The Final Diagnosis

“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?”

“Yes, sir.”

O’Donnell noticed the tone of respect and in other circumstances would have smiled inwardly. Interns and residents—the hospital’s house staff—were a notoriously independent breed, quick to observe shortcomings in the more senior attending physicians, and to be addressed as “sir” by any of their number was something of an accolade.

A few minutes ago two student nurses had slipped into the room and now, following a habit of instruction, O’Donnell began to describe procedure as he worked.

“An exchange transfusion, as perhaps you know”—O’Donnell glanced toward the student nurses—“is actually a flushing-out process. First we remove some blood from the child, then replace it with an equivalent amount of donor blood. After that we do the same thing again and keep doing it until most of the original, unhealthy blood is gone.”

The assisting nurse was inverting a pint bottle of blood on a stand above the table. O’Donnell said, “The blood bank has already crossmatched the patient’s blood with that of the donor to ensure that both are compatible. What we must be sure of also is that we replace exactly the amount of blood we remove. That’s the reason we keep a score sheet.” He indicated the intern’s clip board.

“Temperature ninety-six,” the assisting nurse announced.

O’Donnell said, “Knife, please,” and held out his hand.

Using the knife gently, he cut off the dry portion of the umbilical vein, exposing moist tissue. He put down the knife and said softly, “Hemostat.”

The intern was craning over, watching. O’Donnell said, “We’ve isolated the umbilical vein. I’ll go into it now and remove the clot.” He held out his hand and the nurse passed forceps. The blood clot was miniscule, scarcely visible, and he drew it out, painstakingly and gently. Handling a child this small was like working with a tiny doll. What were the chances of success, O’Donnell wondered—of the child’s survival. Ordinarily they might have been fair, even good. But now, with this procedure days late, the hope of success had been lessened drastically. He glanced at the child’s face. Strangely it was not an ugly face, as the faces of premature children so often were; it was even a little handsome, with a firm jaw line and a hint of latent strength. For a moment, uncharacteristically allowing his mind to wander, he thought: What a shame this all is I—to be born with so much stacked against you.

The assisting nurse was holding a plastic catheter with a needle attached; it was through this that the blood would be drawn off and replaced. O’Donnell took the catheter and with utmost gentleness eased the needle into the umbilical vein. He said, “Check the venous pressure, please.”

As he held the catheter vertical, the nurse used a ruler to measure the height of the column of blood. She announced, “Sixty millimeters.” The intern wrote it down.

A second plastic tube led to the bottle of blood above them; a third ran to one of the two Monel-metal basins at the foot of the table. Bringing the three tubes together, O’Donnell connected them to a twenty-milliliter syringe with a three-way stopcock at one end. He turned one of the stopcocks through ninety degrees. “Now,” he said, “we’ll begin withdrawing blood.”

His fingers sensitive, he eased the plunger of the syringe toward him gently. This was always a critical moment in an exchange transfusion; if the blood failed to flow freely it would be necessary to remove the catheter and begin the early preparation all over again. Behind him, O’Donnell was conscious of Dornberger leaning forward. Then, smoothly and easily, the blood began to flow, flooding the catheter tube and entering the syringe.

O’Donnell said, “You’ll notice that I’m suctioning very slowly and carefully. We’ll also remove very little at any one time in this case—because of the smallness of the infant. Normally, with a term baby, we would probably take twenty milliliters at once, but in this instance I shall take only ten, so as to avoid too much fluctuation of the venous pressure.”

On his score sheet the intern wrote, 10 ml. out.”

Once more O’Donnell turned one of the stopcocks on the syringe, then pressed hard on the plunger. As he did, the blood withdrawn from the child was expelled into one of the metal basins.

Turning the stopcock again, he withdrew donor blood into the syringe, then, tenderly and slowly, injected it into the child.

On his score sheet the intern wrote, 10 ml. in.

Painstakingly O’Donnell went on. Each withdrawal and replacement, accomplished gradually and carefully, took five full minutes. There was a temptation to hurry, particularly in a critical case like this, but O’Donnell was conscious that speed was something to be shunned. The little body on the table had small enough resistance already; any effect of shock could be immediate and fatal.

Then, twenty-five minutes after they had started, the baby stirred and cried.

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.