5. Stranger in The Mind-Chapter 5

Chapter 5.  January

January 1.

The phone wakes me and I glance at my clock as I pick up the receiver. Already 5:00AM  Lucky.  Got full night’s sleep.   “This is Dr. Morton.”

“Happy New Year, Dr. Morton.  This is Susan in the ER and we have a patient for you at last.”

“You don’t have to sound so damn cheerful about it, Susan, but Happy New Year to you too.  What do you have for me?”

Seventeen hours, a whole lot of patients, and several admissions later, Cliff and I are more than ready to turn over the ER to the Night Float at 10:00 PM.  We part company at the side corridor to the HOB. 

“Good night Cliff.  Glad that’s over.  At least we won’t have anymore overnight calls this month while we’re on ER duty.”

“That may be fine for you married guys who go home to wives and apartments, but it doesn’t make that much difference for those of us living in the HOB,” says Cliff.

“Well at least you won’t get wakened after ten,” I say.

“Every night’s shot anyway, working until ten,” is Cliff’s parting comment. 

What a crab.  Month’s going to be a delight.  I continue on to the main entrance and out into the brittle-cold winter night to my car.  Try something more pleasant * * * *

“Hi Sal.  Glad you’re still up.  How’d your New Year’s Eve go?  Did you have a wild, drunken time last night?”

“Pretty quiet, both yesterday and today.  I’m not inclined to celebrate boisterously.  But you must be tired after being on for so long, and in the ER yet.”

“Not inclined to celebrate boisterously.”  Is Sal old, a recluse, confined, prisoner even?  “Yeah.  Glad last night was unusually quiet and I got some sleep.  Cliff wasn’t so lucky during the first half of the night.  But Sal, didn’t you even toast the New Year with a little champagne?  It’s a new decade after all.”

“No, just a quiet, sane changing of the years for me.”

January  6.

I’m driving home after the ER.  Time to check in with Sal * * * *

“Hi Sal, is this too late to be calling you?”

“I was starting to drowse off, but it’s okay.”

“You know, this whole month I’ll be getting off at ten or later, if it’s busy like it was tonight.  Maybe I should call you during the day when it’s slow.  If you’re tied up, then just tell me and I’ll try again later.”

“Sure.  That sounds like a good plan.  How do you like this rotation so far?”

“Busy.  The winter viruses just pile the kids and their parents on the benches in front of the ER like we’re having a fire sale.  And tiring, since we work each weekday from 8:00AM to 10:00 PM and till noon on Saturday, with Sunday off.  But at least I sleep at home every night.”

“Karen must like that, even though she has a long wait for you to get home.”

“Yeah, but this week I’ve been too tired to do anything but sleep.”

“That has a familiar ring to it,” says Sal.

“What do you mean–Oh, I see.  You’re thinking back to when I coerced Karen into having sex when she was tired.  That was a cheap shot, Sal.”

“The shoe’s on the other foot, isn’t it?  Just remember how you feel now if you get the urge to push her in the future.”

“Yeah.  Huh.  Well, I’m home.”  I make a right turn into Beacon Street.  “Talk with you tomorrow.  Good night, Sal.”

Looking out for Karen.  Who invited him?  Damn busy body.  Wants to be my conscience.  Guess he means well.  Sure free to talk whenever though.  What’s he do?  Must not need undivided attention.  What’d he say when I tried to see if he was Saul Norman?  ‘I can walk and chew gum at the same time.’  Something like that.  Maybe his mind is just very powerful.  Certainly beyond mine.  He someone like a monk who spends lot of time alone?  Monasteries in Boston?  Solitary confinement?  Lighthouse keeper?  Henry David Thoreau?  Getting ridiculous.  Forget it.

January 11.   

Today it was my turn to come in at 10:00 AM, and Cliff’s to start alone at 8:00.  Since it usually doesn’t get busy until later in the day, we can take turns sleeping late.  But as luck would have it, Cliff has had a busy early morning.

“Glad you’re here at last,” he greets me without a smile.  “I’ve already done an LP on a kid with a febrile convulsion, and had an admission for diarrhea-dehydration.”

“Whatever happened to saying ‘good morning?” I answer.  “I’m here right at 10:00, and the room’s empty.”

“Yeah, well that’s because I’ve already done all the work.  Look, now that you’re here, I’m going to take a break.”

Only 10:00.  He’s in a crappy mood.  Going to be long day.   

Usually late afternoon, when the outpatient clinic closes, is when business picks up.  But more serious problems can come in at any time, as they did today, and may again tomorrow morning when it’s my turn to be the early person.  It’s all a matter of luck.  Bad luck for Cliff today; maybe bad for me tomorrow.  But he’s such a crab.

The rest of the morning goes by quietly. Cliff returns after a long break, but I don’t say anything.  We take turns going to lunch.   

