Chapter 6. February.
“Hello Mary Ann,” says Dr. De Young, our pediatric hematologist. “Do you remember Dr. Morton? He was the doctor who saw you in the Emergency Room the day you were admitted, and now he’ll be working with me to take care of you. How are you feeling today?”
We’re rounding on hematology patients and now we’re on the Sixth Floor. Mary Ann is in one of the two private rooms, with glassed-in partitions separating it from the rest of the ward, since her resistance to infection is low. Dr. De Young is perhaps fifty, balding with a thick mustache and wire-framed glasses, the short side of medium height, and tending towards stoutness.
Mary Ann shrugs. Her face is starting to grow round and ruddy, from her high dose of prednisone. “Fine, doctor,” she says.
“Hi Mary Ann, do you remember me?” I ask. “You must have seen many doctors since you arrived.”
“I think so,” she says, wrinkling her nose.
“She only needed two transfusions, right after her bone marrow aspiration. And her nodes decreased in size very nicely,” says Dr. De Young. “So has her spleen. Her platelet count is staying up now.” We examine her as we speak.
“She’s having a good response, then,” I say.
“They almost all have a good initial response to prednisone—-the problem is that they develop resistance rapidly and their blast counts go right back up.”
“So what do you do when that happens?”
“Bob, I want you to tell me. Go to the literature and read about cyclic therapy for A.L.L. Then let’s discuss it on Monday. And think about when you might want to do the next bone marrow aspiration on her. I’ll walk you through it, but you’ll be the one to actually do it.”
Father Salerno is coming to see Mary Ann as we turn to leave. “Hello Father Joe,” I say. “Mary Ann’s parents ask you to see her?” As for a cure, prayer is as good as anything we offer. Maybe better.
Later that afternoon, I’m sitting at a thick oak table in the hospital library, doing a literature search. The narrow horizontal windows set high up on the wall provide a glimpse of dense, gray clouds. I decide to contact Sal and see if he would be willing to access more information than what I’ve been able to find. I tap out the ashes from my pipe on top of the stale butts in the ashtray, refill the bowl, and light up with a wooden match as I talk to Sal.
“Poor kid, she’s responding now, but she’ll lose that sensitivity,” I say. “What I’m trying to find out is, if it’s better to change her to another drug when her leukemia become resistant to it, or do it before resistance develops, which seems to be the current consensus from what I’m reading. But since the literature always lags behind what people are doing with patients, do you think you could look into what others, who are the experts in town, are doing? In fact just seeing what Dr. De Young thinks, might be a good way to do that since he’d know what’s being done by the others in the field.”
“And why don’t you just ask him yourself on Monday?”
“I plan to. Look, I’m not trying to score Brownie points with him by plagiarizing, and passing off someone else’s thesis as my original thoughts. I’m just really curious, after doing the reading, whether anyone’s come up with anything that’ll give her a longer remission. Ten months is a better survival than what it used to be before treatment, but still not terrific.”
“Fair enough. You just can’t wait. I’ll bet you read the last chapter of novels too. All right, I’ll satisfy your curiosity, since you’ve already done a lot of work on your own, going through the Index Medicus, and tracing journal articles. I’ll get back to you on the way home.”
During the rest of the afternoon, I impatiently wait to hear what Sal has discovered. “Hi, Sal,” I say as I’m driving up Bay State after Chief’s Conference, “so what did you find out?”
“Unfortunately, there’s not much more to add to what you’ve already found. There have been no dramatic breakthroughs.”
“No Silver Bullets, huh? What about that old reference I found to Cooley’s Toxin? Anybody working on that?”
“No. But wasn’t that more for solid tumors?” asks Sal.
“Yeah, I guess so. But I wondered if it might also have been tried with leukemia out of desperation. It looks like A.L.L.’s still a death sentence. It just takes longer to carry out.”
“I’m afraid so. Maybe someday, there’ll be a cure discovered. But not in time for Mary Ann.”
I’m eating dinner with Lou when I hear myself paged. The operator puts me through to Dave, the SR covering the Nursery.
