Ward 402

by Ronald J. Glasser

  “Maybe in a court of law. But last night I decided. If he hadn’t agreed I would have gone ahead anyway.”

  Shaken as I was, I still worried that McMillan might be going too far. Prader was the boss and if he found what we had done unacceptable, he could do what he wanted to either of us or both. But except for a slight tightening of the lips, his expression remained unchanged.

  “I treated a medical emergency,” McMillan said. “I didn’t institute therapy to treat her disease, but a complication.”

  “And the parents?”

  “They were distressed. They came in with a dying child who had been suffering at home. They had obviously decided in their own minds that the child was gone or they wouldn’t have brought her to the hospital. They had worked out their grief already and they weren’t about to listen to anyone. As far as they were concerned the child was dead.”

  “That’s an opinion,” Prader said.

  “It was my impression.”

  “And you acted on an impression.”

  “I treated a medical emergency and formulated an impression about the patient’s parents and acted on it.”

  “You mean parent,” Prader said. “Parent,” he repeated, and waited a moment to let it sink in. “Mrs. Berquam called me this morning, after your interview with her husband. She was almost hysterical. Afraid we weren’t going to save her child. Your impression, Dr. McMillan, was rather incomplete. Histories, if you remember, are taken from both parents.”

  McMillan flushed, but kept grimly silent as Prader turned to me. “If you are going to be responsible for patients, you had better learn to rely on yourself, not on the people you work with.”

  I could see McMillan stiffen.

  “You are to take your own case histories, no matter how inconvenient it may seem at the time. In case you haven’t realized it yet, medicine is not all for the doctor’s convenience. Despite what you may have heard, or what may be practiced, it is a twenty-four-hour-a-day business; five in the morning is no different from three in the afternoon. I want the history from the Berquams on my desk this afternoon. Is that clear?”

  I nodded my head like a dumb fool.

  “They’re waiting on 402—As for you, Dr. McMillan, I’d advise that you go back to the ward and try to find out what the hell is going on.”

  Prader rose from his chair, “That will be all,” he said.

  Relieved, I was about to make my exit when McMillan said, “And what protocol will we be using?”

  “Let’s have a diagnosis first,” Prader said sharply, making no effort to hide his annoyance.

  “The smear is almost unequivocal—”

  “Another impression? Or is it an opinion this time?”

  A quick flash of temper, and McMillan left without replying.

  “Well?” I said, when I had caught up with him. “What the hell happens now?”

  “Make the diagnosis,” he said.

  “You don’t seem worried.”

  “Maybe she doesn’t have leukemia,” he said sarcastically.

  “That’s not the point. I don’t think that’s what’s bothering him.”

  “Whatever it is, it will pass.”

  “I mean I don’t think it’s just the protocol,” I persisted.

  “If it’s not now, it will be,” McMillan said.

  We rode down the elevator in silence. McMillan was playing it pretty cool, but I was sore. To be talked to like that! Like a child! As if I didn’t know what medicine was! I had never felt more abused.

  Walking back through the main lobby I looked at the clock over the information desk. The business with Prader hadn’t taken as long as I’d thought; there was still a lot of morning left.

  McMillan seemed at ease as we crossed the crowded lobby, but I was still fuming. Damn Berquams! I thought. As if things weren’t hard enough without them. Still, our encounter with Prader could have been much more of a disaster. All things considered, I had got off fairly well. And so had McMillan, despite his inviting trouble.

  “Did they get the chest film on that ENT admission?” I asked.

  “A portable.”

  “Did you see it?”

  McMillan shook his head. We had to slow down to let a stretcher by.

  “There’s time,” I said. “I’ll get that history out of the way, then go down to X-ray and see what it looks like. Do you want me to bring it up?”

  “Yeah,” he said absently. “If it’s worth seeing.”

  The Berquams were in the conference room. Suddenly unsure of myself, I hesitated at the door. As physicians we were used to being respected, even adored. These are attitudes we have come to expect from patients—or, in a pediatric ward, from parents—the starting point of all our interactions. To have to confront parents I knew in advance were hostile, to have that adoration gone at the very beginning, made me feel unarmed, unready. Still, the interview had to be done, and I felt resentful enough to want to get it over with in a hurry.

  I introduced myself as the intern on the ward and sat down in the chair facing Mary’s parents. Berquam was grim, but he answered my background questions quickly and in detail. As he spoke, his wife leaned forward nervously in her chair, hanging on his every word but saying nothing herself, even letting him answer my questions directed at her about her daughter’s birth or her own prenatal care.

  “When did you first know she had leukemia?” I asked.

  “About three months ago,” Berquam answered matter-of-factly, as if I was still asking about the child’s immunizational history, or growth and development, or diet.

  There seemed to be no point in prolonging the interview or trying to soften the questions. “How did you find out?” I said. “I mean about her having leukemia.”

  “From the family physician. She was sick for three days. Like everyone else we thought it was the flu. When she started throwing up, we took her to our doctor. He agreed with our diagnosis,” Berquam said drily, “gave her six hundred thousand units of procaine penicillin. So we took her home and two days later she began bruising. I called the doctor again, took her back in—We got a smear and white count and made the diagnosis of lymphocytic leukemia.”

