The Final Diagnosis
Reaching into the incubator through the two porthole-like apertures in its side, Dr. Dornberger carefully examined the Alexander baby. Three and a half days had gone by since birth, a fact which, of itself, might normally be taken as a hopeful sign. But there were other symptoms, increasingly apparent, which Dornberger knew must be looked on with disquiet.
He took his time about completing the examination, then stood back thoughtfully, weighing the available evidence in his mind, filtering it through his long years of experience and the countless other cases now behind him. At the end his reasoning confirmed what instinct had already told him; the prognosis was extremely poor. "You know," he said, "I thought for a while he was going to make it."
The young nurse in charge of the premature nursery - the same nurse whom John Alexander had seen a few days before - had been looking at Dornberger expectantly. She said, "His breathing was quite steady until an hour ago, then it became weak. That was when I called you."
A student nurse around the other side of the incubator was following the conversation closely, her eyes above her gauze mask darting from Dornberger to the charge nurse and back again.
"No, he's not breathing well," Dornberger said slowly. He went on, thinking out loud, trying to be sure there was nothing he had missed, "There's more jaundice than there should be, and the feet seem swollen. Tell me again - what was the blood count?"
The charge nurse consulted her clip board. "R.B.C. four point nine million. Seven nucleated red cells per hundred white."
There was another pause, the two nurses watching while Dornberger digested the information. He was thinking: There's altogether too much anemia, though of course it might be an exaggerated normal-type reaction. Aloud he said, "You know, if it weren't for that sensitivity report I'd suspect this child had erythroblastosis."
The charge nurse looked surprised. She said, "But surely, Doctor," then checked herself.
"I know - it couldn't happen." He motioned to the clip board. "All the same, let me see that lab report - the original one on the mother's blood."
Turning over several sheets, the charge nurse found the form and extracted it. It was the report which Dr. Pearson had signed following the altercation with David Coleman. Dornberger studied it carefully, then handed it back. "Well, that's definite enough - negative sensitivity."
It should be definite, of course; but at the back of his mind was a nagging thought: Could the report be wrong? Impossible, he told himself; the pathology department would never make a mistake like that. All the same, he decided, he would drop in and talk with Joe Pearson after rounds.
To the charge nurse Dornberger said, "There's nothing more we can do at the moment. Call me again, please, if there's any change."
"Yes, Doctor."
When Dornberger had gone the student nurse asked, "What was it the doctor said - erythro . . . ?" She stumbled on the word.
"Erythroblastosis - it's a blood disease in babies. It happens sometimes when the mother's blood is Rh negative and the father's Rh positive." The young charge nurse with the red hair answered the question carefully but confidently, as she always did. The students liked being assigned to her; as well as having a reputation for being one of the most able nurses on staff, she was little more than twelve months away from her own student days, having graduated at the top of the senior class the year before. Knowing this, the student had no hesitation in extending her questioning.
"I thought when that happened they changed the baby's blood at birth."
"You mean by an exchange transfusion?"
"Yes."
"That only happens in some cases." The charge nurse went on patiently, "It may depend on the sensitization report on the mother's blood. If the report is positive, it usually means the baby will be born with erythroblastosis and must be given an exchange transfusion immediately after birth. In this case the lab report was negative, so an exchange transfusion wasn't necessary." The charge nurse stopped. Then she added, thoughtfully, half to herself, "It's strange, though, about those symptoms."
Since their argument of several days ago on the subject of laboratory checks the senior pathologist had made no reference to David Coleman's activities in the serology lab. Coleman had no idea what this silence implied - whether he had achieved his point and was to have direct charge of Serology, or if Pearson intended to return to the attack later. Meanwhile, though, the younger pathologist had fallen into the habit of dropping into the lab regularly and reviewing the work being done. As a result he had already formulated several ideas for changes in procedure, and some of the minor ones had been put into effect during the last day or two.