“Sounds like you’re in the dining room,” he says. “You’re helping to cover the nursery this month during your elective, right? Well, finish eating, then come up. We’ll be doing an exchange transfusion as soon as we can get the blood from the blood bank. Have you done one before?”
“I helped with one when I was on Eight, and with one when I was an intern at Westchester.”
“Okay,” says Dave. “Like the saying goes, ‘see one, do one, teach one.’ You’ve even seen two, so it’s time to do one. This one’s a full-term, fourteen-hour old male with erythroblastosis fetalis from Rh incompatibility. Come up and we’ll go over the lab work while we wait for the blood.”
My first solo exchange! Hope I remember the steps.
I return to my meal, wolf it down excitedly, and say good bye to Lou. After taking my tray to the dirty tray window, I head for the obstetrics building through the tunnel system. Obstetrics is on the opposite side of the hospital lot from pediatrics, in an older four-story building. The nursery is on its second floor along with the delivery rooms and one operating room in which Caesarian sections are performed.
Dave is waiting in the chart area. “You sure gulped down your dinner,” he says with a smile. “An eager beaver.”
“What’s the history?” I ask.
“Mom’s Rh negative and had two previous miscarriages. This is the first baby she’s carried to term. Cord blood was A positive, Coombs positive. Hemoglobin was a little low at 13, and the reticulocyte count was elevated at eight percent. The kid looked jaundiced at six hours and the indirect bilirubin was nine. It was rechecked after five hours and was up to fourteen, and the hemoglobin was down to eleven. So we got things rolling, and since you’re on tonight, you get the honors.”
“So this is the first pregnancy that this mother delivered, and yet the baby is erythroblastotic? How’d that happen?”
“It’s theorized that the miscarriage of an Rh positive fetus can sensitize a mother,” says Dave, “Just as much as the delivery of a term pregnancy. That’s why you always need to get a complete pregnancy history with every Rh negative mother.”
“Mom knows what’s happening and what we’re planning to do?”
“Yeah, Cliff talked to her before he went off.”
“How many exchanges has Cliff done this month?”
“Just one. But he did one during internship. I’ll talk you through it since it’s your first time as the operator. But it’s not rocket science,” says Dave. “Mostly it’s a matter of attention to detail, like getting the catheter in the right place, not taking off too much blood at one time, and not going too fast. The blood comes out, and the blood goes back in.”
I read to refresh my memory till the unit of blood arrives from the blood bank. We begin to set up in the converted storage closet off the hallway between the second and third nurseries. To keep the baby warm while the procedure is done, the nurses fill rubber hot water bags with warm water, cover them with a blanket, and then place the baby on top of them. We secure his arms and legs with gauze strips. Then Dave and I scrub. The baby’s umbilical cord has been kept moist with saline in anticipation of doing an exchange. I begin to set up the syringes, stopcocks, tubing, and other paraphernalia, under Dave’s watchful eyes. Then I prep the cord and surrounding belly with Betadine, secure the cord, and clip off the plastic cord clamp. “Be sure to leave some cord, in case he needs to be re-exchanged tomorrow,” says Dave. “Don’t cut it off flush to the skin.”
I carefully slice through the cord, cloth ligature ready to control bleeding, exposing the ends of the three vessels.
“Okay, now identify the umbilical vein,” says Dave.
I slip the tip of a thin, red-rubber catheter, connected to a saline-filled glass syringe, into the vein, and, after a bit of jiggling, am able to advance it easily. There is a free flow of blood when I pull back the syringe plunger. I switch the end of the catheter from the syringe to the setup I’d prepared earlier.
“Now it looks like you’re set to go,” says Dave. “First check the venous pressure. Then draw twenty cc’s of blood from the baby. Slowly. Discard it. Draw twenty cc’s from the bag, and push it in.”
Twenty out, twenty in; add some calcium after each hundred cc’s; mix the bag of blood at intervals by inverting it. Finally five hundred cc’s of blood have been exchanged. I did it! My first solo exchange.
I fill a couple of tubes of blood for future typing and tests.
