I had just hung up after talking to Prader when Barbara, who was working reliefs, came into the doctors’ station and announced that Mary’s temperature was 104.
I stared at her in disbelief. “I was with her less than an hour ago,” I said. “It was normal.”
“Well, it’s a hundred and four now.”
I told her to call McMillan, and hurried to Mary’s room. I found her sitting up but breathing strangely, apprehensively, as if she was afraid that at any moment somebody might suck all the air out of the room and leave nothing for her to breathe.
“How long has she been like this?” I asked her mother.
“Like how?”
“These short little breaths.”
“Almost since you left,” Mrs. Berquam said. “I thought it was just something that had to do with your drawing her blood. She got so excited. Should I have called somebody?”
“It’s alright,” I said, to calm her. “I think though it would be better if you waited outside. I want to examine Mary again and it will be easier on her and on you.”
“What do you think it is?” she asked, alarmed. “Do you think it’s serious?” She was getting up to leave when McMillan came in.
“Mrs. Berquam is going to wait outside,” I said.
“Fine,” McMillan said pleasantly. “We’ll be right out and let you know what’s happening.”
Barbara, who had just walked into the room, stepped aside to let Mrs. Berquam out.
“Mary,” I said, leaning over her bed, “does anything hurt?”
She looked up at me but her eyes were dulled and distant, her drawn face almost expressionless.
So quick! I thought. Jesus!
Barbara pulled back the covers and I saw that Mary’s legs were trembling. I took her hand in mine.
“She’s clammy,” I said to McMillan who had moved to the other side of the bed.
He made to raise her head so the pillow could be removed and she would be lying flat on her back, but he had scarcely lifted it when she grimaced with pain. We exchanged glances. Carefully he moved her head again and this time the pain was so obvious I thought she would scream. McMillan gently laid back her head.
“It takes a while to become evident,” he said calmly. “There is a natural course to any illness.” He turned to Barbara. “Can you get a spinal tap tray?”
McMillan knew what I was feeling. “You did all you could,” he said. “She had no signs. It could just as well have been the flu. All infectious diseases start out the same. Vaguely. Nausea, a rash, coughing, a couple of days of feeling bad. Then the bulging ear drum, pneumonia, or stiff neck. Nobody can fault you. You can’t treat until you’re sure. Now we know.”
My God! I groaned inwardly. Meningitis. As gently as I could I tried to free my hand from Mary’s but she wouldn’t let go.
I started to ask if we needed a permit, but my voice cracked and I couldn’t go on.
It was Barbara who asked the question for me. “Have you got permission for the tap?” she said.
McMillan shook his head.
“But you need one. It’s an operative procedure. We had a nurses’ conference on permissions and Mrs. Gowan told us to be sure the doctors—”
McMillan cut her short. “I’ve called Mr. Berquam. He knows his daughter is ill, and that her blood culture may be positive.”
“He doesn’t know she has meningitis.”
“It’s a life-threatening situation,” McMillan said impatiently.
“Not so loud,” I said. “Mrs. Berquam’s right outside.” McMillan looked at me. “Come on, will you, let’s just get it done.”
“Set up the tray,” McMillan told Barbara. “I’ll talk to her.”
“Mary,” I whispered when they had left the room. “Mary.” I pulled loose my hand. “We’re going to have to turn you on your side, and put a little needle into your back. It will be just like a little bee sting, no more. The same kind of needle we use to take blood from your arm. It won’t hurt any more than that. Honest.”
I thought she heard me but I couldn’t be sure. Her face remained expressionless but her lids fluttered open slightly.
“OK,” McMillan said when he came back. “Let’s get on with it.”
When we were ready with the spinal tap I held Mary while McMillan, sitting on a stool by the edge of the sterile-draped bed, pushed the four-inch spinal needle into the small of her back. He worked it slowly through the muscles until finally, with most of its length buried in her back, he slid it between the spines of her vertebrae. When it held up a bit, he changed the angle and shoved.
Wincing, Mary pushed against me and I held her closer.
