The Final Diagnosis
"For Christ sake, what are they doing over there? Why haven't we heard yet?"
Dr. Joseph Pearson's fingers drummed a nervous tattoo upon his office desk. It was an hour and a quarter since the blood sample had been taken from the Alexander baby and promptly dispatched to University Hospital. Now the elder pathologist and David Coleman were alone in the office.
Coleman said quietly, "I called Dr. Franz a second time. He said he'll phone the moment they have a result."
Pearson nodded dully. He asked, "Where's the boy - Alexander?"
"The police drove him back. He's with his wife." Coleman hesitated. "While we're waiting - do you think we should check with the health office about the kitchen situation, make sure the foodhandler checks are being started?"
Pearson shook his head. "Later - when all this is over." He said intensely, "I can't think of anything else until this thing is settled."
For the first time since this morning's events, which had erupted so explosively in the lab, David Coleman found himself wondering about Pearson and what the older man was feeling. There had been no argument about the validity of Coleman's statements concerning the sensitization test, and Pearson's silence on the subject seemed a tacit admission that his younger colleague was better informed than himself, at any rate in this area. Coleman thought: It must be a bitter thing to face; and for the first time he felt a stirring of sympathy for the other man.
Pearson stopped drumming and slammed his hand hard on the table. "For Pete's sake," he said, "why don't they call?"
"Is there any news from Pathology?"
Dr. Charles Dornberger, scrubbed and waiting in a small operating room which adjoined Obstetrics, asked the question of the charge nurse who had entered.
The girl shook her head. "No, Doctor."
"How close are we to being ready?"
The nurse filled two rubber hot-water bottles and placed them beneath a blanket on the tiny operating table that was used for infants. She answered, "Just a few minutes more."
An intern had joined Dornberger. The intern asked, "Do you intend to go ahead with an exchange transfusion - even if you don't have the Coombs test result?"
"Yes," Dornberger answered. "We've lost enough time already and I don't want to add to it." He considered, then went on, "In any case, the anemia in the child now is sufficiently marked to justify a blood exchange even without the test."
The nurse said, "By the way, Doctor, the baby's umbilical cord has been cut short. I wondered if you knew that."
"Yes, thank you, I did." To the intern Dornberger explained, "When we know in advance that an exchange transfusion will be necessary, we leave the umbilical cord long at birth. It makes a convenient point of connection. Unfortunately in this case we didn't know, so the cord was cut."
"How will you proceed?" the intern asked.
"I'll use a local anesthetic and cut down just above the umbilical vein." Turning back to the nurse, Dornberger asked, "Is the blood being warmed?"
She nodded. "Yes, Doctor."
Dornberger told the intern, "It's important to make sure the new blood is close to body temperature. Otherwise it increases the danger of shock."
In a separate compartment of his mind Dornberger was aware that he was talking as much for his own benefit as for the instruction of the intern. Talking at least prevented him from thinking too deeply, and for the moment deep thinking was something Charles Dornberger wanted to avoid. Since he had left Pearson after the showdown in the lab his own mind had been engaged in a torment of anxiety and recrimination. The fact that, technically, he himself was not to blame for what had happened seemed unimportant. It was his patient who was in jeopardy, his patient that might die because of the worst kind of medical negligence, and the ultimate responsibility was his alone.
About to continue talking, Dornberger checked himself abruptly. Something was wrong; he had a feeling of dizziness; his head was throbbing, the room swirling. Momentarily he closed his eyes, then opened them. It was all right; things were back in focus, the dizziness almost gone. But when he looked down at his hands he saw they were trembling. He tried to control the movement and failed.
The incubator containing the Alexander baby was being wheeled in. At the same moment he beard the intern ask, "Dr. Dornberger - are you all right?"
It was on the edge of his tongue to answer "yes." He knew that if he did he could carry on, concealing what had happened, with no one but himself aware of it. And then perhaps, even at this late moment, by exercise of skill and judgment he could save this child, salving, at least in some measure, his conscience and integrity.
Then, in the same moment, he remembered all that he had said and believed over the years - about old men clinging to power too long; the boast that when his own time came he would know it and make way; his conviction that he would never handle a case with his own facilities unpaired. He thought of these things, then looked down at his shaking hands.
