Artropods and Human Disease 2 page

O’Donnell was well aware of the problem. Like other surgeons, Rufus would frequently operate on a patient with a tumor. When the tumor was exposed he would remove it for examination by the hospital’s pathologist, Dr. Joseph Pearson. The pathologist would then make two studies of the tissue. First, working in a small lab adjoining the operating room, and with the patient still under anesthetic, he would freeze a small portion of tissue and examine it under a microscope. From this procedure could come one of two verdicts—“malignant,” meaning the presence of cancer and indicating the need for major surgery on the patient; or “benign,” a reprieve which usually meant that nothing more need be done once the tumor was out. If a frozen section produced a “malignant” verdict, surgery would continue at once. On the other hand, the opinion “benign” from the pathologist was a signal for the surgeon to make his closure and send the patient to the recovery room.

“There’s no delay in frozen sections, is there?” O’Donnell had not heard of any, but he wanted to be sure.

“No,” Rufus said. “You’d hear plenty of howling if there were. But it’s the full tissue report that’s taking so long.”

“I see.” O’Donnell was maneuvering for time while he marshaled his thoughts. His mind ran over procedures. After a frozen section any removed tumor went to the pathology lab where a technician prepared several slides, more carefully and working under better conditions. Later the pathologist would study the slides and give his final opinion. Sometimes a tumor which had seemed benign or doubtful at frozen section would prove malignant during this subsequent, more close examination, and it was not considered abnormal for a pathologist to reverse his opinion in this way. If this happened the patient would be returned to the operating room and the necessary surgery done. But obviously it was important for the pathologist’s second report to be prompt. O’Donnell had already realized that this was the nub of Rufus’ complaint.

“If it were just once,” Rufus was saying, “I wouldn’t object. I know Pathology’s busy, and I’m not trying to get at Joe Pearson. But it isn’t just once, Kent. It’s all the time.”

“Let’s get specific, Bill,” O’Donnell said crisply. He had no doubt, though, that Rufus would have facts to back up a complaint like this.

“All right. I had a patient in here last week, Mrs. Mason—breast tumor. I removed the tumor, and at frozen section Joe Pearson said benign. Afterward, though, on surgical report he had it down as malignant.” Rufus shrugged. “I won’t quarrel with that; you can’t call them all the first time.”

“But?” Now that he knew what it was about, O’Donnell wanted to get this over with.

“Pearson took eight days to make the surgical report. By the time I got it the patient had been discharged.”

“I see.” This was bad all right, O’Donnell thought. He couldn’t duck this one.

“It isn’t easy,” Rufus was saying quietly, “to call a woman back and tell her you were wrong—that she does have cancer after all, and that you’ll have to operate again.”

No, it wasn’t easy; O’Donnell knew that too well. Once, before he had come to Three Counties, he had had to do the same thing himself. He hoped he never would again.

“Bill, will you let me handle this my way?” O’Donnell was glad it was Rufus. Some of the other surgeons might have made things more difficult.

“Sure. As long as something definite is done.” Rufus was within his rights to be emphatic. “This isn’t just an isolated case, you know. It just happens to be a bad one.”

Again O’Donnell knew this was true. The trouble was, Rufus was not aware of some of the other problems which went with it.

“I’ll talk to Joe Pearson this afternoon,” he promised. “After the surgical-mortality conference. You’ll be there?”

Rufus nodded. “I’ll be there.”

“See you then, Bill. Thanks for letting me know about this. Something will be done, I promise you.”

Something, O’Donnell reflected as he moved down the corridor. But what exactly? He was still thinking about it as he turned into the Administration suite and opened the door to Harry Tomaselli’s office.

O’Donnell did not see Tomaselli at first, then the administrator called to him. “Over here, Kent.” On the far side of the birch-paneled room, away from the desk at which he spent most of his working hours, Tomaselli was leaning over a table. Unrolled before him were whiteprints and sketches. O’Donnell crossed the thick pile carpet and looked down at them too.

“Daydreaming, Harry?” He touched one of the sketches. “You know, I’m sure we could put you a fancy penthouse there—on top of the East Wing.”