“Be sure that you’ve got the vessels secured,” says Dave as we finish. “We don’t want the baby to bleed out. And keep the cord moist with sterile saline in case he needs a re-exchange later.”
“Thanks for the help, Dave. You want a post-exchange bili (bilirubin), and hemoglobin, don’t you.”
“Yes,” says Dave, “and a culture. Oh, and stop by his mother and let her know that things went well. Be sure to mention that he may need to have this repeated tomorrow, if his bili gets up to twenty.”
“Congratulations, Robert. Well done.”
I’m driving home and have been talking excitedly to Sal about the past night and day.
“Yeah Sal. My first exchange transfusion. It’s a milestone for me to finally do one, although it was reassuring to have Dave there, talking me through it.”
“How’s the baby doing now?”
“The bili rebounded as anticipated, and late this afternoon reached twenty, and Cliff had to do a second exchange. I hope that that wraps it up.”
“I’m happy for you.”
“Thanks Sal. I know it’s kind of childish to feel so excited, since it’s not like doing thoracic surgery. Still, it’s one of the few surgical-type procedures that we pediatricians get to do and, as one of my ward attendings pointed out, one of the few times we get paid like surgeons.”
“But you didn’t go into pediatrics to get rich.”
“That’s true,” I reply, “But it’s nice to know that your services are valued. Unfortunately, society has few meaningful ways of showing appreciation except by monetary rewards.”
“Now you’re the one sounding cynical. But to return to happier thoughts, you probably keep a mental list of the skills that you need to learn during residency. Now you can check one off.”
“Yeah, a really big one. And next week I get to do a bone marrow on Mary Ann, to see if she’s ready to go home.”
I manage to find a parking space, and say goodnight to Sal. The sidewalks are icy since the temperature drops quickly after sunset, and I set my feet down carefully as I walk.
“I’m home,” I announce dramatically, flinging the apartment door open.
“Hi Bob,” says Karen from the bedroom. “I’m in here.” Her voice sounds flat. She hasn’t changed from her school outfit and is sitting on the edge of the bed and looks up sadly as I walk in. She lifts her face to be kissed.
“What’s wrong?” I ask, sitting next to her, my mood rapidly deflating, replaced by anxiety.
“One of the parents complained about me to the principal. Said I wasn’t being fair to her son.”
“Oh Karen.” I put my left arm over her shoulder. “What happened?”
“Two of the boys had a shoving match at the start of recess yesterday. I asked them who started it, but neither would tell me, so I scolded them both, and made them stay in. Today, one mother said that her son wasn’t at fault and shouldn’t have been punished.”
“What else could you do if neither of them owned up? I’m sure the principal realizes that you did your best to be fair.”
“The problem is, I’m still on probation since this is my first year at Peabody. I can’t afford to have too many complaints or my contract won’t be renewed next year. I have to meet with Miss Bartlett, the principal, tomorrow afternoon. I’ve been trying so hard to do a good job too.”
“Well the parents at Thanksgiving sure thought you were doing a great job with their kids. I’m sure she must have heard a lot of positive comments about you. And she hasn’t talked to you about any problems before this. I would hope she’ll be fair about this one time.”
“I talked with Maggie after school–you know, the other first grade teacher. She tried to reassure me and told me the same thing. But I guess I needed to tell you too.”
“I remember how nervous I felt when I had to meet with Dr. Wasserman after that digitalis fiasco, so I can imagine how you must feel. Come, I still remember how to open a can of corned beef. I’ll fix dinner tonight. Take it easy. Want to join me in a scotch now?”
“Yes,” she says, “let’s go to the living room to have it.” She sounds more like herself—thank God. I stand, reach out to take her hands, and pull her to her feet. We walk to the living room with our arms around each other’s waists.
“You feeling any better?” I ask, stealing a glance sideways at her. “You looked pretty glum when I walked in.”
“Yes I was. Thanks. And I can fix dinner.”
“The thought of canned corned beef and onions cured you, eh?”
“So how did your night go? You must have been busy, since you didn’t call.”
