I left the room feeling completely drained, emotionally and physically. Even before the call about Mary had come in I had felt bone-tired. Now, with all that had happened and hardly any rest in the past twenty-four hours, I had the whole ward facing me again, including drawing the bloods.
And yet the realization that Mary was alive partly because of me, because of what we had done, gave me a kind of buoyancy. In the last analysis, it made all other concerns meaningless. It kept me going; it kept all of us going. The thought that at any other time in history she’d have died, that so many of our patients—but for us and what we had been able to do for them—would be dead, gave us our pride. It gave us a belief in medicine, plus a kind of unquestioning certainty that what we were doing and how we were doing it was right and unchallengeable. It was what our professors trumpeted, what they’d sold to us as medicine, and, like the very breaths our patients drew, it became the only touchstone of success and failure.
20
MRS. GOWAN COULDN’T GET a special until noon; in the meantime she put an aide in to watch Mary. Neither McMillan nor I was satisfied with this arrangement, so we took turns checking Mary ourselves. I had just looked at her and was about to leave her room when the Berquams walked in. Damn it, I thought, a few seconds more and I’d’ve been in the clear. I mumbled hello and went on putting my things back into my case.
Mrs. Berquam, too troubled to speak, remained standing in the doorway. Her husband stood opposite me by the bed, his eyes fixed on the blotches of discolored skin on his child’s face and arms. Shaking his head, he stared at the IV bottle and the drops dripping slowly into the tubing, then looked closely at where we had cut into her neck.
“Idiot,” he said, so softly he might have been talking to himself, and raising his eyes to me, in a voice that was ominously calm, he added: “You stupid, blundering idiot.”
“Herb!” Mrs. Berquam said, starting toward him in alarm.
Her husband ignored her. “You stupid goddamn fool,” he said. “Have you done enough now?” And raising his voice menacingly: “Well, have you?”
“Please, Herb, stop,” Mrs. Berquam pleaded.
“Me stop!” he burst out. “Me! Is this what you wanted?” He seized her hand and dragged her over to the bed. “Look at your child. See what they’ve done to her.” He pulled back the sheet. “Go on, look at her.”
“My God!” Mrs. Berquam moaned. “Oh, my God!”
I grabbed the sheet from his hand. “What the hell—”
“Shut up!” he hissed through clenched teeth.
His wife was sobbing now, with her fists pressed tightly against her mouth.
“Berquam,” I said, “I want you out of here. Just get the hell out of here. Now!”
“Why, you arrogant young—”
I guess I saw it coming, but either I didn’t believe it possible or was too hemmed in between Berquam and the bed to move. I got my arm up but his fist skidded off my forearm and caught me on the side of the jaw, snapping my head around. The second blow landed on my shoulder. In the confusion of the moment I saw McMillan hurrying into the room, with others crowding behind him.
“Hold it!” McMillan said.
Berquam turned from me. “You sonofabitch!” he cried, “are you satisfied now? Look at her. Look!” His voice bounced off the walls and out into the corridor. “Haven’t you tortured her enough?”
Without warning he hurled himself on McMillan and the two men hit the floor. I heard a sharp crack. Berquam was on top and getting ready to swing when I seized his arm. At the same time somebody grabbed me from behind. Twisting around I caught whoever it was with my elbow. McMillan managed to push Berquam off him, but before he could get up Berquam was on him again, punching him in the face. I swung at Berquam and got hit myself. Stunned, out of the corner of my eye I saw Handelman, with blood gushing from his nose, getting ready to swing again. But suddenly there were arms around him and others were grabbing Berquam and me.
“Let me go,” Berquam screamed hysterically, struggling to free himself. “Look what they’ve done to her. She’s dead. Can’t they see it? She’s dead. She’s dead. Don’t they know it? She’s dead. She’s dead. She’s dead.”
Mrs. Gowan was the one who straightened things out and got the ward functioning again. Within minutes she had the hallway cleared, parents and visitors back into their own rooms, and the ward looking as if nothing unusual had happened. She had Mrs. Berquam taken to an empty room and gave her a sedative herself, had an aide take Handelman down to radiology to have his nose X-rayed, and called one of the psychiatric residents down to see Berquam. McMillan had to have the inside of his mouth stitched up. As for me, except for a feeling of confusion and a couple of bruises, I was okay if still stunned.
Prader of course found out what had happened, and within a half hour was on the ward. He talked with Mrs. Gowan and apparently tried to talk to Berquam who refused to see him. I expected to find Prader angry, even furious, but he was quite calm even when he talked to us. It was plain, though that he was put out, that the edge was on.
“I know how it ended,” he said dryly. “How did it begin?”
McMillan told him about Mary’s vomiting and aspirating, the respiratory arrest, the intravascular consumption and its treatment. He reported on the lab values, the medications and their dosages, the route of administration, the cut-down, the central venous pressure, the arrhythmias, and transfusions.
Prader seemed to be studying me while McMillan was talking, but I felt too exhausted to react or care. To hell with it, I thought. We’d done what had to be done, and we’d done it right. What happened wasn’t our fault.