“It’s alright,” I whispered. “It’s alright. It’s over.”
I felt Mary relax in my arms and I nodded for McMillan to continue.
Leaving the needle embedded in her back, he carefully pulled out the stylet. The point, fixed in her spinal canal, swung slowly, rhythmically up and down with her breathing. A moment later a thick greenish fluid began bubbling out of the end of the needle.
My God!
“Can you believe that?” McMillan said softly. “Pure pus.” He took a sterile test tube from the tray and began collecting the infected fluid as it dripped out of the needle; in all he took out 20 cc’s in four separate tubes.
The last few drops were as foul-looking as the first had been. Her spinal canal must have been one sack of pus, infected from top to bottom. It made me sick to think of it. I could feel Mary breathing, could feel her heart beating against mine. A lovely intelligent child, with her whole life still before her, become a culture medium.
McMillan pulled out the needle and threw it into the waste basket. “She OK?” he said.
“Yeah. OK,” I said.
He pulled off his gloves and handed me one of the tubes. “I’ll start the IV while you take this to the lab and smear it.”
“What are you going to use?” I asked.
“Penicillin, Staphcillin, kanamycin—the works. Half right after I start the IV, the rest dripped in over the next twelve hours.”
I was relieved not to find Mrs. Berquam in the corridor. I took the tube down to the lab and smeared some of the spinal fluid on a clean slide. It dried almost immediately into thick greenish streaks; I put the slide face up on the staining rack and poured the purple stain over the dried area.
I can remember sitting there in that empty lab waiting for the stain to work. I felt discouraged and depressed. I was annoyed at myself for being glad Mrs. Berquam hadn’t been in the corridor so I didn’t have to speak to her, embarrassed at the way I’d handled Mary’s question about death, and terribly worried about her condition. I sat alone in that quiet room surrounded by all the equipment of modern medicine, and after four years of medical school and almost a year of internship, of working as hard as it was possible to drive myself, I felt inadequate, inauthentic.
When the slide was ready I shook off the excess stain and put it under the microscope. I found a suitably stained field, and switching to a higher magnification cut down into the thick stain.
“My God!” I cried out loud, as happy as I was surprised.
In the midst of flakes of precipitated stain, cellular debris, and white cells I saw deeply colored purple clumps of cocci—hundreds of them, like great purple kidney beans, filling the field, crisscrossing every millimeter of the microscopic field.
To check I switched to another stained section, and saw the same thing. I had just finished when McMillan walked in.
“Good news, man,” I said. “They’re pneumococci.”
“You sure?” McMillan said.
“They’re all over, but they’re definitely pneumo. Penicillin should do it. Gives us a fighting chance. Right? That blood culture must have been a contaminate.”
I got up to let McMillan have a look. “Yeah,” he said. “Incredible. I thought for sure that spinal fluid would be full of pseudomonas, or one of the other resistant organisms. I mean,” he said as surprised and
pleased as I was, “a child with leukemia on prednisone and vincristine, not to have an antibiotic resistant organism but only a common everyday one like pneumococcus, one sensitive to reasonable doses of penicillin: who would believe it?”
“We might just win this one,” I said, all my depression and discouragement dissipated in the euphoria of the moment.
“A better chance, anyway,” McMillan said soberly.
I asked about Mrs. Berquam. He told me that after the tap he’d told her what we’d found and she was calling her husband.
Later Barbara explained how he’d obtained the permit from Mrs. Berquam. He had told her that while we thought Mary had meningitis we couldn’t be sure until we did the tap, and so she should wait to call her husband until we had the results and would know for sure.
Strange, I thought. After all, we knew Mary had meningitis when we examined her. The only thing the tap told us was the organism.
I expected trouble from Berquam, but there wasn’t any. I didn’t even know he had come and gone until Barbara told me. When I asked her what had happened, she gave me an offhand answer. She was still peeved about McMillan’s arguing with her about the permission. I tried to explain that at some hospitals you didn’t need a permission for a tap; it was considered routine procedure, like blood drawing.
