“Look,” I said, “I need to know what’s going on around here. Anything that affects patient care is—”
She started to push the cart but I stopped her again. “Come on. I saw you talking to Berquam just now. Fine. It’s a free country. You can do what you want. All I want to know is what he’s up to. What’s he planning to do next?”
Chris looked at me as if she thought I might be slightly paranoid. “He’s not planning anything,” she said.
“So he’s not planning. Then just tell me whom he’s going after next. I don’t like calling McMillan in on his night off for something like this. Once is enough.”
“I told you he’s not going after anybody.”
“Oh, no? I don’t know if he hates all doctors or just us, and I don’t care. But I’m not going to have another patient submitted to what Handelman just went through.”
“What Handelman just went through,” Chris said scornfully. “Excuse me, I’ve got to pass my meds.”
I grabbed the cart. “No games, damn it. This is—”
But at that moment Berquam came out of his daughter’s room. His sudden appearance, not more than five feet away from me, put an end to our conversation. He was the last person I wanted to talk to and I went on my way.
McMillan must have finished talking to Handelman while I was busy with a new emergency admission, because I didn’t see him leave. The child was an asthmatic in respiratory failure and he kept me in the treatment room most of the rest of the night.
15
THE NEXT MORNING THE picture was brighter. Freddy was cheerful. The Reye’s syndrome had stopped seizing and it looked as if his liver wasn’t as badly damaged as we had thought. The two children with dehydration were ready to go home, the asthmatic child was breathing better, all the surgical patients were stable, and no one seemed to be infected.
When we came into Mary’s room we found her perched on top of the bed covers with her legs folded under her, playing with a picture puzzle. Despite McMillan’s concern about what he considered the inadequacy of her drugs, she had been improving for days and was becoming everybody’s favorite, mine especially. The wispiness that had seemed so fragile, so alarming when she was desperately ill hadn’t disappeared, but had become a kind of delicateness that was all the more disarming because it was so open and appealing.
“Hello,” she said, scanning our faces one by one as we filed into her room, quickly, precisely, as if she was checking us off a boarding list. Apparently satisfied we were all there, she began picking up the pieces of the puzzle to clear the bed.
“No, no, it’s alright,” McMillan said. “We’re just here to say hello. No examination.”
She nodded, and just as quickly began putting the pieces back in place. She was wearing a light blue flannel nightgown with a frilly collar, every bow neatly tied. Her hair, parted precisely down the middle and pulled back tightly into braids, accented her big brown eyes and high cheek bones, and made her look older than she was. Suddenly, without looking up from her puzzle, she asked if she could go home.
“I mean,” she added quickly, “when I’m better.”
“Sure,” McMillan said, “we can get you home.”
I watched a small smile curl the corners of her mouth and vanish as quickly as it had appeared. She was so feminine, so engaging.
And so alive. What a fool her father was, I thought.
The following day things didn’t go so well. Nothing disastrous, just a lot of confusion and a lot of work. Conditions on the other pediatric wards made it necessary for us to take most of the scheduled hospital admissions. As I remember it, seven or eight new patients came in that day, and in the midst of having to work all of them up we had two emergencies. There were times when the parents were standing two and three deep in the hallway just waiting to get their children into the rooms or have a history taken.
Our ward was always on the verge of being understaffed; that day pushed us over the line. Lang and I cut our histories to the barest essentials and did the minimum necessary physical examinations. To clear the backlog McMillan even began doing off-service work-ups himself. The nurses were absolutely swamped. We tried to help them by keeping our initial orders to a minimum, but even so the day staff didn’t have time for lunch and were still hours behind.
When the shifts changed, Mrs. Gowan, who had been busy all day not only with primary care and keeping up with all the orders, but directing the other nurses as well, had to stay to help the three to eleven staff get the new patients to their rooms, medications passed and charted, and orders transferred to the card index.
Some of the parents among those who had to wait the longest became irritable, as well they might. We tried to calm them by explaining that the situation was abnormal and emergencies simply had to be taken care of first, but there were still some who refused to be pacified and complained openly, stalking back and forth between the rooms and the doctors’ station until they were finally taken care of and out of everybody’s hair. More than once I saw Mrs. Gowan, in the middle of everything else, having to stop to calm some parent, sometimes the same one several times. Lang, having to do the same thing, began mumbling angrily to himself and my own temper was not exactly under control.
We all had to work well into evening visiting hours. The three of us—Lang, McMillan, and myself—were through about nine o’clock, but the nurses were still catching up. Mrs. Gowan was exhausted. She had been on her feet since six-thirty that morning, so it was no wonder she was beginning to get short with everyone. Then all of a sudden she was standing in front of the nurses’ station, glaring at one of the parents, a man named Braden.
“I’m saying that you’ll have to leave,” she said sharply. “I’m sorry, but that’s the hospital rules.”
“Fifteen goddamn minutes ain’t going to break the system,” Braden answered angrily.
“There are thirty-seven other children on this floor who would like their visitors to stay an extra fifteen minutes. The rules—”
“To hell with your rules,” Braden exploded. “I had to work late tonight and I just got here. I want more time with my son.”
