Dying Declaration (3 page)

5

THIS WAS ONE OF THE REASONS
that Thomas Hammond avoided hospitals like the plague. He had no health insurance, just a strong faith in miracles. And now they would make him feel like a criminal.

“Occupation?” the intake clerk asked. She sat on the other side of a large Formica countertop. Thomas juggled Tiger on his knee, while Stinky stayed in the waiting room watching television.

“Self-employed.”

“Insurance?”

“None.”

“Excuse me?” She stopped writing, looking up from her paperwork for the first time, an eyebrow raised in condemnation. “You have no health insurance?”

“No, we’ll pay for it ourselves.”

She shook her head slightly, disapprovingly, her lips pursed. “Who is your child’s primary-care physician?”

“He doesn’t have one,” Thomas said defensively. He watched the look flash on the lady’s face again. She made no effort to hide it. She might as well have said the words.
White trash.

“Maybe this wasn’t such a good idea bringing him here,” Thomas mumbled.

“Why in the world would you say that?” the bureaucrat asked as she reached in her top right drawer and pulled out a stack of Medicaid forms.

Dr. Sean Armistead stopped outside Emergency Intake Room 4 to study the assessment from the triage nurse. He always studied the chart before talking to a patient, even on nights like tonight when they were crazy busy. Armistead wanted to know what he was up against. A doctor should exude confidence; patients always felt better if a doctor knew what he was talking about right from the beginning.

He had been working since three in the afternoon and, in addition to the usual parade of ER illnesses, had already been in emergency surgery twice. A knife fight and a shooting. Virginia Beach was rapidly becoming big-city America.

The surgeries had wreaked havoc on his already crowded ER schedule. Now he and his partner had them stacked up and waiting. This one had better be quick, and the chart had better be perfect. He had no time for anything less.

Time of admission: 9:04.
It was now 9:30. The patient had been waiting a few minutes, but that was unavoidable.
Patient’s name: Joshua Hammond. Age: 20 months.
He glanced down to the patient complaint section of the chart.
Pt w/ fever 106,
activity,—playfulness, generalized achiness, n, v, x 3 days, sore and distended abdomen.

This child was in acute distress.

The temperature of 106 would have been taken rectally, and rectal temperatures were always a degree high. Still, even a temp of 105 was in the danger zone. The kid had no energy, no zip. According to the note, he showed decreased activity and negative playfulness. He hurt all over—thus the notation for generalized achiness—but was particularly sore and swollen in the abdomen. This kid had been nauseated and vomiting for three days. Three days!
What kind of parent would allow these symptoms to persist for three days before seeking medical help?

Just from reading the chart, Armistead formed a working diagnosis. Peritonitis. Poison in the system. Not literal poison but just as deadly. It could lead to a total breakdown of the nervous system and vital organs as a result of a severe bacterial infection. In this case, a likely culprit was the appendix, possibly ruptured and spewing the contents of the intestines into the abdominal cavity and ultimately the bloodstream of tiny Joshua.

It would not have been life threatening on day one. Or even day two. But now, with Joshua lethargic, running a high-grade fever, an elevated pulse of 118, dangerously low blood pressure, and a respiratory rate of 28, there were no guarantees.

Armistead knew what to expect. They would open the child up to remove the appendix and find all kinds of inflammation caused by pus and fecal matter in the lining of the abdomen. He had seen some bad cases of peritonitis straggle into the emergency room, but none this bad. The child was hypotensive and in acute distress. Three days fighting a losing battle against the bacteria had taken its toll.

Armistead tucked the chart under his right arm, shook his head, and prepared to enter Intake Room 4. He pushed open the door and extended his hand to a mother who had waited three long days before bringing her dying baby to him for help.

He forced himself to smile.

Theresa looked up as the door opened.

“I’m Dr. Armistead; how are we doing here?” the doctor asked, pleasantly enough.

Theresa was sitting on the examining table with Joshie on her lap. Her son was listless and lying on his left side against her, knees pulled up to his chest. Theresa shook hands with Dr. Armistead and did her best to return the doctor’s thin smile.

He was younger than Theresa expected. And shorter. He had receding light blond hair, sharp cheekbones, penetrating eyes, and a prominent jaw. His smile displayed rows of perfect white teeth and created quite a contrast with the narrow gray eyes that stared intensely out from behind small wire-rimmed glasses.

His impeccable presentation, ramrod posture, and pressed lab coat made Theresa self-conscious of her own appearance. She had not thought about how miserable she looked until this very moment, confronted with a doctor who exuded confidence and composure.

