Ward 402

by Ronald J. Glasser

  “For Chrissake,” he complained, “somebody’s feeding them that kind of technical information. How the hell would they know that the Mayo clinic is using half the ALG dose we are. I’m telling you, McMillan, it’s Berquam. He’s the only one who could be doing it, and you’ve got to stop him.”

  We were on afternoon rounds. McMillan looked questioningly at Mrs. Gowan.

  “We can’t stop them from talking,” she said. “At least, I can’t.”

  McMillan said he would talk to the Handelmans the next day, and it seemed to quiet things for a while. But then Freddy had a seizure and we had to call them in at three o’clock in the morning because we thought he might die.

  We were faced with the problem of any high-powered teaching and training center—continuity of care. Dr. Kadden was head of the transplant service. He did the surgery or supervised it. But as head of the department and an international authority on transplantation, he was hardly ever around for the more routine things. He left the daily care to his residents and they were forever changing, so that there were times when even we weren’t sure whom to call. It was only natural that parents sometimes found the situation confusing.

  Cane was the chief resident of the transplant service the night when Freddy had his seizure. He came over, in his surgical greens, as soon as we called, but by the time he got to the ward we had already stopped the seizure. The child was very sick and close to arresting. We had had to do a cut-down, and the room was a mess of tubes, gauze, and emergency equipment.

  “Looks bad,” Cane said. “His blood pressure still up?”

  “Yeah. He might have bled into the brain,” I said.

  “No question, we’ll have to take out his kidney tonight. Are his parents here to sign the consent?”

  “They’re on their way.”

  The Handelmans wanted Kadden. In the middle of the night, with nurses, aides, doctors, and technicians running in and out of the room, tubing and catheters all over the place, their son unconscious and connected to monitors clicking and flashing all around him, they wanted the chief.

  Cane tried to talk to them. “I know how you feel,” he said, “but Dr. Kadden is out of town at a conference.”

  “Then what about Dr. Simpson?” Handelman asked.

  “He’s no longer on this service. I’m responsible—”

  They knew Cane was the new chief resident, but they still wanted Kadden.

  “He’s not here,” Cane said again.

  “Then get him,” Handelman demanded.

  Cane kept his cool. “Look,” he said, “time is important. Your son’s already had one hypertension seizure. The medications aren’t helping him. If we don’t act promptly he may have another and end up severely brain damaged—or dead. I’ll try to get hold of Dr. Kadden, but in any case the kidney will have to come out tonight.”

  Cane couldn’t reach Kadden. He called Singleton, one of the staff surgeons, and after explaining the situation to him handed the receiver to Handelman who proceeded to complain bitterly about the lack of concern and the shifting of responsibility. When he saw there was no real choice, Handelman finally and reluctantly signed the operative consent, and with that signature he agreed, as he must have known, not only to the removal of the kidney but to beginning the ordeal all over again, since it would be impossible for his son to live without a kidney.

  Half an hour later they were wheeling Freddy out of his room to the OR.

  14

  FREDDY SURVIVED. AFTER THE operation, Cane, still in his scrub suit, went to talk to the parents while McMillan and I accompanied the patient to the recovery room, wrote the pediatric post-op orders, made sure the nurses understood what we wanted and that all the cut-downs were working well. The whole thing wasn’t over and settled until it was almost day. Yet when Mrs. Berquam appeared a little after nine she already knew what had happened. Even before she had seen her own daughter she stopped me in the corridor to ask how Freddy was doing.

  In the course of the morning several of the other mothers, obviously informed about the surgery, also questioned me. Mrs. Birkell, whose daughter had been admitted only two days before for a tonsillectomy, even asked specifically if Dr. Kadden was back in town. When I told her I didn’t think so, she asked me if he had been reached.

  “I don’t know,” I said. “Why?”

  “Oh nothing.” She shrugged off my question.

  “No, tell me,” I said, “I’d like to hear. Do you know the Handelmans?”

  “Not really.”

  “Believe me, Mrs. Birkell,” I said, trying to reassure her, and at the same time resenting her defensive attitude, “the operation had to be performed. There was no other choice.”

  “But Dr. Kadden was their doctor, wasn’t he?”

  “Yes, in a way, as the head of the transplantation service.”

  “He did put in the last kidney, didn’t he? I mean he did the last operation. Don’t you think he should have been there? After all, the child was his patient. It was his operation that failed.”

  I was taken aback that she thought the head of the department of the largest transplant unit in the country had to be immediately on hand, especially for anything as simple as removing a kidney.

  “He’s a busy man,” I said impatiently. “He can’t always be present. He teaches, he travels, he lectures. Emergencies are bound to occur, and if he’s not around, things still have to be done. It’s not as if he leaves his patients unattended, you know. The doctors under him are superb surgeons. They go right from his program to professorships at other centers. I assure you those who operated last night were thoroughly competent.”

  “Still, he should have been called,” Mrs. Birkell insisted.

  “Perhaps,” I said, backing off. What was it to her that Kadden hadn’t been called, I wondered.

