Ward 402

by Ronald J. Glasser

  “True,” I said.

  “But you did, anyway. And without the protocol.”

  “Correct.”

  “Did either you or Dr. McMillan contact the parents to let them know your plans, or what you were doing?”

  “No.” I put the tube in the sample rack.

  “Why not?”

  “Because it was an emergency.”

  By the time Lang and I had finished drawing the bloods McMillan was on the ward, going over the nurses’ report with Mrs. Gowan and reading the problem sheet. When we had labeled the last sample, she took the blood tray off the cart and, letting the three of us alone to begin work rounds, took the samples into the nurses’ station to separate them for the various labs.

  Morning rounds with McMillan were really work. Some of the other residents, indeed most of them, used the rounds just to keep themselves up to date, so all we had to do was tell them what was going on with the patients. Or they used them as a way of showing off by getting into long tortuous monologues about most anything from urine cultures to the Heavy Chain diseases. McMillan kept his rounds patient-oriented. What were we doing to find the diagnosis? What had gone wrong the day before? What could go wrong? What were our plans for the day? What complications did we expect? These were his concerns, and we had to be thinking the whole time. When he had to, he’d dwell on a point, but discussions that would have taken longer than a few minutes he left for later, or for the scheduled conferences. We were there to make sure the day would go right, that was what the mornings were for, and he insisted they be used that way. If at times our rounds dragged a bit it was because he also insisted upon seeing every sick patient and reexamining them himself, even if it was the tenth morning in a row. For the most part, though, the rounds were quick and helpful—to Lang and me as well as to the patients.

  This morning the ward was pretty much under control and we moved through the patients quickly. McMillan cautioned us about the complications from a few of the drugs we had ordered, talking about hypertonic dehydration when we got to Johnny, and recommended additional lab tests on some of our more difficult diagnostic cases. As we went along he kept adding to his own records, mostly concerns about what he thought were deficiencies in nursing care, which Mrs. Gowan was usually able to explain away when she joined us. She asked if he was still planning the bone marrow on Mary we’d ordered the night before and he said he was.

  “Have you got permission?” she said.

  “No.”

  “Don’t you think you should?”

  “It’s not a surgical procedure.”

  “I know, but don’t you think in this case?—”

  McMillan shrugged off the suggestion. “It’s a routine procedure.”

  “It could be helpful,” Mrs. Gowan said, “during report—”

  “Look,” McMillan interrupted, “there’s no need for a consent.”

  She seemed surprised at his abruptness. It wasn’t like him to ignore procedures.

  “Maybe not in the formal medical-legal sense,” she said. “But these are concerned and difficult parents, and no matter what you may think, my nurses are going to have to deal with them.”

  “We’ll all have to.”

  “Then don’t you think it would help to start off right?”

  “OK,” McMillan said. “We’ll get you one.”

  “It’s not for me,” Mrs. Gowan said.

  We were down at the far end of the corridor discussing that morning’s last patient when Mary’s father came on the ward. Lang and Mrs. Gowan were facing the other way and McMillan simply didn’t see him. I just happened to look up as he was opening the door to his daughter’s room. A moment later he was back in the doorway, searching up and down the corridor until he caught sight of us. He was livid.

  “Doctor!” he barked.

  Startled, McMillan looked in his direction and Mrs. Gowan and Lang turned to see Berquam charging toward us. An aide who at that moment was stepping out of a room, carrying a specimen, bumped into him and he pushed her out of his way so roughly the tube fell from her hand. Leaving the spilled specimen where it had fallen she started after him angrily, only to be stopped by McMillan.

  “It’s alright,” he said, keeping between them. “It’s alright.”

  “Son-of-a-bitch,” she swore. “I’ll—”

  “What the hell’s the meaning of that IV?” Berquam demanded.

  “It’s alright,” McMillan assured the aide again, ignoring Berquam’s question. “It’ll be taken care of. Just go on with what you were doing.”

  Reluctantly, still glaring past McMillan at Berquam, she moved to go.

  “What the hell’s the meaning of that IV?” he demanded again, his voice strident with anger.

  McMillan waited until the aide was some distance away before he turned around to face Berquam. “This is not the place to discuss your daughter’s condition,” he said. “Nor to knock people around.” And when Berquam was about to protest, “Not here,” he warned. “If you want to talk, I’ll talk with you in the conference room.”

  Berquam had no choice but to follow McMillan down the corridor. He slammed the door shut behind them.

  “Jesus!” Lang said.

  “Was that Mr. Berquam?” Mrs. Gowan asked.

  “Who?” said Lang.

  “The father of the new leukemic,” I said.

  “The one you treated?”

  “Yeah. Mr. Berquam in person.”

  “Christ! He’s nuts—Is that the guy you were worried about?” Lang asked Mrs. Gowan.

  She flushed. “I believe you are referring to the child’s father,” she said.

  “Come on,” I said. “Let’s finish.”