“Oh—well, I got to do my first exchange transfusion.”
“What’s an exchange transfusion anyway? I vaguely remember that you mentioned it before. Was it exciting?”
“It’s when a baby gets really jaundiced, and we try to prevent brain damage by exchanging its blood to lower the level of jaundice.”
“That sounds complicated and dangerous. Is it?”
“It’s not actually that complicated. Once the tube is in the right place, it’s just a matter of pulling out a little blood, then pushing back a little blood, over and over, till a unit of blood has been exchanged.”
I stop by the Malloy’s flower shop after conference, to pick up a red rose bud.
“No celebration or problems, Mrs. Malloy. My wife just needs a pickup because she’s been working too hard. Still sixty cents each?”
“I’m sorry, but roses are harder to get in the winter so they’re a dollar, but I’ll let you have them for seventy-five cents each.”
“Thanks Mrs. Malloy, but I just need one.” I lay out the coins, and turn to leave. “Good night, Brian,” I say to her son.
“Goo nigh, doc.”
“Good idea,” says Sal, as I go to the car, with the flower inside my coat to keep it from freezing. My breath forms an advancing cloud in front of my face as I set my feet carefully on the icy bricks. “She’ll appreciate it more because it isn’t for a special occasion.”
“Sometimes I do manage to think of these things on my own. I’m learning.”
“Poor Karen,” says Sal. “To be on a one-year contract and then have to discuss a parent complaint with the principal. Just like your experience after Russell.”
“It was easier for me. I got the call to see Stan the Man, then saw him right away. Karen had to stew about it yesterday, last night, and all morning today. She sure didn’t sleep well.”
Sal leaves after I park the car on Arundel St. and cross Beacon to our apartment. Hope it wasn’t too hard for Karen. Principal sounds like strict old battle-ax.
I open the apartment door quietly and cautiously call out, “I’m home.”
Karen bounces out to meet me with a smile, “I still have my job next year.”
“So it went okay,” I say after our kiss.
“Yes. Miss Bartlett was very supportive. She asked me what happened, and I explained. Then she went over my work for the year, which she rated quite highly, and told me that she did not think that I’d been deliberately unfair. She explained that she always tells parents with complaints that she will talk to all parties concerned first, and then get back to them with her evaluation. Miss Bartlett’s been at Peabody for years, and the parents trust her.”
Sorry what I thought of you, Pear-lady. You’re a peach, not a prune, after all.
“Oh, and I picked this up for you,” I say, handing Karen the rosebud.
“Thank you, it’s so perfect,” says Karen, bringing it to her nose. “You must have been really worried about me.”
Her smile is back. “I was. I’m glad everything turned out okay. After all, we can’t afford to have you fired. We need both incomes.”
“You’re a louse, Bob. You married me just for my money, didn’t you.”
“Of course. Say, what smells so delicious?”
“I stopped on the way home to pick up some chow mein, sweet-sour ribs, and stir-fry vegetables. Guess I felt like celebrating. Let me put this rose bud into a vase, and then we can eat. I don’t know about you, but I’m starved. Want a beer too?”
“You and I will talk to the O’Connor’s later today about follow-up visits for Mary Ann,” says Dr. De Young. “Now that the bone marrow you did shows clearing, she can go home on 6-MP, while we taper her prednisone.”
“But it’s still not a cure.”
“Unfortunately not. But we’re making incremental progress. When I started practice, there was no treatment. All we could offer was sympathy after making the diagnosis of leukemia. The children went downhill quickly. Now we can extend their lives for many months, sometimes much more than a year. And there will be more drugs developed, and we’ll learn to use them more effectively. That’s the hope. Children like Mary Ann will not die in vain. We learn from them, and some day there will be cures.”
Later that afternoon, Dr. De Young and I crowd into the small office on the Sixth floor to meet with Mary Ann’s parents. The desktop is cluttered with journals, stray sheets of chart paper, three unwashed coffee mugs, and a half-filled ash tray. The O’Connors sit tensely upright in their chairs. Dr. De Young sits opposite them in the third chair behind the desk, while I stand against the wall.