During the early afternoon, there are a few minor school yard injuries, a baby with a scald burn from her mother’s cup of tea, an accidental ingestion of an over-the-counter cold medicine that requires gastric lavage and observation, several after-school falls and cuts, and a twelve year old with a black eye from a fight.

I call Sal between patients * * * *   “Hi Sal.  Are you free now?”

“Yes, I can talk.  How’s the ER?”

“Quiet, which is why I’m able to call.”

“I see that you’re annoyed by Cliff.”

“Does the way I feel come through that transparently to you?  Yeah.  He’s an irritating person to work with,” I reply, “and there are twenty more days to this month.”

“And is he worth getting an ulcer over?”  asks Sal.

Kate says, “I’m going to go use the bathroom now.  Okay?”

“Sure,” I reply, “Don’t rush.” 

“Just wash your hands well afterwards,” says Cliff.

“I think I see where you’re going with this,” I say to Sal.

“Do you?  Ask yourself if you can change Cliff or avoid him, this month,” says Sal.  “If you can’t do either, then what you’re left with is changing your reaction to what he does.”

“Easy for you to say,” I reply.  “You don’t have to work with him.”

“Remember, it’s your blood pressure rising, and it’s your intestinal lining that’s getting eaten by acid, not his.  You’re getting a double whammy-—one of his doing, and one of your own.”

“You’ve got a point,” I concede.  “I’ll think about it.”

Kate goes off duty at 3:00, and Jackie comes on, to work till 11:00PM.

Around 4:00, a mother arrives carrying her infant, who is wheezing faintly.  Jackie directs them to cubicle one, takes the baby’s weight and vital signs, and then brings the clipboard back to the desk.  “Don’t fight over this, fellas, but this kid’s probably going to need admission.  Bronchiolitis, I think.”

“Guess it’s my turn,” I say to Cliff.  “Why don’t you go to Dr. Wasserman’s conference, and I’ll call if I need help.  He shrugs in agreement.  You’re welcome, Cliff.  Could have said, “Let’s flip.”  No.  Try to remember what Sal said.   Try to be positive or at least not negative.  He’s not out to bug me on purpose.  Just self-centered.

I pick up the clipboard and read the registration sheet.  William Donovan.  Seven-months old.  Wheezing and coughing.  I take the short walk to the first cubicle.  “Hello, Mrs. Donovan, I’m Dr. Morton.  Billy’s been sick, has he?”  Focuses on me though he looks tired.  Tight cough.  Breathing fast, expiratory wheeze, some nasal flaring.  Face and lips look pink.

“Yes doctor, he’s had a cold for the past two days, but this morning he started to cough more, and he developed this wheezing in his chest.  And it’s just gotten worse as the day’s progressed.”  Sounds like she’s from the Auld Sod.

“Has he been eating and drinking alright?”

“No, not as much as usual.”

“Do you think that it’s because he’s working so hard to breathe?”

“Yes.  He’s just not able to nurse for very long, and he’s got no interest at all in his baby foods.”

“You said that he started wheezing this morning, Mrs. Donovan, has he had this before?”

“No, this is the first time for Billy, but my daughter used to do this, when she was a baby.”

“And when did his fever begin?”

“Well, he felt warm yesterday, but after lunch today he felt much warmer.”

I complete my questions, and ask Mrs. Donovan to undress Billy so that I can examine him.  Yeah, using his accessory muscles to breathe.  Retracting.  Respiratory rate’s sixty-four.  He looks very tired.

“Has he been wetting his diapers as much as usual?”

“Less, doctor.”

I continue my exam.  His chest is hyperresonant, and his breath sounds are reduced, and he has diffuse fine inspiratory rales, and expiratory wheezes.  His heart is moving along at 160.  And his liver is down two and a half finger breadths.

“I think that Billy has an infection called bronchiolitis,” I say, “and he looks like he’s working so hard to breath that he’s getting tired.  Certainly too tired to nurse enough.  I’m afraid that he’s too sick to go home.  We’ll need to admit him.  I’m going to put him on some oxygen by mask so that he’ll be more comfortable.  I also want to get an x-ray of his chest to make sure that he doesn’t have pneumonia.  And I’m going to ask the nurse to give him a shot of adrenaline now, to see if that relieves his wheezing.”

“Please take good care of him, doctor, he’s very precious to us.” 

“We’ll certainly try to, Mrs. Donovan.  Hey Jackie.”

“What?”

“You were right.  He’s going to need to be admitted, but could you give him a shot of aqueous adrenaline, 1:1000, 0.1ml subQ, before he goes to x-ray?  And put him on O₂ by mask at 3 liters.” 

I call the conference room to notify Peter Norris, the JR on eight that he’ll be getting an admission.  “Hi Peter, this is Bob in the ER.  Am I missing a lot at conference?  Look, I’ve got a seven-month old boy with bronchiolitis who’s pretty tired and tight, and you’re up for the next admission.  No, I don’t think he’s in heart failure.  I’m going to send him to x-ray with O₂ running, and give him a shot of adrenaline now.  I’ll page you when he comes back.  And could you tell Dave about the admission too?  He’s the SR on call.  Ask him to call me if he questions it.”