  But that closed door was like a bad thought which kept intruding, and I kept looking in its direction, waiting for the storm to break. Still, ten minutes later, when the door opened and McMillan stepped out, he didn’t look too bad to me.

  “Well?” I said.

  He picked up the vital-signs chart. “We’ll wait for Prader,” he said calmly. “Now what about the new cardiac?”

  We worked on as if nothing had happened. Prader would set everything straight; I was sure of it. There were a lot of things I was sure of then, and Prader was one of the surest.

  7

  I FELT CERTAIN PRADER would not tolerate Berquam’s behavior. But then he probably wouldn’t go along with McMillan’s not using the protocol, either, or my not having the bone marrow ready. Exact, organized, demanding, he was a difficult man to please, but any thought you might have that he was harassing you personally, or persecuting you, was quickly squelched by the recognition of how hard he worked himself; also the fact that no matter how much he abused you, you came out of it knowing more than before he went after you.

  Which didn’t mean I liked him. You could respect Prader, but it was hard to like him. There seemed to be an unnecessary edge to everything he did; he never let up. We all speculated on why he behaved the way he did; when there was nothing else to do it was always good for a five or ten minute rap. Some of the older residents, those who had known him longest, thought it all had to do with his research concerns, that in a sense the ward was another lab to him, and at the time I agreed with them. He was a full professor, one of the three or four in the whole department, but unlike the others who had begun their promotion through their research and kept going through their politicking or administrative skills, he had stayed with his research, if anything getting in even deeper as his clinical responsibilities grew.

  As a hematologist Prader had originally been interested in white blood cells. For years he had worked in his lab exploring the metabolism of leukocytes, publishing papers on the effects of drugs on cellular processes. Eventually his work took him into the chemistry of antimetabolites and finally into the use of these drugs in leukemic cells. Gradually his lab became a center of leukemic research. Physicians from all over the country began to ask his advice and then, under his federally-supported treatment program, to send hi
m their leukemic patients. In response to the patient referrals, the hospital expanded the number of pediatric hematology beds and made Prader the head of hematology.

  His organized lab was a far cry from the chaos of a pediatric ward, but he became a superb clinical hematologist, building one of the largest clinical services as well as research areas in the whole hospital; and one of the most closely run. Right up to their deaths, his patients were the most painstakingly worked-up and followed of any service.

  I had already been involved with a few of his patients. It was at the beginning of my internship, during my hematology elective, and I remember his demanding, even as a child was bleeding to death, that the lab values still be obtained and the results documented. I had watched interns draw white counts on children so bloated they could hardly move, and do bone marrows on patients who had in effect been abandoned, because there was nothing more to do for them. I stood beside him by their beds and listened to him lecture on white-cells inhibition and bone-marrow depression while the children whose disease we were discussing were dying in front of us.

  It took a while to get used to. I never once saw Prader waver. He simply went on teaching, directing, pointing out, no matter how pathetic the child looked or how ill. His research fellows up in his lab said they could tell when one of his patients died; he became even more demanding than usual, more critical about their work and their results. On the ward, though, it was hard to know. He gave no signs of strain and his moods didn’t seem to correlate with his patients’ conditions. He’d get on the house staff just as hard when everything was going well on the wards as when they weren’t. It was only later I realized that many of his patients died at home with none of us knowing but him.

  Part of my hematology elective was to sit in on an initial interview with the family of a newly admitted leukemic. The American Board of Hematologists had originally recommended such an interview, and Prader had made it a part of each new leukemic’s work-up. With his usual thoroughness he insisted not only that the interview be given within twenty-four hours of admission and as close to diagnosis as possible, but that every resident, intern, and medical student on the hematology service sit in on at least one. He called a series of staff meetings to decide on exactly what should be covered, so that each interviewer would deal with essentially the same topics and in the same way. As regimented as the whole thing was, it still filled a need, although some attributed Prader’s concern with the parents not to any humane reasons but to his wanting them to stay with the study until the end.

  Usually the interview was given by the full-time senior hematologist assigned at the time to the clinical service. During my elective it was Prader himself.

  The interview I attended was exactly what you would expect from him: logical, ordered, meticulously thorough. After introducing Bradley to the parents as the intern on the ward, the physician who would be responsible for their son’s daily care, he explained the positions of the various doctors they’d be meeting. Then, “I don’t know what you’ve heard about your son’s illness,” he said, getting up from his chair, “what preconceived notions you may have. Whatever they may be I can assure you that his disease is like any other illness, subject to the same scientific laws, consequences and treatments.”

  Using the blackboard at the front of the room, he described the normal developments of their child’s hematological system. He drew the outline of a bone and filled in the center as he talked. “Every red cell or circulating white cell in a person’s bloodstream comes from cells developing in the bone marrow. And the marrow produces not only red cells to carry oxygen and white cells to fight infection, but also another type of cell. These cells,” he explained, turning to face the parents, “are called platelets and are absolutely necessary to stop you from bleeding. Sometimes—and we don’t know why—the normal controls regulating the bone marrow differentiation of these three types of cells are lost. Then the whole bone marrow factory gets turned on to producing only one kind of cell—an abnormal white cell. The bone marrow soon fills up with them and eventually they overflow the bone marrow space and begin flooding the whole blood stream, eventually infiltrating every tissue of the body. For some reason—and again we don’t know why—these cells are not only produced in too great supply but are themselves abnormal, unable to do what they should do as white cells—that is, fight infection.”

