Ward 402

by Ronald J. Glasser

  McMillan was the only resident who regularly stood his ground. My first week on 402, midway through Prader’s conference, I saw McMillan, who was sitting in the back of the room, raise his hand. The room was packed; it always was on Prader’s rounds. The hematology staff alone almost filled it, so with the ward personnel, medical students, and doctors from the other services crowding in to hear and to learn, many including myself had to stand.

  McMillan was sitting so far back that Prader at first didn’t see his raised hand. Lang had just finished presenting a patient with anemia secondary to kidney failure; the child was on dialysis awaiting a kidney transplant from his sixteen-year-old-brother. Prader lectured a few minutes about the uremic causes of anemia and then questioned two of the transplant surgeons present about the prudence of using a sixteen-year-old donor. They saw nothing wrong with it and Prader agreed that the risk seemed justified, since the brother was the only decent immunological match available. He was going on to the next patient when McMillan, apparently tired of holding his hand up for notice, interrupted.

  “I have to disagree,” he said.

  Everyone turned to look, some even getting up from their seats to see who had the nerve not only to interrupt Prader but to question him.

  “There is a risk,” McMillan said.

  “We know that,” Prader said.

  “A significant risk.”

  Prader leaned back in his chair. “And just what is that risk?”

  “Dying,” McMillan said. “The recently published transplant registry shows there has been one death in a donor—”

  “Yes,” Prader cut in irritated. “But the risk is the same for any donor, any age—”

  “And morbidity,” McMillan continued unruffled. “A greater risk from injury. The older brother is an active adolescent. If after giving up one kidney he has an accident—say an injury in sports—that could damage his remaining kidney he’d be a transplant candidate himself. An inactive adult is not at the same risk.”

  “Do you have any data, Doctor?” Prader asked.

  The two transplant surgeons visibly relaxed.

  “Yes. There have been six thousand kidney transplants done in the country, three thousand with cadaver kidneys and the same amount with those of related donors.”

  Prader remained silent as McMillan went on: “We know that the mortality is at least one per three thousand. The morbidity is harder to assess since the complications to the donors, at least the late complications, are not yet entirely in. It does seem, though—”

  I noticed that the two surgeons were looking less and less relaxed as Prader allowed McMillan to go on without interruption. “Well, Doctor,” he said finally, “what would you recommend?”

  “Protecting the donor. Using a cadaver kidney, or even a poorly matched adult donor.”

  Prader looked at the surgeons. “What do you think of that?” he asked.

  “Well, sir,” one of them offered, “a matched donor kidney has a much better chance of taking.”

  “Not true,” McMillan countered. “If the donor is an identical twin, maybe, but an unrelated donor or a cadaver kidney, with the use of decent immune suppressive therapy, has the same risk of rejection as a related donor.”

  The surgeon hesitated, and looked at Prader as if uncertain what to say.

  “I’d like to see the data,” Prader said. “Please bring it to my office this afternoon.”

  That ended the discussion. The brother was never used as a donor.

  During his own year of internship McMillan had taken, as I had, an elective in hematology and then, like any other intern, had had ward assignments where he was responsible for Prader’s patients. Prader had never seemed to bother him; at least the interns in his group said he gave no evidence of being bothered nor, apparently had Prader ever been able to intimidate him.

  “It’s the way he teaches,” McMillan explained to me. “Some guys are nice about it, some are hard-nosed. As long as you learn, it doesn’t really matter.”

  And then, of course, Prader must have known about McMillan. All the professors knew who the brightest interns were and prided themselves on their accomplishments, and McMillan had been by far the brightest in his group.

  After the episode about the donor, though, I noticed that Prader would occasionally go out of his way to question him and push him on some really rough material. McMillan always did well. Once when he was a bit fuzzy on the mechanics of the hemolytic anemia in Lupus Eranthematosis, Prader became pickier and pickier until neither McMillan nor anyone else in the room had the answer. McMillan didn’t panic. He said he didn’t know, and then, before Prader could get to him, asked for the references so that he could look up the answer. Prader, taken by surprise, suddenly found himself on the receiving end and had no choice but to give the references—which he did, then and there, from memory. After that, he seemed to be more lenient with his younger colleague.

  Even though his formal rounds were only twice a week, Prader rounded himself on each new leukemic patient the morning after the child’s admission. It was a ritual he never missed, and if he happened to be out of town at the time, he came by the first morning he was back. If the parents were around he would introduce himself but he wouldn’t go out of his way to look for them. All he did was read the patient’s chart and then look in for a moment and leave—after setting up the protocol, that is. But he could have done that by phone.

  On the morning after Mary’s admission he must have gotten to 402 a little after ten. I was passing the nurses’ station to get some X-rays when I saw him. He was standing by the rack reading Mary’s chart. For all the confidence he generated, and the worry and concern his presence inspired, he was not physically an imposing-looking man. Of average height, his thinness made him seem taller than he was. His hair, mostly in a thick ring around the back of his bald head, was black, as were his eyebrows, without the slightest touch of gray. He must once have been considered good-looking, in a skinny sort of way, but right now as he stood there reading Mary’s chart he was just plain business-looking.

