Ward 402

by Ronald J. Glasser

  “Yeah, remember? I’m the one who told you it was lymphocytic leukemia.”

  He switched to another field. “How closely did you look?”

  “I looked at it closely enough to make a diagnosis. Want me to tell you what it looks like cell by cell? The cytoplasm is a dark grainy—”

  “It’s not the individual cells,” McMillan said. “Here, take a look.”

  “I did, damn it,” I said. I was too tired to be pushed.

  “Then look again,” he said, and when I made no move, “Look, will you!”

  It was the same smear I had looked at before.

  “Well?”

  “Cells,” I shrugged. “Lymphocytic leukemic cells.”

  “How many?”

  “A lot.”

  “They’re packed,” McMillan said. “Not just a lot. There aren’t even any spaces between them. It’s just one solid sheet of leukemic cells.”

  I looked back into the scope. He was right. Absolutely right.

  “Jesus!” I felt my confidence in my own ability, so hard won, suddenly dissolving right there in front of me. I had missed the main thing. I had fixed on the individual cells and ignored the overall picture. After nine months of internship, to misread a simple blood smear!

  “Her white count must be over three hundred thousand, maybe even half a million,” McMillan said gravely. “She’s suffocating inside out. All those white cells are sticking together, blocking up her smaller arteries, stopping the blood flow to all her organs. That’s why she’s seizing. The problem’s not in her brain but in the capillaries that feed it. That’s why her kidneys can’t concentrate her urine. They’re not getting enough oxygen. Her bone pain—Everything’s affected.”

  “I’m sorry,” I said. “I really am.”

  McMillan wasn’t interested in my apologies. “It’s called a blastic crisis,” he continued. “For some reason the body just unloads billions of leukemic cells into the circulation. It’s rare, but it happens.”

  “I should have picked it up, though,” I said apologetically, “It’s right there on the slide, for God’s sake. A medical student could—”

  “It’s over,” McMillan said. “It could have happened to anyone.”

  I shook my head in disagreement.

  “Now you know,” he continued, “you won’t make that mistake again. Right? OK,” he said dismissing it, “so what should we do now?”

  I was still so disturbed by what I had done, or rather hadn’t done, I could hardly think let alone talk.

  “Come on,” McMillan said impatiently.

  “Get rid of the cells, I guess, and open up the vessels.”

  “What would you use?”

  “Prednisone.”

  “And what else?” He waited, and when no answer was forthcoming, he added, “Allopurinol. Do we have any here on the ward?”

  I was still so awash in self-criticism and embarrassment, it took a while for what he’d said to seep in. Then it hit me.

  “Wait a minute,” I said. “You going to do it?”

  “That’s right.”

  “But that’s the same as treating her leukemia. I thought you said her parents didn’t want her treated.”

  “I’m treating her seizures,” McMillan said calmly.

  “But treating her seizures in this case is the same as treating her leukemia. I mean it’s all the same. You’re going to open up her vessels by destroying all the abnormal leukemic cells. That sounds like the same thing to me.”

  “If she came in bleeding we’d give her blood, wouldn’t we?”

  “Sure. We feed kids with leukemia and give them water to drink. But that’s not treating them.”

  “This is an emergency,” McMillan said, with a touch of impatience in his voice. “If we don’t open her vessels she may not have a brain left when we get her into remission.”

  “OK, OK, I’m convinced. But what about Prader? Prednisone’s on every protocol. If you use it tonight differently than the schedules say—well, he’s not going to like it.”

  “He’s up in the lab and we’re down here.”

  “You’re the boss,” I said. “But he’s still not going to be happy.”

  I wasn’t too happy about it myself. Even when things were going well Prader was tough; when they weren’t, he could be impossible. There were times when his moods affected his responses, so that what was worth a twenty minute harangue one day might be handled with a simple discussion the next. Then, too, there were times when he seemed merely capricious, as when he insisted on having a white cell count on one patient repeated, while the week before he’d let it go on a patient with exactly the same illness. Or he could get angry with you for not having all the red blood cell indices ready when you were treating a patient with iron deficiency anemia when the day before he’d lectured that in most cases of this type of anemia the smear itself was enough for the diagnosis.