Tomaselli smiled. “I’m agreeable, providing you’ll convince the board it’s necessary.” He took off his rimless glasses and began to polish them. “Well, there it is—the New Jerusalem.”

O’Donnell studied the architect’s profile of Three Counties Hospital as it would appear with the magnificent new extension, now in the advanced stages of planning. The new buildings were to comprise an entire wing and a new nurses’ home. “Any more news?” He turned to Tomaselli.

The administrator had replaced his glasses. “I talked with Orden again this morning.” Orden Brown, president of the second largest steel mill in Burlington, was chairman of the hospital’s board of directors.

“So?”

“He’s sure we can count on half a million dollars in the building fund by January. That means we’ll be able to break ground in March.”

“And the other half million? Last week Orden told me he thought it would take until December.” Even at that, O’Donnell reflected, he had considered the chairman to be erring toward optimism.

“I know,” Tomaselli said. “But he asked me to tell you that he’s changed his mind. He had another session with the mayor yesterday. They’re convinced they can get the second half million by next summer and wind up the campaign by fall.”

“That is good news.” O’Donnell decided to shelve his earlier doubts. If Orden Brown had gone out on a limb like that, he would come through all right.

“Oh, and by the way,” Tomaselli said with elaborate casualness, “Orden and the mayor have an appointment with the governor next Wednesday. Looks like we may get that increased state grant after all.”

“Anything else?” O’Donnell snapped at the administrator in mock sharpness.

“I thought you’d be pleased,” Tomaselli said.

More than pleased, O’Donnell reflected. In a way you might call all of this the first step toward fulfillment of a vision. It was a vision which had had its beginnings at the time of his own arrival at Three Counties three and a half years ago. Funny how you could get used to a place, O’Donnell thought. If someone had told him at Harvard Medical School, or later when he was chief surgical resident at Columbia Presbyterian, that he would wind up in a backwater hospital like Three Counties, he would have scoffed. Even when he had gone to Bart’s in London to round out his surgical experience, he had fully intended to come back and join the staff of one of the big-name hospitals like Johns Hopkins or Massachusetts General. With the background he had he could pretty well have taken his choice. But before there was time to decide Orden Brown had come to meet him in New York and persuaded him to visit Burlington and Three Counties.

What he had seen there had appalled him. The hospital was run down physically, its organization slack, its medical standards—with a few exceptions—low. The chiefs of surgery and medicine had held their posts for years; O’Donnell had sensed that their objective in life was to preserve an amiable status quo. The administrator—key man in the relationship between the hospital’s lay board of directors and its medical staff—was a doddering incompetent. The hospital’s intern and resident training program had fallen into disrepute. There was no budget for research. Conditions under which nurses lived and worked were almost medieval. Orden Brown had shown him everything, concealed nothing. Then they had gone together to the chairman’s home. O’Donnell had agreed to remain for dinner but afterward planned to catch a night flight back to New York. Disgusted, he never wanted to see Burlington or Three Counties Hospital again.

Over dinner in the quiet, tapestried dining room of Orden Brown’s home on a hillside high above Burlington he had been told the story. It was not an unfamiliar one. Three Counties Hospital, once progressive, modern, and rated high in the state, had fallen prey to complacency and lassitude. The chairman of the board had been an aging industrialist who most of the time had delegated responsibility to someone else, appearing at the hospital only for the occasional social function. The lack of leadership had permeated downward. Heads of divisions had mostly held their posts for many years and were averse to change. Younger men beneath them had at first fretted, then, becoming frustrated, had moved elsewhere. Finally the hospital’s reputation became such that young, highly qualified graduates no longer sought to join the staff. Because of this others with lesser qualifications had been allowed in. This was the situation at the time O’Donnell had come on the scene.

The only change had come with the appointment of Orden Brown himself. Three months earlier the aged chairman had died. A group of influential citizens had persuaded Brown to succeed him. The choice had not been unanimous; a section of the old guard on the hospital board had wanted the chair for a nominee of their own—a long-time board member named Eustace Swayne. But Brown had been chosen by a majority, and now he was trying to persuade other board members to adopt some of his own ideas for modernization of Three Counties.

