ah.thefinaldiagnosis-第61部分

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unting　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　shortings　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　patible。　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；　acplished　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。
　O'Donnell　was　conscious　of　a　lessening　of　tension　in　the　room。　He　began　to　wonder　if；　after　everything；　this　baby　would　pull　through。　He　had　seen　stranger　things　happen；　had　learned　long　ago　that　nothing　was　impossible；　that　in　medicine　the　unexpected　was　just　as　often　on　your　side　as　against　you。
　〃All　right；〃　he　said；　〃let's　keep　going。〃
　He　withdrew　ten　milliliters；　then　replaced　it。　He　withdrew　another　ten　and　replaced　that。　Then　another　ten…in　and　out。　And　another。
　Then；　fifty　minutes　after　they　had　begun；　the　nurse　announced　quietly；　〃The　patient's　temperature　is　falling；　Doctor。　It's　ninety…four　point　three。〃
　He　said　quickly；　〃Check　the　venous　pressure。〃
　It　was　thirty…five…m