“As long as we have to, I suppose.”
Apparently he had heard enough, for he made no further comment, but turned on his heel and walked away.
“Did Prader talk to you?” I asked McMillan later.
“Yeah.”
“What’s going on?” I asked. “He’s pretty disturbed.”
“Pressures,” McMillan said. “Prader’s a great man, and he’s got a difficult job. Did he argue about Mary? How long to treat her?”
“In a way. He’s not one to argue much.”
“He runs a big department,” McMillan said thoughtfully. “How many leukemics does he take care of? A hundred, a hundred and twenty-five? Plus his research program? Plus his teaching? Even for somebody like him it’s hard to keep driving all the time.”
“So you think the protocol he sent down—”
“It was appropriate.”
“Sure,” I said, “but you wanted more.”
“No—It would probably be more accurate to say I couldn’t find a reason why more shouldn’t be done.”
“So you decided?—I mean, did you actually think Prader was shortchanging the patient? Giving her less than adequate therapy?”
“It doesn’t matter what I thought. The protocol might have been better. That’s arguable. We had no control over that. The important thing is since then we’ve been doing everything that we should be doing. That’s what counts—You look surprised.”
I hesitated. “I guess I am,” I said finally.
McMillan shrugged. “The father didn’t want her treated. She was desperately ill. And remember, she wasn’t on the study. Everyone could do what he wanted. No more rules.”
“So when she started to go sour you decided to make sure that nobody would shortchange her again, or could. Not Prader, not her parents. Nobody.”
“Preventive medicine,” McMillan said. “Right or wrong, you don’t lose either way.”
But what if he was right? It was hard to believe that Prader would ever do less than the maximum, that any doctor would, for that matter, much less Prader. He wasn’t the type to be rattled or pushed into doing what he didn’t want to do or what he felt was wrong.
Yet even as I thought about it, Prader’s question: “How long are you going to support her?” kept surfacing in my mind.
23
IF MARY HAD DIED right then and there—or begun to improve even the slightest—things would have settled down, not only for the ward but for me too. I would have been able to dismiss my own concerns and confusion by simply going on.
But Mary didn’t die. She just lay there and, in a sense, kept the whole thing going. True, the problems of the ward had taken on a momentum of their own, but her presence fed it. Parents of the new patients stopped talking when they passed her room; those who had been on the ward for some time pointedly ignored it. And I was plagued seeing her unmoving day after day, watching her mother barely able to bring herself to walk into the room, knowing her father was hiding somewhere.
Had we performed a miracle, or taken part in a disaster? The extraordinary thing was that despite all that was happening—or not happening—I was still expecting some kind of improvement in Mary—in fact counting on it. Didn’t we have all of science and medicine working for us?
In addition to examining Mary twice a day, morning and evening, I looked in on her before going to my room when I was on call to make sure the IV was fixed properly into her vein and running well. There weren’t many veins left to use and we didn’t want to lose any more than we had to.
It was about ten o’clock when Barbara called me to tell me there was something wrong with Mary.
“Her heart has speeded up a little,” she said when I joined her in the nurses’ section. “Just a little,” she added, seeing the anxiety in my face, “but it’s a pretty constant elevation.”
“How fast?”
“It’s been seventy, seventy-five. It’s eighty-five now.”
“Her fluids.”
“Right on schedule.”
Outwardly Mary’s condition seemed unchanged, but her pulse was eighty-five and the change in her respirations worried me. The change was subtle but I had watched her so intently for so long I knew they weren’t the same.
“Thanks, Barbara, I’ll check her over,” I said, and waited for her to leave the room. I wanted to be alone with Mary. I lifted her arm out from under the sheet. It was warmer than I expected. Even with her lying perfectly still her pressure was elevated. Ill at ease I checked the vital-signs chart on the wall; all her preceding blood pressures were normal. I stared at the straight lines, the days of straight lines—the heart rates, blood pressures, and respirations—which ran unerringly hour after hour across the chart.