Between himself and Carl Bannister, the elderly lab technician, there was something with might be considered close to an armed truce. John Alexander, on the other hand, had made it plain that he welcomed Coleman's attention to the lab and in the last two days already had made a few suggestions which Coleman had approved.
Alexander had returned to work the day after his wife had been brought to the hospital, despite a gruff but kindly suggestion from Pearson that he could take time off if he wished. Coleman had heard Alexander tell the old pathologist, "Thank you all the same, Doctor; but if I don't work I'll think too much, and it wouldn't help." Pearson had nodded and said that Alexander could do as he pleased and leave the lab to go upstairs and see his wife and baby whenever he wished.
Now David Coleman opened the door of the serology lab and went in.
He found John Alexander at the center lab bench, looking up from a microscope, and, facing him, a white-coated woman with extremely large breasts whom Coleman recalled vaguely having seen around the hospital several times since his own arrival.
As he entered Alexander was saying, "I think perhaps you should ask Dr. Pearson or Dr. Coleman. I'll be making my report to them."
"What report is that?" As Coleman asked casually, the heads of the other two turned toward him.
The woman spoke first. "Oh, Doctor!" She looked at him inquiringly. "You are Dr. Coleman?"
"That's right."
"I'm Hilda Straughan." She offered him her hand and added, "Chief dietitian."
"How do you do." As she shook his hand he noticed, fascinated, that her magnificent breasts moved with her arm - an undulant, whalelike rolling motion. Checking his thoughts, he asked, "Is there some sort of problem we can help you with?" He knew from his own experience that pathologists and dietitians usually worked closely in matters of food hygiene.
"There's been a lot of intestinal flu these past few weeks," the dietitian said. She added, "Mostly among the hospital staff."
Coleman laughed. "Tell me a hospital where it doesn't happen now and again."
"Oh, I know." Mrs. Straughan gave the faintest hint of disapproval at the flippancy. "But if food is the reason - and it usually is - I like to pin down the cause if it's possible. Then one can try to prevent the same thing occurring again."
There was an earnestness about this woman which David Coleman found himself respecting. He asked politely, "Do you have any ideas?"
"Very definitely. I suspect my dishwashing machines, Dr. C."
For a moment Coleman was startled at the form of address. Then, recovering, he asked, "Oh, why?" Out of the corner of his eye he saw Bannister enter the room. Now both lab technicians were listening to the conversation.
The dietitian said, "My hot-water booster system is quite inadequate."
The phraseology tempted him to smile, but he resisted it and asked instead, "Has anyone ever pointed that out?"
"I certainly have, Dr. C." Obviously this was a subject on which Mrs. Straughan had strong feelings. She went on, "I've talked to the administrator, Mr. Tomaselli, on several occasions. It was my last talk with Mr. T., in fact, which caused him to ask Dr. Pearson for new lab tests on the dishwashers."
"I see." Coleman turned to John Alexander. "Did you run some tests?"
"Yes, Doctor."
"What did you find?"
"The water temperature isn't high enough." Alexander consulted a clip board holding several pages of notes. "I did three tests on each dishwasher, each at a different time of day, and the temperature range was 110 to 130 degrees."
"You see?" The dietitian held up her hands expressively.
"Oh yes." Coleman nodded. "That's much too low."
"That isn't all, Doctor." John Alexander had put the clip board down and taken a slide from the lab bench. "I'm afraid I've found gas formers of the fecal group. On the plates - after they've been through the dishwashers."
"Let me see." Coleman took the slide and moved to the microscope. When he had adjusted the eyepiece the characteristic worm-like bacteria were visible at once. He straightened up.
Mrs. Straughan asked, "What is it? What does it mean?"
Coleman said thoughtfully, "The slide shows gas-forming bacteria. Normally the hot water should destroy them, but as it is they're getting through the dishwashers onto your clean plates."
"Is that serious?"
He considered carefully before answering. "Yes and no. It probably accounts for some of the intestinal flu you spoke of, but that's not too serious in itself. The way in which it might become dangerous is if we happened to get a disease carrier in the hospital."