“Mary Ann has had a very nice response to the prednisone, and to the other medicine, that we started this past week, 6-MP,” he says. “The bone marrow test that Dr. Morton did yesterday shows that she’s had remarkable clearing of her tumor cells. What we term a good remission.”
The O’Connors nod stiffly. Mr. O’Connor is blocky with a strong neck and the beginnings of a beer-belly, a contrast to his small thin wife.
“We plan to maintain her remission with the 6-MP for another month, while we taper off her prednisone. Then we’ll cycle her to another drug called methotrexate.”
“How long will she be treated?” asks Mr. O’Connor. “Is she going to be cured by these medicines?”
“I’m afraid that she will need to remain on some medicine indefinitely in order to suppress the leukemia. But we will keep rotating her medicines so that the tumor cells don’t become resistant to treatment.”
“But will she be cured?”
“I must be honest with you,” says Dr. De Young, “there really is no permanent cure for leukemia yet. But her life can be extended many months, even more than a year, with treatment. Without treatment . . . well, the end would come much sooner.”
Mrs. O’Connor begins to weep softly, and Mr. O’Connor wipes his eyes.
“I’m sorry,” says Dr. De Young, reaching out to touch her shoulder, “but there’s no easy way to say these words.”
“She’s so young, doctor. It’s just not fair.”
“We’ll make sure that whatever we do will hurt Mary Ann as little as possible. And I’ll always be available to you. I’ll give you my phone numbers before you go.”
Mr. O’Connor sniffs, and blows his nose in a handkerchief.
“This first medicine made her put on so much weight,” says Mrs. O’Connor. What about these other medicines?”
“No, they should not. But I would like to go over their possible side effects and what to watch out for, and the schedule that we will use with Mary Ann, as well as when we will be rechecking her.”
“Please tell us again what will happen if we just stop the medicines now.”
Dr. De Young patiently answers their questions, until they indicate that they understand and are ready to take Mary Ann home. Mr. O’Connor shakes our hands and Mrs. O’Connor gives Dr. De Young a hug as they leave the room. No, no cure. Just death deferred.
After work I cross Franklin Ave. to Mangione’s. It’s Valentine’s Day, and I have managed to not forget. “Hi Salvatore,” I say as I step through the door.
“Hey doc, what’s up these days? We don’t see you much since you moved out of the South Side.”
“Life’s busy, but good. I need something for Valentine’s Day for the wife. You got any boxes of Whitman’s Sampler?”
“Yeah, and they got special Valentine’s wrappings for the same price.”
“What a deal, Sal, I’ll take one.” Sal. Nah just can’t be Sal. Went through this before. “Okay, thanks and good night. You take care of yourself.”
I walk down the street a block and arrive at the Malloy’s flower shop to buy a single pink rose, feeling pleased with myself for remembering. Glad Mrs. Malloy told me women like single roses. Be sensitive yet cheap at the same time.
We’ve finished dinner with Wilson Wee, sitting around the small table in our narrow kitchen, and now the dishes are in the sink.
“Thanks, Karen, those stuffed pork chops were terrific after all the Friday cod fish at the hospital,” says Wil, pushing back from the table so that he can retrieve his pipe and tobacco pouch from his jacket in the living room. “Good to have meat. Back home we’d say, ‘real ono.’ That means delicious in Hawaii.
“Why don’t we move to the living room to have our coffee,” says Karen. She sets the coffeepot on the stove, and I put a couple of folk LP’s—Belafonte and Richard Dyer-Bennet–on the Garrard changer, turning the volume low.
“How about an after-dinner drink?” I ask. “I’ve got Kahlua and Cointreau–the real stuff this time.” I get the bottles and glasses from the kitchen; put them on a tray which I carry to the cloth-draped footlocker that serves as our coffee table. Wil settles into the canvas sling chair.
Wil laughs, “Do you know what this cheapskate used to do as a student before you married him, Karen? He used to take elixer turpin hydrate with codeine, a cough syrup with an orange flavor, pour it into an empty Cointreau bottle, then serve it up with a straight face.”
