Ward 402

by Ronald J. Glasser

  “She’s probably right,” McMillan said. “We should talk more.”

  “Let me know when you find the time,” I said.

  There was no question McMillan went out of his way to keep parents posted. I’d watched him keeping Berquam informed on every change in his daughter’s condition, every fluctuation in her laboratory values, every up and down in her vital signs. And not only Berquam; he did the same for other parents as well. Now, I wonder if that’s what he meant by talking to parents, if he wasn’t really talking at them instead. I doubted even then if it was what Chris meant.

  Anyway, it was almost three hours later before I could get back to Mary. One of our patients, a hemophiliac who had come in two days before because of bleeding into his knee joint, had begun bleeding again. It took most of the afternoon to treat him—pumping hyalin concentrate into his IV, ice-packing his knee, keeping his blood pressure up and the swelling in his knee down.

  17

  WHEN AT LAST I was able to look in on Mary I found her half-sitting up, using the pillow as a sort of prop to rest against while she read. She was alone.

  Putting down her book she watched me come into the room. I thought she looked troubled. There was still nothing I could put my finger on. She didn’t look ill, if anything she looked more alert than in the morning, but there was something about her, a kind of uncertainty, a vague unsettled look in her eyes that made me feel apprehensive, like hearing thunder on a clear day.

  I glanced at the day sheet. Her vital signs were normal, and when I asked her how she felt she said again she felt fine.

  “Come here.” I pulled her closer to the edge of the bed and cupped her chin in my hand. “Anything hurt?”

  She shook her head. But the look was definitely there, right under the surface, behind the eyes.

  “Mary, tell me,” I said, almost pleading for a clue, “is there anything wrong? Something bothering you? Your stomach, or your eyes, your ears?”

  She shook her head again.

  “Sure?”

  “Sure.”

  “Could you stand up, here by the side of the bed?”

  She swung her feet over the edge and jumped to the floor.

  “Dizzy?”

  “No.” She had no hips and her pajama bottoms began slipping down. She quickly yanked them up, untied the draw string and pulling it tighter retied it, then studiously went about making a bow of the string. I offered to help.

  “Never mind,” she said, “I’ll do it.”

  When she had finished and her pajamas were adjusted to her satisfaction she looked up at me. “Do many people die here?” she asked.

  Her question was so unexpected, her gaze so demanding, I just stood there, not knowing what to say.

  “Well?” she said impatiently.

  “Why do you ask?”

  “Daddy says it’s better if you die at home. He says doctors only care about what other doctors think—I heard Daddy say it,” she added as if that answered in advance any objection I might make.

  “Well, daddies can be—” I caught myself short. “What do you think dying means?” I asked.

  “They put you in the ground.”

  “No, no,” I said quickly. “You go to heaven. It’s sort of nice.”

  Mary lowered her eyes as if she felt embarrassed for me, and indeed as soon as I had spoken I felt how foolish I sounded, even to myself—foolish and false—and angry at my incapacity to answer this child as simply and directly as she questioned me. I was in fact totally unprepared for what she asked and it was not too surprising. Not once during medical school or during my internship had anyone—professor or instructor—discussed the dying patient, except to indicate what to do for a failing heart, or falling blood pressure. In the whole time I had been responsible for patients there had not been a single scheduled conference, or informal discussion, not one comment on the difference between a ten year old dying and a dying toddler, or how we might as physicians help make our patients’ dying less terrifying, less lonely, or even, for that matter how we might feel about death ourselves. We were simply left on our own, and we did not do very well. At times, I think, we made things worse.

  “Come,” I said now, taking Mary’s hand to hide my embarrassment. “A couple of blood pressures and we’re finished.”

  Usually she watched with interest whatever was being done to her. Even when we drew blood she watched to make sure the needle was pointed the right way, the tourniquet placed exactly where it had been before. If we missed the vein she’d wrinkle her little nose and look up at us with such disdain there was no need for her to say anything.

  Today her interest was gone. She lay with her eyes closed paying no attention to what I was doing. As I was unwrapping the last of the cuff, her mother came in. She looked tense and worried.

  “She didn’t touch her lunch,” Mrs. Berquam said.

  “You didn’t, Mary?” I said.

  She turned her head to look at me.

  “Did you drink anything?”

  “My milk.”

  “I still think it’s a virus, or the flu,” I said to Mrs. Berquam. She was standing there so expectantly, I felt obliged to say something, though the truth was I didn’t know what was wrong and so I blamed it on a virus. As doctors we had been trained to cater to such expectancy, to give an answer to whatever the question of the moment might be. Actually, I can’t remember one of us who ever really admitted to a parent that he didn’t know the answer. McMillan came closest, once or twice, but even he hedged and gave the percentages, cited statistics, instead of expressing the concern he must have felt—or just saying he didn’t know.

  “I’ll keep checking her though, just to make sure,” I said. “But right now she’s OK.”

  I wrote an order for some blood tests—nothing spectacular, merely a serum sodium and potassium—telling myself it was for a base line, though it was just to do something. I could not get out of my mind that troubled look I had seen on Mary’s face when I walked into her room.