"A disease carrier?"
Coleman went on to explain. "It's someone who carries disease germs in their body without having the clinical disease themselves. A carrier can be an apparently normal, healthy person. It happens more frequently than you'd think."
"Yes, I see what you mean," Mrs. Straughan said thoughtfully.
Coleman had turned to the two technicians. He asked, "I suppose we are doing regular lab checks on all food handlers in the hospital?"
Bannister answered, self-importantly, "Oh yes. Dr. Pearson's very fussy about that."
"Are we right up to date?"
"Yeah." The senior technician thought, then added, "Don't think we've had any for quite a while."
"When was the last?" Coleman asked the question casually, as a matter of routine.
"Just a minute. I'll look at the book." Bannister crossed to the opposite side of the lab.
In his mind David Coleman was weighing the factors involved. If the dishwashers were inefficient - and they appeared to be - something needed to be done promptly; there was no question about that. On the other hand, as long as a careful check was being kept on food handlers - and, according to Bannister, it was - there was no real reason for alarm. Indifference, though, was something else again. He told John Alexander, "You'd better get your report to Dr. Pearson as soon as you can."
"Yes, Doctor." Alexander went back to his clip board of notes.
Across the room Bannister looked up from a ruled ledger he had spread open on a file cabinet. He called out, "February the twenty-fourth."
Surprised, Coleman asked, "Did you say February?"
"That's right."
"That's almost six months ago." To the dietitian he observed, "You don't appear to have much of a turnover in kitchen staff."
"Oh yes, we do - unfortunately." Mrs. Straughan shook her head emphatically. "We've taken on a lot of new people since February, Dr. C."
Still not understanding, Coleman asked Bannister, "Are you sure about that date?"
"That's the last one." Bannister was cockily sure of himself. It was a pleasing change to be able to tell something to this know-all young doctor. He added, "See for yourself if you like."
Ignoring the suggestion, Coleman said, "But what about the new employees - those who've been taken on since then?"
"There's nothing else here." Bannister shrugged. "If the health office doesn't send us specimens for test, we've no way of knowing about new food handlers." His attitude was one of complete indifference, almost contempt.
A slow burn was rising in Coleman. Controlling it, he said evenly to the dietitian, "I think this is a matter you should look into." For the first time he had begun to realize that something, somewhere, was seriously wrong.
Mrs. Straughan appeared to have had the same thought. She said, "I will - immediately. Thank you, Dr. C." Her breasts bouncing with each step, she went out of the lab.
There was a moment's silence. For the first time Coleman sensed a feeling of unease in Bannister. As their eyes met he asked the technician icily, "Had it occurred to you to wonder why no tests for food handlers were coming in?"
"Well . . ." Bannister fidgeted, his earlier confidence evaporated. "I guess I would have - sooner or later."
Coleman surveyed the other with disgust. He said angrily, "I'd say later, wouldn't you? - especially if it meant that you would have had to do some thinking." At the door he turned. "I'll be with Dr. Pearson."
The color drained from his face, the older technician still stood, looking at the door through which Coleman had gone. His lips framed words - bitter and defeated. "He knows it all, don't he? Everything in the book. Every perishing thing."
At this moment around Bannister was an aura of failure and downfall. His own familiar world - the world he had believed inviolate and therefore had done nothing to protect - was crumbling. A new order was emerging, and in the new order, through his own shortcoming, there was no room for himself. Crestfallen, out of place, he appeared only a weak, pathetic figure whom time was passing by.
Joe Pearson looked up from his desk as Coleman came in.
Without preliminary the younger pathologist announced, "John Alexander has found gas-forming bacteria - on clean plates which have been through the dishwasher."
Pearson seemed unsurprised. He said dourly, "It's the hot-water system."
"I know." David Coleman tried, but failed, to keep sarcasm from his voice. "Has anyone ever tried to do something about it?"
