The Final Diagnosis

The hubbub had not died and, this time more loudly, he repeated his injunction that they start.

Bill Rufus called out, “I don’t think Joe Pearson is here yet.” The gaudy necktie which O’Donnell had observed earlier made Rufus stand out from the others around him.

“Isn’t Joe here?” O’Donnell seemed surprised as he scanned the room.

“Has anyone seen Joe Pearson?” he asked. Some of the others shook their heads.

Momentarily O’Donnell’s face revealed annoyance, then he covered up. He moved toward the door. “Can’t have a mortality conference without a pathologist. I’ll see what’s keeping him.” But as he reached the doorway Pearson walked in.

“We were just going to look for you, Joe.” O’Donnell’s greeting was friendly, and Lucy wondered if she had been wrong about the flash of irritation a moment ago.

“Had an autopsy. Took longer than I figured. Then I stopped for a sandwich.” Pearson’s words came out muffled, principally because he was chewing between sentences. Presumably the sandwich, Lucy thought; then she saw he had the rest of it folded in a napkin among the pile of papers and files he was carrying. She smiled; only Joe Pearson could get away with eating lunch at a mortality conference.

O’Donnell was introducing Pearson to Hilton. As they shook hands Pearson dropped one of his files and a sheaf of papers spilled out on the floor. Grinning, Bill Rufus collected them and replaced the file under Pearson’s arm. Pearson nodded his thanks, then said abruptly to Hilton, “A surgeon?”

“That’s right, sir,” Hilton answered pleasantly. A well-brought-up young man, Lucy thought; he shows deference to his elders.

“So we have another recruit for the mechanics,” Pearson said. As he spoke, loudly and sharply, there was a sudden silence in the room. Ordinarily the remark would have passed as banter, but somehow from Pearson it seemed to have an edge, a touch of contempt.

Hilton was laughing. “I guess you could call it that.” But Lucy could see he had been surprised by Pearson’s tone.

“Take no notice of Joe,” O’Donnell was saying good-naturedly. “He has a ‘thing’ about surgeons. Well, shall we begin?”

They moved to the long table, some of the senior staff members going automatically to the front rectangle of chairs, the others dropping into the row behind. Lucy herself was in front. O’Donnell was at the head of the table, Pearson and his papers on the left. While the others were settling down she saw Pearson take another bite from his sandwich. He made no effort to be surreptitious about it.

Lower down the table she noticed Charlie Dornberger, one of Three Counties’ obstetricians. He was going through the careful process of filling his pipe. Whenever Lucy saw Dr. Dornberger he seemed to be either filling, cleaning, or lighting a pipe; he seldom seemed to smoke it. Next to Dornberger was Gil Bartlett and, opposite, Ding Dong Bell from Radiology and John McEwan. McEwan must be interested in a case today; the ear, nose, and throat specialist did not normally attend surgical-mortality meetings.

“Good afternoon, gentlemen.” As O’Donnell looked down the table the remaining conversations died. He glanced at his notes. “First case. Samuel Lobitz, white male, age fifty-three. Dr. Bartlett.”

Gil Bartlett, impeccably dressed as ever, opened a ring notebook. Instinctively Lucy watched the trim beard, waiting for it to move. Almost at once it began bobbing up and down. Bartlett began quietly, “The patient was referred to me on May 12.”

“A little louder, Gil.” The request came from down the table.

Bartlett raised his voice. “I’ll try. But maybe you’d better see McEwan afterward.” A laugh ran round the group in which the e.n.t. man joined.

Lucy envied those who could be at ease in this meeting. She never was, particularly when a case of her own was being discussed. It was an ordeal for anyone to describe their diagnosis and treatment of a patient who had died, then have others give their opinion, and finally the pathologist report his findings from the autopsy. And Joe Pearson never spared anyone.

There were honest mistakes that anybody in medicine could make—even, sometimes, mistakes which cost patients their lives. Few physicians could escape errors like this in the course of their careers. The important thing was to learn from them and not to make the same mistake again. That was why mortality conferences were held—so that everyone who attended could learn at the same time.

Occasionally the mistakes were not excusable, and you could always sense when something like that came up at a monthly meeting. There was an uncomfortable silence and an avoidance of eyes. There was seldom open criticism; for one thing, it was unnecessary, and for another, you never knew when you yourself might be subject to it.

Lucy recalled one incident which had concerned a distinguished surgeon at another hospital where she had been on staff. The surgeon was operating for suspected cancer in the intestinal tract. When he reached the affected area he had decided the cancer was inoperable and, instead of attempting to remove it, had looped the intestine to bypass it. Three days later the patient had died and was autopsied. The autopsy showed there had, in fact, been no cancer at all. What had really happened was that the patient’s appendix had ruptured and had formed an abscess. The surgeon had failed to recognize this and thereby condemned the man to death. Lucy remembered the horrified hush in which the pathologist’s report had been received.

In an instance like this, of course, nothing ever came out publicly. It was a moment for the ranks of medicine to close. But in a good hospital it was not the end. At Three Counties nowadays O’Donnell would always talk privately with an offender and, if it were a bad case, the individual concerned would be watched closely for a while afterward. Lucy had never had to face one of these sessions herself, but she had heard the chief of surgery could be extremely rough behind closed doors.