I walk back to Mrs. Donovan.  “I just spoke with Dr. Norris, who will be coming to admit Billy after he gets his x-ray taken.  Dr. Siegal, the Senior Resident will also be down.  And I’ll be back to listen to him after his shot, to see if it helps his wheezing.”

In the meantime, a few more patients have arrived and have been placed in cubicles by Jackie.  Their clipboards are stacked on the desk by the door.  I take the top one, and go to that patient. 

“Hello Franklin, I’m Dr. Morton,” I say to the fourteen-year old, waiting with his mother, “What’s bothering you?”

“You mean besides school, doc?”  It turns out that he has tonsillitis.  He departs after getting a throat culture.

Billy and his mother return from x-ray.  His breath sounds may be slightly better and his wheezing a little improved after the adrenaline shot, but he still needs admission. I page Peter and Dave to come down.

Six o’clock, and I’ve taken care of the waiting patients, and we’re in our usual dinnertime lull.  Cliff calls at the end of conference to see how things are, and I tell him to eat before returning.  When he finally returns, I head through the tunnels to the cafeteria. 

I’m back at the ER after a half-hour.  By 7:30, the after-dinner rush is on.  Tonight there seems to be a discount on ear infections, and we prescribe a lot of oral antibiotics. 

“Things seem to be slowing at last,” I say to Jackie late in our shift.  Cliff is with his last patient. 

We hear the receptionist up the hall say loudly, “Hey!  You’ve got to stop here first!”  Then running feet approaching. 

A young policeman bursts into the room, carrying a blanket-wrapped child, followed by his partner and a receptionist.  “Please help him.  He stopped breathing in the squad car after a convulsion.  I gave him mouth to mouth all the way in.”

“Put him here,” says Jackie leading them to an exam table, and unwrapping the blanket.  She puts an oxygen mask with ventilating bag on the boy, while I look at him.

“What happened?” I ask, while starting a quick examination.  About three or four.  Color not good.  Skin’s real hot.  And covered with purpura and petechiae.  Not breathing.  No heart beat.  “Cardiac arrest,” I say.

  Cliff has come over, and gives a soft whistle as I open the boy’s blue cowboy pajamas.  He takes over from Jackie, squeezing the bag on the oxygen mask.  “Get me adrenaline with an intra-cardiac needle,” he tells her.    

“We got a call that a boy was having a convulsion,” says the policeman, “and when we arrived at the address, he wasn’t responding.  So we put him in the squad car and right afterwards, he stopped breathing.  His parents are coming in after us.”

Cliff pounds the boy’s chest twice over the heart, with his fist.  “Anything?”

“Nothing,” I reply after listening for a long moment with the stethoscope.

“You got that adrenaline ready, Jackie?  Okay, give it to me.”  Cliff feels for the fourth left interspace, thrusts the needle through into the heart, draws back, sees dark blood in the syringe confirming the needle’s location, and pushes the adrenaline.

“Anything?”  he asks.

“Still nothing.”

“Let’s have another dose,” he says to Jackie.

He repeats the injection.  Still no response.

“How long did it take you to get here?” I ask.

“About seven minutes,” replies the policeman’s partner. 

Damn.  Brain’s probably fried.

“I’m going to try closed-chest cardiac massage,” says Cliff.  “You take over bagging him.”  He kicks out the foot stand beside the table, stands on it, and begins to do chest compressions as I bag.

The parents arrive at the door, his mother crying, “My baby, my baby.” 

Jackie pulls the curtain closed, then goes out to them, “The doctors are working on him right now.  Please wait here.”

“But is he all right?” I hear his father ask.  “What’s going on?”

Cliff compresses and I bag for long, long minutes.

“Stop and let me check him,” I say, and put the stethoscope on the boy’s chest.  Nothing.  We switch places and continue till Cliff signals me to stop.  He listens to the heart again. 

“Still nothing,” he says. 

The policeman looks at me.  I look at Cliff and shake my head slightly.  He nods in agreement, and steps away.

“Officer, I’m sorry,” I say softly, “In spite of all you did, he’s gone.”

“Shit, dead?” whispers the policeman. 

“What’s happening to Robbie?”  screams his mother.

“I’ll go to the parents,” says Cliff, pushing through the curtain.

“I know you tried your best,” I say to the policeman.  “But I don’t think anything that you could have done would have saved him.” 

I hear Cliff talking to Robbie’s parents who are both crying.  Jackie is on the phone to the operator to page Mark, the SR on duty tonight.  Then she goes back to helping Cliff with the parents. 

“Let’s go over to your son,” says Jackie.  I pull the curtain back and step aside for them.  His mother hugs Robbie, wailing.  Cliff pats her shoulder.  Her husband stands silently behind her, hand on her waist, tears streaming down his cheeks. 