  Then I learned from Lang that one of the other mothers had quizzed him if Kadden had agreed to the emergency procedures.

  “She wanted to know if he’d been consulted,” Lang said. “Hell, I was surprised she even knew who he was.”

  “How about the others?” I asked. “Did anybody else ask you what happened last night?”

  Lang nodded.

  “Doesn’t it bother you? I mean all of a sudden everybody getting so concerned about what’s going on with one patient?”

  “No,” Lang said. “Not particularly. Gossip is always with us. An operation in the middle of the night is an interesting event.”

  “I don’t mind the questions,” I said. “It’s the way they’re asked. As if we were all being put on the spot.”

  The Handelmans had stayed through the rest of the night, waiting near the recovery room. Mrs. Handelman left in the morning, and then only at McMillan’s and Cane’s urging, and perhaps because she had to get her other children ready for school. Her husband stayed on, and when in the afternoon the surgeons transferred Freddy back to 402 he stayed with him until the child was settled in and beginning to wake up. None of the parents who had questioned Lang and myself spoke to him. For all their seeming earlier concern, they acted as if nothing had happened.

  We had two emergency admissions that morning one after the other. The first was a newborn infant in massive heart failure from a congenital heart defect. The other, admitted at almost the same time, was a toddler with encephalitis and liver failure.

  As soon as they reached the ward we had them in the treatment room, side by side on separate tables. I did the cut-down on the newborn, while Lang started on the toddler. Standing between the tables McMillan directed us, helping where he had to. Mrs. Gowan ran the nurses, cracking open vials of medicine, drawing up the drugs, assisting where she could.

  The baby was cold, his skin a mottled sickly gray. Even with Mrs. Gowan holding the oxygen mask over his face, he was struggling to breathe, his little chest moving in pathetic exhausted heaves. Every now and then while I was working I heard McMillan beside me asking for something—a new needle, a syringe, some Apresoline, but I was too busy to look
up. Within five minutes I had the cut-down in and had pushed in the first dose of digitalis and diuretic. I stopped only to let the portable chest film be taken and then moved back in again.

  While I was putting in the central venous pressure, McMillan had called the cardiologist and on the basis of the X-ray it was decided to do an emergency heart cath. Meanwhile the neurologist who had come up to help Lang told him that his patient would have to have an exchange transfusion. By now there were so many doctors and nurses in the room you could hardly move. While they were setting up the cath lab I went out with McMillan to talk to the baby’s father who had ridden to the hospital in the ambulance with him: the mother was still in the hospital recovering from the delivery.

  We took a quick history about the delivery or rather what he knew about it, explained what we felt was wrong and what had to be done, and got permission for the heart cath. The child did not survive the catheterization procedure; he died on the table.

  It took a while to explain to the father that the heart defect would have been inoperable even if the child had not died during the catheterization, that the trouble was not due to a genetic defect but was simply an abnormality of organ development. We explained there was no reason to believe that their future children would be at any greater risk with regard to heart defect than any other child being born. We arranged for the autopsy permission and had him sign the forms.

  It’s hard to tell a parent his baby is dead, but the father took it well, at least while we talked to him. It was not until later, much later, it struck me that neither McMillan nor I had asked him how he felt, or about his wife and how he thought she would take the unhappy news. All we had done was give him the medical facts.

  We were not very good with death. Indeed, death was something rarely mentioned on the ward, or any ward for that matter. In a world of dying, death was the really unacceptable thought.

  By the time we got to the treatment room, the other patient was already being transfused. “It looks like a Reye’s syndrome,” Lang said. “At least his blood glucose is eight, and his liver function tests are really screwed up. His SGOT is 7,000. The neurologist agrees.”

  “You’ve got to be sure,” McMillan cautioned. “You’ll have to do a spinal tap.”

  We had three more children admitted that afternoon. The last one needed tomograms so that it was well into the evening before I got back to 402. The ward was quiet. A few of the parents not sitting in the rooms were in the auditorium with their children watching television. I was surprised to see the light on in the conference room. We liked to keep that room available for emergencies, a place to put parents while we were working on their child. There was no place else on the ward that was private; if we didn’t want to use the patients’ rooms, the conference room was all we had.

  I went to ask whoever was using it to leave, and was about to walk in when I heard Berquam’s voice and saw the back of his head through the partly open door.

  “Believe me, Herb,” he was saying, “I’ve been around hospitals long enough to know they could have got Kadden for you if they’d wanted to. How hard do you think Cane tried? If you were a bank president or the head of some big company, you can bet they would have let Kadden know. Hell, Kadden would have chewed Cane’s ass if they had done a major procedure on an important person without first getting his permission.”

  “He was out of town,” Handelman said.

  “It’s been eighteen hours since. Have you heard from him yet? There is absolutely no reason why you should have to deal with anybody but the boss, especially with doctors—residents you’ve never seen before. He’s your child, not theirs.