“I’m very busy,” Mrs. Gowan said coldly. “If you have any complaints you can submit them on paper to the hospital administrator or the medical director. But right now you’ll have to leave.”
“You write the complaint,” Braden snapped, his face flushed. “I’m staying. God knows I’m paying enough for the privilege.”
All the while they were arguing, parents and visitors were passing by on their way out of the ward. Some slowed to listen; others, embarrassed, pretended that nothing was happening.
“He’s my child,” Braden continued, wagging his finger at Mrs. Gowan. “Just remember that.”
She remained silent, biting her lips, taken aback not so much by what Braden was saying as the threatening way he said it. She looked relieved to see McMillan approaching.
“More of your Mr. Berquam’s doing,” I said to Chris who happened to be standing nearby. “Let him keep on and the whole place’ll go to shit.”
And in a way it did—or seemed to, at the time. It was as if the ward had become unbalanced. We all felt it in little ways, little requests and demands, even looks that before we would have dismissed or ignored, that we probably wouldn’t even have noticed, now suddenly became important. The whole tone seemed changed. No one knew how many parents were involved, how many were really pushing us. Probably just a few. But we were so unfamiliar with any kind of abuse, so used to having others do what we ordered, to expecting our requests and decisions to be adhered to without exception and without discussion, it began to seem like everyone.
Even Lang, who had always made favorites of certain parents, spending more time with them, talking more, gave that up and began treating everybody the same.
“When I’m off this damn ward,” he said, “I’ll go back to being my usual charming self.”
The thing that broke everything open was what happened to Mary
.
16
MARY’S WHITE COUNT HAD been normal for days. Her bone pain had disappeared, her liver and spleen had shrunk back to normal size, her eyes were clear and bright.
Prader saw her only twice a week now, on his formal hematology rounds. Since she was my patient I presented her case to his group during rounds, beginning each time with her newest lab values and then going on to her hospital course. Everyone seemed pleased with our increasing success, everyone except Prader who expressed neither pleasure nor displeasure, said nothing in fact, only listened expressionless each time I presented the case. With Mary’s lab values normal for over a week and her magnificent clinical responses, some of his research fellows allowed themselves to speculate on the possible length of her remission.
“The average remission in Konster’s series was about eighteen months,” Kramer said.
“But that,” someone offered, “was with radiation to the central nervous system.”
“She had central nervous system involvement didn’t she?” said another.
“True,” Kramer answered, “but it wasn’t due to leukemic infiltration.”
“Yes, but according to the Bellevue study—”
“That will be enough,” Prader said.
There was a sudden awkward silence. I had never seen him stop a discussion so abruptly. Usually if he wanted to change the subject he would simply ask an impossible question.
“Next case, please,” he said now, matter-of-factly.
I began cutting down the number of times I examined Mary and even rewrote the orders for her vital signs so that she could sleep through the night without being waked. All evidence of her disease was gone, apparently wiped out.
I took to stopping by just to visit. Initially I had treated her as a child, but she would have none of that. When I learned to treat her as she thought she should be, we became good friends, or rather I should say she permitted me to become her friend. Mary was indeed something special. No matter how hard I was working or how tired I might be, walking into her room was like walking into springtime. She loved to read. Curled up on her bed she devoured the books her parents brought her by the armful from the library.
She was a collector, too. “Before I was sick I used to collect everything,” she said. “I had a lot of bugs. People are afraid of bugs, but I wasn’t. I’d keep them for a while and then let them go. I used to collect rocks, too, but it was too much trouble lugging them around.” She was thoughtful for a moment and then, as if she were dismissing the whole thing, she added: “But I guess I’m getting too big for that sort of thing now.”
One day in the midst of telling me how to cast on in knitting she suddenly stopped to ask: “Do other girls get sick like me?”
“Yes,” I said, “some.”
“Does it hurt them too.”
“Yes,” I said, “for a while.”
She nodded knowingly and went back to showing me how to knit.
We were pretty self-satisfied with our success with Mary; indeed, we were even casual about it. The fact that daily we were giving her potentially dangerous drugs was of course recognized but it was played down. In the same way the fact that all we were doing as her doctors was injecting chemicals into her body, and it was the drugs that were clearing her bloodstream, was ignored or minimized in our shared achievement of a normal white count.
We were programmed for success. All through medical school we had been told about the wonders of medicine, the triumphs of surgery. The complications, the price paid for each advance, the “trade-offs,” were acknowledged but somehow they were never presented to us with the same emphasis as the accomplishments. If our professors had any reservations about certain medications or procedures, these seemed to fade away in the course of their lectures; certainly they were not stressed. We left school buoyed with the idea of success, indeed expecting it as part of medicine. In a world of medical miracles, failures were aberrations and in a way became the patient’s fault, not ours, who had after all done all we could. Which explains, I suppose, why we were not so much ill at ease as taken by surprise when a miracle failed.
Our miracle began to fail some two and a half weeks after it began.