“I should have brought him in today,” she sobs over and over.

The young policeman looks shaken.  “I got a two year old of my own.”

“I know it’s hard to talk right now,” I say to the father after a time, “but do you have other children at home?”

“Yes, three.”

“Anyone sick or running a fever?”

“No, no one.  Why?  You don’t think they could have what Robbie has?”

“This is important for you officers too, especially since you gave mouth-to-mouth to him,” says Cliff.  “Just from his appearance, we think that Robbie had an overwhelming infection with a germ called meningococcus.  It is contagious.  So we need to treat everyone with a sulfa drug, even before the results of the tests that we’re going to do, come back.”  Robbie’s mother cries harder.

“Damn,” says the policeman, “I got his spit right in my mouth the whole time I was mouth-to-mouth with him.”  He goes to the sink and gargles with tap water.

Mark arrives.  I take him aside to quickly fill him in.

“Doc,” says the policeman, “my son–if I take the medicine–it’ll prevent him from getting it from me?”

“That’s why we’re all going to take it,” I reply.

“We always blame ourselves at times like this,” I say to the parents, “but Robbie really didn’t have a chance.  His infection moved so quickly that even before the rash appeared, he was probably doomed.”  At my words, his mother sobs harder.  Doomed wasn’t best way to say that.  “Please don’t blame yourselves.  We want to be sure that you and your children don’t get it too.”

“Please send for a priest,” asks Robbie’s mother.

“I’ve already put in a call for Father Salerno,” says Jackie.

Maury, the Night Float, arrives after Father Salerno has spent time comforting the sobbing parents and left.  Then the parents and police leave with their sulfadiazine.  Maury will check and culture their other children when they’re brought in tonight, using the orthopedic room, while the pediatric room is thoroughly cleaned.  A masked, gowned, and gloved orderly arrives to wrap Robbie’s body in a white shroud and transport it to the morgue. 

Finally, Cliff, Jackie, and I swallow our sulfa pills and go off duty through the tunnels.

“Thanks for stepping up to the plate tonight, Cliff,” I say as we arrive at the turnoff to the HOB.  “What a way to end the day.”

“Don’t mention it,” he says.

An asshole at times, but tonight he really pitched in.

It’s near midnight by the time I get home and Karen is already asleep.  She awakens enough to mumble, “You’re late.  What happened?”

“Go back to sleep, I’ll tell you in the morning.  I’m going to take a shower.”  I scrub myself very, very well.  And gargle.

January 12.

“But that’s so horrible,” says Karen, as we hurriedly dress in the morning.  “How could the infection spread so fast?  His parents must be devastated.”

“I’m sure they’ll feel very guilty no matter how often they’re told the infection was so overwhelming that their son had no chance.”

“There’s no chance that you brought the germs home on your clothes?”

“None.  And I told you that I took sulfa too, so I wouldn’t carry it.”

“After that story, I’ll be worried sick every time our children have a fever.”

“Karen, we don’t even have a kid yet. But it’ll stick in our minds when we do.  And I’ve got to run now.  It’s my turn to cover early today.”

“But you haven’t had breakfast yet.” 

“I don’t have time.  I’ll see you tonight.  And don’t worry!”  A quick kiss, and I’m out the door and into traffic.  No breakfast.  Price for sleeping through alarm.  Should have told Karen with more time to explain.  Not surprising she’s worried with no medical background.

At mid-morning, I get a call from pathology. 

“Hello Bob, this is Ulrich Uhr.  How have you and Karen been?  Haven’t seen you since Thanksgiving.  Say, I’m doing the posts today, and I saw your name on this young boy who came DOA to the ER last night.  I’ve scheduled his autopsy for around two.  Do you want me to call you when I start?”

“Karen and I have been fine.  And thanks for thinking of me when you set up the autopsies.  Two is perfect, because I’ll be able to present your findings at four o’clock rounds to Dr. Wasserman.  I’ll be over, unless the ER gets busy.”

The policeman calls after lunch, “Hi.  Are you the doctor who was on last night when we brought that poor kid in DOA?”

“Yes officer.  What’s up?”

“Doc, I took those sulfa pills, but now I’m starting to get a sore throat.  You don’t think I could be catching what that kid had?”

“Why don’t you come into the adult medicine ER and get checked.  I doubt it, but it’s best to be sure.  What’s your name again?”

“Sean Brody.”

“Okay Officer Brody, I’ll call the adult ER and tell them to expect you.”

At Chief’s Rounds, I present Robbie’s history and the autopsy findings to Dr. Wasserman, the department, and Saul Norman and his fellows. 

“What do you think, Saul?” asks the Chief, turning to his left.  “Classic Waterhouse-Friderichsen Syndrome?  We haven’t had one of them for a couple of years.”

“Yes,” replies Dr. Norman, absent-mindedly running his fingers through his thinning white hair.  “Even to the lack of reaction in his spinal fluid.”