  I noticed how closely Prader watched the parents as he spoke. He stopped a number of times, even going back to explain things he must have felt might still not be clear to them. At the same time he seemed to go out of his way to itemize and even to dwell on the complications that could be expected by this take-over of the white cells.

  “Anemia will result because red cells are no longer being made, and bleeding will occur because platelets are no longer available to stop it, and even though there are billions of white cells being produced, infections will be a problem. Anemia, infections, and bleeding, these are the complications. We expect them, and have available therapy.”

  Prader didn’t mention the pain from the leukemic cells getting into the nerves and bones but he did talk about the changes exerted on the body by the runaway production of such a mass of abnormal cells—the wasting of normal tissues, as nutrients were diverted from them to white cell production, the difficulty the child would have (with so much of his protein intake being shunted into white-cell production) in making normal amounts of necessary proteins like antibodies and clotting factors.

  Sitting in the back of the room, as I listened I could forget he was talking about an afflicted child. He seemed to be talking about a machine breaking down, explaining the disaster by showing how this valve got clogged and that one was overwhelmed.

  It worked, though. In the course of minutes, without conjuring up big words or concepts, he’d removed all the mystery and managed, by mechanizing the whole thing, to hold out hope where there was no hope at all, to calm parental fears without in any way diminishing them. Even as he talked I could see the parents gradually relax in the security of knowing what had happened to their child. It was all just a matter of one type of cell pushing the rest out of the way.

  “Our therapy,” Prader continued, “is aimed at destroying these abnormal cells, eliminating them from the bone marrow, blood stream, and any other organs they may have lodged in. By getting rid of them we give the other three types of normal blood cells enough oxygen, nutrients, and room to begin to grow again, take over the blood stream, and do their job. We have medications now, and more potent ones are being developed all the time. Hopefully, we’ll have a major development during your son’s illness. That’s part of the work we’re doing right here in our own labs. Unfortunately, at the present time, while the drugs we have are very powerful, they are not one hundred percent effective. They do work, though, and while they are effective your son will be able to live an absolutely normal life.”

  Leaving the blackboard Prader went back to his table. I thought the conference was over and was about to get up to leave, but to my surprise he sat down again. Even more surprising to me was the way he sat for a quiet moment looking down at his hands folded on the table. Then, raising his eyes, instead of talking further about bone marrow, cellular differentiation, or caloric shunting, he spoke about families and relatives, about grief and guilt.

  “This will be a difficult time for you,” he said softly. “Believe me, honesty and frankness will be our most important weapons and crutches; indeed, they will be absolute necessities.”

  Then, unfolding his hands, he reverted to his former matter-of-fact tone. “There are a few things you should be aware of. First of all, this is not a familial disease. We don’t know what causes it—probably a virus or a lack of immunological control—but whatever it is, it is not genetic and it does not run in families, nor does there appear to be a carrier state.

  “Nothing you have done or have not done is known to contribute to the development of this disease—not smoking during pregnancy, excess vitamins, die
t patterns or anything else. Your friends may, and probably will, make comments that will seem inappropriate and even critical of you as parents. You will simply have to remember that such remarks are made in the hope of being helpful, and accept them as such. I can guarantee that your son is getting the best possible care. Again I must caution you not to blame yourselves; nothing you could have done would have made any difference. An earlier diagnosis would in no way have changed the picture.”

  Thinking about the interview later I realized Prader had not once mentioned the word leukemia. At the time I was impressed by what seemed to me his unexpected consideration for the parents and his concern with the nonmedical aspects of the disease. But then that same day, after the interview, he chewed Bradley out in front of me for not getting a chest film on the child he’d just discussed.

  8

  AS A RULE, WE saw Prader only during his formal hematology rounds on Wednesday afternoons and Saturday mornings. Dr. Sharf, an assistant professor in neurology, was our daily attending, while the rest of the hematology group—whoever was available at the time—came to help out on the emergencies, or problems that came up between Wednesdays and Saturdays. Prader’s rounds were really something. The only relief was that he was as tough on his own staff as he was on us. He knew everything that had happened since his last rounds, and he spent a good part of each of his sessions grilling his own research fellows as well as the house staff about why we had done what we did. His knowledge of hematology as a whole, not only his own field of leukemia, was phenomenal. He read literally everything on the subject and had as personal friends all the real experts in the various fields of blood disorders. He served as editor on several hematology journals, deciding on what should be accepted for publication and what rejected, so that he not only had important information in advance of almost everybody else, but knew what had already been tried and hadn’t worked. You simply couldn’t beat him; most of the time you just listened and tried to defend yourself.