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.
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—much too low.
“He’s not breathing well,” the intern said. “Color isn’t good.”
O’Donnell told him, “Check the pulse.” To the nurse he said, “Oxygen.”
She reached for a rubber mask and held it over the infant’s face. A moment later there was a hiss as the oxygen went on.
“Pulse very slow,” the intern said.
The nurse said, “Temperature’s down to ninety-three.”
The intern was listening with a stethoscope. He looked up. “Respiration’s failing.” Then, a moment later, “He’s stopped breathing.”
O’Donnell took the stethoscope and listened. He could hear a heartbeat, but it was very faint. He said sharply, “Coramine—one cc.”
As the intern turned from the table O’Donnell ripped off the covering sheets and began artificial respiration. In a moment the intern was back. He had wasted no time; in his hand was a hypodermic, poised.
“Straight in the heart,” O’Donnell said. “It’s our only chance.”
In the pathology office Dr. David Coleman was growing restless. He had remained, waiting with Pearson, ever since the telephone message had come announcing the blood-test result. Between them they had disposed of some accumulated surgical reports, but the work had gone slowly, both men knowing that their thoughts were elsewhere. Now close to an hour had gone by and there was still no word.
Fifteen minutes ago Coleman had got up and said tentatively, “Perhaps I should see if there’s anything in the lab . . .”
The old man had looked at him, his eyes doglike. Then, almost pleadingly, he had asked, “Would you mind staying?”
Surprised, Coleman had answered, “No; not if you wish,” and after that they had gone back to their task of time filling.
For David Coleman, too, the waiting was hard. He knew himself to be almost as tense as Pearson, although at this moment the older man was showing his anxiety more. For the first time Coleman realized how mentally involved he had become in this case. He took no satisfaction from the fact that he had been right and Pearson wrong about the blood test. All he wanted, desperately now, for the sake of the Alexanders, was for their child to live. The force of his own feeling startled him; it was unusual for anything to affect him so deeply. He recalled, though, that he had liked John Alexander right from the beginning at Three Counties; then later, meeting his wife, knowing that all three of them had had their origins in the same small town, there had seemed to spring up a sense of kinship, unspoken but real.
The time was going slowly, each successive minute of waiting seeming longer than the last. He tried to think of a problem to keep his mind busy; that always helped when you had time to kill. He decided to concentrate on some of the aspects of the Alexander case. Point one, he thought: The fact that the baby’s Coombs test now shows positive means that the mother has Rh-sensitized blood also. He speculated on how this might have come about.
The mother, Elizabeth Alexander, could, of course, have become sensitized during her first pregnancy. David Coleman reasoned: It need not have affected their first child; that was the one who had died of—what was it they had told him?—oh yes, bronchitis. It was much more common to find the effect of Rh sensitization during a second pregnancy.
Another possibility, of course, was that Elizabeth might have been given a transfusion of Rh-positive blood at some time or other. He stopped; at the back of his mind was a nagging, unformed thought, an uneasy feeling that he was close to something but could not quite reach it. He concentrated, frowning. Then suddenly the pieces were in place; what he had been groping for was there—vivid and sharply in focus. His mind registered: Transfusions! The accident at New Richmond! The railroad crossing at which Elizabeth’s father had been killed, where she herself had been injured but had survived.
Once more Coleman concentrated. He was trying to remember what it was John Alexander had said about Elizabeth that day. The words came back to him: Elizabeth almost died. But they gave her blood transfusions and she made it. I think that was the first time I was ever in a hospital. I almost lived there for a week.
It could never be proved, of course, not after all this time; but he was willing to wager everything he had that that was the way it happened. He thought: Existence of the Rh factor only became known to medicine in the 1940s; after that it took another ten years before Rh testing was generally adopted by all hospitals and doctors. In the meantime, there were plenty of places where blood transfusions were given without an Rh cross match; New Richmond was probably one. The time fitted. The accident involving Elizabeth would have been in 1949; he remembered his father telling him about it afterward.
His father! A new thought came to him: it was his own father—Dr. Byron Coleman—who had taken care of the Alexander family, who would have ordered the transfusions Elizabeth Alexander had received. If she had had several transfusions they would have come from more than one donor; the chance of at least some of the blood being Rh positive was almost inevitable. That was the occasion, then, when Elizabeth had become sensitized; he was sure of it now. At the time, of course, there would have been no apparent effect. None, that is, except that her own blood would be building antibodies—antibodies to lurk hidden and unsuspected until, nine years later, they rose in anger, virulent and strong, to destroy her child.
Naturally David Coleman’s father could not be blamed, even if the hypothesis were true. He would have prescribed in good faith, using the medical standards of his day. It was true that at the time the Rh factor had been known and in some places Rh cross matching was already in effect. But a busy country G.P. could scarcely be expected to keep up with everything that was new. Or could he? Some physicians of the time—G.P.’s included—were aware of the new horizons opened up by modern blood grouping. They had acted promptly to enforce the latest standards. But possibly, David Coleman reasoned, these were younger men. His father at that time was growing old; he worked too hard and long to do much reading. But was that an adequate excuse? Was it an excuse that he himself—David Coleman—would accept from others? Or was there perhaps a double standard—a more lenient set of rules when it came to judging your own kin, even a father who was dead? The thought troubled him. He sensed uneasily that a feeling of personal loyalty was obtruding across some of his own most cherished views. David Coleman wished he had not thought of this. It gave him an uneasy feeling of doubt, of not being absolutely sure . . . of anything at all.
Pearson was looking across at him. He asked, “How long is it now?”
Coleman checked his watch, then answered, “Just over an hour.”