“Suppose he had come in just as the rash was appearing,” asks Dr. Wasserman.  “Do you subscribe to the idea that giving a large dose of steroids IV might favorably altered the course of the illness?”

“No I don’t,” says Dr. Norman.  “There‘ve been just a handful of case reports purporting to show that.  Nobody sees enough of them to really do a proper controlled study.”  He turns to one of his fellows sitting in the row behind him.  “But perhaps we should look into organizing a collaborative study with other institutions.”

“What about doing open chest cardiac massage instead of closed-chest?” asks one of the students.  “Would that have been more effective?”

“The early data shows that outcomes are similar, but more studies need to be done,” says Vinny.  “In this case, with a history of probably seven or more minutes of arrest, the kid’s brain was probably already fried.”   

The discussion continues.  How would Robbie’s parents feel if they heard him discussed so clinically.  But that’s how we learn.  High cost tuition.

January 15.

We’re sitting on the living room floor, leaning back against the orange, Scandinavian-style couch, with the Sunday Boston Globe and New York Times spread around us.  “My Fair Lady” is coming softly from the corner speaker enclosure.

“When do you want brunch?” asks Karen.

“Maybe another hour?” I reply.  “Are you hungry?  How about some fruitcake?  I’m getting more coffee–want me to refill yours?”

“Yes please.  Oh, here’s the obituary for that boy you took care of–Robert Wilson?”

“Yeah?  Can I see it?”  I reply from the kitchen.  I return and hand Karen her mug, set the plate of fruit cake slices down on the floor in front of us, then sit back down with my coffee and read what she passes to me.

“I haven’t been able to get that poor boy out of my mind ever since you told me about him,” says Karen.  “He was only three.  How do parents ever get over something like that?  Isn’t there some way to prevent it?”

“I’m not sure they’ll ever get over it.  The pain must just gradually decrease with time but never go away.  There’s no immunization for meningococcus yet, though Dr. Scott said that there is a vaccine being developed.  Actually the infection is usually easily treated when caught in time.  It’s just a very few patients who get an overwhelming infection like this boy had.”

“It may be rare, but for this family, it was 100% fatal.”

  “By the way, would you like to try skating again this afternoon?” I ask to change the subject.  “If we drive over to Cambridge Common, it might be less crowded than at Boston Common.”

“Yes, that would be fun,” says Karen.  “I’m glad we bought those cheap skates for me at Raymond’s.  And since we haven’t eaten out for several weeks, we can have dinner at the Wursthaus afterwards.”

We drive over to Cambridge around two-thirty, sit on a cold green park bench to lace on our skates, and then begin to make our wobbly way around the flooded baseball diamond, leaning unsteadily against each other like a tripod missing one leg, trying to laugh off the falls.  The hazy winter sun gives no warmth, and the ice is hard.  It takes a while for our muscles to warm up, but eventually we’re able to make slow circuits without falling, letting go of each other as we gain confidence.  But everyone else, young and old, seems to glide effortlessly past us.

“Hello Bob,” says Sal. “Okay for me to visit now?” 

That’s just enough for me to lose my focus and my feet slide out on a turn and I sit down with a thump.  “Damn it, Sal, I was doing so well too.”

“Sorry that I broke your concentration.  But I thought pastimes were supposed to be fun.  How masochistic of the two of you to spend your free time collecting bruises.”

“And I suppose you’re a demon skater, Sal?  Well, if you are, don’t gloat.  After all, we didn’t grow up with skates in California.”

“Maybe I shouldn’t disturb you right now.  I’ll talk with you tomorrow.”

“You can hang around if you like, without talking.”

“No thanks.  I don’t I want to experience the pain each time you fall.  You may be a masochist, but I don’t need to be one.  Goodbye Bob.”

Karen comes skating up after her circuit of the ice.  “What took you so long to get going again?  Are you all right?”

“Yeah, I’m okay.  I thought I’d wait till you skated back around rather than try to catch up to you.”  And we set off again side-by-side.

When some kids start a hockey game, contrary to park rules, we are ready to use that as an excuse to leave the ice.  Anyway, it’s after four PM, brunch was a long time ago, and the pale sun is sinking low behind buildings.

The Wursthaus in Harvard Square, is dimly lit, with dark wood booths and tables.  Dinner is solid, reasonably-priced German fare: sausage, red cabbage, sauerkraut, and potatoes, and chewy, dark-brown pumpernickel, washed down with water instead of beer, that can’t be sold on Sundays, because of the Blue Laws.  We shift from one buttock to the other on the wood seats, trying to ease our bruises, and talk about our afternoon, relaxed from the exercise and the cold air.  Glad Karen’s mind is off that boy for now. 

January 16.

“Well Sal, for once I got off at ten, which is surprising since it’s a Monday night.”  I’m walking to the car, with my navy-blue knit cap pulled down over my ears.  The night is clear, but biting cold.  Gloved hands are jammed deep into the pockets of the Loden coat.  My eyes and ears stay alert, but it’s so cold that it’s unlikely any muggers would be out.