“Not here,” she said. “You doctors can say the heck with it, but we get the heat. What do you think I’d have heard from Mrs. Gowan in tomorrow’s report if there was no permission?”
When I admitted she was probably right she seemed appeased. She said Berquam had stayed only a few minutes. McMillan had told him that Mary had meningitis and had been put on the critical list, but in her case being on critical was more procedural than anything else. Barbara said he’d gone on to tell him that with the organism he’d found as the cause for Mary’s meningitis, there was a very good chance the antibiotic would be effective.
“And Berquam?” I said. “He accepted it?”
“No trouble,” Barbara said. “None. Dr. McMillan said he just got up and left.”
“You sure?” I said.
“I was there,” Barbara said.
It still didn’t make sense to me. Not as I knew Berquam. Not in view of the situation.
IV
19
ABOUT ELEVEN O’CLOCK I checked Mary again. She was sleeping. The nurse’s notes said she was rousable, but not much more. The IV taped into her arm was running well.
There was a mild croup admitted from the ER about 1:30 in the morning. The child’s chest film was clear and he wasn’t in much distress, so I just put him in the mist tent with orders to hydrate him orally through the night.
Chris was the RN on duty. These days Chris and I weren’t talking any more than we had to. When I asked her about Mary she said there had been no change, so I went to the snack bar for a coke and then back to my room.
I didn’t bother to get undressed. When the phone rang, it was light outside. My watch said quarter to six. Still half asleep I reached for the receiver.
“Yes?” I said.
“This is the aide on 402. The nurse wants you to come right away.”
I sat up. “What’s wrong?”
“I don’t know, Doctor.”
“Well, what the hell’s the problem?”
“The little girl with meningitis. She’s throwing up blood.”
The room was a shambles. Chris was holding Mary’s head over the side of the bed. Blood and vomit were all over the sheets and the floor.
“I think I got most of it out of her mouth,” she said shakingly. “But some of it might have got into her lungs.”
Mary’s limp body, half on and half off the bed, was tangled up in the sheets. I didn’t notice her back until I was close to the bed. What I saw was so startling I just stood there open-mouthed.
The skin on her back and on what I could see of her buttocks once so smooth and delicate had turned a sickening black. Great blue-black welt-like areas ran up and down along her side, as if someone had beaten her with a club. Even as I stood there looking I saw her fingers turning blue and the same color like a stain spreading up her arm.
Chris looked at me uncomprehending, and then I saw terror in her eyes. I pushed her out of the way and jerked Mary’s head around so I could see her face. Her mouth fell open and her eyes rolled back. I hit her as hard as I could in the middle of her chest with my fist.
“Get the emergency cart!”
I hit her chest again, then twisted her around on the bed so she was lying flat, and grabbing her chin shoved her head back. For a second I gagged on the sour-sweet smell of vomit. Then I began breathing into her mouth, at the same time keeping my eye on her chest. It didn’t move. I could feel the resistance against my own breath.
Frantically I probed her mouth with my fingers, and reaching to the back of her throat pulled out half-digested pieces of food mixed with blood and mucus. Her face and neck, a pasty gray, began breaking out in the same blue-black spots as the lesions on her back and arms. I dug out as much as I could and began breathing into her mouth again.
Come on! Come on! I thought desperately. Come on!
Now her chest moved slightly. Taking great breaths I blew harder and harder in the effort to get more air past whatever was still blocking her airway, until I felt my own heart pounding in my head. I was getting dizzy when Chris crashed open the door with the emergency cart. McMillan was right behind her.
“She’s consuming,” he said.
Sometimes when there’s an overwhelming infection, the organisms in the bloodstream start a reaction that causes all the circulating clotting factors suddenly to be used up. With nothing left to stop the bleeding, all the blood vessels and capillaries begin to ooze like a million little cuts.
Leaning over me, McMillan slid his hand up under Mary’s pajama pants. “There’s a femoral pulse, but she’s clammy.”
I was fast running out of breath.