The old man was looking at him quizzically. He said, with surprising quietness, "I suppose you think things are run pretty poorly around here."
Pearson had flung open a lower drawer of his desk, fumbling among files and papers, talking as he searched. He seemed to be speaking with a strange mixture of anger and sorrow. "You're so young and green and full of lofty ideas. You come here, and it happens to be a time when there's a new administration, when money is freer than it has been in years. So you figure that whatever's wrong is because nobody has thought of changing it. Nobody's tried!" He had found what he wanted and flung a bulging file of papers on the desk.
"I didn't say that." The words were snapped out, almost defensively.
Pearson pushed the file toward him. "This is a record of correspondence about the kitchen hot-water supply. If you'll take the trouble to read it, you'll find I've been pleading for a new system for years." Pearson's voice rose. He said challengingly, "Go ahead - take a look!"
Opening the file, Coleman read the top memo. He turned a page, then another, then skimmed the other pages beneath. At once he realized how much in error he had been. The memos contained a damning condemnation by Pearson of hospital kitchen hygiene, couched in even stronger terms than he would have used himself. The correspondence appeared to go back several years.
"Well?" Pearson had been watching as he read.
Without hesitation Coleman said, "I'm sorry. I owe you an apology - about that anyway."
"Never mind." Pearson waved his hand irritably, then as the words sank in, "You mean there's something else?"
Coleman said evenly, "In finding out about the dishwashers I also discovered there haven't been any lab tests of food handlers for more than six months."
"Why?" The question rapped out like a sharp explosion.
"Apparently none were sent down from the health office. The chief dietitian is checking on that now."
"And you mean we didn't query it? Nobody in Pathology asked why none were coming?"
"Apparently not."
"That fool Bannister! This is serious." Pearson was genuinely concerned, his earlier hostility to Coleman forgotten.
Coleman said quietly, "I thought you'd want to know."
Pearson had picked up the telephone. After a pause he said, "Get me the administrator."
The conversation which followed was brief and to the point. At the end Pearson replaced the phone and stood up. To Coleman he said, "Tomaselli is on his way down. Let's meet him in the lab."
It took only a few minutes in the lab to run over, for a second time, what David Coleman had already learned. With Pearson and Harry Tomaselli listening, John Alexander recapped his notes and Pearson inspected the slides. As he straightened up from the microscope the chief dietitian entered the lab. The administrator turned to her. "What did you find out?"
"It's incredible but true." Mrs. Straughan shook her head in a gesture of unbelief. She addressed Pearson. "Earlier this year the health office hired a new clerk, Dr. P. Nobody told her about lab tests on food handlers. That's the reason none were sent down."
Tomaselli said, "So there have been no tests now for - how long?"
"Approximately six and a half months."
Coleman noticed Carl Bannister standing dourly away from the group, apparently occupied, but he sensed the senior technician was missing nothing of what was going on.
The administrator asked Pearson, "What do you suggest?"
"There should be a checkup first on all the new employees - as quickly as possible." This time the elder pathologist was incisive and brisk. "After that there will have to be re-examination of all the others. That means stool culture, chest X-ray, and a physical. And it should include all the kitchen workers and anyone else who has anything to do with food at all."
"Will you arrange that, Mrs. Straughan?" Tomaselli said. "Work with the health office; they'll handle most of the detail."
"Yes, Mr. T. I'll get onto it right away." She undulated out of the lab.
"Is there anything else?" Tomaselli had returned his attention to Pearson.
"We need a new steam booster system for those dishwashers - either that or rip them right out and put new ones in." Pearson's voice rose heatedly. "I've been telling everybody that for years."
"I know." Tomaselli nodded. "I inherited the file, and it's on our list. The trouble is, we've had so many capital expenditures." He mused. "I wonder what the comparative cost would be."
Unreasonably, irritably, Pearson said, "How should I know? I'm not the plumber."