“Nobody ever complained.”
“Well, let me have the real McCoy this time. Hey, maybe we should try a blind taste test.”
“Sorry, I don’t have anymore of that fake stuff. Karen’s brought class, as well as her salary, into my life. Kahlua for you, Karen?”
The coffee is ready, and we sit with our mugs, liqueur, and apples.
“Have you definitely decided what you’re going to do next year, Wilson?” asks Karen.
“I’ve got no choice. I owe Uncle Sam three years in the Air Force.”
“Do you know where you’ll be stationed?”
“Well, since I’ll be in anyway, I thought I’d put in for Europe. I’ve never been there. Just pray that there won’t be a shooting war any time soon.”
“It’s way off in the future,” I ask, “but have you thought about after the Air Force, Wil? I remember you were thinking about a fellowship at one time. Wasn’t it neurology?”
“It’s still too early to say. But my folks are getting older. Dad will be retiring in five years. They’re hoping that I’ll return to Hawaii since I’m the oldest son. They’d like me to settle down and start a practice, so I may have to think hard about doing that. And they’d probably like some grandchildren.”
“You’re not even married yet. They got some nice Chinese girl in mind? Don’t they arrange these things for you?”
“You’re thinking of Flower Drum Song, Karen. My folks were born and raised in the Islands.”
“It’s hard not to worry about family obligations,” I say. ”My brother Tom and I are the first in our family to finish college, let alone go beyond. My folks have really sacrificed for us. Mom and Dad grew up when the Depression started, and Dad had to drop out of college after one year, to look for work. He wanted to be an engineer. And Mom went to work and never even finished her senior year of high school. I know they were happy when Karen and I got married. Since then, they haven’t said anything about the future, but they’d probably like us somewhere in Northern California eventually, so we could be closer to San Sebastian.”
“Yeah.” says Wil. A long silence follows.
“What’s practice like in Hawaii?” Karen finally asks.
“Chinese like to be their own bosses, and so they generally go into solo practice, although there are two big clinics in town, staffed mostly by Caucasians or ‘haoles,’ as we say back home. We do have a children’s hospital and if I do go back right out of the Air Force, I may apply to be chief resident there as a way of connecting to the medical community. There’s also a maternity hospital, and a large General hospital of 500+ beds, as well as a few smaller ones. Hawaii may be 2200 miles from California, but we do know what penicillin is. I mean, everyone gets trained on the Mainland before returning. After all, we’re a state now.”
“What’ll your folks say if you bring back a fraulein?”
“I hope they’ll say, ‘Welkommen’ and not ‘Weggehen’.”
“You know, Sal,” I say, driving in to Saturday rounds, “I’m going to miss Wil after he finishes. But in today’s world, that’s what happens. You meet people, get to be friends, and then you, or they, move on. It’s not like in my parents’ generation.”
“Maybe not like your parents’ generation, but what about the one that came right after them and just before yours? They went off to fight a World War in places that most of them never knew existed before they arrived.”
“Well, wartime’s an exception. I’m thinking peacetime.”
“Or the generation or two before your parents; those who went out West in covered wagons, or sailed over from Europe and Asia in steerage to take their chances on making a fresh start in a New World?”
“Well, maybe so,” I concede. “I didn’t think about those pioneers and immigrants. Yeah, they really had guts to leave everything familiar behind.”
“You realize that in a year’s time, we’ll be going through what you’re facing with Wilson today,” says Sal.
“My God Sal, you’re right. That hadn’t occurred to me. Or maybe I’ve just been avoiding the thought. How can we stay in contact? We’ve only got a range of thirty miles.”
I’ve been thinking about it and I don’t have any answers. The army will ship you off to where it needs you,” says Sal. “It will be very hard for me to go back to what it was like before we became friends.”
“Me too. I could put in a request for a base in Massachusetts or at least New England, but even those will be out of range. Maybe I’ll come back to Boston afterwards, or you could move to where I go, assuming that you can or would want do that. That’s the problem with not knowing anything about you. There’s just no way to think of any solutions. You’re going to have to let me in on your secret. I can’t understand why you won’t trust me after we’ve known each other for this long.”