  I asked what happened after the diagnosis was made.

  “Nothing,” Mrs. Berquam said. “She just got sicker.”

  Stony-faced, her husband looked down at his hands and then up at me.

  “After the diagnosis,” he went on as if there had been no interruption, “we decided to let her die in peace. She would stay at home with us as long as possible, and then finally she would die in the hospital, sedated and painless.”

  Mrs. Berquam was sobbing now, but he made no effort to comfort her.

  “Very well,” I said, closing my pad. “We can talk again tomorrow.”

  “Doctor!” Mrs. Berquam cried as I got up to leave.

  Her husband put out his hand to stop me. “We want her comfortable,” he said. “You understand? Comfortable.”

  “Doctor!” Mrs. Berquam cried again, as if she was pleading with me to understand more than what her husband was saying.

  “Marquette!” he said sharply. Then, more softly, “We’ve decided, haven’t we? We’ve decided.” He turned to me. “We just don’t want her to suffer.”

  “Neither do we,” I said. “I assure you, we don’t either.”

  10

  THE FILM WAS IN the portable box. I took it into one of the nearby dimly lit rooms, clipped it up on the view box and switched on the lamp. Like most portable films it was not a very good X-ray. The heart borders and pulmonary vessels were blurred, and the lung fields themselves had a hazy overall granular appearance. Even the bones were washed out because of the poor quality.

  I took my time and went over it leisurely, area by area. After the tension in Prader’s office and the conference room, it was soothing to stand there in the cool silence of the viewing room with nothing to worry about except the film.

  The X-ray department, indeed radiology itself, had always been
comforting to me, even in medical school. There was a precision to X-rays that was appealing, almost seductive. It was all there, everything you needed; no frills, no foolishness. I’ve lost track of the number of times I’d worried about a pneumonia in one of my patient’s lungs only to have my concerns settled by a chest film; or the nights I’d wondered about whether an ankle was sprained or broken only to see that thin hairline fracture on the X-ray. Everything unnecessary or superfluous was gone, burnt away by the high-energy beam.

  It was pure; the kind of definitiveness that we strove for in everything else. If you knew what to look for and how to look for it, there was little chance of missing the diagnosis. Sometimes after an X-ray conference I’d wonder how the older physicians had been able to practice at all. And then their poor patients—tumors missed, pneumonias untreated, fractures unset or set wrong, osteomyelitis left alone to destroy whole bones, knees injured for life.

  I moved closer to get a better look at the film. Even with the poor quality the right lower lobe of the lung looked a bit too hazy. I thought of Prader again. He might complain about procedures and protocols, but he’d complain a lot more if one of us misread an X-ray or ignored a low hemoglobin value. And parents too; some of them might fuss about this or that, but they’d be a lot more angry if we missed a fracture and sent their sons home with only an Ace bandage.

  I was about to take the film down to use the spotlight on it when the radiology resident walked in.

  “Not too good, eh?” he said.

  “You mean the technique?” I asked.

  “No, that lower lobe.”

  “It’s sort of hard to tell, isn’t it?”

  “That’s not all poor technique. That’s an infiltrate. It’s just too fluffy. And see the way the haziness moves out laterally,” he said, tracing out the area with his finger. “Here, along the rib margins. That’s an infiltrate and fairly diffuse. What’s his problem?”

  “Post operative fever. Had a T and E two days ago.”

  “Why don’t you send him down for a regular film. We can get a lateral view then, too.”

  “OK. Can I take this up with me? McMillan wants to see it.”

  “Yeah, it’s dictated. Just take the film jacket with it.”

  “You want it back for the X-ray conference?”

  “No hurry. Conference is not till three o’clock.”

  I took the film up to the ward. Right inside the double doors there were several small groups of parents and visitors standing in the corridor. It struck me as unusual, because it was lunch time when the kids were eating in their rooms and the halls were normally empty of visitors. Further down the corridor I could see more visitors standing in the doorways talking with one another. As I walked by, those nearest me stopped talking; even those farther down the corridor became silent as I approached.

  “What’s going on here?” I thought. I said hello to several parents I knew and was surprised to see some of the mothers ignore me or turn away. Even those who acknowledged my greeting seemed to do so hesitantly, as if something had come between us. Yes, something was wrong, that was plain, though I had no idea what might have brought about this sudden chilling of the atmosphere; I even thought I must be imagining things.

  Chris was in the doctors’ station. She was one of the RNs who worked days. For a while she had been working permanent nights, so that she could take courses at the university. But after surviving a semester of this, plus the social activities of a very attractive young woman, she had given up and gone back on the regular nurse’s rotation, with the idea of returning to school full time in the fall. “It was too much,” she said. “It seemed like I was going weeks without sleep.”

  She was a good nurse and liked the kids. Sometimes she would take one of her little ones along with her to the nurses’ conferences and keep the child in her lap, playing with him during the whole meeting. She got pretty close to the parents, too, but for the most part, even though she had ideas of her own about how things should be done, she kept to herself. Mrs. Gowan liked her, and obviously trusted her; she gave her as much responsibility as she could, sometimes even putting her in charge.