It was proving an uphill fight. There was an alliance between a conservative element on the board, for whom Eustace Swayne was spokesman, and a group among the senior medical staff. Together they resisted change. Brown was having to tread warily and to be diplomatic.

One of the things he wanted was authority to increase the size of the hospital board and bring in new, more active members. He had planned to recruit some of the younger executives and professional men from Burlington’s business community. But so far the board had not been unanimous and temporarily the plan was shelved.

If Orden Brown had wanted, he had explained frankly to O’Donnell, he could have forced a showdown and had his own way. He could, if he wished, have used his influence to ease some of the elderly, inactive members out of office. But this would have been shortsighted, because most were wealthy men and women and the hospital needed the legacies which normally came to it when its patrons died. If defeated now, some of the people concerned might well change their wills, cutting the hospital off. Eustace Swayne, who controlled a department-store empire, had already hinted that this might happen. Hence the need by Orden Brown for diplomacy and caution.

Some progress had been made, though, and one step which the chairman had undertaken with approval from a majority of the board members was to negotiate for a new chief of surgery. That was why he had approached O’Donnell.

Over dinner O’Donnell had shaken his head. “I’m afraid it’s not for me.”

“Perhaps not,” Brown had said. “But I’d like you to hear me out.”

He was persuasive, this man of industry who, though a scion of a wealthy family, had worked his way from puddler, through the mills, to the administrative office and eventually the president’s chair. He had a feeling, too, for people; the years in which he had rubbed shoulders daily with laborers in the mill had given him that. This may have been a reason he had accepted the burden of lifting Three Counties out of the mire into which it had fallen. But for whatever reason, even in the short time they had been together O’Donnell had sensed the older man’s dedication.

“If you came here,” Brown had said to him near the end, “I couldn’t promise you a thing. I’d like to say you’d have a free hand, but I think the chances are you’d have to fight for everything you wanted. You’d meet opposition, entrenchment, politics, resentment. There would be areas in which I couldn’t help you and in which you would have to stand alone.” Brown had paused, then added quietly, “I suppose the only good thing you could say about this situation—from the point of view of someone like yourself—is that it would be a challenge, in some ways the biggest challenge a man could take on.”

That was the last word Orden Brown had said that night about the hospital. Afterward they had talked of other things: Europe, the coming elections, the emergence of Middle East nationalism—Brown was a much-traveled and well-informed man. Later his host had driven O’Donnell to the airport and they had shaken hands at the ramp. “I’ve enjoyed our meeting,” Orden Brown had said, and O’Donnell had returned the compliment, fully meaning it. Then he had boarded the airplane, intending to write off Burlington and to think of his journey there as a learning experience.

On the flight back he had tried to read a magazine—there was an article about championship tennis which interested him. But his mind wouldn’t register the words. He kept thinking about Three Counties Hospital, what he had seen there and what was needing to be done. Then suddenly for the first time in many years he began to examine his own approach to medicine. What does it all mean? he had asked himself. What do I want for myself? What kind of achievement am I seeking? What have I got to give? At the end what will I leave behind? He had not married; probably he never would now. There had been love affairs—in bed and out—but nothing of permanence. Where is it leading, he wondered, this trail from Harvard, Presbyterian, Bart’s . . . to where? Then suddenly he had known the answer, known that it was Burlington and Three Counties, that the decision was firm, irrevocable, the direction set. At La Guardia, on landing, he had sent a wire to Orden Brown. It read simply, “I accept.”

Now, looking down at the plans of what the administrator had called flippantly “the New Jerusalem,” O’Donnell thought back to the three and a half years which lay behind. Orden Brown had been right when he had said they would not be easy. All the obstacles which the board chairman had predicted had proven to be there. Gradually, though, the most formidable had been overcome.

