“Well, at least, she’s on her way.”
“Mrs. Gowan tells me Freddy Handelman is coming in.”
“Oh Christ!” Lang said. “When?”
“Soon.”
“How many does that make?”
“Three,” McMillan said.
“I thought it was four admissions.”
“No. There was a cadaver kidney and a living donor. His mother, I think.”
“You up?” Lang asked me.
“No,” I said. “You are.”
“Damn.” Lang looked at McMillan. “Anything wrong?”
“I was thinking of Freddy’s parents,” McMillan said. “They’re apt to be a bit hyper—”
Another Berquam, I thought.
“We’ll need a renogram for the kid when he gets here,” Lang said.
I told them I was going back to the doctors’ station and would call X-ray and schedule it.
On the way I met the aide whom Berquam had almost knocked down. She was still looking upset and I started to apologize for his behavior.
“I shouldn’t have gone off the handle myself,” she said.
“You know how it is,” I said. “If you’re a parent and have a child as sick as his—leukemia—you can get a bit freaky.”
“You mean it’s like he said? She’s going to die?”
“What do you mean, like he said?”
“You know, when he was out there yelling at Dr. McMillan.”
“What else did he say?”
She looked embarrassed. “Just things,” she said. “I’ve got to go now,” and lowering her eyes she hurried past me.
Just things, I thought as I sat down heavily at the nurses’ desk. Things I felt I ought to be more aware of, but wasn’t. Like those people in the corridor who seemed to be sharing a secret they didn’t want me to know about. And then Chris suddenly acting peculiar, as if she had a chip on her shoulder. And now the aide.
To hell with it. There was too much to do to worry about what people said, or didn’t say. I read the typed three-by-five index card pasted at the bottom of the glass partition in front of me. It was the nurses’ list of that day’s scheduled admissions: Two ENT patients, two urology, one general surgery, two eye patients and one pediatric admission with a possible diagnosis of rheumatoid arthritis. They all had to be worked up, but the pediatric admissions were the ones we really took our time with. All we did for the off-service admissions was a physical to be certain they were ready for surgery, a quick history to make sure the surgeons didn’t do anything foolish or inappropriate, and a kind of weary follow-up post-operative.
For 402 it was a routine admission list. Freddy Handelman’s coming in simply made it more routine. I made the call to X-ray and then crossed off the list on my own note-pad what had already been done. Most of the morning’s lab tests were still out, so I called for the results. The lab slips came up at the end of each day, but the tests were run around noon, and by calling then I could get a good three hour jump on what had to be done, and the advantage of day-time staffing to help get it done. I usually started with chemistry, getting the day’s electrolytes, then microbacteriology for the culture reports, serology, and finally immunochemistry.
11
I HAD ALMOST WORKED through my complete list when I saw Mrs. Berquam walk hesitantly on the ward. She was looking around, apparently for someone who might help her. When she saw me behind the glass she gave me a pathetically open smile and quickened her pace in my direction.
“Is Dr. Prader here?” she asked, standing in the doorway of the station.
When I told her no, she looked confused. “He called me at home and asked me to meet him here.” She glanced at the clock. “He said twelve-fifteen.”
It was almost that now. “He should be here soon,” I said. “He’s pretty punctual,” and added, “Your daughter’s better.”
“Yes, I know.”
“Who told you? I mean, were you here this morning?”
“No, Dr. McMillan called me at home to tell me.”
“When was that?”
“A little before lunch. Why?” she said, suddenly frightened. “Is she worse?”
“No, no,” I reassured her. “In fact, she’s probably even a little better.”
“Is my husband here? Dr. Prader wanted to see us both.” She smiled diffidently. “I’ll be in Mary’s room. Is that alright?”
“Sure. I’ll tell Dr. Prader you’re there.”
I closed my notebook, hoping to get away before Prader showed up. He had a way of pushing interns, sometimes even medical students, into areas that were really the resident’s responsibilities. I had had enough of that earlier in his office, and I didn’t feel like making an afternoon of it too. I was just on the point of leaving the station when he walked on the ward with Berquam. Motioning Berquam on to the conference room, he came into the station.
“Is Dr. McMillan available?” he said.
I said I thought he was at lunch.
“Have him paged. Tell the paging operator he’s wanted in the conference room. Immediately.”
“Yes, sir.”
“I want you there, too. Is Mrs. Berquam here?”
I told him she was in Mary’s room, and while I dialed the operator he went to get her. Later, as I followed them down the corridor to the conference room, I could hear the operator paging McMillan over the loudspeakers.
Prader didn’t waste any time, but began talking even while we were getting settled. “I wanted to talk to both of you this morning,” he said, choosing a chair that faced the Berquams. “Unfortunately, I was called away. I apologize.”
Mrs. Berquam glanced at her husband who remained stonily silent. Prader gave me a fleeting look and continued: “As I am sure you are aware, our hospital is a major referral center. In a very real sense then, it is as much a place where the most difficult to manage and potentially dangerous medical situations are continually presenting themselves as it is a high-powered diagnostic center. With the kind of hospital this necessitates, and the type of severely ill patients we receive, actions must be swift and at times begun almost reflexly. I’m sure you understand and appreciate the need for that.”