"I know a little about plumbing; perhaps I can help." At the softly spoken words the others turned their heads. It was Dr. Dornberger, his hands, inevitably, busy with his pipe. He had come into the lab quietly and unnoticed. Seeing Harry Tomaselli, he asked, "Am I interrupting something?"
Pearson said gruffly, "No. It's all right."
Dornberger saw John Alexander watching him. He said, "I was with your baby awhile ago, son. I'm afraid he's not doing too well."
"Is there any hope, Doctor?" Alexander asked the question quietly. The others had turned, their expressions softening. Bannister put down a glass pipette and moved closer.
"Not very much, I'm afraid," Dornberger said slowly. There was a silence, then, as if remembering something, he turned to Pearson. "I suppose, Joe, there couldn't be any doubt about that blood-sensitization test on Mrs. Alexander?"
"Doubt?"
"I mean, that it could be wrong."
Pearson shook his head. "No doubt at all, Charlie. Matter of fact, I did it myself - very carefully." He added curiously, "Why did you ask?"
"Just checking." Dornberger puffed at his pipe. "For a while this morning I suspected the child might have had erythroblastosis. It was only a long shot though."
"Be highly unlikely." Pearson was emphatic.
Dornberger said, "Yes, that's what I thought."
Again the silence, their eyes turning to Alexander. David Coleman felt he wanted to say something - anything to divert attention, to make things easier for the young technologist. He told Dornberger, almost without thinking, "There used to be some doubt about sensitization tests - when labs were using just the saline and high-protein methods. Sometimes then a few positive cases would get recorded as negative. Nowadays, though, with an indirect Coombs test as well, it's pretty well foolproof." As he finished speaking, he realized that this lab had only made the change since his own arrival. He had not meant to take a dig at Pearson; at this moment he found himself hoping the old man would not notice. There had been enough quarreling between them without adding to it needlessly.
"But, Dr. Coleman . . ." Alexander's mouth was gaping, his eyes alarmed.
"Yes? What is it?" Coleman was puzzled. Nothing he had said was enough to produce this reaction.
"We didn't do an indirect Coombs test."
Despite his concern for Alexander, Coleman found himself becoming annoyed. Because of Pearson he had wanted to avoid pursuing this subject. Now he was being given no choice. "Oh yes, you did," he said offhandedly. "I remember signing the requisition for Coombs serum."
Alexander was looking at him despairingly, his eyes pleading. He said, "But Dr. Pearson said it wasn't necessary. The test was done just in saline and high protein."
It took Coleman several seconds to absorb what had been said. He saw that Harry Tomaselli, not understanding, was watching the scene curiously. Dornberger's attention had suddenly perked up.
Pearson appeared uncomfortable. He said to Coleman, with a trace of unease, "I meant to tell you at the time. It slipped my mind."
David Coleman's brain was now ice-clear. But before going further he wanted to establish one fact. "Do I understand correctly," he asked Alexander, "that there was no indirect Coombs test whatever?"
As Alexander nodded Dr. Dornberger cut in abruptly. "Wait a minute! Let me get this straight. You mean the mother - Mrs. Alexander - may have sensitized blood after all?"
"Of course she may!" Not caring, Coleman lashed out, his voice rising in pitch. "The saline and high-protein tests are good in a lot of cases but not in all. Anybody who's kept reasonably up to date in hematology should be aware of that." He glanced sideways at Pearson, who appeared not to have stirred. To Dornberger he went on, "That's why I ordered an indirect Coombs."
The administrator was still trying to grasp the medical significance. "This test you're talking about; if you ordered it, why wasn't it done?"
Coleman wheeled on Bannister. His eyes merciless, he asked, "What happened to the requisition I signed - the requisition for Coombs serum?" As the technician hesitated, "Well?"
Bannister was shaking. Barely audible, he mumbled, "I tore it up."
Dornberger said incredulously, "You tore up a doctor's requisition - and without telling him?"
Relentlessly Coleman said, "On whose instructions did you tear it up?"