  All of which made things a bit more nervous and difficult, because you never knew for sure which way Prader was going to jump. There was no doubt in my mind, though, about how Prader would react to McMillan’s treatment of the new patient. He wouldn’t like it at all. McMillan might at least have called him, and I think at the time I assumed he had. It was only later I realized he hadn’t.

  The prednisone we gave Mary destroyed the billions of leukemic cells clogging her vessels, but that didn’t mean we cured her disease, any more than stopping her seizures meant saving her life. If the treatment of leukemia is difficult, it is not because the individual leukemic cells are resistant to medications, but because the overall disease itself—the sheer mass of abnormal cells—obeys first order chemical kinetics. Concern and suffering aside, it is eventually the physics of cellular destruction that beats you. It is impossible to destroy every leukemic cell; no matter what drug you use, in what combination or over what period of time, there are always a few that escape.

  No one really knows why. In his lectures Prader attributed treatment failures to the fact that the medications never reached some of the more remote cells, those hidden away in the recesses of organs. Hematologists at other centers disagreed with him, holding that the first order kinetics was due not to sequestration of a few cells but to the development of some kind of cellular resistance to the drugs themselves. The only thing that everybody did agree on was that a few leukemic cells hidden away in some poorly perfused part of an organ, hiding in a capillary or venule, managed to escape destruction and, continuing to divide, eventually broke out again, repopulating the entire body with a whole new series of leukemic cells.

  McMillan knew this—he probably knew it better than any other resident in the hospital—but that didn’t stop him. He even drew up the medications himself.

  It took us over five minutes to inject all the prednisone, and then using the same vein, merely changing syringes, another five minutes to give Mary the allopurinol. Before we had quite finished she began twitching again.

  While we watched, helpless, having already done everything we could, the whole left side of her face started trembling. She was still unconscious, but her left eye and the corner of her mouth were twitching in a kind of grotesque wink. Then as suddenly as it had begun it faded away.

  “Well,” I said, relieved, “that’s one for our side.”

  “It’s a beginning anyway,” McMillan said, allowing himself the first smile I’d seen all night. “Come on, let’s get some more coffee.”

  In the cafeteria we milked the urn for the last two cups and took them over to the side of the room still set up for the night staff. Yawning, McMillan stirred some sugar in his cup but hardly took more than a sip.

  I was still fretting about that smear. McMillan said I’d never miss one again, but that was small comfort. I was too conditioned by the attitude fostered in medical school and nurtured there, that with all the machines and new techniques, with lab values read out to milligrams percent and X-rays that can show almost anything, there is no reason to make mistakes. I was beginning to see
that medicine was not that simple. Even if you knew what had to be done there were still the trade-offs, the morbidity from the treatments themselves, and these gray areas of when and how much. And then there was the business of putting it all together and holding on to it. I’d heard about blastic crisis, I’d read about it, I knew about it, but at 4:30 in the morning it simply had not registered.

  What do you do about things like that? Work harder? Read more? Ask more? Missing the smear might have been humbling if it had been acceptable. Well, I thought, at least my night on duty was almost over. True, there was still a whole day ahead, but with daylight at hand you can begin to think about the end of the thirty-six-hour stretch, and that makes it almost over.

  McMillan was stirring his coffee aimlessly, lost in thought.

  “Why don’t you clean up?” I said. “It will take a while to get all the bloods drawn before rounds.”

  “Very well,” he said. “I’ll be back up about quarter to eight.”

  He got up to go and I left soon after, when I had finished my coffee. You get a kind of second wind in the morning. No matter what happened during the night, no matter how tired or pushed you felt, or maybe even abused, it still buoyed you up to know that while others were sleeping you’d been working, doing what had to be done.