After O’Donnell’s arrival the former chief of surgery had slipped quietly out. O’Donnell had rallied some of the surgeons already on staff who were sympathetic to raising the hospital’s standards. Between them they had tightened surgical rules and had formed a strong operating-room committee to enforce them. A tissue committee, almost defunct, was reactivated—its job, to ensure that mistakes in surgery, particularly the unnecessary removal of healthy organs, were not repeated.

The less competent surgeons were gently but firmly urged to limit themselves to work within their capabilities. A few of the botchers, the assembly-line appendix removers, the incompetents, were given the choice of resigning quietly or being ousted officially. Though to some it meant partial loss of their livelihood, most chose to leave quietly. Among the latter was one surgeon who had actually removed a kidney without ascertaining that the patient had already lost one in previous surgery. The dreadful mistake had been revealed at autopsy.

Removal of that surgeon from the hospital’s roster had been easy. Some of the others, though, had proved more difficult. There had been rows before the County Medical Committee, and two surgeons, formerly on Three Counties’ staff, now had law suits pending against the hospital. This, O’Donnell knew, was going to mean some bitter controversy in court, and he dreaded the publicity which was certain to surround it.

But despite these problems O’Donnell and those behind him had had their way and the gaps in staff were painstakingly filled with new, well-qualified men, some of them graduates from his own alma mater whom O’Donnell had cajoled and persuaded to set up practice in Burlington.

Meanwhile the Division of Medicine had a new head—Dr. Chandler, who had been on staff under the old regime but had been frequently outspoken against it. Chandler was a specialist in internal medicine, and while he and O’Donnell sometimes disagreed on hospital policy, and O’Donnell found the other man at times pompous, at least Chandler was uncompromising when it came to upholding medical standards.

In O’Donnell’s three and a half years administration methods had been changed as well. A few months after his own arrival O’Donnell had told Orden Brown about a young assistant administrator, one of the best he had known in his hospital experience. The chairman had flown off and, two days later, come back with a signed contract. A month after that the old administrator, relieved to get out from under a job which had grown beyond him, had been honorably pensioned and Harry Tomaselli installed in his place. Now the whole administrative side of the hospital reflected Tomaselli’s brisk but smooth efficiency.

A year ago O’Donnell had been elected president of the hospital’s medical board, which made him the senior practitioner at Three Counties. Since then he, Tomaselli, and Dr. Chandler had successfully broadened the hospital’s intern and resident training program, and already applications for enrollment were growing in number.

There was still a long way to go. O’Donnell knew that in some ways they were only at the beginning of a long program which would embrace the three basic tenets of medicine: service, training, research. He himself was forty-two now, would be forty-three in a few months. He doubted if, in the active years remaining to him, he would complete in full what he had set out to do. But the start was good; that much was reassuring, and he knew that his decision on the airplane three and a half years earlier had been right.

There were soft spots, of course, in the present setup. There had to be. Nothing this big was achieved easily or quickly. Some of the seniors on medical staff still fought off changes, and their influence was strong among the older members of the board, some of whom still remained—Eustace Swayne, as obstinate as ever, at their head. Perhaps this was a good thing, O’Donnell reflected, and perhaps there was justice sometimes in the assertion that “young men make too many changes too quickly.” But because of this group and its influence there were occasions when planning had to be tempered with prudence. O’Donnell accepted this fact himself but sometimes had difficulty in getting it across to the newer staff members.

It was just this situation which had made him thoughtful after talking with Bill Rufus. The pathology department at Three Counties was still a stronghold of the old regime. Dr. Joseph Pearson, who ran it like a personal possession, had been thirty-two years at the hospital. He knew most of the old board members intimately and was a frequent chess companion of Eustace Swayne. More to the point, Joe Pearson was no incompetent; his record was good. In his earlier days he had been recognized as an active researcher, and he was a past president of the State Pathology Association. The real problem was that the work in Pathology had become too much for one man to keep the reins in his own hands. O’Donnell suspected, too, that some of the pathology department’s lab procedures were in need of overhauling. But desirable as changes might be, this one was going to be tough.