“The real problem,” McMillan said, “was that the Berquams got into the room before I could talk with them. I called them, but they had already left for the hospital. I didn’t see them when they came in. They went directly to their daughter’s room. I didn’t have a chance to warn them, or even tell them what had happened.”
“Why didn’t you call them last night?” Prader said, “or early this morning when you realized she was becoming worse?”
“We were working. I called them the first chance I got.”
“Then why didn’t you have the nurse call, or an orderly?”
Jesus Christ, I thought, what’s this, the third degree or something? McMillan just looked at Prader a moment, and then said calmly: “I was busy. All my thoughts and energy were centered on saving her life.”
I thought Prader was going to go after him. Instead he turned to me, and I told him what had happened in the room.
“I was standing there, about to leave,” I explained, “when Berquam came at me. He just freaked out. I guess I blocked the first punch, but he kept coming. The second one glanced off the side of my head. Then Dr. McMillan came in and he turned on him.”
“And Mrs. Berquam?”
“She tried to stop her husband, but he just pulled the sheets off the patient and asked his wife if that’s what she wanted. It would have made any mother hysterical.”
“And what did you do then?” Prader asked.
“What do you mean?” I asked.
Prader ignored my belligerent tone. “I asked what you did then.”
“I took the sheet away from him.”
“And Mr. Handelman?”
“I was trying to help McMillan. I swung around and I guess I hit Handelman with my elbow.”
“Breaking his nose is hardly helping Dr. McMillan.”
“He was trying to get Berquam off me,” McMillan said.
“He can speak for himself,” Prader snapped.
I resented the inquisition. “Hitting Handelman was an accident,” I said angrily. “My only concern was to get McMillan free of Berquam and I’d do it again if I had to.”
Prader looked at McMillan. “Do you agree with that? Hitting him if it happened again?”
The question was so unexpected it caught us both offguard.
“Well, Doctor, I’m waiting,” Prader said. “Never mind�
��From now on I want to know about any change in the patient’s condition. And I want you to check with me about any change in her orders. Any change. Is that understood.”
Afterwards I thanked McMillan for trying to bail me out.
“It’s OK,” he said, calmly as if nothing had happened.
The ward didn’t settle down. It’s not every day that you have a brawl in a patient’s room, not every day that doctors are attacked and parents injured. The tension remained. And it was growing; I could see it in the looks we got. I found myself having to explain things two or three times and even then, in some cases, I could only get a provisional kind of acceptance. Several parents demanded to see a staff man before they would sign an operative permit or agree to a procedure no matter how small. Even the most cooperative parents seemed suddenly to view all of us with caution. The whole situation made me uncomfortable, as I knew it did Lang.
McMillan acknowledged there was a problem but shrugged it off. “Any time a system breaks down, or shows signs of strain—especially one as important and intricate as medicine—there’s bound to be a period of confusion,” he explained. “It makes people leery. But it will pass. Don’t let it bother you.”
But it did bother us. For Lang and myself it was becoming a trial just to walk on the ward. Mrs. Gowan, too, was feeling the pressure, spending a great deal of time just trying to keep the peace between the parents and us. Some of the nurses, especially the older ones like Barbara, were as concerned as we were and sympathized with us, while others like Chris said nothing.
Chris was in the room with me when a mother asked for a weekend pass for her child. “You’re not doing anything but taking her temperature and giving her pills,” the mother said. “I can do that myself.”
I explained why her daughter had to stay, that we had to watch her blood pressure. “It may not seem as if we’re doing much, but we are,” I said and I went over the whole thing again; what we were doing and why, the need for taking temps and blood pressures. Finally I managed to convince the mother that her child should stay. And all the time Chris went on with what she was doing, offering no help or support.
“I could have used you on my side,” I said when we left the room.
“I’m not on any side,” she said. “I just listen.”
“So you think that’s enough, just to listen.” She was about to turn away when I grabbed her arm. “For Chrissake,” I said, “it’s like pulling teeth. This place is becoming a real burden. What’s going on is interfering with everything. If you like listening, then listen. I could grind out the next couple of weeks here making like I was blind and deaf, but I don’t want to play games.”
Chris looked at me searchingly.
“We had a good ward,” I said. “What’s happening?”
“Can’t you see for yourself?”
“I can see Berquam’s stirring them up.”
“Oh, for God’s sake! They’re not children. Do you think Braden gave Mrs. Gowan an argument because Mr. Berquam talked him into it? That the Handelmans are bitter because Mr. Berquam told them things they didn’t know?”
“Well, he sure doesn’t help any,” I said.
“He’s not the problem. Take Mr. Berquam off this ward and the parents would still feel the same way. Yes, they would and they’d still be abused in the same way. They’d still be intimidated in the same way. They’d still be angry.”
“What are you talking about?” I said with some heat.