  Mrs. Berquam must have called her husband at work because an hour later he came on the ward still wearing his own technician’s whites. I saw him from the far end of the ward making directly for his daughter’s room.

  I was on my way to one of our surgical patients, a little boy who had had an abdominal tumor removed three days before and had been hypertensive ever since. We weren’t too worried. McMillan had talked with the experts on high blood pressure and tracked down the articles they’d recommended, showing that hypertension was a common result of abdominal surgery and usually disappeared on its own within a week after operative procedure. Still, we kept checking; I agreed with him that even if the high blood pressure was going to disappear eventually we didn’t want it to get too high while it was still around.

  I was about to begin examining the patient when Mrs. Gowan came into the room to say that Berquam wanted to see me.

  “I’m busy,” I said. “Get McMillan. He’s been dealing with Berquam. Besides, I just got through talking to Mrs. Berquam.”

  “Dr. McMillan’s not around. He went down to the coffee shop.”

  “Well, he’ll be back soon.”

  “You’d better see Mr. Berquam now,” she said firmly.

  “She’s not feeling well,” Berquam said as I came into the room. Mary was asleep, the shades had been drawn, and in the dim light I did not see him at first. He was standing at the far side of the bed, facing his wife.

  “She began feeling poorly this morning,” I said. “I’ve already explained to your wife—”

  “Explained, explained,” Berquam interrupted impatiently. “She didn’t eat her lunch, doesn’t want her supper. Her head hurts. What are you doing about it, that’s what I want to know.”

  I didn’t like being confronted like this but I made an effort to control myself. “Nothing, at present,” I said. “As I told your wife there is nothing to treat yet. I’ve gone over her, we’ve ordered lab tests, and—”

  “I’m not asking you
to find out what’s wrong,” Berquam broke in. “I already know what’s wrong. What I want is for you to make her comfortable. Not tomorrow, or the next day, but now. I want you to give her something now—”

  “But—”

  “No buts. I don’t want any more blood tests. I don’t want her to be stuck any more. I don’t want you or anybody else waking her up every hour on the hour. I want her to be left alone, and given something for her headache or any other pain she has. Is that clear?”

  “Hold it,” I warned. “The reason we check her so often, whether you like it or not, is because we don’t know what’s wrong now—and we have to know what’s wrong in order to help her. As for giving her something to make her comfortable—no, wait a minute, let me finish—that might make her feel better for the moment, but it can also keep us from knowing what’s wrong until it’s too late. Whatever pain medication we give her now could very well mask any real symptoms—Damn it! Will you please just listen—I don’t like pain any more than you do. I don’t want to see my patients suffer. But I’d rather see them suffer a little than see them dead.”

  “What the hell is she going to be?” Berquam shouted. “Now you listen to me, Dr. Wiseguy. You do something and you do it now.”

  “Robert,” Mrs. Berquam pleaded, “please.”

  His attitude was so threatening and I was so angry we might have come to blows had his voice not wakened Mary.

  “Daddy! Daddy!”

  Startled, he saw her struggling to sit up—her arms outstretched to him. It was too much; Berquam dashed past me and out the door like a madman.

  “It’s alright, Mary,” I said, trying to keep my voice calm though my heart was pounding. “Daddy’ll be back. Just lie down again, honey, and rest.” And to Mrs. Berquam, who sat there looking stricken: “I’m sorry,” but she seemed not to hear me and I left the room.

  Jesus! I thought, we knock ourselves out. To imply we weren’t doing our best, that we’d willingly let our patient suffer. I was furious.

  I was still simmering when McMillan came back and I told him what had happened. “I think we should call Prader,” I said.

  “What are you going to tell him?” McMillan said. “That Mary’s not feeling well? If we are going to call anybody it should be someone from the infectious disease group.”

  “It’s Berquam I’m thinking about.”

  McMillan rubbed his chin. “Well,” he said, “it’s partly our fault. We should have been the ones to tell him about her not feeling well, not his wife.”

  “Maybe so,” I said, not wanting to get into it. “What about Mary? I’m worried.”

  McMillan said he would check her himself.

  “Something’s definitely wrong,” he said afterward. “Why don’t you get some blood cultures? What’s the matter, you don’t think she needs them?”

  “I guess it’s a good idea. But to do it right I’ll have to stick her five, six times, and her arms are pretty sore already.”

  “Just get two, then. An hour apart. That should be enough. And a urine culture, just in case. Her electrolytes OK?”

  “Sodium’s a little down. But not bad.”

  McMillan was looking at me closely. “You alright?”

  “Yeah, I’m alright,” I said.

  Mary was restless. I drew the last blood culture a little after eight.

  “It’s just in case,” I told Mrs. Berquam. “So we’ll know if she’s infected. Sometimes, when you’re on prednisone and vincristine you can be infected and not know it. These cultures are a way of finding out.”

  18

  TIRED AS I WAS, I had trouble sleeping that night. I felt that things were getting out of hand, and I didn’t know what to do about it, even where to begin to do something. If parents couldn’t see how hard we were working, what we were doing for their children, where had we failed? The sudden tenuousness of our position distressed me. I fell asleep at last thinking how simple it was just to diagnose and treat, and how small a part of the picture it was becoming.