There was the drive for funds for the hospital extension to be considered. If there were trouble between O’Donnell and Joe Pearson, how would Pearson’s influence with Eustace Swayne affect Orden Brown’s plans for raising all the money by fall next year? Swayne’s own donation would normally be a big one, and loss of that alone could be serious. But equally serious was Swayne’s influence with other people in the town; in some ways the old tycoon possessed the power to make or mar their immediate plans.

With so many things pending O’Donnell had hoped the problem of Pathology could be left for a while. Nevertheless he had to take some action, and soon, about Bill Rufus’ complaint.

He turned away from the plans. “Harry,” he said to the administrator, “I think we may have to go to war with Joe Pearson.”

Three

In contrast with the heat and activity of the floors above, in the white-tiled corridor of the hospital’s basement it was quiet and cool. Nor was the quietness disturbed by a small procession—Nurse Penfield, and alongside her a stretcher gliding silently on ball-bearing casters and propelled by a male orderly wearing rubber-soled shoes below his hospital whites.

How many times had she made this journey, Nurse Penfield speculated, glancing down at the shrouded figure on the stretcher. Probably fifty times in the past eleven years. Perhaps more, because it was not something you kept score of—this final journey between the ward and the hospital’s morgue, between the territory of the living and the dead.

A tradition, this last walk with a patient who had died, discreetly timed and routed through back corridors of the hospital, then downward in the freight elevator, so that the living should take no darkness or depression from death so close at hand. It was the last service from nurse to her charge, an acknowledgment that, though medicine had failed, it would not dismiss the patient summarily; the motions of care, service, healing, would continue for at least a token time beyond the end.

The white corridor forked two ways here. From a passage to the right came the hum of machinery. Down there were the hospital’s mechanical departments—heating plant, hot-water systems, electrical shops, emergency generators. Pointing the other way, a single sign read: “Pathology Department. Morgue.”

As Weidman, the male orderly, swung the stretcher left, a janitor—either on work break or stolen time—lowered the Coke he had been drinking and moved aside. He wiped his lips on the back of his hand, then gestured to the shroud. “Didn’t make it, eh?” The remark was to Weidman; it was an amiable gambit, a game played many times.

Weidman, too, had done this before. “I guess they pulled his number, Jack.”

The janitor nodded, then raised his Coke bottle again and drank deeply.

How short a time, Nurse Penfield thought, between life and the autopsy room. Less than an hour ago the body under the shroud had been George Andrew Dunton, living, age fifty-three, civil engineer. She remembered the details from the case history on the clip board under her arm.

The family had behaved as well after the death as they had before—solid, emotional, but no hysterics. It had made it easier for Dr. MacMahon to ask for permission to autopsy. “Mrs. Dunton,” he had said quietly, “I know it’s hard for you to talk and think about this now, but there is something I have to ask. It’s about permission for an autopsy on your husband.”

He had gone on, using the routine words, how the hospital sought to safeguard its medical standards for the good of everyone, how a physician’s diagnosis could be checked and medical learning advanced, how this was a precaution for the family and others who would use the hospital in time to come. But none of this could be done without permission . . .

The son had stopped him and said gently, “We understand. If you make out whatever is necessary, my mother will sign it.”

So Nurse Penfield had made out the autopsy form, and here now was George Andrew Dunton, dead, age fifty-three, and ready for the pathologist’s knife.

The autopsy-room doors swung open.

George Rinne, the pathology department’s Negro diener—keeper of the morgue—looked up as the stretcher rolled in. He had been swabbing the autopsy table. Now it shone spotlessly white.

Weidman greeted him with the timeworn jest. “Got a patient for you.”

Politely, as if he hadn’t heard the line a hundred times before, Rinne bared his teeth in a perfunctory smile. He indicated the white enameled table. “Over here.”

Weidman maneuvered the stretcher alongside, and Rinne removed the sheet covering the naked corpse of George Andrew Dunton. He folded it neatly and handed it back to Weidman. Death notwithstanding, the sheet would have to be accounted for back in the ward. Now, with a second drawsheet under the torso, the two men slid the body onto the table.