“You said you wanted to know what was happening, didn’t you? Do you think Mr. Braden blew up over a stupid ten or fifteen minutes of visiting rights? Or that Mr. Handelman’s worried about Freddy not getting the care he needs? Nonsense. He’s worried, alright, but not about whether the catheter’s in the right place or the ALG’s the right dose. What’s eating him is how in heaven’s name he’s going to get the money to keep paying for his child’s care. How’s he going to pay for another transplant with what his insurance covers. Have you, or Lang, or McMillan, ever asked him how he feels about going through the whole thing all over again?”
I was about to protest, but Chris had the bit in her teeth and nothing could stop her.
“It’s like the Berquams,” she said. “For some reason you all seem to feel that everything begins and ends here on the ward. You’re wrong. These parents go home. They have other lives, other feelings, other concerns. Take one instance: Did any one of you know that Mrs. Berquam is pregnant?”
“That’s not our concern,” I said.
“Obviously not.”
“Damn it, we do talk to them. You know we do.”
“Well, you don’t do it very well. Some of these kids—especially the older ones—feel so guilty about their illness, the burden they are to their families. Holidays their brothers can’t take because all the money goes to pay hospital bills. The new car the family can’t buy because they have to pay for a new heart valve. These kids see how worried their fathers are about bills, and they get so depressed, some of them, they wish they were dead. They don’t take their medications, they don’t follow advice, they don’t stick to their diets.
“Not a day goes by when the nurses and even the aides aren’t asked questions that you doctors should have answered. Or at the very least been aware of. If you don’t think those concerns affect patient care, you’re crazy.”
“It’s not that we aren’t always available,” I said. “I’ve never ignored a question, nor has McMillan, or Lang, or anyone I know of.”
“Sure. You talk to them about sodiums, potassiums, urine culture results, and all the rest, and they don’t understand what you’re talking about. You don’t answer a damn thing, actually. You’re all so smug and self-centered and unapproachable that most parents are just plain afraid to ask you about the things that really bother them. The little things that mean so much. They’re afraid you’ll laugh at them.”
“For God’s sake, Chris,” I protested, “we’re not mind readers.”
“Oh, come off it,” she said. “You don’t have to be a mind reader to know how much depression, how much anxiety, anger, and guilt there is out there. The only thing that’s preventing a real revolt is that eventually most get a little of what they want. Their kids get better soon enough. As for the rest, it’s only fear that keeps them in line. If you get angry with them, they’ve got no place to go.”
We had over twelve hundred admissions a year and most parents left realizing that we’d done all we could and their children had got the best medical care available. There would always be those who left unhappy or disgruntled or angry. I felt that Chris had gone off the deep end. Still, if she felt so strongly that we weren’t handling things right I was willing to give it a try. I was all for doing anything to make it easier for the parents—and for me.
It was like falling into a bureaucratic nightmare. Little things I thought could easily be done became impossible to accomplish. When parents complained about having to wait so long to see the surgeons I tried to help by paging them myself. I might have spared myself the effort. I only succeeded in angering two of the chief residents who told me to quit paging them, they would come when they were ready. And when I tried to facilitate work-ups, the X-ray department refused to schedule two procedures the same day or do anything on Saturdays.
The nursing office was opposed to allowing patients on medications to leave for overnight stays, and the administration absolutely refused to sanction passes for more than twenty-four hours. “If you want to let them go for over twenty-four hours,” I was told, “you will have to discharge them and readmit them.”
Laboratories closed at three in the afternoon, which made it necessary to keep the patient another day at $140 for a follow-up lab test, rather than discharge him and have him brought back the next day. With most fathers working and families having only one car, there was no way the patient could be brought back to the hospital before three, so we had to keep him.
I began to see that in a very real sense the hospital was run fo
r the people who worked in it, rather than for the patients. I had never thought of this before, and even now it was hard to accept, but there it was.
21
LIKE A FAIRY PRINCESS, Mary stayed in her trance, unwaking and unwakeable. Her skin lesions began to fade, but aside from that she did not respond. Watching her, it was as if her frail stricken body was struggling desperately and alone to put itself in order.
There were times when it seemed she was close to waking. “Mary,” I would whisper as I stood by her bed, “Mary,” imploring her in my heart to wake. At times I felt she heard me; her eyelids fluttered, but her eyes remained closed. She seemed so close to waking in those tense quiet moments.
We did two more spinal taps. McMillan called Prader about the first one. Judging by how long he stayed on the phone, I thought there must have been some kind of argument.
“Something wrong?” I asked when he hung up.
“No—not really.”
“What do you mean, not really? I don’t like this being in the middle without knowing what’s going on. Prader’s not the easiest guy to read but it’s obvious he’s not pleased. You were on the phone quite a while. Doesn’t he want us to do the spinal tap?”
“He agreed,” McMillan said.
“Agreed! That means—”
“Like you said, he’s impossible to read.”
“I said difficult, not impossible.”
“Come on,” McMillan said. “Let’s get the tap done.”
He let me do the tap while he held Mary steady. Every tube filled with blood. Unhappily, I held them up one at a time to show him; the last one was as bloody as the first.
“She bled into her skin, why not into her brain?” he said, “same process, only different organs.”
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