AFTER DROPPING OFF ALLISON at school, Herb returned to his office. He found a note from Kevin taped to the door, asking him to attend noon conference. The case to be discussed would be Larry Winton. Herb knew Kevin’s team had just admitted fourteen patients to the wards in addition to Winton in the ICU, which meant Kevin would have already been awake for twenty-eight consecutive hours when the conference began. He wondered why Flagler, the elderly head of infectious diseases, said the residents were getting soft.
Herb sat at his desk dictating reports and letters for the rest of the morning. His office, part of an interior suite, had white walls and floors. Hospital wards fanned out in all directions, allowing Herb to see patients, teach, and conduct research with maximal efficiency. He didn’t mind working in a windowless hive. There was more than enough drama here to distract him. Seven years into this job, Herb was absolutely certain it would never become boring.
In the conference room, a chief resident sat on either side of Flagler who motioned Herb to join them at the “pontificators’ table.” Kevin stood at a blackboard that spanned the entire east wall. Chalk in hand, he made notes while his medical student summarized the case. Kevin wrote acronyms, distilling the salient features of Larry Winton’s history, physical exam findings, and laboratory results into an even briefer synopsis. He asked Herb to comment on the chest x-ray. Herb pointed out the obvious. Both lung fields were solid white throughout.
Kevin continued to make notes as the discussion proceeded. Larry Winton’s clinical diagnosis was severe pneumonia. The differential diagnosis Kevin scribbled on the board, a list of all plausible causes of his pneumonia in the order of their probability, numbered twenty by the end of the hour when people began leaving. Yet the process was hardly finished. It had been easy enough to achieve consensus in eliminating common causes. It was the obscure autoimmune, allergic, and infectious diseases that generated controversy. Kevin gained energy with each comment he wrote for or against a rare illness. He drew arrows connecting candidate diagnoses to tests which could confirm or exclude the condition and medications that could treat it. Since some tests could help nail down or rule out more than one diagnosis and some drugs could treat more than one disease, his arrows branched and crossed forming a web.
Herb left after two hours and worked in his office until four-thirty. On his way out of the hospital, he walked by the conference room. Kevin was still there, holding a stub of chalk, erasing and re-writing in the few empty interstices remaining on the blackboard. Herb was about to insist Kevin go home and sleep when his pager sounded. A moment later so did Kevin’s. Both displayed the ICU phone number, followed by 9-1-1. They looked at each other, said “Winton” simultaneously, and ran to the unit.