He waited a moment and then went on. “We try to minimize the initial shock of the admission and any confusion that the logistics of the situation may generate, by talking—either myself or one of my staff—with the parents of the newly-admitted child so they know exactly what they can expect, what will be done, the possible complications of the various procedures, and, probably most important, what the diagnosis really means. I am convinced that this kind of initial discussion is important, not only in regard to disorders of the blood, but any chronic disease where there is a likelihood of repeated admissions, clinic visits, continuing therapy, or where the medications themselves may be dangerous or debilitating.
“The neurologists have such discussions for the degenerative brain diseases; the endocrinologists with their new diabetics; the renologists with their renal transplantation candidates. We in hematology make a very special effort in this regard. We believe it is particularly important, with diseases like your daughter’s, to discuss what we are up against.
“In this case, Mr. Berquam, with your obvious knowledge of the field, such a discussion would be superfluous.” Prader paused to let this sink in. “However,” he continued, “I must point out that work is going on, here in our own research laboratories and elsewhere as well, not only to develop better drugs but to give us a better understanding of the disease itself, so that we may find a cure.”
Here he turned to Mrs. Berquam who was sitting nervously on the edge of her chair. He had been speaking directly to her husband; now he was attentive to her. “If your daughter has the type of leukemia I think she has, then I’m fairly confident we can stop her disease and clean up her blood. As physicians we can offer her time, perhaps a good deal of time, and a large part of it, we can say from our experience, will be symptom-free.”
Mrs. Berquam looked at her husband h
opefully. Prader must have seen how stubbornly, if almost imperceptibly, he was shaking his head, but he chose not to notice.
“Tell me, Mr. Berquam,” he said, “what would you say about the treatment of a child with cystic fibrosis?”
Berquam was taken back by the direct question. “I don’t know about cystic fibrosis,” he said. There was an awkward silence as Prader waited for him to go on. “Many of them have anemia,” he said, obviously feeling pushed, “but that’s all I know.”
Prader nodded in agreement. “What you say is true. Unfortunately, the reason for the anemia is that the treatment of their basic disease is at best palliative. For the more severely affected children, however, the prognosis is hopeless.”
Berquam stared at him with continued hostility, but he was obviously listening as Prader continued: “It is the same with other chronic diseases. Sickle cell anemia is one that I’m personally familiar with. Those affected by it will have constant pain, constant liver disease, constant kidney destruction, neurological deficits, lung problems, bone problems, and heart failure. They will die well before they are twenty-five, and most of those twenty-five years will be spent in hospitals where we can do nothing but give them IV fluids and send them home between admissions.
“And then, of course, there is multiple sclerosis, amyotrophic lateral sclerosis, metachromatic leucodystrophy; the agammaglobulemias, Aldrich Syndrome, the fatal granulomatosis diseases of childhood, and so on. Believe me when I tell you the world has been lulled into a false sense of medical security, and expectation of medical miracles, of escape from pain and suffering, of sudden cures, all because in one field of medicine—infectious disease—there is the magic bullet of antibiotics. But even in that field we barely keep ahead of disaster by expending millions of dollars of research to keep up a constant infusion of newer and newer antibiotics as the older ones become useless. As for the rest, we are still fumbling around in the dark ages. Today we use prednisone and Imuran with the same lack of knowledge as when we used mustard seed and witch hazel. Most treatments today are still prolonged and painful, and the results for chronic diseases, no matter what they might be, are spotty at best. At the most they—” and here Prader hesitated as if he suddenly realized he’d gone too far, then added quickly, “at the most, they simply give us time.
“Tell me, Mr. Berquam, as a medical professional, what would you do in the case of any chronic disease I’ve mentioned, where the eventual outcome, no matter what you do, is death?”
“I’m not an expert on chronic diseases,” Berquam said.
“Well, I am, and today leukemia is no more terrible than the other diseases I’ve named. Today in hematology we have drugs that give remissions which specialists dealing with other chronic diseases would give anything to have. A cure may be still a long way off, but eventually we will have a whole armamentarium of drugs on our shelves just like antibiotics, to be used one after another so we can maintain our patients in a constant state of remission.”
Mrs. Berquam was watching her husband, her body tense, her face taut with anxiety, while he sat there, chin down, maintaining his stubborn silence.
“What would you think,” Prader went on, “of a parent who didn’t want his child with sickle cell anemia treated because no matter what we did the child would not live past twenty or twenty-five? Or wouldn’t want a pneumonia to be treated in a son with cystic fibrosis because it would not affect the basic disease process and the child would die anyway?” He paused as Berquam glanced at his wife who seemed on the verge of tears.
“Your daughter has a dread and deadly disease. There is no magic bullet. But there is a treatment.
“As I said before, we have a lot to learn and a long way to go, but we couldn’t have got as far as we have without the help of parents like you. We need your help as much as you needs ours. All the drugs we have now are effective to some degree, but how much more effective one is than the other, or if it is better to give them all together, or give them every other day, or three days a week, that we don’t know. The only way to find out is to use them in various combinations and then compare the results.