"No," he said, "I don't think I am all right." He paused, and aware for the first time of a deep emotion which made it hard to control his voice, he asked, "Will someone please call Dr. O'Donnell? Tell him I'm unable to go on. I'd like him to take over."
At that moment, in fact and in heart, Dr. Charles Dornberger retired from the practice of medicine.
As the telephone bell rang Pearson snatched the instrument from its cradle.
"Yes?" A pause. "This is Dr. Pearson." He listened. "Very well. Thanks."
Without putting the receiver back he flashed the exchange and asked for an extension number. There was a click, then an answer, and Pearson said, "Get me Dr. Dornberger. It's Dr. Pearson calling."
Pearson replaced the phone. Then he looked up, to find David Coleman's eyes upon him.
Dr. Kent O'Donnell was striding through the hospital's main floor on his way to Neurology. He had arranged a consultation there to discuss a partial paralysis condition in one of his own patients.
It was O'Donnell's first day back at Three Counties after his return from New York the evening before. He still felt a sense of exhilaration and freshness from his trip; a change of scene, he told himself, was what every physician needed now and then. Sometimes the daily contact with medicine and sickness could become a depressive, wearing you down after a while without your own awareness of its happening. In the larger sense, too, a change was invigorating and broadening for the mind. And akin to this, more and more since his New York meeting with Denise, the question of ending his own tenure at Three Counties, and of leaving Burlington for good, had kept coming back, to be assessed and weighed in mind, and each time the arguments in favor of a move had seemed more convincing. He knew, of course, that he was strongly motivated by his feelings for Denise and that even until their latest meeting the thought of leaving Burlington had not occurred to him. But he asked himself: was there anything wrong with an individual making a professional choice which weighed in favor of personal happiness? It was not as if he would be quitting medicine; he would merely be changing his base of operations and giving of his best elsewhere. After all, any man's life was the sum of all its parts; without love, if once he found it, the rest of him might wither and be worthless. With love he could be a better man - zealous and devoted - because his life was whole. Again he thought of Denise with a rising sense of excitement and anticipation.
"Dr. O'Donnell. Dr. O'Donnell."
The sound of his own name on the hospital P.A. system brought him back to reality. He stopped, looking around him for a telephone on which to acknowledge the call. He saw one in a glass-enclosed accounting office a few yards away. Going in to use it, he reported to the telephone exchange and a moment later was given Dornberger's message. Responding promptly; he changed direction and headed for the elevators which would take him to the fourth floor and Obstetrics.
While Kent O'Donnell scrubbed, Dornberger, standing alongside, described what had happened in the case and his own reason for calling in the chief of surgery. Dornberger neither dramatized nor held anything back; he related the scene in the pathology lab, as well as the events leading up to it, accurately and without emotion. Only at two points did O'Donnell stop him to interject sharp questions; the remainder of the time he listened carefully, his expression growing grimmer as Dornberger's account proceeded.
O'Donnell's mood of elation was gone now, shattered suddenly and incredibly by what he had learned, by the knowledge that negligence and ignorance - for which, in a very real sense, he himself Was responsible - might snuff out the life of a patient in this hospital. He thought bitterly: I could have fired Joe Pearson; there was plenty of reason to. But no! I dallied and procrastinated, playing politics, convincing myself I was behaving reasonably, while all the time I was selling medicine short. He took a sterile towel and dried his hands, then plunged them into gloves which a nurse held out. "All right," he told Dornberger. "Let's go in."
Entering the small operating room, O'Donnell ran his eye over the equipment which had been made ready. He was familiar with exchange-transfusion technique - a fact which Dornberger had known in calling for the chief of surgery - having worked with the heads of Pediatrics and Obstetrics in establishing a standard procedure at Three Counties, based on experience in other hospitals.
The tiny, frail Alexander baby had been taken from its incubator and placed on the warm operating table. Now the assisting nurse, with the intern helping her, was securing the infant in place, using diapers - one around each arm and leg - folded in long narrow strips and fastened with safety pins to the cover of the table. O'Donnell noticed the baby lay very still, making only the slightest of responses to what was being done. In a child so small it was not a hopeful sign.