I remember, it was after our morning X-ray conference. Every day, from nine-fifteen to nine-forty-five, the whole pediatric house staff would gather in the X-ray department to go over the previous day’s films with the pediatric radiologists. On this particular morning McMillan was questioning the radiologist’s reading of a chest film on a new cardiac that had been read as negative but which showed hazy areas near the heart. Pushed by our clinical data the radiologist finally admitted the haziness could be due to an infiltrate. At the moment the argument seemed academic since on McMillan’s suggestion we had treated the child the night before, but McMillan didn’t want a negative report on the chart if the film was in fact positive, even minimally positive.
They were discussing another film when I left to go back to the ward to do a bone marrow I wanted to have down in the lab before lunch. I was in the doctors’ station filling out the lab slips for the test, and labeling the tubes with the child’s name and hospital number when Chris came in. She waited until I had finished stamping the last slip before she spoke.
“Mary’s complaining of a headache,” she said. “I thought you should know.”
“We just saw her this morning on rounds,” I said. “She looked fine.”
“Well, she’s complaining now.”
I found Mrs. Berquam in Mary’s room. She was bent over the bed, anxiously stroking her daughter’s forehead. As I came in she looked up at me. I could see she was frightened and I tried to reassure her.
“We checked Mary this morning before you got here, and she was OK,” I said. “There’s a lot of flu and stuff going around, you know.”
Mary watched me as I walked around to the other side of the bed. The sparkle was gone from her eyes. She looked tired.
“She was fine until only a little while ago,” Mrs. Berquam said, almost apologetically. “I don’t understand it. She was doing so well.”
“She’s still doing well.” I thought of asking Mrs. Berquam to leave so I could examine her daughter without her being in the way but she was hanging on to Mary’s hand and I didn’t want to worry her more. Besides, Mary didn’t seem to be in any distress. She wasn’t having any trouble breathing, and her color was good.
“How do you feel?” I said.
She frowned. “My head hurts.”
“Well, let’s see what the trouble is.”
I went over her from top to bottom but I couldn’t find a thing. Her eyes, ears, nose, and throat were normal. For a moment after she sat up she looked a bit shaky, but that quickly passed. Her mother tried to help her remove her pajama top, but Mary brushed her hand away irritably and pulled it off herself.
Her skin was smooth and cool. I listened to her chest; her lungs were clear.
Now that she was sitting up she seemed more animated. She smiled when I sat her over the edge of the bed with her feet dangling and made her knees jerk despite her trying to stop them.
I asked her to lie down again on her back, and felt her abdomen and listened to her stomach. Then I lifted her head and flexed her neck until her chin rested on her chest. I did it again. “Does it hurt,” I asked.
She pouted, thought for a moment, then shook her head.
“Sure?” I bent her head once more. “OK, you can sit up now.”
“I can’t find anything,” I said to Mrs. Berquam who had been hanging on every move I made. I handed Mary her pajama top and she brushed her hair back with both hands and pulled the top carefully over her head.
“How do you feel now?” I asked.
“Good,” she said, but I noticed that instead of continuing to sit up she lay back on her pillow. This troubled me; it wasn’t like her to be so listless. Still, there was no evidence of infection nor a sign really of anything else physically wrong.
“It’s probably the flu,” I
concluded, patting Mary’s leg. “We’ll watch her though. Don’t worry.”
Mrs. Berquam smiled as brightly as she could and went back to stroking Mary’s head as I left the room.
“She’s dragging,” I told Chris. “It could be just a cold, but let’s watch her for a while. I’ll check her again myself in a few hours.”
“Do you want any lab tests?”
“Why don’t you ask the hematology tech to come up and get a white count and smear? And a urinalysis and urine culture. I’ll write the orders later.”
“Mrs. Berquam’s very worried,” Chris said.
“I know,” I said testily. “I’m not blind.”
“Did you talk to her?”
“Jesus Christ. I told her exactly what I told you. Satisfied?”
Goddamn! I thought as I walked away. For a nurse who was supposed to be helpful, Chris was sure becoming a pain in the ass.
The truth was I was on edge. I felt that something was wrong but I didn’t know what and it bothered me.
At lunch with McMillan I told him about Mary, how she was not as active as she had been and complained that her head hurt. “There’s no fever, her white count’s normal, hematocrit is stable; her physical exam was absolutely normal. I went over every inch of her. Nothing—not a thing.”
“Blood pressure?” McMillan asked.
“Stable. There was nothing I could find.”
“Well, just keep going over her. If it’s something it’ll show up. Better up her vital signs again and tell the nurses to start taking blood pressures every four hours as well as temps.”
I was about to go on with my sandwich when I put it back on the plate.
“Yeah?” McMillan said, looking up from his bowl of soup.
“I was just wondering—What do you think of Chris?”
“A good nurse. Why?”
“Oh, nothing.”
“Come on. What’s bugging you.”
“Well, she’s been talking with Berquam, and I think she may be getting in with some of the other parents. I don’t say she’s egging Berquam on, but she’s agreeing with him anyway. As for the rest of the parents I don’t know, but she’s been on me about our not talking with the parents enough.”
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