  The next morning Mary ate her breakfast and seemed a bit sprier, but I was still worried, not only about her but about her father. I kept expecting more trouble from him, and wondering if I should call Prader. I decided McMillan was probably right. After all, what could I tell Prader? That Berquam wasn’t happy? That Mary was uncomfortable? Still, McMillan’s not answering Prader’s page bothered me, his insistence that we do it all ourselves. Sooner or later we would have to account to Prader.

  Mrs. Berquam stayed on the ward the whole day. She was as considerate as always, but she looked more worn and exhausted than ever. I realized later that I should have talked to her. After all, she had spent the evening with her husband; something must have happened, they must at least have talked, and I should have found out what they’d said. But I didn’t know how to begin, or maybe even how to handle whatever she might tell me. After lunch I found a half-eaten sandwich, still in its wrapper, under her chair. It was probably the only thing she had eaten all day.

  The next day I got a call from bacteriological lab that one of Mary’s blood cultures had some growth in it. The blood culture bottles were kept in the bacteriology lab in a large walk-in incubator. I went in with one of the techs. It was warm and humid in the room but not uncomfortable. Mary’s two bottles were on the shelf marked 402.

  “They don’t look bad,” I said.

  “Hold the first one to the light,” the tech said.

  The amber fluid towards the bottom of the bottle had the barest haziness to it; the rest was crystal clear.

  “The other’s OK,” she said.

  “But if there is growth there’s not much here. Right?” I said.

  “No—But we call any growth positive.”

  “Did you plate it out?”

  “We’ve subcultured it, but it will take another day or so to grow out.”

  “Did you smear the subculture and stain it?”

  “We do that routinely. It’s a gram positive cocci, in chains.”

  “It could be a contaminate, though,” I said hopefully.

  She looked at me. “Could be,” she said. “There’s really not much growth.”

  “And the other bottle is still negative.”

  “I’ll have more for you when the subcultures grow out. Sorry,” she said, “wish I could be more definite.”

  So do I, I thought, as I went back up to the ward to find McMillan and tell him about the cultures.

  “It’s probably a contaminate,” I said. “I mean it’s only in one bottle. And there’s not much growth.”

  He thought for a moment, chewing on his lip. “Maybe,” he said, “but we can’t take any chances. We’ll have to treat her.”

  “That’ll mean starting an IV to give her the antibiotics,” I said. “If it’s a contaminate, she’s been sort of crabby all day and having an IV will really bother her.”

  “And if it’s not?” McMillan said. “We’ll just start the IV and treat her till we find out—and know for sure. You’d better get some more blood cultures, too, before we start the antibiotics.”

  “And Berquam?” I said.

  “I’ll tell him.”

  I got the culture tray and took it to Mary’s room. Mrs. Berquam got up from her chair. Mary looked at me suspiciously.

  “You already took today’s sample,” she said.

  “I know; it’s like what we talked about, Mary. There are times when we have to do things to keep you feeling well. Now I’d like to talk to your mother for a moment. OK? I’ll tell you everything we say.”

  In the corridor I tried to reassure Mrs. Berquam about what we’d found. “There’s only minimal growth in one bottle. If she really had organisms growing in her bloodstream they would be in both bottles, and it would be a much heavier growth.”

  “But where did they come from?” she asked nervously. “I mean the ones in the first bottle.”

  “Maybe off her skin. Even with all the alcohol we use to sterilize it there could have been one or two
organisms that survived and got caught on the needle. Or they might even have been on the stopper of the culture bottle and got carried into the broth when I pushed the needle through the rubber to transfer the blood from the syringe to the medium. It could have been contaminated in any number of ways.”

  “Sorry, Mary,” I said when we came back into the room. “I’ve got to take a few more cultures.”

  “No,” she protested tearfully, “no more.”

  “Mary, please, honey,” her mother pleaded with her.

  “No. No more,” she cried.

  I asked her mother to leave, but I couldn’t calm her myself. For the first time I had to ask someone to come in and help hold her down.

  Crying and whining was so unlike Mary, and her mother was so worried about the change in her behavior, I didn’t have the heart to mention starting the IV or beginning antibiotics. I took the cultures down to the lab myself and decided to call Prader after all. If anything suddenly broke, I didn’t want to have to worry about him, too. Maybe he might even offer some good advice.

  When I called from the doctors’ station, his secretary answered the phone. She said he was in his lab and I called him there.

  “Have you talked to the parents?” he said when I told him about the culture.

  I said I had talked to Mrs. Berquam and McMillan was calling Mary’s father.

  “How do you think they’ll take it?” he asked.

  “Well,” I hesitated, not expecting such a question, “the mother’s OK, I think, but I don’t know about Mr. Berquam. He can be pretty difficult, as you know. I—”

  He cut me short. “What are you planning to do?” he asked.

  “I just drew two more cultures. We’re going to start an IV and begin antibiotics.”

  “How sick is she?”

  “Well, sir, she’s not really that sick. No fever. She’s eating alright. But she’s a bit cranky. I mean—”

  “Which antibiotics?” he asked.