And then Meomartino was presenting again and he heard all the details he knew so well. Her name, and her age, and the facts of the automobile accident, the date he had seen her in Emergency, her past history, the films that had been made in X-ray and oh God the films that had not been made, how he had released her on his own, how she had gone home—

Hold on now, he thought with sudden urgency. What is going on here?

O you sneaky bastard.

What about the call I made to the Surgical Fellow? The call I made to you, he thought numbly.

But Meomartino was finishing up, telling how the riddle lady had come back to the hospital for the last time, dead on arrival.

Dr. Sack described what they had learned at the post-mortem, briskly presenting the findings in a few minutes.

Dr. Longwood sat back in his chair. “This is the worst kind of case to lose,” he said. “Yet, inevitably, we lose patients like this. Why do you suppose that happens, Dr. Robinson?”

“I don’t know, sir.”

The hollow eyes held him. He saw with a terrible kind of fascination that a fine tremor had begun to jerk Dr. Longwood’s head almost imperceptibly.

“It’s because this type of case demands that we recognize an injury we don’t see every day. An injury which is correctable and yet which, if uncorrected, can cause death.”

“Yes, sir,” Spurgeon said.

“Nobody has to tell me the kind of pressures and the heavy work load carried by our house officers. A good number of years ago I was an intern and a resident here, and then a Visiting Surgeon before I assumed a full-time position with this hospital. I know we get patients who are neglected, complicated and thrown at us in such number that some private institutions wouldn’t believe what we accomplish.

“But it’s precisely the poor shape of many of our patients and the demands on our time which make it necessary for us to be doubly alert. Which make it necessary for every intern to ask himself if he’s fully aware that every diagnostic procedure, every necessary x-ray has been taken.

“Did you ask yourself these things, Dr. Robinson?”

The tremor had become more pronounced. “Yes, I did, Dr. Longwood,” he said steadily.

“Then why did this woman die?”

“I suppose I didn’t know enough to help her.”

Dr. Longwood nodded. “You lacked the experience. Which is why an intern should never take it upon himself to release a patient from this hospital, even though the patient may complain bitterly about being kept waiting until an experienced doctor can find time to release him. No patient ever died of complaining. Our responsibility is to protect him from himself. Do you know what would have happened if you hadn’t released her?”