The nurse unfolded a sterile sheet and draped it over the infant, leaving exposed only the head and navel, the latter area still in process of healing where the umbilical cord had been severed at birth. A local anesthetic had already been administered. Now the girl passed forceps to O'Donnell and, taking them, he picked up a gauze pad and began to prep the operative area. The intern had taken up a clip board and pencil. O'Donnell asked him, "You're going to keep score?"
"Yes, sir."
O'Donnell noticed the tone of respect and in other circumstances would have smiled inwardly. Interns and residents - the hospital's house staff - were a notoriously independent breed, quick to observe shortcomings in the more senior attending physicians, and to be addressed as "sir" by any of their number was something of an accolade.
A few minutes ago two student nurses had slipped into the room and now, following a habit of instruction, O'Donnell began to describe procedure as he worked.
"An exchange transfusion, as perhaps you know" - O'Donnell glanced toward the student nurses - "is actually a flushing-out process. First we remove some blood from the child, then replace it with an equivalent amount of donor blood. After that we do the same thing again and keep doing it until most of the original, unhealthy blood is gone."
The assisting nurse was inverting a pint bottle of blood on a stand above the table. O'Donnell said, "The blood bank has already crossmatched the patient's blood with that of the donor to ensure that both are compatible. What we must be sure of also is that we replace exactly the amount of blood we remove. That's the reason we keep a score sheet." He indicated the intern's clip board.
"Temperature ninety-six," the assisting nurse announced.
O'Donnell said, "Knife, please," and held out his hand.
Using the knife gently, he cut off the dry portion of the umbilical vein, exposing moist tissue. He put down the knife and said softly, "Hemostat."
The intern was craning over, watching. O'Donnell said, "We've isolated the umbilical vein. I'll go into it now and remove the clot." He held out his hand and the nurse passed forceps. The blood clot was miniscule, scarcely visible, and he drew it out, painstakingly and gently. Handling a child this small was like working with a tiny doll. What were the chances of success, O'Donnell wondered - of the child's survival. Ordinarily they might have been fair, even good. But now, with this procedure days late, the hope of success had been lessened drastically. He glanced at the child's face. Strangely it was not an ugly face, as the faces of premature children so often were; it was even a little handsome, with a firm jaw line and a hint of latent strength. For a moment, uncharacteristically allowing his mind to wander, he thought: What a shame this all is I - to be born with so much stacked against you.
The assisting nurse was holding a plastic catheter with a needle attached; it was through this that the blood would be drawn off and replaced. O'Donnell took the catheter and with utmost gentleness eased the needle into the umbilical vein. He said, "Check the venous pressure, please."
As he held the catheter vertical, the nurse used a ruler to measure the height of the column of blood. She announced, "Sixty millimeters." The intern wrote it down.
A second plastic tube led to the bottle of blood above them; a third ran to one of the two Monel-metal basins at the foot of the table. Bringing the three tubes together, O'Donnell connected them to a twenty-milliliter syringe with a three-way stopcock at one end. He turned one of the stopcocks through ninety degrees. "Now," he said, "we'll begin withdrawing blood."
His fingers sensitive, he eased the plunger of the syringe toward him gently. This was always a critical moment in an exchange transfusion; if the blood failed to flow freely it would be necessary to remove the catheter and begin the early preparation all over again. Behind him, O'Donnell was conscious of Dornberger leaning forward. Then, smoothly and easily, the blood began to flow, flooding the catheter tube and entering the syringe.
O'Donnell said, "You'll notice that I'm suctioning very slowly and carefully. We'll also remove very little at any one time in this case - because of the smallness of the infant. Normally, with a term baby, we would probably take twenty milliliters at once, but in this instance I shall take only ten, so as to avoid too much fluctuation of the venous pressure."
On his score sheet the intern wrote, 10 ml. out."
Once more O'Donnell turned one of the stopcocks on the syringe, then pressed hard on the plunger. As he did, the blood withdrawn from the child was expelled into one of the metal basins.
Turning the stopcock again, he withdrew donor blood into the syringe, then, tenderly and slowly, injected it into the child.
On his score sheet the intern wrote, 10 ml. in.