  When I came back he was still behind the glass, holding the chart as he talked to Mrs. Gowan. She looked mighty sober to me. We’re in for it, I thought, as I hurried by the station before he could see me.

  Lang was in the treatment room, using the view box to look at some chest X-rays. He was about to put up another film when I came in.

  “He’s here,” he said.

  I didn’t need to be reminded. “Just check the X-rays,” I said. “I want to use the view box.”

  “He sure came up somber. Like he’s getting himself ready for the onslaught.”

  “Don’t act so disinterested,” I said. “You’ll be close enough to get some of the spinoff.”

  Lang shook his head. “I know. That’s what’s bothering me.”

  “Come on,” I said impatiently, “I’ve got to look at these. Finish, will you.”

  “OK, OK, if you’re in such a hurry—If I were you,” he said as he was leaving the room, “I’d stay in here for a while.”

  It took only a few minutes to look at my films, a follow-up IVP on a child who’d been admitted a week before, uremic from massively infected kidneys secondary to an obstructed bladder. He’d already been operated on. His kidneys were so bad—there was so little tissue left—that the surgeons, hoping to protect what little remained, had completely diverted him, draining what urine his kidneys could make into a bag on the outside of his body.

  The X-rays looked terrible—small shrunken kidneys with big dilated tubes leading into the ileostomy bag—but at least the situation wasn’t any worse than before the operation. If you pushed a bit, maybe it was a little better.

  I put the X-rays back into their folder, and went down the corridor away from the nurses’ station. I should have taken them to the nurses’ area where they could be returned to the X-ray department, but I was anxious to avoid Prader as long as I could, so I carried them with me and went to tell the child’s mother
what the X-ray showed.

  I found Mrs. Leroy standing by her boy’s bed.

  “How do they look?” she said.

  “Alright,” I said, reassuringly I hoped. “Better anyway.”

  The child was sitting up, opening one of the presents she had brought him.

  “Do you think he’ll have to be operated on again?” she said, almost timidly.

  “No, I don’t think so. The place where the urine comes out—the hole through his skin—may with time contract and have to be revived.”

  I was sure the surgeons had already explained to her what the operation had entailed, but the word “hole” seemed to frighten her.

  “The surgeons explained, didn’t they?” I said.

  She nodded, but she still looked apprehensive.

  “Did you understand?”

  “A little,” she said in a way that told me she didn’t.

  I should have known, I thought. There were times when I had trouble keeping up with some of the surgeons. “Here, let me show you,” I said. I took out my notebook and drew a diagram to show her what had been done and what I meant about the stoma contracting. I didn’t show her the X-rays; none of us ever showed parents the studies themselves. It was a kind of informal tradition that you were to interpret what the lab results revealed, not show the tests. The idea was not to make the parents nervous with technical details they were not prepared to understand. That it could also be a device to keep control, to keep the mystery—and patient respect—alive and working, had not occurred to me then.

  I had not quite finished explaining when Prader walked in. He didn’t waste any time.

  “Excuse me for interrupting,” he said to Mrs. Leroy. “Could I see you for a moment, Doctor.”

  He didn’t wait for an answer, but turned away and walked out into the corridor.

  Mrs. Leroy and I exchanged glances. “I’ll be right back,” I said.

  Prader was waiting for me a few steps down the corridor. “Were you on last night?” he asked. His face was expressionless, but his question sounded more like a demand.

  “Yes sir,” I said. “I was.”

  “Did you write the orders on Mary Berquam?”

  “Yes sir. And I signed them. They’re in the order book.”

  “You know there’s only one history on the chart—Dr. McMillan’s.”

  “Yes sir, I know. It was late and I did the physical while Dr. McMillan did the history. We—”

  “So you didn’t talk to the parents then.”

  “No, but—it was three or four in the morning and the child was desperately ill. One of us had to be with her. The parents were obviously distressed and exhausted—”

  Prader’s face hardened.

  “We judged it was better for one of us to take the history,” I continued defensively, “than for both of us to put the parents through the same set of questions.”

  “Did you talk to them this morning?”

  “No—Mr. Berquam—”

  Prader cut me short. “I know about Mr. Berquam,” he said. “I’d like you and Dr. McMillan to be in my office in fifteen minutes.”

  Round one, I thought as he walked away. He had known everything he asked. It was going to be a tough morning.

  When I returned to Mrs. Leroy I found her sitting on her son’s bed, helping him put together his toy.

  “That was Dr. Prader, wasn’t it?” she asked.

  “Yes, it was.” I hadn’t thought she knew his name. “He’s not always that gruff. It’s just that he’s got a lot on his mind.” I picked up the folder of X-rays I’d left at the foot of the bed. “How did you happen to know that was Dr. Prader? I mean, Gregg’s never had anemia or anything like that, has he?”

  “No, no,” Mrs. Leroy said. “It’s just what I’ve heard from some of the other parents. He’s the world expert on leukemia, they say.”