George Rinne grunted as he took the weight. This had been a heavy man, a six-footer who had run to fat near the end of his life. As he wheeled the stretcher clear Weidman grinned. “You’re getting old, George. Be your turn soon.”

Rinne shook his head. “I’ll still be here to lift you on the table.”

The scene ran smoothly. It had had many performances. Perhaps in the distant past the two had made their grim little jokes with an instinct to create some barrier between themselves and the death they lived with daily. But if so this was long forgotten. Now it was a patter to be run through, a formality expected, nothing more. They had grown too used to death to feel uneasiness or fear.

On the far side of the autopsy room was the pathology resident, Dr. McNeil. He had been shrugging into a white coat when Nurse Penfield and her charge came in. Now, glancing through the case history and the other papers she had handed him, he was acutely conscious of Nurse Penfield’s nearness and warmth. He sensed the crisp starched uniform, a faint breath of perfume, a slight disarrangement of hair beneath her cap; it would be soft to run his fingers through. He snatched his thoughts back to the papers in hand.

“Well, everything seems to be here.”

Should he try for Nurse Penfield or not? It had been six weeks now, and at the age of twenty-seven six weeks was a long time to be celibate. Penfield was more than averagely attractive, probably thirty-two, young enough to be interesting, old enough to have long since shed innocency. She was intelligent, friendly; good figure too. He could see a slip beneath the white uniform; in the heat she probably was not wearing much else. Roger McNeil calculated. He would probably have to take her out a couple of times before she came through. Then that settled it; it couldn’t be this month—money was too short. Save it for me, la Penfield. You’ll be back; other patients will die and bring you here.

“Thank you, Doctor.” She smiled and turned away. It could be arranged; he was positive of that.

He called after her. “Keep ’em coming! We need the practice.” Again the timeworn jest, the defensive levity in face of death.

Elaine Penfield followed the attendant out. Her journey was done, tradition honored, the extra, unasked service given. She had gone the second mile; now her duty lay with the sick, the living. She had a feeling, though, that Dr. McNeil had come close to suggesting something. But there would be another time.

While George Rinne slipped a wooden headrest under the neck of the body, arranging the arms at the side, McNeil began to lay out the instruments they would need for the autopsy. Knives, rib cutters, forceps, power saw for the skull . . . all of them clean—Rinne was a conscientious worker—but not sterile, as they would have to be in the operating room four floors above. No need here to worry about infection of a patient on the table; only the pathologists need take precautions for themselves.

George Rinne looked at McNeil inquiringly, and the resident nodded. “Better phone the nursing office, George, Tell them the student nurses can come down now. And let Dr. Pearson know we’re setting up.”

“Yes, Doctor.” Rinne went out obediently. McNeil, as pathology resident, had authority even though his hospital pay was little more than the janitor’s own. It would not be long, though, before the gap between them would widen. With three and a half years of residency behind him only another six months separated McNeil from freedom to take a post as staff pathologist. Then he could start considering some of the twenty-thousand-dollar-a-year jobs, because fortunately the demand for pathologists continued to be greater than the supply. He would not have to worry then about whether he could afford a pass at Nurse Penfield—or others.

Roger McNeil smiled inwardly at the thought, though he did not betray it on his face. People who had to deal with McNeil thought he was dour, which he often was, and sometimes lacking in a sense of humor, which he was not. Actually he did not make friends easily with men; but women found him attractive, a fact he had discovered early and turned to advantage. When he was an intern his colleagues had found this puzzling. McNeil, the gloomy, brooding figure of the common room, had had uncanny success in whisking a succession of student nurses into bed, frequently where others who fancied their ability as paramours had failed.

The autopsy-room door swung open and Mike Seddons breezed in. Seddons was a surgical resident, temporarily assigned to Pathology, and he always breezed. His red hair stood up in odd places as though a self-created wind would never leave it static. His boyish, open face seemed creased permanently in an amiable grin. McNeil considered Seddons an exhibitionist, though in his favor the kid had taken to pathology a lot more readily than some of the other surgical residents McNeil had seen.

Date: 2014-12-21; view: 866