“Not every night is going to be like last Wednesday and Friday,” says Sal.  “Otherwise you’d be toast.”

“Just spread some marmalade on me.”

I fumble with the keys at the car, dropping them once, before taking off my right glove to unlock the door.  Then I roll the window down to keep the windshield and my glasses from fogging up, until the defroster kicks in.

“I’ve been wondering,” asks Sal as I start the car, “How do you really feel about Robbie, that boy who died?”

“That’s a funny question, Sal, coming out of the blue.  Why do you ask?”

“I couldn’t help but pick up your feelings, last week, about how clinical and dispassionate the discussion at rounds about him seemed to you.  That started me thinking about how you doctors in training must sometimes be caught between your human feelings and the excitement of learning and doing.”

Doctors in training—so he probably isn’t in the medical field or he’d know.  Or maybe he just wants to explore my reactions. “Yeah.  Well, it was just that from the parents’ perspective, they might have found the discussion pretty cold-blooded.”

“And yet, you learned, so his death wasn’t for naught.” 

For naught!  Sal’s waxing pretty formal.  “As we’ve been told, the best way to learn is to see or experience and do.  It’s when that experience involves a patient’s death that it gets sobering.”

“Just sobering?  Do you also feel sorry for the patient and the parents?”

“Of course we do.  Why am I feeling defensive?  But you can’t get blubbery about it and let your emotions interfere with how clearly you think or it’ll affect how you perform.”

“When Cliff was doing chest compressions on Robbie, he felt a mixture of exhilaration and fear.  Excitement that he was getting a chance to actually try something that he had only read about and heard described, and fear that he might somehow goof up and be responsible for Robbie’s death.  But I didn’t get a sense that he was feeling pity or sorrow at that moment.”

“Well, of course not,” I reply.  Damn, I’m actually defending Cliff.  “If he had allowed himself to feel that, he would have been less effective and focused.  Hey wait a minute.  Were you in our minds while we were working on Robbie?”

“No, but after you told me about that night, I checked into Cliff’s mind as I was thinking about it.  I’ve found that residents often try to avoid showing their feelings as they go through training.  It’s not only a matter of maintaining objectivity, but so many seem to feel that it’s unprofessional to express their emotions.  It’s that whole superhuman image.  Anger is okay, but you can’t appear soft.  It’s just not cool.”

“Ah hah!  So you do hang out around hospitals.  You let that slip out, Sal!  Also, with all your ethical concerns, how do you justify poking around in someone else’s thoughts?”

“That I know how residents feel, doesn’t necessarily mean that I am either physically present or professionally connected.  I also ‘hang out’ around the universities, as I’ve told you previously, and elsewhere.  And I’ll tell you now, I’m neither a student nor a faculty member.  As to the ethics of entering someone’s mind, while it might be considered voyeuristic, since I can neither converse with them nor influence their behavior, it does them no harm.”

“So why bring this up, Sal?”

“Because you’re a decent person Bob.”

“Gee thanks.”

“And there are good and decent doctors who finished training, but forgot to take their feelings out of that box that they’d put them away in.  And they’re diminished as human beings because of that.  I just thought you might want to start thinking about it now.”

Don’t know what to say.  “That’s heavy stuff.”

“Good night, Robert.  You’re home.”

“Oh yeah, so I am.  Goodnight Sal.  And thanks.”

January 20.

“What did you think of Kennedy’s inauguration speech, Sal?”  Can I get a rise out of him for not voting?

“It was memorable.  Offering us a new vision of America.  Were you able to watch it at all?”

“Not in the ER.  And it was way too busy to get away to the HOB common room.  But Cliff brought in his transistor radio, so we heard parts of it between patients.  What we heard sounded good though.  Guess I’ll see what Karen thinks, and read about it in the paper.”

“I watched it on television, says Sal.  “Kennedy really looked vigorous; standing there hatless on a freezing day.  A new generation who grew up fighting the war, taking over.  Soldiers instead of generals.  Ike looked old and tired.”

“Ike was a pretty good president,” I reply.  “He got us out of fighting in Korea, and kept the peace.  And don’t forget Nixon also served in the navy during the war.  You know Sal, it’s obvious you’re as taken by Kennedy as Karen.  That’s why I was really surprised when you said that you didn’t bother to vote.”

“Yes, it wasn’t very civic of me not to.”

Guarded and evasive again. Guess I’m not going to get more out of him.

“Well, maybe I can catch it on tonight’s news,” I say finally.

At our apartment Karen is on the couch watching the six o’clock news, on our small TV set.  The grainy black and white figure of our hatless new president, looking energetic and youthful, is just concluding his address.

“Too bad you missed it,” says Karen as she rises to give me a kiss.  “He was really excellent.  A new day for the country and a call to service.  Stirring the nation.  He has a truly eloquent way with words.  How could you not have voted for him?”