Painstakingly O'Donnell went on. Each withdrawal and replacement, accomplished gradually and carefully, took five full minutes. There was a temptation to hurry, particularly in a critical case like this, but O'Donnell was conscious that speed was something to be shunned. The little body on the table had small enough resistance already; any effect of shock could be immediate and fatal.
Then, twenty-five minutes after they had started, the baby stirred and cried.
O'Donnell knew better than to jump to hasty conclusions. Nevertheless, over his shoulder to Dornberger, he said, "Sounds like he's mad at us. Could be a good sign."
Dornberger too had reacted. He leaned over to read the intern's score card, then, conscious that he himself was not in charge, he ventured tentatively, "A little calcium gluconate, do you think?"
"Yes." O'Donnell unscrewed the syringe from the double stopcock and substituted a ten-cc. syringe of calcium gluconate which the nurse had given him. He injected one cc., then handed it back. The nurse returned the original syringe which, in the meantime, she had rinsed in the second metal bowl.
O'Donnell was conscious of a lessening of tension in the room. He began to wonder if, after everything, this baby would pull through. He had seen stranger things happen, had learned long ago that nothing was impossible, that in medicine the unexpected was just as often on your side as against you.
"All right," he said, "let's keep going."
He withdrew ten milliliters, then replaced it. He withdrew another ten and replaced that. Then another ten - in and out. And another.
Then, fifty minutes after they had begun, the nurse announced quietly, "The patient's temperature is falling, Doctor. It's ninety-four point three."
He said quickly, "Check the venous pressure."
It was thirty-five - much too low.
"He's not breathing well," the intern said. "Color isn't good."
O'Donnell told him, "Check the pulse." To the nurse he said, "Oxygen."
She reached for a rubber mask and held it over the infant's face. A moment later there was a hiss as the oxygen went on.
"Pulse very slow," the intern said.
The nurse said, "Temperature's down to ninety-three."
The intern was listening with a stethoscope. He looked up. "Respiration's failing." Then, a moment later, "He's stopped breathing."
O'Donnell took the stethoscope and listened. He could hear a heartbeat, but it was very faint. He said sharply, "Coramine - one cc."
As the intern turned from the table O'Donnell ripped off the covering sheets and began artificial respiration. In a moment the intern was back. He had wasted no time; in his hand was a hypodermic, poised.
"Straight in the heart," O'Donnell said. "It's our only chance."
In the pathology office Dr. David Coleman was growing restless. He had remained, waiting with Pearson, ever since the telephone message had come announcing the blood-test result. Between them they had disposed of some accumulated surgical reports, but the work had gone slowly, both men knowing that their thoughts were elsewhere. Now close to an hour had gone by and there was still no word.
Fifteen minutes ago Coleman had got up and said tentatively, "Perhaps I should see if there's anything in the lab . . ."
The old man had looked at him, his eyes doglike. Then, almost pleadingly, he had asked, "Would you mind staying?"
Surprised, Coleman had answered, "No; not if you wish," and after that they had gone back to their task of time filling.
For David Coleman, too, the waiting was hard. He knew himself to be almost as tense as Pearson, although at this moment the older man was showing his anxiety more. For the first time Coleman realized how mentally involved he had become in this case. He took no satisfaction from the fact that he had been right and Pearson wrong about the blood test. All he wanted, desperately now, for the sake of the Alexanders, was for their child to live. The force of his own feeling startled him; it was unusual for anything to affect him so deeply. He recalled, though, that he had liked John Alexander right from the beginning at Three Counties; then later, meeting his wife, knowing that all three of them had had their origins in the same small town, there had seemed to spring up a sense of kinship, unspoken but real.
The time was going slowly, each successive minute of waiting seeming longer than the last. He tried to think of a problem to keep his mind busy; that always helped when you had time to kill. He decided to concentrate on some of the aspects of the Alexander case. Point one, he thought: The fact that the baby's Coombs test now shows positive means that the mother has Rh-sensitized blood also. He speculated on how this might have come about.
The mother, Elizabeth Alexander, could, of course, have become sensitized during her first pregnancy. David Coleman reasoned: It need not have affected their first child; that was the one who had died of - what was it they had told him? - oh yes, bronchitis. It was much more common to find the effect of Rh sensitization during a second pregnancy.
