The Final Diagnosis

The Final Diagnosis Page 2

Two blocks from Three Counties Hospital the clock-tower bell of the Church of the Redeemer was chiming the hour as Kent O'Donnell made his way from the surgical floor down to Administration. The sound of the bell, off-key as always from a flaw in its long-ago casting, drifted in through an open stairway window. Automatically O'Donnell checked his wrist watch, then moved aside as a group of interns passed him hurriedly on the staff stairway, their feet sounding noisily on the metal treads. The interns quietened a little when they saw the medical-board president and offered a respectful "Good morning, Doctor," as each went by. On the second floor O'Donnell halted to let a nurse with a wheel chair pass. In it was a girl of about ten with a bandage over one eye, a woman, plainly the mother, hovering protectively alongside.

The nurse, whom he smiled at but failed to recognize, appraised him covertly. In his early forties, O'Donnell still rated second glances from women. He had retained the build which had made him an outstanding quarterback in his college years - a tall, erect figure with big, broad shoulders and muscular arms. Even nowadays he had a trick of squaring his shoulders when ready to do something difficult or make a decision - as if readying instinctively to stop the charge of a red-dogging tackle. Yet despite his bulk - mostly bone and muscle with less than a pound of overweight - he still moved lightly; and regular sport - tennis in summer, skiing in winter - had kept him robust and lithe.

O'Donnell had never been handsome in the Adonic sense, but he had a rugged, creased irregularity of face (his nose still carried the scar of an old football injury) which women so often, and perversely, find attractive in men. Only his hair showed the real trace of years; not so long ago jet black, now it was graying swiftly as if the color pigments had suddenly surrendered and were marching out.

Now, from behind, O'Donnell heard his name called. He stopped and saw the caller was Bill Rufus, one of the seniors on surgical staff.

"How are you, Bill?" O'Donnell liked Rufus. He was conscientious, dependable, a good surgeon with a busy practice. His patients trusted him because of a forthright integrity which came through when he talked. He was respected by the house staff - interns and residents - who found Dr. Rufus to have a painless, pleasant way of imparting sound instruction while treating them as equals - a condition not always prevailing with other surgeons.

His only peculiarity, if you could call it that, was a habit of wearing impossibly gaudy neckties. O'Donnell shuddered inwardly as he noticed the creation his colleague was sporting today - turquoise circles and vermilion zigzags on a background of mauve and lemon yellow. Bill Rufus took a good deal of ribbing about his ties. One of the psychiatrists on staff had suggested recently that they represented "a pus crater from an inner seething below a conservative surface." But Rufus had merely laughed good-naturedly. Today, though, he seemed troubled.

"Kent, I want to talk to you," Rufus said.

"Shall we go to my office?" O'Donnell was curious now. Rufus was not the type to come to him unless it were something important.

"No; here's as good as anywhere. Look, Kent, it's about surgical reports from Pathology."

They moved over to a window to avoid the traffic in the corridor, and O'Donnell thought: I was afraid of this. To Rufus he said, "What's on your mind, Bill?"

"The reports are taking too long. Much too long."

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."