Gil Bartlett was continuing. “The case was referred to me by Dr. Cymbalist.” Lucy knew that Cymbalist was a general practitioner, though not on Three Counties’ staff. She herself had had cases referred from him.

“I was called at my home,” Bartlett said, “and Dr. Cymbalist told me he suspected a perforated ulcer. The symptoms he described tallied with this diagnosis. By then the patient was on the way to the hospital by ambulance. I called the surgical resident on duty and notified him the case would be coming in.”

Bartlett looked over his notes. “I saw the patient myself approximately half an hour later. He had severe upper abdominal pain and was in shock. Blood pressure was seventy over forty. He was ashen gray and in a cold sweat. I ordered a transfusion to combat shock and also morphine. Physically the abdomen was rigid, and there was rebound tenderness.”

Bill Rufus asked, “Did you have a chest film made?”

“No. It seemed to me the patient was too sick to go to X-ray. I agreed with the original diagnosis of a perforated ulcer and decided to operate immediately.”

“No doubts at all, eh, Doctor?” This time the interjection was Pearson’s. Previously the pathologist had been looking down at his papers. Now he turned directly to face Bartlett.

For a moment Bartlett hesitated and Lucy thought: Something is wrong; the diagnosis was in error and Joe Pearson is waiting to spring the trap. Then she remembered that whatever Pearson knew Bartlett knew also by this time, so it would be no surprise to him. In any case Bartlett had probably attended the autopsy. Most conscientious surgeons did when a patient died. But after the momentary pause the younger man went on urbanely.

“One always has doubts in these emergency cases, Dr. Pearson. But I decided all the symptoms justified immediate exploratory surgery.” Bartlett paused. “However, there was no perforated ulcer present, and the patient was returned to the ward. I called Dr. Toynbee for consultation, but before he could arrive the patient died.”

Gil Bartlett closed his ring binder and surveyed the table. So the diagnosis had been wrong, and despite Bartlett’s outwardly calm appearance Lucy knew that inside he was probably suffering the torments of self-criticism. On the basis of the symptoms, though, it could certainly be argued that he was justified in operating.

Now O’Donnell was calling on Joe Pearson. He inquired politely, “Would you give us the autopsy findings, please?” Lucy reflected that the head of surgery undoubtedly knew what was coming. Automatically the heads of departments saw autopsy reports affecting their own staff.

Pearson shuffled his papers, then selected one. His gaze shot around the table. “As Dr. Bartlett told you, there was no perforated ulcer. In fact, the abdomen was entirely normal.” He paused, as if for dramatic effect, then went on. “What was present, in the chest, was early development of pneumonia. No doubt there was severe pleuritic pain coming from that.”

So that was it. Lucy ran her mind over what had been said before. It was true—externally the two sets of symptoms would be identical.

O’Donnell was asking, “Is there any discussion?”

There was an uneasy pause. A mistake had been made, and yet it was not a wanton mistake. Most of those in the room were uncomfortably aware the same thing might have happened to themselves. It was Bill Rufus who spoke out. “With the symptoms described, I would say exploratory surgery was justified.”

Pearson was waiting for this. He started ruminatively. “Well, I don’t know.” Then almost casually, like tossing a grenade without warning: “We’re all aware that Dr. Bartlett rarely sees beyond the abdomen.” Then in the stunned silence he asked Bartlett directly, “Did you examine the chest at all?”

The remark and the question were outrageous. Even if Bartlett were to be reprimanded, it should come from O’Donnell, not Pearson, and be done in private. It was not as if Bartlett had a reputation for carelessness. Those who had worked with him knew that he was thorough and, if anything, inclined to be ultra-cautious. In this instance, obviously, he had been faced with the need to make a fast decision.

Bartlett was on his feet, his chair flung back, his face flaming red. “Of course I examined the chest!” He barked out the words, the beard moving rapidly. “I already said the patient was in no condition to have a chest film, and even if he had—”

“Gentlemen! Gentlemen!” It was O’Donnell, but Bartlett refused to be stopped.

“It’s very easy to have hindsight, as Dr. Pearson loses no chance to remind us.”

From across the table Charlie Dornberger motioned with his pipe. “I don’t think Dr. Pearson intended—”

Angrily Bartlett cut him off. “Of course you don’t think so. You’re a friend of his. And he doesn’t have a vendetta with obstetricians.”

“Really! I will not permit this.” O’Donnell was standing himself now, banging with his gavel. His shoulders were squared, his athlete’s bulk towering over the table. Lucy thought: He’s all man, every inch. “Dr. Bartlett, will you be kind enough to sit down?” He waited, still standing, as Bartlett resumed his seat.

O’Donnell’s outward annoyance was matched with an inward seething. Joe Pearson had no right to throw a meeting into a shambles like this. Now, instead of pursuing the discussion quietly and objectively, O’Donnell knew he had no choice but to close it. It was costing him a lot of effort not to sound off at Joe Pearson right here and now. But if he did he knew it would make the situation worse.