  II

  6

  THE DAY NURSES AND aides were already on the ward. Crowded into the nurses’ station they were taking reports from the night shift. Lang, in a clean set of whites was leaning against the wall, listening. When he saw me he left the nurses and followed me into the doctors’ area.

  “What’s with the new admission?” he asked.

  “Which one?” I said, fishing through the file cards for the name plates I needed to stamp out the morning lab slips.

  “The new leukemic.” He pointed toward the nurses. “They seem to be taking sides.”

  “What are you talking about?”

  “Didn’t McMillan treat a leukemic who was almost dead?”

  “She wasn’t almost dead,” I said defensively.

  “Well, did you treat her?”

  “Yeah, I guess so—In a way.”

  “What protocol did you use?”

  “We didn’t,” I said.

  “You didn’t!”

  “It was an emergency, for Chrissake. Besides, it won’t be hard to put her into the study. Every protocol has prednisone as one of the drugs.”

  “Sure,” Lang said skeptically, “but part of the study is how the drugs are given, and this hasn’t been Prader’s month for being kind to the house staff.”

  “Well, anyway, it’s done.”

  “Maybe, but I’m glad I wasn’t on last night.”

  “Let’s get going,” I said, “or we’ll never get all the bloods finished.”

  Even with everything going right on 402 it was still a struggle to get the bloods drawn on time. We drew daily lab tests on almost every patient on the ward. Despite the medical school emphasis on physical examination, and the lip service given physical diagnosis, that was the kind of medicine we practiced. When a patient coughed, we might listen to his chest but the demand was always for the X-ray results. On rounds, and in conferences, it was the smears and white counts that were discussed, the creatinine clearances, the BUNs, the alkaline phosphatases, phosphates, sodium, potassium, magnesium, specific gravities, sedimentation rates, complement levels, differentials, eosinophil counts, Comb’s tests, hapteglobins, PHs, acid-base balances, blood gases. We didn’t just order the tests to have them in the charts; they were what we focused on. We lived with their daily ups and downs, gearing our treatments, fears, and concerns to their fluctuations.

  “I don’t know how he feels; he can’t be better with a sed rate of over a hundred. … Push the steroids till the complement levels are normal. … Keep him on penicillin till the white count comes down. …”

  We watched the numbers. We used them to monitor our medications, confirm our impressions, or make us change our minds. An 8.1 instead of a 7.9 became more important than vomiting, diarrhea, or even pain. In what could have been a confusing world of symptoms and complaints the numbers pointed the way. They made our work precise and sometimes even unarguable. They kept us from ever really being surprised or thinking we could be. It was comforting to be able to say fifteen hundred instead of a thousand. And so each morning Lang and I, like interns everywhere, gathered the blood samples on which everything seemed to turn.

  If we could have split up to draw the bloods it would have been quicker, but there were so many small children on the ward we had to work together and help each other. Some of our patients—the cardiacs and birth defects—were so tiny we had no choice but to do jugular or femoral sticks to get the blood. Even starting fifteen or twenty minutes early we never would have finished on time without the help of Mrs. Gowan, the chief nurse. She usually got to us halfway through our blood drawings, when her own nurse’s report was over.

  Mrs. Gowan had been an RN before quitting to get married. She had raised her two kids past kindergarten and then, finding herself bored with housework, had come back. She was about twenty-eight, as smart as she was good-looking, and returning to work because she wanted to, not because she had to, gave her an independence and freedom that was refreshing, if at times hard to take. It was a struggle to run 402 properly, and if she felt pushed or that her nurses or aides were being abused she’d let you know. With all the problems of patient-load and inadequate staffing, she still managed with a minimum of fuss to keep it all together, pitching in herself whenever she felt her help was needed. She was so competent it was hard to remember she was only a year or two older than Lang or me, but that was all she was and it kept everything loose and open.