“Here,” McMillan said. “Tilt her head back more.”
Pushing her chin with my left hand, with my right I took the laryngoscope he gave me and slipped the blade into Mary’s mouth.
“Where’s the heparin?” McMillan said. “Is that IV still working?”
The sweat was rolling down my arms as I bent close so I could see along the blade to the vocal cords.
“Give me a clamp. She’s obstructed.”
Chris put one in my hand. Straining to keep the laryngoscope steady I reached along the blade to pull out more pieces of half-digested food. Squatting as I was, and cramped over, I couldn’t hold the scope firm and the blade slipped, digging into the back of Mary’s throat. Blood began oozing out of the side of her mouth.
McMillan was listening to her chest. “I can hear it,” he said. “Start breathing again.”
Now there was no resistance, and her chest moved easily with my breaths. Thankfully I closed my eyes. I heard McMillan say, “Get the bicarbonate,” and felt Chris brush by behind me. After every few breaths I had to stop to spit out the blood.
Once I had Mary’s airway open it was just a question of doing the right things in the right order. The fact that her heart had probably slowed but never really stopped made things easier. While I continued to breathe for her, to give her the oxygen she needed, McMillan connected her to the cardiac monitor. With its rhythmic beeping filling the room, he gave her bicarbonate IV to correct her acidosis, an ampule of epinephrine and calcium chloride to make her anoxic heart pump more efficiently, and then more heparin. Bit by bit I was able to stop breathing for her. The heparin, too, must have worked; except for a few bluish-purple spots on her forehead, there were no new skin lesions starting up.
It was hardly the right moment for anybody to walk in on us, but looking up I saw Handelman in the doorway. He had started to come into the room, and obviously shocked by what he saw he was leaving in a hurry. It all happened so quickly I seemed to be the only one who saw him, and we were all too busy for me to mention it.
While we
were straightening Mary out on the bed the IV infiltrated and we had to put in a cut-down. Even when we cut open her arm to find a new vein she didn’t move. We decided we needed a better access in case anything else went wrong, so McMillan put a central venous catheter into her jugular vein.
I held her head as McMillan threaded the catheter down her neck, probing and digging until he found the jugular. Meanwhile Chris was taking blood pressures and drawing up more medications. Twice we had to treat different cardiac arrhythmias, bizarre patterns that showed up on the monitor, and once her blood pressure fell so low that Chris couldn’t get a reading. We gave Mary blood then directly into her heart through the central venous catheter and the pressure came up, but dropped again until we gave her more. The X-ray technicians came up and took three series of portable chest films.
It took over two hours, working every minute, to get Mary stabilized, and during all this time she didn’t move. But she was breathing and for the present that was enough. She looked bad, limp and unconscious, with tubes running into and out of her body, her skin a mass of blue-black welts. But she was alive. We’d kept her alive. We had used all we’d been taught, all we’d been trained for, and I can remember thinking as I stood by Mary’s bed, this is what it’s all about.
McMillan was putting another piece of tubing on the IV. “Since she’s bled into her skin,” he said, “she could just as easily have bled other places—her head, kidneys, spleen, liver. We’ll have to wait and see.”
I stared at the tube sewn into her neck. It was hard to believe that only two hours before—that two hours could make such a difference. God, I thought, even with doing everything it can still happen so quick.
The daytime staff had come on while the three of us were cleaning up, and now Mrs. Gowan joined us and helped Chris finish charting all the meds we’d given. McMillan asked her to get a nurse to special Mary the rest of the day.
“Have you called the parents?” she asked.
“Haven’t had a chance,” McMillan said. “I’ll call them now, on my way to X-ray.”
It was past eight and I was already far behind schedule for drawing the morning bloods, but I stayed to help Chris clean Mary. Together we washed off the blood and alcohol stains, and while I looked for a clean pair of pajamas Chris combed out the dried blood from Mary’s hair and braided it into little wings. I thanked her for all her help and wanted to say more but she was not in a mood to talk as she quietly went about doing what had to be done.
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