Terrence Holt: Internal Medicine: A Doctor's Stories

“When I explained to the mother the next day just what her child had, I stumbled over my words in my hurry to get on to the good news, that there was a doctor who — And there I hung up for a moment. What was it I imagined Schott could offer her child? A cure? I had been about to say it, even though I knew that no one cured leukemia. I think I stammered up some euphemism like ‘a treatment.’ It was enough that when the woman hoisted up her son by one hand and followed me to Schott’s consulting room, I felt I had an ally — and a ray of hope — in what would otherwise have been a dismal, lonely tragedy.

“I still remember the expression on Schott’s face as I ushered the two of them into his office. We found him seated at his desk, under the impressive, black-letter German diplomas and the shelves heavy with journals and books. He stood stiffly at attention as I made the introductions, but his gaze as he shook hands so formally with the mother was all on the child at her feet, and the expression on his face was a curious thing: avid and tender and something else I couldn’t identify at the moment, but which I understood later was fear.

“I didn’t understand that he intended to start treating the child then and there. I didn’t pick up on that part of it until the end of the day, when I got a call from Schott, letting me know he had admitted my patient for what he expected to be two weeks of chemotherapy.

“It didn’t work. The child died before the two weeks were out: tumor lysis; renal failure. At the time, there were only six dialysis machines in the world, and they were all in Seattle. It’s not a painful way to die. There was that, anyway.

“I was surprised at how badly Schott took it. You wouldn’t have thought all that Germanic formality would have permitted the man to cry, but crying was what I found him doing in the stairwell that afternoon.

“ ‘Ach,’ he said, when I found him sobbing. ‘I’m sorry.’ He was actually wringing his hands. I wasn’t sure who he was apologizing to, but I was afraid it was me.

“You see, I had started to have doubts, once it was clear the treatment was going wrong, about my putting the child in Schott’s hands. I had known better. We all knew better. Leukemia was fatal. All this chemotherapy did was take a dying child and turn its death from something tragic into something squalid.

“But Schott’s unhappiness was affecting, and at the moment none of that crossed my mind. I laid a hand on his shoulder and said something to the effect that he had tried, it could have been worse, there had been some benefit. What that benefit had been I wouldn’t have wanted to say: it was just the kind of empty thing one says to a colleague in distress.

“But the effect those words had on Schott was remarkable. He straightened, squared his shoulders, and for a moment I thought he was going to click his heels. ‘You are right,’ he said.

“ ‘With every failure, we advance our knowledge.’

“And that was all. He turned, and without another word made his way back up the stairs.

“I didn’t think of him for a while after that. But a month or two later I heard a rumor about another one of his ‘treatments.’ This one had ended spectacularly, with the patient exsanguinating on the threshold of the emergency room. Schott had been there, the reports had it, wringing his hands, almost as frantic as the child’s parents, almost as much in the way. The emergency room physician had had to physically remove him from the scene.

“ ‘Overinvolved’ was the expression my informant used, and we both nodded wisely. Getting emotional about a patient was one thing. Making a public show of it was something else. But he was a foreigner, and his specialty was inevitably a chamber of horrors, so we were inclined to give him more latitude than we might have otherwise. Better him than me, we were thinking.

“The next time I ran into him was late one night, here in the hospital. I was admitting a twelve-year-old girl in DKA, and was just finishing writing up the orders when I felt something looming over my shoulder. It was Schott, standing there visibly impatient, with the hand-wringing and the sweaty face, beside himself over something.

“ ‘I’m so glad you’re here,’ he started off. He looked over his shoulder. ‘There is a patient,’ he explained, and gestured at one of the rooms in the corner of the PICU. His expression had a guilty quality about it, as though he expected the pursuit to start up at any moment.

“The patient was another one of his treatment failures. This one was in cardiogenic shock, whether from the stress of circulating a volume that was more crystalloid than blood, or some direct toxicity of the treatment, it wasn’t clear. There were some nuances to the treatment of shock in pediatric patients, he said. He would like to call a consult. But we had no pediatric cardiologist in town. Would I mind?

“Of course I didn’t mind, not even when the child continued so unstable I was there in the PICU until dawn, at which point the patient went into arrest and that was it. A mercy, really, considering how things were going.

“To his credit, Schott stayed as well, even though his contributions consisted of little more than hand-wringing, and muttering in German that I assumed was prayer. And he had the goodness to call the child’s parents (something I had forgotten, but then I didn’t know anyone involved in this case besides Schott) and tell them to come in. They arrived in time to witness their child’s last moments. Almost the last. Once the final attempt at resuscitation got under way, the nurses had to pull them out of the room.

“We left the PICU together, Schott and I. I had stayed while he broke the news to the parents, and kept him company as we both went out to the parking lot. It was early June, not yet five in the morning; the air was cool and still and dawn was just breaking. The light was crepuscular, but even so I could see Schott’s features clearly when I turned to him and said, ‘How many does that make?’

“You see, I had realized, as we made our way down the stairs, all this time Schott snuffling and muttering at my elbow, that I was angry. I suppose part of it was at being kept up all night on a consult I didn’t think I was going to find the heart to bill anyone for. And part of it was Schott’s pathetic performance. But most of it was the righteous anger anyone would feel at finding a colleague with such a trail of destruction at his heels.

“Schott stared at me for a moment, those watery eyes very wide. His expression wasn’t surprise, or incomprehension. Where someone truly surprised might stiffen, he just sagged. It was clear he had been expecting something like this.

“You knew this was so because he had an answer ready to hand. ‘How many?’ he whispered. And those eyes of his went far away again. ‘The number is seven here. With this one, eight.’

“ ‘ Eight? ’ I had been thinking it was three, at most. But while I was choking down that number, I found myself contemplating that little detail he had almost slipped by.

“ ‘And elsewhere?’ I demanded. ‘How many before you came here?’

“Schott stood facing me in the silent parking lot, the first light of dawn at his back. Somewhere in the trees birds were beginning to stir.

“ ‘Before?’ he said softly. ‘Before, there was one.’

“ ‘Only one?’ I was sarcastic.

“ ‘No,’ he said, so quietly I could barely hear him over the rising clatter of the birds. ‘There was one. Who lived.’

“ ‘ One? ’ I fairly roared it.

“ ‘One,’ he said again, and as he said this pathetic little word the sadness in his face silenced me momentarily — long enough for him to turn and quickly walk away.