“We still have time, so don’t get worked up about it right now. If you worry too much about the future, you’ll enjoy the present less.”
“That sounds like some quotation again. Who said it?”
“Sal said it, though lots of other people have said similar things.”
“At the very least, you’ll need to give me your address so we can write to each other while I’m in the army, if we can’t telepath.”
“That would be completely revealing myself.”
“Well why not? It’s about time.” “We’ve still got time.”
But I don’t know anything about you, Sal. Can I totally trust what you say? Do I have a choice? Of course, if you’re a psychotic product of my mind–no problem because I’ll never be free of you. But I think you’re real. Who wants to believe they’re crazy? Like believing in telepathy is sane?
The consult for Dr. De Young arrived from the Eighth Floor after lunch, and he dispatched me to review the chart, examine, and evaluate the patient.
Now we are at crib side and I’m presenting my findings to him. “This is the first admission for Isaiah Johnson, a twenty-three month old Black boy with a profound hypochromic, microcytic anemia,” I say. Isaiah is a large, chubby boy who frets whenever approached. I present the history and the positive findings. The history is pretty unremarkable, since he was picked up at a clinic visit for a routine well baby visit. His examination include striking mucosal pallor, very pale palms and nails, a grade two systolic heart murmur, and a palpable liver and spleen. The chest x-ray shows a degree of cardiac enlargement.
“What about his dietary history?” asks Dr. De Young.
“That’s pertinent,” I say. “He was on an evaporated milk formula until six months of age, and he’s been on homogenized milk ever since–drinks about two quarts a day now. He really does not eat much in the way of solids and the little that he does take is mostly starch, like crackers, bread, and rice.”
“Is there a history of pica?”
“Yes. He eats paper and loves to chew on ice, which his mother thinks is cute.”
“What about his housing,” asks Dr. De Young. “Is it old?”
“Not too old. He lives in the project.”
“Since we’re playing ‘Twenty Questions,’ why am I asking about these things?”
“Because you’re probably wondering whether he could also have lead ingestion on top of his iron deficiency. His history of pica (eating foreign objects) would be of concern especially if he lived in older housing. I went to the lab and looked at his red cell smear and didn’t see any stippling.”
“Of course that only appears in severe lead poisoning. Interestingly, pagophagia, or eating ice, as a specific form of pica, is associated with iron deficiency, though no one knows why. Is his sickle cell prep negative?”
“Yes it is.”
“Well, I’m happy that the floor remembered to do one on him without being reminded. Did they also do a stool guaiac?”
“No, I didn’t see that in the chart. Do you think that occult GI bleeding could be the cause of his anemia and that we need to do a GI work up too? There was no mention of tarry stools in the history.”
“Gastrointestinal blood loss occurs in up to half of children with severe iron deficiency. Drinking large quantities of fresh cow’s milk, as this boy has done, can also cause GI bleeding for reasons that aren’t clear, although it’s thought to be some kind of intestinal allergic response. Well, to get down to business, what does the floor staff think that he has, and what do you think that he has?”
“We both think he has severe, chronic iron deficiency anemia due to his high milk intake with little iron-rich solid food. The results of his serum iron and iron-binding capacity are pending.”
“So what’s the question they’re asking us to answer in the consult?”
“Whether he’s in danger of developing heart failure, and whether he needs a transfusion or immediate intra-muscular iron.”
“How would you answer that?”
The questions and answers go on. When we finish, Dr. De Young tells me to write and sign the consult reply; then he co-signs it.
I return the chart to Miss Kennedy, the nursing supervisor, on the way out. “I see Rider is still on the floor. Still can’t get her transferred to Lexington State, eh?”
Miss Kennedy’s smile is tired, “It is just taking forever. Social service says there’s no way to hurry it along. She’s not getting any treatment; we’re just warehousing her. Poor thing.”