“Not real well,” Theresa admitted. “He’s been running a fever for a couple of days, and now he’s pretty . . . lifeless, I
guess.” She grimaced at her own choice of words. Something about Armistead intimidated her, made her feel inadequate.

He bent down and started poking at Josh. He checked ears, nose, and throat. He took Josh’s pulse himself and confirmed a 116. He put a cold stethoscope on bare skin and listened to the lungs.

“Rapid respirations, difficulty breathing,” the doctor confirmed. He put pressure on the lower right abdomen and elicited a moan.

“Hey, buddy,” Armistead said as he poked and prodded. “Can you tell me where it hurts? Does this hurt? . . . How ’bout this?
. . .” Joshie winced at times and remained stoic at others. “Man, you’re a tough little guy.” He rubbed Joshie’s head, tousling already disheveled hair, and then looked over Joshie’s head and directly at Theresa.

“When did you first notice the fever?”

“Um . . . it seems like maybe three days ago.”

“You know we’ve got a pretty elevated fever here. One-oh-six rectally. Anytime that fever gets up over a hundred and two,
you ought to get him checked out, okay?”

“Yes, sir. It was only about a hundred and three earlier today. I tried everything I knew to keep it down.”

Armistead scribbled a few notations on the chart. He stopped for a moment and glanced at Theresa, said nothing, then went back to writing.

“How long has he been listless and lethargic like he is now?”

“That just started today, maybe yesterday. . . . I mean, whenever he runs a fever, he’s not himself, you know, but it was just this morning that I noticed we couldn’t get any reaction out of him at all.”

Theresa stared down at the top of Joshie’s head, unwilling to look at the doctor with the accusing eyes.

“I think we’ve got a case of appendicitis here,” Armistead continued, studying the chart. “He hurts in all the right places. We should have a CBC and a urinalysis done just to get a read on the white blood cell count and to rule out other possibilities.” He was writing again, mumbling more to himself than Theresa. “I don’t know why she didn’t suggest that lab work already; I’d like to have it in process by now.”

He then turned back to Theresa, replacing his plastic smile with a frown. He pulled up a stool in front of her so they were sitting eye to eye. “Appendicitis is not generally life threatening at Joshua’s age if it’s treated soon enough,” he lectured. The absence of emotion made the words even more condemning. “But when a child’s appendix bursts, it spews poison into his system. If that goes untreated long enough, it can lead to peritonitis and ultimately to septic shock. It can affect the circulatory system and central nervous system if the cause of the peritonitis is not treated.

“Joshua is showing classic signs of septic shock. We’ll probably have to operate as soon as possible. But first we’ve got to try and resuscitate him with some IV fluids, start him on some antibiotics, and build up his strength for the operation. Once we get the fluids and drugs in him, you and I will talk again about the risks of surgery. But believe me, the risks of not having surgery, of not treating this problem, are infinitely greater.”

Armistead stopped and let the silence linger. The unspoken accusation hung in the air and screamed for an answer. It was obvious that this doctor had no intention of speaking until Theresa answered his charge.

Why? Why had she waited so long?

“Our church teaches that healing comes from the hand of God, not the hand of man.” She spoke softly, feeling the depth of her own guilt while holding Joshie and patting his back. “My husband and I knew we should come earlier, but we also knew that our church would forbid it. These last few days have been incredibly hard . . .” Her voice trailed off. She had said enough.

Armistead let the punishing silence remain a bit longer. At last he spoke. “These last few days have been hard not just for you and your husband but for Joshua as well. A burst appendix is extremely painful. With today’s medical advances, no child should have to live through the pain of an untreated ruptured appendix for three days. But you’re here now, and it was right for you to come. Let’s try to help Joshua with the pain and get him back on the road to healing.”

He tousled Josh’s hair again and stood up to leave.

“Will he be okay?” Theresa asked. It was more of a plea than a question.

“We’ll do our very best,” Armistead promised. “Nurse Pearsall will be with you shortly.”

And with that, he picked up the chart and left.

In the hallway Armistead quickly scratched out his diagnosis and orders.
Dx:
Appendicitis, w/ onset of peritonitis and sepsis. R/O urinary tract infection. Prep for surgery. Orders: CBC, UR, antibiotics and hyperal.

He needed to prepare Joshua for surgery, build the child’s antibodies, and rule out any other potential causes of lower right abdominal pain, such as a urinary tract infection. All of this was basic stuff. Emergency Room Medicine 101.