Another possibility, of course, was that Elizabeth might have been given a transfusion of Rh-positive blood at some time or other. He stopped; at the back of his mind was a nagging, unformed thought, an uneasy feeling that he was close to something but could not quite reach it. He concentrated, frowning. Then suddenly the pieces were in place; what he had been groping for was there - vivid and sharply in focus. His mind registered: Transfusions! The accident at New Richmond! The railroad crossing at which Elizabeth's father had been killed, where she herself had been injured but had survived.
Once more Coleman concentrated. He was trying to remember what it was John Alexander had said about Elizabeth that day. The words came back to him: Elizabeth almost died. But they gave her blood transfusions and she made it. I think that was the first time I was ever in a hospital. I almost lived there for a week.
It could never be proved, of course, not after all this time; but he was willing to wager everything he had that that was the way it happened. He thought: Existence of the Rh factor only became known to medicine in the 1940s; after that it took another ten years before Rh testing was generally adopted by all hospitals and doctors. In the meantime, there were plenty of places where blood transfusions were given without an Rh cross match; New Richmond was probably one. The time fitted. The accident involving Elizabeth would have been in 1949; he remembered his father telling him about it afterward.
His father! A new thought came to him: it was his own father - Dr. Byron Coleman - who had taken care of the Alexander family, who would have ordered the transfusions Elizabeth Alexander had received. If she had had several transfusions they would have come from more than one donor; the chance of at least some of the blood being Rh positive was almost inevitable. That was the occasion, then, when Elizabeth had become sensitized; he was sure of it now. At the time, of course, there would have been no apparent effect. None, that is, except that her own blood would be building antibodies - antibodies to lurk hidden and unsuspected until, nine years later, they rose in anger, virulent and strong, to destroy her child.
Naturally David Coleman's father could not be blamed, even if the hypothesis were true. He would have prescribed in good faith, using the medical standards of his day. It was true that at the time the Rh factor had been known and in some places Rh cross matching was already in effect. But a busy country G.P. could scarcely be expected to keep up with everything that was new. Or could he? Some physicians of the time - G.P.'s included - were aware of the new horizons opened up by modern blood grouping. They had acted promptly to enforce the latest standards. But possibly, David Coleman reasoned, these were younger men. His father at that time was growing old; he worked too hard and long to do much reading. But was that an adequate excuse? Was it an excuse that he himself - David Coleman - would accept from others? Or was there perhaps a double standard - a more lenient set of rules when it came to judging your own kin, even a father who was dead? The thought troubled him. He sensed uneasily that a feeling of personal loyalty was obtruding across some of his own most cherished views. David Coleman wished he had not thought of this. It gave him an uneasy feeling of doubt, of not being absolutely sure . . . of anything at all.
Coleman checked his watch, then answered, "Just over an hour."
"I'm going to call them." Impetuously Pearson reached for the telephone. Then he hesitated and drew his hand away. "No," he said, "I suppose I'd better not."
In the serology lab John Alexander, too, was conscious of the time. An hour ago he had come back from visiting Elizabeth, and since then he had made several halfhearted attempts to work. But it was obvious to himself that his mind was far removed from what he was doing and he had desisted, rather than risk mistakes. Now, taking up a test tube, he prepared to begin again, but Bannister came over and took it from him.
Looking at the requisition sheet, the older technician said kindly, "I'll do that."
He protested halfheartedly, then Bannister said, "Go on, kid; leave it to me. Why don't you go up with your wife?"
"Thanks all the same, but I think I'll stay. Dr. Coleman said as soon as he heard . . . he'd come and tell me." Alexander's eyes turned to the wall clock again. He said, his voice strained, "They can't be much longer now."
Bannister turned away. "No," he said slowly, "I guess not."
Elizabeth Alexander was in her hospital room alone. She was lying still, head back on the pillows, her eyes open, when Nurse Wilding came in. Elizabeth asked, "Is there any news?"
The elderly, gray-haired nurse shook her head. "I'll tell you just as soon as we hear." Putting down the glass of orange juice she had brought, she said, "I can stay with you for a few minutes if you like."
"Yes, please." Elizabeth smiled faintly, and the nurse pulled a chair near the bed and sat down. Wilding felt relieved to rest her feet; just lately they had been giving her a good deal of pain, and she suspected they would probably force her to quit nursing soon, whether she wanted to or not. Well, she had a feeling she was pretty close to being ready to go.
