ah.thefinaldiagnosis-第13章
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bypass it。 Three days later the patient had died and was autopsied。 The autopsy showed there had； in fact； been no cancer at all。 What had really happened was that the patient's appendix had ruptured and had formed an abscess。 The surgeon had failed to recognize this and thereby condemned the man to death。 Lucy remembered the horrified hush in which the pathologist's report had been received。
In an instance like this； of course； nothing ever came out publicly。 It was a moment for the ranks of medicine to close。 But in a good hospital it was not the end。 At Three Counties nowadays O'Donnell would always talk privately with an offender and； if it were a bad case； the individual concerned would be watched closely for a while afterward。 Lucy had never had to face one of these sessions herself； but she had heard the chief of surgery could be extremely rough behind closed doors。
Gil Bartlett was continuing。 〃The case was referred to me by Dr。 Cymbalist。〃 Lucy knew that Cymbalist was a general practitioner； though not on Three Counties' staff。 She herself had had cases referred from him。
〃I was called at my home；〃 Bartlett said； 〃and Dr。 Cymbalist told me he suspected a perforated ulcer。 The symptoms he described tallied with this diagnosis。 By then the patient was on the way to the hospital by ambulance。 I called the surgical resident on duty and notified him the case would be ing in。〃
Bartlett looked over his notes。 〃I saw the patient myself approximately half an hour later。 He had severe upper abdominal pain and was in shock。 Blood pressure was seventy over forty。 He was ashen gray and in a cold sweat。 I ordered a transfusion to bat shock and also morphine。 Physically the abdomen was rigid； and there was rebound tenderness。〃
Bill Rufus asked； 〃Did you have a chest film made？〃
〃No。 It seemed to me the patient was too sick to go to X…ray。 I agreed with the original diagnosis of a perforated ulcer and decided to operate immediately。〃
〃No doubts at all； eh； Doctor？〃 This time the interjection was Pearson's。 Previously the pathologist had been looking down at his papers。 Now he turned directly to face Bartlett。
For a moment Bartlett hesitated and Lucy thought： Something is wrong； the diagnosis was in error and Joe Pearson is waiting to spring the trap。 Then she remembered that whatever Pearson knew Bartlett knew also by this time； so it would be no surprise to him。 In any case Bartlett had probably attended the autopsy。 Most conscientious surgeons did when a patient died。 But after the momentary pause the younger man went on urbanely。
〃One always has doubts in these emergency cases； Dr。 Pearson。 But I decided all the symptoms justified immediate exploratory surgery。〃 Bartlett paused。 〃However； there was no perforated ulcer present； and the patient was returned to the ward。 I called Dr。 Toynbee for consultation； but before he could arrive the patient died。〃
Gil Bartlett closed his ring binder and surveyed the table。 So the diagnosis had been wrong； and despite Bartlett's outwardly calm appearance Lucy knew that inside he was probably suffering the torments of self…criticism。 On the basis of the symptoms； though； it could certainly be argued that he was justified in operating。
Now O'Donnell was calling on Joe Pearson。 He inquired politely； 〃Would you give us the autopsy findings； please？〃 Lucy reflected that the head of surgery undoubtedly knew what was ing。 Automatically the heads of departments saw autopsy reports affecting their own staff。
Pearson shuffled his papers； then selected one。 His gaze shot around the table。 〃As Dr。 Bartlett told you； there was no perforated ulcer。 In fact； the abdomen was entirely normal。〃 He paused； as if for dramatic effect； then went on。 〃What was present； in the chest； was early development of pneumonia。 No doubt there was severe pleuritic pain ing from that。〃
So that was it。 Lucy ran her mind over what had been said before。 It was true…externally the two sets of symptoms would be identical。
O'Donnell was asking； 〃Is there any discussion？〃
There was an uneasy pause。 A mistake had been made； and yet it was not a wanton mistake。 Most of those in the room were unfortably aware the same thing might have happened to themselves。 It was Bill Rufus who spoke out。 〃With the symptoms described； I would say exploratory surgery was justified。〃
Pearson was waiting for this。 He started ruminatively。 〃Well； I don't know。〃 Then almost casually； like tossing a grenade without warning： 〃We're all aware that Dr。 Bartlett rarely sees beyond the abdomen。〃 Then in the stunned silence he asked Bartlett directly； 〃Did you examine the chest at all？〃
The remark and the question were outrageous。 Even if Bartlett were to be reprimanded； it should e from O'Donnell； not Pearson； and be done in private。 It was not as if Bartlett had a reputation for carelessness。 Those who had worked with him knew that he was thorough and； if anything； inclined to be ultra…cautious。 In this instance； obviously； he had been faced with the need to make a fast decision。
Bartlett was on his feet； his chair flung back； his face flaming red。 〃Of course I examined the chest！〃 He barked out the words； the beard moving rapidly。 〃I already said the patient was in no condition to have a chest film； and even if he had〃
〃Gentlemen！ Gentlemen！〃 It was O'Donnell； but Bartlett refused to be stopped。
〃It's very easy to have hindsight； as Dr。 Pearson loses no chance to remind us。〃
From across the table Charlie Dornberger motioned with his pipe。 〃I don't think Dr。 Pearson intended〃
Angrily Bartlett cut him off。 〃Of course you don't think so。 You're a friend of his。 And he doesn't have a vendetta with obstetricians。〃
〃Really！ I will not permit this。〃 O'Donnell was standing himself now； banging with his gavel。 His shoulders were squared； his athlete's bulk towering over the table。 Lucy thought： He's all man； every inch。 〃Dr。 Bartlett； will you be kind enough to sit down？〃 He waited； still standing； as Bartlett resumed his seat。
O'Donnell's outward annoyance was matched with an inward seething。 Joe Pearson had no right to throw a meeting into a shambles like this。 Now； instead of pursuing the discussion quietly and objectively； O'Donnell knew he had no choice but to close it。 It was costing him a lot of effort not to sound off at Joe Pearson right here and now。 But if he did he knew it would make the situation worse。
O'Donnell had not shared the opinion of Bill Rufus that Gil Bartlett was blameless in the matter of his patient's death。 O'Donnell was inclined to be more critical。 The key factor in the case was the absence of a chest X…ray。 If Bartlett had ordered an upright chest film at the time of admission； he could have looked for indications of gas across the top of the liver and under the diaphragm。 This was a clear signpost to any perforated ulcer； therefore the absence of it would certainly have set Bartlett thinking。 Also； the X…ray might have shown some clouding at the base of the lung； which would have indicated the pneumonia which Joe Pearson had found later at the autopsy。 One or another of these factors might easily have caused Bartlett to change his diagnosis and improved the patient's chances of survival。
Of course； O'Donnell reflected； Bartlett had claimed the patient was too sick for an X…ray to be taken。 But if the man had been as sick as that should Bartlett have undertaken surgery anyway？ O'Donnell's opinion was that he should not。
O'Donnell knew that when an ulcer perforated surgery should normally be begun within twenty…four hours。 After that time the death rate was higher with surgery than without。 This was because the first twenty…four hours were the hardest； after that； if a patient had survived that long； the body's own defenses would be at work sealing up the perforations。 From the symptoms Bartlett had described it seemed likely that the patient was close to the twenty…four…hour limit or perhaps past it。 In that case O'Donnell himself would have worked to improve the man's condition without surgery and with the intention of making a more definitive diagnosis later。 On the other hand； O'Donnell was aware that in medicine it was easy to have hindsight； but it was quite anoth