Bannister was looking at the floor. He said reluctantly, "On Dr. Pearson's instructions."
Dornberger was thinking quickly now. To Coleman he said, "This means the child may have erythroblastosis; everything points to it, in fact."
"Then you'll do an exchange transfusion?"
Dornberger said bitterly, "If it was necessary at all, it should have been done at birth. But there may be a chance, even this late." He looked at the young pathologist as if, by implication, only Coleman's opinion could be trusted. "But I want to be sure. The child hasn't any strength to spare."
"We need a direct Coombs test of the baby's blood." Coleman's reaction was fast and competent. This scene was between himself and Dornberger now; Pearson was standing still, as if dazed by the swiftness of what had happened. To Bannister, Coleman rapped out, "Is there any Coombs serum in the hospital?"
The technician swallowed. "No."
This was something within the administrator's orbit. He asked tersely, "Where do we get it then?"
"There isn't time." Coleman shook his head. "We'll have to get the test done somewhere else - where they've facilities."
"University will do it; they've a bigger lab than ours anyway." Harry Tomaselli had crossed to the telephone. He told the operator, "Get me University Hospital, please." To the others he said, "Who's in charge of pathology there?"
Dornberger said, "Dr. Franz."
"Dr. Franz, please." Tomaselli asked, "Who'll talk with him?"
"I will." Coleman took the phone. The others heard him say, "Dr. Franz? This is Dr. Coleman - assistant pathologist at Three Counties. Could you handle an emergency Coombs test for us?" There was a pause, Coleman listening. Then he said, "Yes, we'll send the sample immediately. Thank you, Doctor. Good-by." He turned back to the room. "We'll need the blood sample quickly."
"I'll help you, Doctor." It was Bannister, a tray of equipment in his hands.
About to reject the offer, Coleman saw the mute appeal in the other man's eyes. He hesitated, then said, "Very well. Come with me."
As they left the administrator called after them. "I'll get a police cruiser. They'll get the sample over there faster."
"Please! I'd like to take it - to go with them." It was John Alexander.
"All right." The administrator had the telephone to his ear. Into it he snapped, "Get me the City Police." To Alexander he said, "Go with the others, then bring the blood sample to the emergency entrance. I'll have the cruiser waiting there."
"Yes, sir." Alexander went out quickly.
"This is the administrator, Three Counties Hospital." Tomaselli was talking into the phone again. "We'd like a police car to deliver an urgent blood sample." He listened briefly. "Yes; our people will be waiting at the emergency entrance. Right." Hanging up the phone, he said, "I'd better make sure they all get together." He went out, leaving Pearson and Dornberger alone.
Within the past few moments a ferment of thoughts had been seething in the elderly obstetrician's mind. Inevitably, in his long years of medical practice, Charles Dornberger had had patients die. Sometimes about their deaths there had seemed almost a predestination. But always he had fought for their lives, at times savagely, and never giving up until the end. And in all occasions - successes as well as failures - he could tell himself truthfully that he had behaved with honor, his standards high, nothing left to chance, the utmost of his skill expended always. There were other physicians, he knew, who were sometimes less exacting. But never, to the best of his own knowledge and belief, had Charles Dornberger failed a patient through inadequacy or neglect.
Until this moment.
Now, it seemed, near the close of his own career, he was to share the sad and bitter harvest of another man's incompetence; and worse - a man who was a friend.
"Joe," he said, "there's something I'd like you to know."
Pearson had lowered himself to a lab stool, his face drained of color, his eyes unfocused. Now he looked up slowly.
"This was a premature baby, Joe; but it was normal, and we could have done an exchange transfusion right after birth." Dornberger paused, and when he went on the turmoil of his own emotions was in his voice. "Joe, we've been friends a long time, and sometimes I've covered up for you, and I've helped you fight your battles. But this time, if this baby dies, so help me God! - I'll take you before the medical board and I'll break you in two."