  “Have you seen McMillan?” I asked Chris.

  “He’s in with Mary,” she said, without looking up from what she was doing.

  I took the films over to the small view box at the back of the station, and clipped up the films.

  “Is her father still around?” I asked.

  When there was no answer, I said, “Why the silence, Chris?”

  “He’s gone,” she said. “He was really put out.”

  “Gone? Gone where?”

  “To the hospital administrator.”

  “What for?”

  “What for! To sign his daughter out of the hospital against medical advice.”

  “Wait a minute,” I said. “Is that what’s going on out there? I mean with the visitors?”

  “You guessed it,” Chris said, crushing out her half-finished cigarette in the ash tray.

  “How did it happen? I mean did Berquam and McMillan get into it again?”

  “Not exactly. Dr. McMillan simply walked into the room and announced to Mr. Berquam that he was going to draw blood for more tests.”

  “So?”

  “He could have done it differently. Instead of just announcing it.”

  “You don’t think Berquam will really sign her out, do you?” I said.

  “That’s not the point, and you know it. You doctors!”

  Chris was plainly in no mood to be reasoned with, so I switched on the view box and went out to get McMillan. He was just leaving Mary’s room with a handful of blood-filled sample tubes.

  “There’ll be no doubt about the diagnosis now,” he said. “There’s not a reasonably valid test I haven’t drawn.”

  “Did you know Berquam left to sign his daughter out?” I said.

  “He was loud enough about it. They must have heard him in the next ward. He was pretty hot.”

  “Did you talk to him first?”

  “No. When I walked in with the syringe and tubes and started to explain, he just went crazy. He didn’t give me a chance to talk.”

  “Maybe you should have, I mean, maybe tried to talk to him first.”

  “Maybe. But I don’t think it would have made any difference. Anything would have turned him on. Besides, what would we have done if he’d said no? Don’t worry,” McMillan added, holding up the blood-filled serum tubes. “It’s when we treat her there’ll be trouble. These are just tests.”

  “Do you think we should let Prader know?” I suggested.

  “If you want to. Right now, I’ve got to get these down to the lab.”

  I decided against calling. Prader would have wanted to have all kinds of answers. Anyway, McMillan was probably right. It’s difficult for a parent to sign his child out of a hospital against medical advice. It happens, but it’s rare. The pressure on parents not to sign their children out is fantastic, the greatest being the problem of where to take them after they leave. It’s a closed market. Of course I could be wrong. And in that case I wondered if it would not be better in the long run to let Prader know.

  I was standing there by Mary’s half-closed door, still hung up on what to do, when Mrs. Gowan came up behind me.

  “Sorry to interrupt,” she said, “but Freddy Handelman’s on his way in.”

  “Oh God!” I said, “that’s all we need.”

  “The emergency room just called. He’s a direct admission.”

  “Have you told McMillan?”

  “No, not yet.”

  “How long before he gets here?”

  “I don’t know. A few hours, I suppose.”

  “Have you checked Mary lately?”

  “Chris is taking care of her today. Why?”

  “Nothing. Thanks. I’ll be in with her a while.”

  Mary was still unconscious. I looked at the vital-signs chart taped to the top of the small dresser near the side of her bed; her blood pre
ssure, respiration, and heart rate ran in three straight lines across the chart—no change. I checked the IV that hung over the bed, watched the drops slowly drip into the tubing, and made sure the needle was still fixed firmly in her thin arm.

  Everything was in order, yet I continued to stand by her bedside, unwilling to leave. She looked so delicate as she lay there, so vulnerable, as if the least wind could blow her away. Chris, or one of the aides, had braided her tawny hair into two little beribboned pigtails which lay like wings on the pillow on either side of her head. They seemed too playful for her expression. Even though she slept her lips kept something of their tension, a kind of grim expectancy.

  I don’t know how many sick children I’ve looked at, how many I’ve treated. There are so many, you lose track of them; they come and they go. But every now and then there’s one who gets to you right at the beginning, a child with a special magic. You fight it because it makes everything so much harder, but it stays with you. Mary was like that.

  I smoothed her cheek gently with the back of my hand and let my fingers touch the edge of her mouth. Unexpectedly, her eyes opened, and without moving her head she looked up at me, barely able to focus.

  “Are you going to stick me again?” she said in a faint little voice that despite its weakness was still fearful, and I saw the tears welling up in her eyes.

  Maybe I was just overtired, or overwrought, maybe it was just four weeks of 402, or simply how she’d asked and how she looked at me, trying not to cry, or maybe I don’t even have to find an excuse, but for a moment there I had to fight back my own tears.

  “No, Mary,” I said, “I’m not going to do anything to you.”

  “My tummy feels funny.”

  “I know—Just close your eyes and rest.” Reluctantly they closed again, and I stayed a while longer watching her breathe.

  I found McMillan in another room down the corridor talking with Lang about one of his patients.

  “Did you know Mary’s awake?” I interrupted.

  “Yeah,” McMillan said. “She’s been coming around all morning.”

  “She’s looking better—Coherent, anyway.”