And in the silence of the moment I knew, as surely as I had ever known anything, that Mary would never wake again.
“What was her last blood pressure?” I asked Barbara when I came back to the nurses’ station.
“Hundred ten, hundred twenty, over eighty,” she said.
“Well, it’s up now. Who’s the neurology resident on call?”
“Dr. Brown, I think. I’ll find out. What do you think’s wrong?”
“Her head. Increased intracranial pressure. Pressing on her brain stem affecting the nerve centers that control her respiration and blood pressure. Her lungs are clear. The last chest film was negative. There’s no other reason except her brain for her breathing to change or her blood pressure to fluctuate.”
In a few minutes Brown came in. I gave him Mary’s history and said what I thought was wrong. After examining her he agreed there probably was increased pressure.
“Since she’s bled into her head,” he said, “the clots could be breaking up and swelling, causing the pressure to increase.”
“What would you do?” I asked.
He shrugged. “Watch her. If she gets worse—glycerol, maybe mannitol. I’d cut back on the IV fluids and run her a bit dry.”
“How will we know?” I said. “I mean about her getting worse.”
Brown looked at me strangely. “More fluctuation in her blood pressure and respiration. Her heart may become erratic—speeding up, slowing down. Her pupils will dilate—she has to be watched, and closely. It can go quick; the brain stem can herniate in minutes—Those fading blotches on her body?”
“Purpura. She bled into her skin.”
“She has leukemia—right?” Brown gave me that look again. I knew what he was thinking. “OK,” he said finally. “I’ll be on all night. If anything changes give me a call.”
As he was leaving, Barbara walked in, obviously disturbed.
“Excuse me,” she said, “but Mr. Bera doesn’t want to leave.”
“What’s that?” I said.
“Visiting hours are over and he won’t leave.”
“Barbara,” I said wearily, “we’re going to need a special nurse for Mary.”
“But visiting hours are over,” she insisted.
“For Chrissake,” I said. “I don’t give a good goddamn if he stays all night.”
“But—”
“But nothing. If you’re so concerned, call Mrs. Gowan. I don’t want to hear anything more about it. We need a special now. Can we get one?”
The nursing office reported it was too late to get one before the night shift; those nurses who had been available had already been assigned to other wards.
“I’ll watch her myself,” I said to Barbara.
The ward was quiet, and after calling the ER to make sure there were no admissions coming up I took a couple of the journals I was going to read anyway and went back to Mary’s room.
Leaving the main light off I adjusted the small wall lamp so I could read by it, and sat down by the bed, opening to an article I had to read. But my eyes were on Mary. If you didn’t know she had not moved, or uttered a sound, or opened her eyes in over a week, you’d have said she was sleeping peacefully.
Through the partly open door muted night sounds filtered into the room. Nights on a ward,
even a busy ward, are always quiet periods. There is a kind of hush that hovers over everything; it is as if you can almost hear the ward breathing. Kids who during the day cry out for attention, seem only to whimper at night. Concerns that appear so glaring and critical in the light lose their edge in the dark, become needs rather than urgencies. Everyone seems so alone, so separate.
I tried to read, but it was no go, and I sat there with the journal open in my lap watching Mary lying in the shadow beyond the light of the wall lamp. She really did look like a sleeping princess. Only I was no prince, there were no magic potions any more, and no kiss could wake her. I watched her breathing until I seemed to be breathing for her.
The voice of the paging operator cut through the silence. What was I doing sitting here? I wondered; what did I hope to accomplish? I was simply there, as people had always been there with the dying, so those they cared about, those they loved, would not be alone.
I was holding Mary’s hand when the door opened wider. I thought it was Barbara coming to tell me about a new admission or an IV that had infiltrated, but it was Mrs. Gowan.
“So you’re the new special nurse,” she said softly, as she came into the room.
Embarrassed I let go of Mary’s hand. “Yeah,” I said self-consciously, “I guess I am.”