“This is where we ask your help. I feel strongly that your daughter should be treated. She is of course your daughter, and I can understand your concerns and feelings. But our position, and I don’t think it is an unreasonable one, is that we should use what we have struggled so hard and so long to obtain, and at such great expense and suffering, not only for your daughter but for those others who will be coming after her.”
Berquam glanced at his wife whose eyes were fixed on him as she wavered between hope and fear.
“What we would like to do,” Prader went on, “if you agree, is to use a special protocol of medications for your daughter, where dosages and time of treatment have already been established. Whether the particular group of drugs we use will be more effective, or less, than the other protocols we are using, I don’t know. Nor does anyone else. I can guarantee, though, that each drag by itself has proved effective to some degree.”
“But in the end,” Berquam said, “she’ll die anyway. Right?”
“Yes, she will die anyway.”
Despite her effort to control herself, Mrs. Berquam’s eyes welled with tears.
“And for a large part of whatever time she’ll have left she’ll be ill,” Berquam said. “Right?”
“At the end, yes.”
“And the beginning? And the middle?”
“There is that possibility, though our patients usually spend less than ten percent of their survival time hospitalized, and most of that is at the end.”
Mrs. Berquam was sobbing openly now. The discussion was a cruel trial for her.
“And the fevers? And the infections?” Berquam demanded. “The bleeding.”
“No one can tell how long the remissions will last.”
Prader waited. Berquam, shaking his lowered head, was obviously unconvinced, and at the same time painfully aware of his wife’s misery. I could feel the tension in the room, like a physical presence as she watched her husband through her tears, mutely pleading with him. At last, with a deep sigh, he reached across and took her hand.
“I don’t want our child to suffer,” he said softly, so softly I could hardly hear him.
“Nor do we,” Prader said.
“Very well,” Berquam said, almost with a groan, as if consent had been wrenched from his very guts. “We’ll do as you say.”
If Prader felt anything at the moment—satisfaction at having persuaded Berquam, pity for the parents’ anguish, whatever—his face did not show it. “While your daughter is in the hospital,” he said, “the house staff will be responsible for her care. That is the policy of the department. They are all competent physicians and they will of course be responsible to me.”
It was over. It had been a magnificent performance on Prader’s part—no question about that. If it had been any other professor I might have congratulated him, but Prader didn’t give me a chance. He didn’t even look at me as he walked out.
12
IT WAS ONLY AFTER I left the conference room that I realized McMillan had not shown up despite his being paged. I thought perhaps there had been an emergency, but when I called the paging operator she said McMillan had answered and she’d given him Prader’s message.
I asked if he’d had any other pages and she said no. Nor had there been any call from the emergency room. It wasn’t like McMillan to ignore a page; worried, I went to look for him. I found him in the lab, going over some urinalyses.
“The operator said you answered the page,” I said.
He looked up from the samples. “That’s right.”
“But you didn’t show. Anything wrong? I mean—”
“No,” he said. “Nothing’s wrong. I just had a lot to do.”
“Didn’t the operator tell you Prader wanted you in the conference room?”
McMillan shrugged. “I know what has to be done. They’re going to let her be treated, are
n’t they?”
“So you see,” he said when I nodded, “Prader didn’t need me. This place is too busy to be where you’re not needed.”
“Yeah, but he’s not going to see it that way,” I said.
“That’s his business. Even when I’m not needed I go if I can learn something. But just to sit is not my thing. I don’t learn any more from such conferences.”
I guess my face must have registered dismay or something, the way McMillan went on trying to explain.
“Look,” he said, “they can’t do everything. Some professors, I admit are better than others, but all the bosses around here are researchers and/or administrators.” He put the test tube he had been holding back in the rack and picked up the one next to it. “That’s their interest; that’s how they run this place and how they maintain their position and why they’re promoted. Talking to patients or parents is not their thing, even if they think it is, or are forced into it. They really don’t know how; even if they care, they don’t know. Oh, I admit they can get a patient to do things and you can learn all the tricks by listening to the professors, but once you’ve learned it’s silly to keep going back to them.”
“Wait a minute,” I said defensively, “I’ve sat in on two of Prader’s conferences, and—”
“Don’t get me wrong. If something’s the matter with your heart you want Professor Brown to find out what it is. And Blanchard to operate on it. You want to listen to everything they have to say about heart disease, and to Prader about hematology. You need them and the patients need them. But being an expert on parts doesn’t make you an expert on the whole. Learn all you can. I only wonder if you’ll be sitting in on Prader’s conferences next year because you’re learning something or because you want to keep him on your side.
“Believe me,” McMillan added, “no matter how hard you listen, there will still be times around here when you’ll be on your own.”
A short time later Cranston, one of Prader’s research fellows, came by the ward with the protocol for Mary’s treatment.
“Dr. Prader wants you to use this protocol,” he said, “but since the patient is already on prednisone, he’s not going to include her in the study.” He handed me the card.
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