“Life is full of missed opportunities,” I say.  “Guess I’ll have to learn to live with that one.”

Karen picks up a cushion and throws it at me.

January 25.

I finish writing prescriptions for penicillin and Gantrisin syrup for a two-year old boy with ear infections, and hand them to his mother, “Now be sure to get them filled right away at your usual drugstore, and give both of them to him for the full seven days.  The County Pharmacy also stays open till ten.  And then bring him back to the pediatric outpatient clinic, or to your own doctor, for a recheck in one week.  Sooner, if his fever and pain don’t go away.”

“Thanks, doc.  I’ll call the clinic.”

“I take the next clipboard from the top of the tall pile of backlogged charts on the desk and read the registration sheet.  Okay, Mary Ann O’Connor.  Six years.  Fever and cough. 

I walk over to the third cubicle where the girl is lying on the gurney with her mother standing beside her in a brown wool coat.  “Hello Mary Ann and Mrs. O’Connor, I’m Dr. Morton.”   Pale and tired.  Thin wisp of a colleen.  Dark circles under eyes.  Wet sounding cough.  “How are you feeling?” I say to Mary Ann.

“I’m coughing and hot and I don’t feel good.”

“How long has Mary Ann been sick, Mrs. O’Connor?”  Mrs. O’Connor is small and thin like her daughter, angular planes to her face, dark hair in a bob, fine, white complexion.

“She started with a cold five days ago, but then began to run a fever and cough more, just yesterday.”

I ask more questions about her illness, and think that I’ve obtained a pretty complete picture.  To close, before beginning the physical exam, I ask, “Is there anything else about Mary Ann that I should know?  Do you have any other concerns?” 

“Well doctor, even before she caught the cold, she wasn’t acting herself for about two or three weeks.  She was feeling tired, and she had pains in her legs.”

“Oh.  Is that something new for her?”  That’ll teach me to look for trouble.  Probably growing pains.

“Yes it is.  She’s usually a very active child.  And what is funny is that although she wasn’t playing as hard as she usually does, she got some big bruises on her legs.”

Oh, oh.

“Let’s have a look.”  I lift the hem of her gown.  She does have large blue bruises across both shins.  “Where do your legs hurt, Mary Ann?” 

“Here,” she says, indicating her knees.

They don’t look swollen, but when I squeeze them and then press around her thighs just above the joint, she says, “Ow,” and grimaces, pushing my hands away.  Just last week, Dr. De Young told us to remember that leukemia belongs in differential diagnosis of joint and bone pain.  Can’t be.  Do her cervical nodes look swollen?

“What do you think is wrong with her, doctor,” asks Mrs. O’Connor. “It is just a cold, isn’t it?”

“I need to do a complete exam first, Mrs. O’Connor, before I can say.”

But by the end of my examination, there’s little doubt in my mind.  Yeah, her lymph nodes diffusely enlarged, even at elbows.  Spleen down two finger breaths.  So’s her liver.  Nails, tongue, eyes very pale.  Fresh bruises on legs and forearms.  Probably very anemic.  Platelets got to be way depressed.  Must be A.L.L. (acute lymphoblastic leukemia) Blood’s got to be full of blasts.  Most likely got pneumonia too.  How am I going to tell mother?

Mrs. O’Connor has been watching me do my exam with increasing concern.  “Doctor, what is it?  Mary Ann doesn’t have something bad?  Like leukemia–does she?”

“Well, I’m glad that you brought her in tonight.  She does have more than a cold.  She probably has early pneumonia.  So we’ll have to admit her for antibiotic treatment.”

“Is that all?  I was getting so worried about how tired and pale she was looking.”

“Well, as part of her work up, we’ll also do some other tests to see about that.”

“Are you sure it’s just pneumonia that she has?”

I take a big breath, stalling.  “We want to be sure that we take care of all her problems, so that’s why we’ll be doing tests.  We’ll get some tonight and more tomorrow.  We’ll start with a chest x-ray down here.  Then an orderly will come to get you both as soon as possible.”  Oh man.  How am I going to tell her?  What’ll I say?  We’re so backed up too.  Guess I’ll call the floor resident to come admit her.  “Mary Ann will be on the Sixth floor, and I’m going to ask Dr. Peterson to admit her, and Dr. Wee who’s the Senior Resident.   They’ll come to talk with you and Mary Ann.  I’m going to call them now.  Please wait right here for the orderly to take you to x-ray.  Bye, Mary Ann.”

I go to the desk and ask the operator to page Allie and Wil.  As I hang up the phone, I steal a peek around corner at the benches in the hall outside.  The benches are packed with children and parents waiting to be seen.  Allie calls back promptly.   

“Allie, I’m sorry to dump this on you, but we are totally swamped down here, and I just saw a six year old girl with what I’m afraid really looks like A.L.L.  She’s also got pneumonia.”

“How bad is she?”