Mrs. Gowan went over to the foot of the bed and I looked at her as if I was seeing her for the first time. I had never seen her out of uniform before, had never thought of her as other than a nurse. She was wearing slacks and a fluffy pullover sweater, and her dark hair fell straight and loose to her shoulders. She was lovely.
“You came because of Bera?” I said. “I’m sorry.”
“That’s alright,” she said. “He’s on his way now.” She moved to the side of the bed opposite where I was sitting. “How’s she doing?”
“Worse,” I said. “She’s not going to make it.”
I expected some kind of objection, some argument, but Mrs. Gowan made no comment.
“You knew it without my telling you, is that it?” I said when she still remained silent. “Why didn’t you say something?”
She smoothed the sheet around Mary’s shoulders. “What was there to say? You’re not children. I can’t tell you what to see.”
She spoke without rancor, yet suddenly I felt betrayed. All the time we were congratulating ourselves on the miracle we had performed, she and Chris and God knows who else were shaking their heads behind our backs.
“That business of the parents. You were part of it, weren’t you? I mean you knew all about what was going on, that Chris was supporting Berquam and the rest, yet you let it go. You could have helped.”
“How?”
“You could at least have turned Chris off and withdrawn a kind of professional approval of their attitude. It would have made things easier for all of us.”
I knew there was no point in my going after Mrs. Gowan like this, but I couldn’t help myself. What was digging at me, I suppose, was the sense of my own helplessness, my recognition that we had failed.
“I have enough trouble,” she said, “just keeping the ward going. Keeping it staffed and handling the more flagrant abuses of medical care. Like not enough nurses and aides. And doctors who forget that nurses can’t be in two places at once. And schedules that are impossible for patients to keep. And night shifts that are unstaffable. Just keeping things together is a fulltime job. The problem you’re talking about isn’t a nurse’s problem.”
“I know,” I said. “I shouldn’t have been accusing you. I’m sorry.”
“Handelman will soon be gone. The others will have their kids discharged and things will be back to being pretty much the same as they’ve been before. It took somebody like Berquam who knows about hospitals and doctors to really push. And soon he’ll be gone, too.”
“Still you could have made it easier for all of us.”
“I don’t know if I wanted to,” she said.
“But why? Why not?”
“Because,” she said, “some day one of my children may be in a hospital.”
24
WE WERE ON ROUNDS the next morning when Chris came running out of Mary’s room.
Mary had stopped breathing.
McMillan hurried into the room after Chris and we crowded after them. He was already breathing for Mary when Mrs. Gowan and Lang pushed in the emergency cart. I could see her chest rising and falling with each breath.
“She just stopped,” Chris said. “Just like that. One minute she was breathing and the next she had stopped.”
“How long?” I said.
“Ten seconds. Fifteen before I got to you.”
Mrs. Gowan had half the emergency vials already opened. She handed me a syringe. “Bicarbonate,” she said. “Ten cc’s,” and turned back to the cart to break open the rest of the meds.
Without waiting I picked up Mary’s IV and emptied the syringe directly into her vein.
“Her heart’s OK,” Lang said, looking up from where he was kneeling by the bed, the stethoscope still in his ears.
McMillan kept breathing for Mary for another thirty seconds, then stopped.
“Hold it,” Lang said. “Her heart rate’s dropping.”
“She’s not breathing,” I said. Her fingertips were turning blue.
Mrs. Gowan handed me another syringe of bicarbonate. I injected it while McMillan began breathing for Mary again and Lang continued to listen to her heart.
“It’s back,” he said.
But when McMillan stopped, the heart rate dropped again. He tried a third time and a fourth with the same results.
Lang shook his head. “It’s no good,” he said.
McMillan called for the endotracheal tube and Mrs. Gowan handed it to him along with the laryngoscope. Tilting back Mary’s head he opened her mouth, and using the scope as a guide slipped the end of the tube down into her lungs and breathed quickly into it several times. Once again her chest moved with each breath.
