by the time we got the tube into her rectum, but it worked. With the room reeking with the pungent odor of paraldehyde, she suddenly relaxed and slumped back against the bed.
McMillan put the syringe back on the tray.
“Better do the tap now while she’s quiet.”
“You sure?” I asked. She didn’t look very good to me.
“Do you know how much medication she’s taken? Half of it would be enough to stop a horse from seizing. There’s something going on in her head.”
We just dumped everything—the used syringes, IV tubing, cotton balls, empty vials—onto the floor, and broke open the spinal tap tray. The nurse straightened the bed as best she could and then with McMillan she turned Mary on her side with her back towards me. I sterilized her back with alcohol and did the tap. It went smoothly. As wasted as she was, there was no trouble finding the right intravertebral space. The needle slipped easily between her vertebrae into her spinal canal.
The spinal fluid began flowing smoothly out of the end of the needle. I would have taken off more fluid but it looked like she was beginning another seizure, so I pulled out the needle.
When they let go, her body twitched again, but it stopped short of a seizure.
McMillan was rolling down his sleeves. He shook his head as he looked compassionately at the stricken child.
“What’s her smear like?” he said.
“OK,” I said. “There are some bad-looking cells, though.”
The main lab was down two floors. The night technician was not around so I set up the spinal sample myself. There are a number of tests that are routinely done on all spinal fluid samples, but the important one was the bacterial stain. I divided the sample of spinal fluid and put one part away for the sugar, protein, and culture determinations; the rest I smeared on a slide to look at under the scope. It takes three minutes for the dye to take; when it had set long enough I took the slide off the staining rack and, using the distilled water over the sink, carefully washed off the excess color. Then clipping the slide into the frame I looked through the lens and cranked the slide into focus. I could make out the grains of dye fixed to some dirt that had stayed on the slide, but no bacteria. I checked another field, and then another—and then quickly scanned the whole slide. Her spinal fluid was negative for microorganisms. Even those one or two white cells that might or might not have been considered as part of the normal fluid were absent.
McMillan wasn’t often wrong; when he told you to look for something it was usually there. I went over to the reagent shelf, took down the bottle marked bromosulfophthalein, and picked up the second part of the spinal sample. I was taking a chance screwing up the culture, but with no bacteria on the smear and no white cells it was hard to believe that the fluid would grow out any organisms. If there were cells that for some reason I’d missed there would have to be protein too—abnormal amounts. So I measured out four cc’s of the bromosulfophthalein and, opening the sample of spinal fluid, poured it in. If there was any protein the bromosulfophthalein would precipitate it out of solution. For a moment the two fluids mixed and then dissolved one into the other, but nothing came of it. I held the sample up to the light; there were no particles settling out—not even a hint of precipitate. That amount of reagent would have precipitated out any protein in the fluid, even trace amounts. The spinal fluid was normal—there was nothing there: no cells; no protein; nothing.
While I was shaking the tube and holding it up to the light, the technician walked in. She carried her own samples to the work bench.
“That’s spinal tap fluid—or what’s left of it,” I said.
“It’s opened,” she said. “We wouldn’t be able to culture it.”
“I know. Just do a sugar on it.”
“Who’s it on?” she asked.
“The new leukemic.”
“Oh! I’m sorry, I haven’t done the white count yet. I’ll do it now.”
“Don’t hurry. We won’t need it till morning rounds.”
“Was that man who stopped me her father?”
“Yes. He was just upset. He’ll be alright in a couple of days.”
As I climbed the two flights of stairs back to the ward, through the windows I could see the dawn lightening the sky. I found McMillan sitting on the desk in the nurses’ station, the phone balanced on his shoulder. Down the corridor the light in Mary’s room was still on.
“Nothing,” I said.
“But there must be cells.”
Holding up his hand, he stopped me from talking. “OK, OK, OK,” he said. Shaking his head he hung up the phone. “You sure about the smear?”
“Yeah.”
“How much fluid?”
“About two or three cc’s.”
“Did you use the new stain?”
“I used the one that was there.”
“I don’t know,” he said. “She’s still seizing.”
“What about her electrolytes?”
“Normal—that’s what I was on the phone about. I’ve given her just about the whole damn pharmacy. Hell, this doesn’t even happen with brain tumors.” He frowned. “Where’s the stain on her spinal fluid?”
“Down in the lab. It’s negative.”
“Could you get it?”
“Look,” I said, “I know how to make stains.”
“I’d like to see it myself,” McMillan said.
“That’s not going to change anything. Looking at it up here won’t make it positive.”
“I know,” he said impatiently. “I just want to see it.”
I felt p
retty sore about McMillan’s questioning my competence. He could really get to you at times. For a moment, on my way down to get the smear, I thought of going back to tell him if he was so damned worried he’d better do everything himself, maybe call a neurologist—or Prader, for that matter.
Of course I didn’t. Not because I was afraid to set him off, but because I knew he wanted to make sure; I was that way myself. Besides, Prader would probably ask him if he’d looked at the stain; at the very minimum he would demand a differential diagnosis of what could be wrong.
There was a small library next to the lab. It wasn’t much of a library—no journals, just a few reading desks and a couple of shelves of books. I picked two of the newer textbooks of pediatrics, and opening them to the chapters on neurology, quickly ran down their lists of convulsive disorders. In both texts the lists ran to over a page and a half, but all the items fitted somewhere under the six usual pathological classes: poisons, tumors, congenital malformations, vascular disorders, infections, or metabolic defects—we’d screened for all of them. In one way or another the blood and urine tests we’d ordered, and the spinal tap I’d done, covered every class. If there was something making her seize, it wasn’t in those lists.
I got the stain from the lab and took it back upstairs to McMillan.
He was writing down more lab results. “Did she look dehydrated to you?” he asked as I handed him the stain.
“A little, but more wasted than dry.”
“Well, she can’t concentrate her urine. The lab just called with her urinalysis report. The specific gravity on her sample is low. If she was dehydrated she’d be concentrating her urine—trying to conserve water.”
Bothered, McMillan took the stain over to the microscope.
“Is this Mary’s peripheral smear?” he asked. “This slide already on the scope?”
“It’s the one I looked at earlier,” I said. “I guess I left it here.”
He sat down and looked at it. “Did you look closely?” he said, adjusting the fine focus.
Ward 402 Page 3