  I don’t know why I should have been surprised that parents exchanged information, but I guess my face showed I was.

  “Oh,” she said, smiling, “we parents all talk about the doctors.”

  I might have asked what she’d heard. Whom she’d talked with. What they said. What their feelings were. That way I might have found out what was happening on the ward. But I didn’t ask, because I thought the parents were not my concern, and that anything they might say hardly mattered. We were doing the best we could to take care of their children. That was enough, wasn’t it?

  The question remained with me as I walked back to the nurses’ station. The truth was we had no idea what the parents thought about, and really didn’t care. We saw them only as visitors coming and going, or as future nursing aides who would one day be responsible for carrying out our orders. When we talked to them we talked about medicine. Even those of us who became friendly did so tentatively, so as not to become involved. There was too much to do, if parents got in the act we would never be able to finish our work.

  McMillan was in the nurses’ station talking to Mrs. Gowan when I came in to put the X-rays in the return box.

  “You know—” I said.

  “I know.” He looked at his watch. “We still have a few minutes.”

  “What did Prader want from you?” I asked Mrs. Gowan.

  “Data,” McMillan said drily.

  “He wanted to see the evening nurse’s notes,” Mrs. Gowan said.

  “Nurse’s notes?” I said.

  “That’s right.”

  “Jesus!”

  “Come on,” McMillan said impatiently.

  “Did he see Berquam?” I asked as we walked toward the elevator.

  “He did.”

  “What happened?”

  McMillan shrugged. “I don’t know. I wasn’t there.”

  “Well, what did he say to you?”

  “That he wanted to see us in his office. That’s all.”

  “What do you think it’s all about,” I said as we came to a stop by the elevator bank. “I mean, I know what it’s about, but—”

  He pressed the button. “The protocol, I suppose.”

  “But why the nurse’s notes?”

  “Well, you know, he likes being sure.”

  “You don’t sound too worried.”

  “What can he say? I know what I did, and the reasons.”

  “Then you’d better do the talking,” I said.

  We had to step aside for the group of nurses coming out of the elevator.

  “You mean the answering,” McMillan said.

  9

  PRADER’S OFFICE WAS AWAY from the main hospital, in the hematology research area. The elevator opened on a corridor cluttered with equipment. Dented oxygen tanks and liquid nitrogen containers lined the narrow, pitted corridor. This was the oldest part of the hospital. Removed from the patient areas, it had never been remodeled and what changes there were had been made solely for the purpose of utilizing every available inch of space for research. The labs were little rooms off the corridor; the original space had been divided and subdivided until there wasn’t enough room for all the equipment, which overflowed into the hallways, making them as much a part of the labs as they were thoroughfares.

  As we approached Prader’s office at the end of the corridor we had to walk single file to get by the freezers and centrifuges. We could see the research fellows at their benches; several looked up from their work to wave or nod as we passed. We knew most of them; at one time or another they had been on the wards themselves, or at least had accompanied Prader on his visits to the hematology patients. No matter what research his fellows were doing, he required they be there for his rounds.

  Prader was talking to one of them when we reached his office, and we waited outside until he had finished. It was the same old office he had held on to since he’d become a professor. The hospital had expanded, new buildings gone up, new departments organized, new office space allocated, but he’d stayed on in the research area. People said he just wanted to be obstinate, but the likelihood was he simply felt more comfortable in the midst of
his research.

  He was standing by his file cabinet when we walked in, putting away a folder. The office was small and cluttered. Books and journals lined the walls. The desk was covered with papers, and open journals with passages outlined and marked were piled one on top of the other. On the radiator behind the desk were stacks of patient charts reaching above the window sill.

  Prader didn’t offer either of us a chair. “What do you think of the problem?” he said, closing the cabinet drawer.

  I looked at McMillan but he didn’t seem about to answer.

  “Well,” Prader said as he turned to face us, “do you have any plans?”

  McMillan still made no move to speak. In the silence I could hear the hum of the equipment out in the hallway.

  Prader looked at me. I could feel myself sinking, but I’d be damned if I’d be the one to open my mouth first and get the first blast. Despite myself, my heart was pounding.

  “I’m waiting,” he said quietly.

  “Put her on protocol,” McMillan said. “Prednisone is the primary medication for all of them.”

  At last, I thought, relaxing.

  “And you?” Prader said.

  “Me?” For a surprised moment I thought of just dropping the whole thing back on McMillan, but I had sense enough to know it wouldn’t work. Prader wasn’t one for pushing off responsibility.

  “Well, sir,” I managed to say, “treat her—”

  “You have,” he said. “That’s not the problem.”

  I thought he might simply be using me to develop some point, but there was nothing didactic in his tone.

  “Do you know what the problem is?” he said.

  “Yes, sir.”

  “What is it, then?”

  All I could do was stand there, trying to think of something.

  “He has nothing to do with what happened last night,” McMillan said.

  Prader turned to him. “He wrote the orders, didn’t he?”

  “Signed them,” McMillan corrected. “I decided what had to be done.”

  “In a court of law,” said Prader, “he decided.”