  When Mrs. Gowan joined us that morning we had just finished struggling with a three year old who had shrieked at the top of his lungs and fought us the whole time we were drawing his blood. Lang literally had to lay himself across the child to hold him steady, with the kid screaming the whole time almost directly into his ear, while I drew the blood. When we walked out my ears were tingling, and Lang could hardly hear.

  Mrs. Gowan was in the corridor, straightening up the top of the blood cart.

  “Could have used you in there,” Lang said, shaking his head to clear his ear.

  “You’ll get better at it,” she said.

  “It’s my ears I’m worried about.”

  “They’ll get better at it too.”

  Lang grinned. Mrs. Gowan was too pretty and feminine for him to accept her readily as the accomplished nurse she was. He considered himself a ladies’ man, and he was, but 402 had put a damper on his playing around. At the beginning of our six-weeks rotation he had tried to continue with everything he’d been doing on the other, less busy, wards—making day-time dates for coffee, visiting nurses on other wards, spending his nights off with his girl friends. It didn’t take more than the first week for him to realize that the demands of 402 were extreme; the time required to get everything done did not allow for anything but medicine. He took to making phone calls from the ward. “Just to keep things going,” he said with a wink, “till this rotation’s over.”

  I had my own concerns—a nurse I’d met just before I came on 402; we’d sort of agreed to put everything in abeyance for the six weeks I was on the ward. I didn’t think she liked the idea and I know I didn’t, though I did feel a bit righteous telling her how necessary it was if I was going to do 402 right. In truth, from what I’d heard about the ward I could see no other way, and as it turned out there really wasn’t. We did manage a few quick dinners together, but that was all. When things got extra rough I consoled myself with the thought that only a few more weeks and we’d be together again.

  At the beginning of our rotation Lang seemed a bit bemused by Mrs. Gowan’s efficiency, especially when she became angry enough to get on him to get things done. As the weeks passed his bemusement became a kind of flirtatiousness. Mrs. Gowan could handle it, but she was probably counting the numb
er of days Lang had left on 402 as much as he was.

  “Have you got to Johnny yet?” she asked now.

  “Who?” I said.

  “The child with dehydration who was admitted last night. On report Barbara said his IV was a little behind.”

  “How much behind?” Lang asked.

  “Hundred and fifty cc’s.”

  “That’s not much,” I offered. “It was a small needle.” Lang didn’t look convinced. “It’s OK,” I assured him. “He got enough.”

  We pushed the blood cart farther down the corridor, past the linen closet to the next set of rooms. Lang picked up a five cc syringe and said he’d get the dehydration himself.

  I didn’t argue about it. If he wanted his patient back he could have him. Technically the child was mine, but we still had three weeks to work together and it wasn’t worth making a fuss. 402 was hard enough as it was; to start letting egos get in our way would have made things intolerable.

  I picked up another syringe and went with Mrs. Gowan into the room across from Johnny’s. We came out before Lang was through with his patient. Mrs. Gowan held the sample tube while I emptied the syringe into it. I took the needle off the syringe and threw it into the discard box.

  “I suppose you heard,” I said, although I knew, of course that she must have learned what happened from the night staff’s report.

  When she made no sign of having heard my remark—she could be very tight-mouthed when she wanted to be—I asked her if she’d seen the new admission, and suggested we both go in to see the patient.

  We paused just inside the doorway. The window blind was down, but the morning sunlight angled in between the slats. Mary looked so wispy as she lay there on the bed not moving, her eyes closed, her drawn face delicately etched on the pillow. Tired as I was and hard-nosed as I thought I’d become, I simply had to stop and stare at this lovely little girl.

  “We’ll need a white count,” I said, breaking the spell.

  Back in the corridor again Mrs. Gowan said: “I’m told the parents didn’t want her treated.” She handed me the white-count tube. “They were quite definite about it, at least to the nursing staff.”