  “And the money! Where the hell are you going to get the money? Those guys you talked with last night, are they going to give it to you? Think they even take the expense into consideration? Just sitting here’s a hundred and seventy-five dollars a day. And what about another transplant with the additional surgical and intensive care charges? Anybody ask how you’re going to pay for all that? Anybody even care? What about the rest of your family? How are they going to live? You’ve got to learn to take care of yourself, Herb.

  “I’ll bet nobody’s mentioned home dialysis to you, have they? It’s not because they don’t know about it. It’s because the experts in home dialysis aren’t here; they’re up in Boston. They’re pushing their own things down here and you pay the price. The patients always have to pay the price. Kadden’s thing is recipient typing and transplantation, not dialysis. If you were in Boston they’d be talking dialysis, not transplantation. Each specialist pushes his own thing, tears down the other guy’s ideas while he minimizes the risks and complications of his own. The patient be damned.”

  I couldn’t believe my ears. I just stood there coming to a slow boil as Berquam continued his harangue.

  “Why do you suppose the Krugers are using that expensive antibiotic, instead of a less expensive one? I’ll tell you why. It’s because the damn urologists don’t even know how much the drugs cost that they prescribe. That kind of knowledge isn’t part of their work-up. Or take the Hartmans. Having to have that skin biopsy on Friday instead of the following Monday, with a weekend of sitting around doing nothing at a hundred and forty a day? Or those iron pills the intern gave Joan Birkell to take, just to see if they worked.

  “Look, Herb, I’ve been around hospitals a long time. I’ve seen enough wrong diagnoses, wrong treatment, wrong medications. Weeks and months of pain because people were afraid to question their doctors. Doctors don’t like being challenged or told they’re wrong or even being questioned—about anything. It’s a closed shop. Hell, we have an obstetrician at our hospital who induces all his labors and has a higher incidence of brain-damaged newborns than any other obstetrician in the area. They all know about it. The nurses talk and make sure that none of their friends go to him, but he’s still practicing and making a fortune. Nobody stops him. Believe me, Herb, I know doctors, and a more self-assured, self-righteous lot you’ve never seen—”

  Enough, I thought, I’ve had enough. Goddamned troublemaker. That’s the thanks we get for saving his daughter’s life.

  In the doctors’ station Chris was bringing the vital-signs chart up to date.

  “Have you seen McMillan?” I asked angrily. I must have sounded strange, the way she looked at me. I was really burned up.

  “He’s not on tonight,” she said.

  “Do you have his phone number?”

  “It’s in the top drawer, over there.” She pointed to the admitting desk. “What’s wrong? One of the patients?”

  “No, one of the grateful parents.”

  “Mr. Berquam?”

  “Right the first time. Bastard’s working Handelman over.”

  “Why bother Dr. McMillan?”

  “You want another parent trying to check his child out against medical advice? This kind of thing is best stopped at the outset.”

  “What kind of thing?”

  “Why the hell don’t you go over to the conference room and listen for yourself?” I said.

  “I have,” Chris said, as cool as I was hot.

  “You have? What do you mean you have?”

  “I’ve heard him talking to other parents.”

  “Like that? You mean—”

  “Like what?”

  “Like scaring Handelman. Like telling him we’re not competent and he’d better check up on everything we’re doing.”

  “I don’t think he’s saying that.”

  “You don’t, eh? Then for Chrissake go listen yourself.”

  “Maybe you’re the one should go back and listen,” Chris said stiffly, and walked out of the station.

  I wasn’t used to having a nurse walk out on me like that. My hand shook as I dialed McMillan’s number.

  “Sorry to bother you,” I said. “There’s something going on here you should know about.” I told him what I’d overheard.

  “Yeah, OK,” McMillan said. “Handelman still there?”

  I gu
ess I knew when I called him he’d come in. I felt relieved when he said he would.

  He came on the ward about fifteen minutes later, wearing wash pants and a blue shirt open at the neck, and looking thoroughly bushed.

  “Sorry,” I said. “I suppose it could have waited. But—”

  McMillan shrugged. “What about Freddy.”

  “Stable. Blood pressure’s OK and he looks like a rose. We’ll be able to cut back his dialysis to twice a week instead of every other day—What are you going to say to him?”

  “Which one, Handelman or Berquam?”

  “Christ! I wasn’t even thinking of Berquam. He’s like a lost cause. I mean Handelman.”

  McMillan puffed out his cheeks. “I’ll tell him what he already knows. This isn’t a perfect place, but it’s the best available, and as far as medicine goes, there’s none better.” He paused, frowning, as if trying to recall something that had slipped his memory. “Where is he?”

  “I saw him go into his son’s room just before you came in.”

  McMillan nodded and left the station. I finished the last of the progress notes and was about to leave when I saw Chris standing near the medication cart in front of Mary’s room, talking to Berquam. It bothered me to see them talking in such a friendly way, and I was aware of my annoyance as I went to check two kids who had spiked fevers earlier in the evening. When I came out Chris was pushing the med cart down the corridor to the next set of rooms. I stopped her.