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.”
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?”
“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?”
“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?”
“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 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.”
“Since you ask me—yes.” Coleman’s own lips were tight. He wondered how long the two of them could continue working together in this kind of atmosphere.
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?”
“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?”
“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.”
“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.”
A voice spoke briefly, then Pearson said, “All right, then give him a message. Tell him I’ve just heard from the university. The blood test on the Alexander baby is positive. The child has erythroblastosis.”
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?”
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.
It was a frail, thready cry—a weak and feeble protest that ended almost as soon as it began. But it was a signal of life, and above the masks of those in the room eyes were smiling, and somehow hope seemed a trifle closer.
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.
Pearson was looking across at him. He asked, “How long is it now?”
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.”