“OK,” Lang said, still listening.
“What’s wrong?” Chris asked tensely.
“She won’t breathe on her own,” I said.
“What do you mean, won’t?”
“Her brain. Something’s happened to the cells in or near the area that controls breathing.”
McMillan reached for the breathing bag, hooked the outlet over the tube, and began squeezing the bag. The valve popped in and out as he squeezed, hissing air into Mary’s lungs.
“Give her some mannitol,” he said to me. “Ten cc’s per kilogram.” And to Mrs. Gowan: “Call central supply for a respirator.”
“Well,” he said impatiently when Mrs. Gowan seemed to hesitate. “I can’t squeeze this bag all day. Get a respirator.”
“Will she ever be able to breathe again on her own?” Mrs. Gowan asked.
“Chris,” McMillan ordered, “call central supply.”
Confused, Chris looked from one to the other.
“You stay here,” Mrs. Gowan said. “I’ll call.”
“Wait a minute,” I said. “What are her chances? No, I mean it. What chance has she got?”
“None,” McMillan said. “None, if we stop.” He looked at Mrs. Gowan. “Go on,” he said.
It took only a few minutes to hook the respirator up to the end of the endotracheal tube and adjust the flow rates and pressures so that the machine was working properly. I taped the tube down, crisscrossing Mary’s jaw and nose with the tape. Lang and Chris removed the emergency cart and I finished up with McMillan who chose to ignore my silence. The only sound was the respirator hissing behind us.
“How much bicarbonate did you give her?” he asked finally.
I didn’t have a chance to answer. McMillan was looking over my shoulder and when I turned around I saw Prader standing in the doorway. Mrs. Gowan was behind him. For a moment our eyes met, and then she was gone.
Prader looked at the two of us and then at the respirator. “Who ordered this?” he asked.
“I did,” McMil
lan said.
“Why?”
“Why? Because it was called for.”
Prader walked into the room. He glanced at Mary, then back at McMillan. “Don’t you think it’s time to stop being heroic?” he said.
“We’ve done nothing heroic,” McMillan said. “She stopped breathing half an hour ago. Her heart rate stayed up as long as I breathed for her, so I put her on the respirator.”
“Come now,” Prader said. “Use your head. A child with leukemia, disseminated intravascular coagulation, meningitis, an intercerebral bleed, brain damage, unconscious for six days, irregular vital signs, a respiratory arrest, no spontaneous respirations after half an hour of resuscitation—”
“That’s because of increased intracranial pressure,” McMillan interrupted. “We’ve just given her mannitol. It will take a while.”
“Don’t you think enough is ever enough?”
“Enough?” McMillan echoed uncomprehending. For the first time since I had known him I saw him too surprised to speak. He stared at Prader’s impassive face. “Enough!” he repeated after a moment’s silence. “You of all people to talk about enough. I don’t expect miracles, but I’m not going to stop using what’s available. I’m not going to go back ten years for you or anybody.”
Prader’s face hardened. “And if she does wake up? And if you can get her off the respirator? What then?”
“Then she may have the same chance as any other child with leukemia.”
“And if you’re wrong? Would you wager five people’s lives on being right?”
“I’m sorry,” McMillan said. “I don’t know what you mean.”
“Are you blind?” Prader pointed to Mary. “What the hell do you think is happening to this child’s family?”
“Her family! My God, look at your own clinic,” McMillan said. “They’re all dying and you keep giving them all those poisons week after week, trying to get another goddamn month out of them. Or is it a week? Or a day?”
Prader looked stunned. “You’re not treating that child,” he said icily, “you’re treating yourself.”
“Me! treating myself!” McMillan said bitterly. “I don’t have any protocols to hide behind. I don’t have any rigid rules to protect myself, scientific excuses of the greater good to get me off the damn hook. I’m here on the ward taking care of kids, not up in the lab tabulating figures.”
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