“Her pneumonia probably isn’t that bad, though she hasn’t gone to x-ray yet, but she’s very pale, has ecchymoses of her shins and forearms, and enlarged nodes and spleen and liver.”

“Did you tell her parents about your suspicion?”

“Her mother is already worried about the diagnosis, but no, I was noncommittal.  I told her that she needed some tests to be sure that we take care of everything.”

“Bob, you chicken!  You’re dumping on me!”

“Allie, I’m sorry, but we are so backed up.  If I told her mom, I’d have to stay with her for a long time.  You know that I couldn’t just tell her and leave–wham, bam, so sorry ma’am.”

“Yeah, I guess you’re right.  Damn.  Now I’m going to be the one to tell them the bad news.”

“Anyway, they’ll be going for a chest film.  I haven’t even had a chance to draw blood.  Maybe you can send one of the students over to do a CBC.  I’ll call you to come down when they get back from x-ray.”

I hang up and the phone rings again.  I answer and it’s Wil.  “Hi Wil, I’m doing this in reverse, but I just talked to Allie about an admission.”  I lower my voice as I see Mrs. O’Connor looking my way.  “Got a six-year-old girl who looks clinically like A.L.L.  Yeah, I’ll try to get a CBC first, if I can.”  I hang up.

Mrs. O’Connor comes up to the desk.  “I’m going to use the pay phone and call my husband to let him know that she’s going to be admitted.  I think Mary Ann is okay by herself.  Thank you doctor.”

“You’re welcome.  Here, you can use the desk phone, as long as you aren’t on it for too long.  Dial nine first.”  Thanks for what?  Giving her a death sentence?  Enjoy this time with her.  Before you get hit with the truth.  I got to get going.  Look at that stack of charts in the in-box. 

I finish scribbling my note on her ER sheet, put it in the completed basket, then pick up the next clipboard from atop the pile of waiting patients, look at the registration page, and walk over to cubicle six.  “Hi, I’m Dr Morton, and this must be Galvin.  Tell me, what’s the problem?” 

January 28.

“I won’t be sorry to see this month come to an end,” I say to Sal, as I drive home on Saturday afternoon. 

“It has been a busy one for you.  We haven’t had that much chance to talk.” 
“The days just got increasingly busy, so there was less and less chance to contact you during work hours.  Lately I haven’t been able to break away at 10:00, so it’s been too late to call you on the way home.  Even though I get home every night to sleep, I feel pooped all the time.”

“As much as when you were the Float?”

“No, you’re right; not as bad as that.  I do get to sleep at night.  It’s a mental thing too.  I’m stuck in that one room most of the day.  At least as Float, I was on the move through the hospital.”

“And you’ve had those two bad cases—the three-year-old who was DOA, and now, Mary Ann,” says Sal.  “Those will get you down.”

“Well, next month should be an easy one before it gets busy again.  So we’ll be able to talk more.  I should have thought of it sooner, but you can just contact me anytime, and if I’m occupied, well, just ‘hang up.’  That’s what you told me to do with you, and now that I’m getting the knack of handling internal and external conversations simultaneously, I think that I can do it too without getting confused.”

“True.  You’ve been able to do it in the past, when you weren’t worried about it and it just happened naturally.  I really don’t think that you’ll have any trouble at all.”

January 31.

“Next month will be a welcome change from ER,” I say, as Jackie, Cliff, and I sit at the desks by the door, waiting for the Float to relieve us.

“January and February are always the busiest months,” says Jackie. “Where are you going next, Dr. Morton?”

“Hematology elective with Dr. De Young.”

“Guess you’ll have a chance to follow-up on that leukemic girl you picked up last week,” she says.  “How about you, Dr. Symonds?”

“I go from busy to busy without a chance to rest like Lucky Bob here,” says Cliff.  “I’ll be in the nursery.”

“It’s almost ten,” I say.  “Maybe we’ll finish on a quiet note, without another patient.”

The phone rings and it’s the registration desk, telling us of a late arrival.

“Well, you had to go ahead and jinx us, Bob,” says Cliff as mother and child appear at the door, registration slip in hand.  The child is walking and does not appear uncomfortable or ill.  “I’ll take care of this one,” he says to Jackie and me. 

“What’s the matter, mother?”  He asks, looking up from his chair without a smile, feet propped up on the desk.

“My boy’s bowels is locked.”

“For how long, mother?”

“Today makes three days.”

“Any vomiting, loss of appetite, fever, or fussiness?”

“No.”

“How ‘bout stomach ache?” asks Cliff.  “Not as far’s I can tell.”

“He tinkling okay?”

“Yeah.”

“Well, we don’t have the bowel keys here,” says Cliff.  “You’ll need to take him to the outpatient clinic tomorrow to get him unlocked.  That’s where they keep the master key.”  And he waves in dismissal.  “There ought to be a way to screen out these kinds of patients with no emergencies,” he says after they leave.  “They got no business, coming to the ER, and wasting our time.”