Wilding wished, though, that she could do something for these two young people. She had taken a fancy to them from the beginning; to her the two of them - husband and wife - seemed almost children. In a way, taking care of this girl, who, it seemed now, was likely to lose her baby, had been almost like caring for the daughter that long ago Wilding had wanted but never had. Wasn't that silly now? - she, with all her years of nursing, getting sentimental at this late day. She asked Elizabeth, "What were you thinking about - when I came in just then?"
"I was thinking about children - fat, roly-poly children scrambling on green grass in afternoon sunshine." Elizabeth's voice had a dreamlike quality. "It was like that in Indiana when I was a little girl - in the summers. Even then I used to think that someday I would have children and that I would sit beside them while they rolled on the grass in the sunshine, just as I had."
"It's a funny thing about children," Wilding said. "Sometimes things turn out so different from the way you thought they would. I had a son, you know. He's a man now."
"No," Elizabeth said, "I didn't know."
"Don't misunderstand me," Wilding said. "He's a fine man - a naval officer. He got married a month or two ago; I had a letter from him telling me."
Elizabeth found herself wondering - what it would be like to bear a son and then have a letter, telling about his getting married.
"I never did feel we got to know one another very well," Wilding was saying. "I expect that was my fault in a way - getting divorced and never giving him a real home."
"But you'll go and see him sometimes?" Elizabeth said. "And there'll be grandchildren, I expect."
"I've thought a lot about that," Wilding said. "I used to think it would be fun. You know - having grandchildren, living somewhere near, then going in the evenings to baby-sit, and all the rest."
Elizabeth asked, "But won't you - now?"
Wilding shook her head. "I have a feeling that when I go it'll be like visiting strangers. And it won't be often either. You see, my son is stationed in Hawaii; they left last week." She added with a touch of defiant loyalty, "He was coming to see me and bring his wife. Then something came up at the last minute, so they couldn't make it."
There was a silence, then Wilding said, "Well, I'll have to be getting on now." She eased to her feet, then added from the doorway, "Drink your juice, Mrs. Alexander. I'll come and tell you - just as soon as we hear anything at all."
Kent O'Donnell was sweating, and the assisting nurse leaned forward to mop his forehead. Five minutes had passed since artificial respiration had begun, and still there was no response from the tiny body under his hands. His thumbs were on the chest cavity, the remainder of his fingers crossed around the back. The child was so small, O'Donnell's two hands overlapped; he had to use them carefully, aware that with too much pressure the fragile bones would sunder like twigs. Gently, once more, he squeezed and relaxed, the oxygen hissing, trying to induce breath, to coax the tired, tiny lungs back into life with movement of their own.
O'Donnell wanted this baby to live. He knew, if it died, it would mean that Three Counties - his hospital - had failed abjectly in its most basic function: to give proper care to the sick and the weak. This child had not had proper care; it had been given the poorest when it needed the best, and dereliction had edged out skill. He found himself trying to communicate, to transmit his own burning fervor through his finger tips to the faltering heart lying beneath them. You needed us and we failed you; you probed our weakness and you found us wanting. But please let us try - again, together. Sometimes we do better than this; don't judge us for always by just one failure. There's ignorance and folly in this world, and prejudice and blindness - we've shown you that already. But there are other things, too; good, warm things to live for. So breathe! It's such a simple thing, but so important. O'Donnell's hands moved back and forth . . . compressing . . . releasing . . . compressing . . . releasing . . . compressing . . .
Another five minutes had passed and the intern was using his stethoscope, listening carefully. Now he straightened up. He caught O'Donnell's eye and shook his head. O'Donnell stopped; he knew it was useless to go on.
Turning to Dornberger, he said quietly, "I'm afraid he's gone."
Their eyes met, and both men knew their feelings were the same.
O'Donnell felt himself gripped by a white-hot fury. Fiercely he ripped off the mask and cap; he tore at the rubber gloves and flung them savagely to the floor.
He felt the others' eyes upon him. His lips in a thin, grim line, he told Dornberger, "All right. Let's go." Then, harshly, to the intern, "If anyone should want me, I'll be with Dr. Pearson."