At four PM Chief’s Rounds, one of the Eighth Floor residents presents Isaiah, and Dr. De Young asks me to discuss the recommendations that we made, on which he elaborates.
“You know, Sal,” I say on the way home, “Dr. De Young is treating me more like his fellow rather than a resident. That’s a very nice feeling. I’m glad that I’m taking this elective with him.”
“He does seem to be a thoughtful, almost humble man,” says Sal. “Not at all caught up in self-importance. Perhaps he’s learned to be patient and modest from his patients, since some, like Mary Ann, are unfortunately incurable.”
“I wouldn’t mind going into hematology in the future. And speaking about the future, Sal. You really will need to tell me more about yourself at some point. So why not now?”
“Robert, you’re being very persistent. I’m sorry that I brought it up. You will just need to learn about delayed gratification. I am not going to tell you anything more at this time.”
It was Karen’s turn to drive to work on Friday. I ride the MTA home on Saturday morning after call: first to Washington, then the short transfer to Park, and finally the Beacon Street car. Sal and I talk, but he hasn’t altered his decision to not tell me anything more about himself. This impasse has weighed on our recent conversations. We finally reach an understanding by the Copley Square stop, to let the subject go for now, to our mutual relief. I notice an older woman across the aisle staring at me curiously, and realize that I’ve probably been frowning and smiling while speaking with Sal. I know that I don’t move my lips anymore. When I get off the tram I smile and say goodbye to the lady, who quickly looks away. That was mean of me.
I walk the block to the apartment, go up the stairs, and let myself in. “Good morning Karen, I’m home,” I call out. She comes to my arms. Looks great. Did something different to her hair.
“Bob, I already went grocery shopping this morning. That’ll save us some time this afternoon. How tired are you?”
“Not very. Why, what do you have in mind?”
“Well, there’s the Impressionists exhibition that opened last week at the Museum. We could go to that. Unless you have something else planned. In which case we could go tomorrow.”
“No, I don’t have anything special in mind. Let’s go today. That way we’ll have all day tomorrow to do something, even if it’s nothing.”
We drive over after lunch. If the weather were nicer, we would walk over, but it’s still damp, gray and cold. We slowly stroll through the exhibition, take a coffee break in the cafeteria, then browse other galleries, spending a leisurely afternoon.
Dinner is in a small, inexpensive Greek restaurant just off Kenmore Square. We return home to watch television, till it’s time to shower and go to bed. Tomorrow morning, we’ll sleep in late. It’s been a low-key, but very pleasant afternoon and evening.
Karen and I read in bed for a while, leaning against the wall; then we kiss each other, and lie down. Something about today. What? Just before I turn out the light the realization hits me with a jolt. It’s her birthday!
I sit bolt upright. “Karen, today is your birthday! I completely forgot! I had planned to celebrate it. Oh, I’m so sorry. I feel like such a klutz.”
Karen laughs. “I wondered if you’d remember sometime during the day. That’s okay. It’s no big deal not to celebrate.”
“But it is a big deal that I forgot. I even got you a present earlier, and hid it. I’ll go get it from the closet now.”
“Don’t I get a ‘Happy Birthday’ kiss first?”
“Of course.” I kiss her contritely. “Happy Birthday, darling.” Then I go to the hall closet and reach to the back of the top shelf for the blouse, wrapped in white tissue paper, still in its gray Jordan Marsh bag. Damn, forgot to wrap it.
“If it doesn’t fit or you don’t like the color, you can take it back,” I say as I hand her the bag. “I’m really sorry, Karen, I don’t know how I forgot. Please don’t read anything Freudian into this.”
“I like it,” she says, holding it out in front of her at arm’s length. “It’s a pretty shade of blue, and you’re getting better at remembering my size. Today was a really pleasant way to celebrate my birthday. We spent a lovely afternoon together at the museum and had a nice, quiet dinner afterwards. The only thing I didn’t get was a candle to blow out, but I really can’t think of anything else that I’d wish for right now.”
“Please let me take you out tomorrow to make up. Cake and all.”
“Let’s see how we feel tomorrow, but it isn’t necessary.”