Toxin (13 page)

Kim pondered this as he pushed through the swinging doors to the outside. The blast of cold air felt good on his face. He stopped on the platform and took a deep breath. He slowly let it out. Tracy still had a hold of his arm.

“I guess you're right,” he said finally. “It's hard for me to see Becky lying there and so vulnerable.”

“I can imagine,” Tracy said. “It must be very difficult.”

Their eyes met.

“You can understand?” Kim asked. “Seriously?”

“Absolutely,” Tracy said. “You're a surgeon. You are trained to act. And who would you want to take care of more than your own child. For you the hardest thing in the world is to see Becky in need and not do something.”

“You're right,” Kim said.

“Of course I am,” Tracy said. “I'm always right.”

In spite of himself, Kim smiled. “Now, I'm not going to go that far. Frequently maybe, but not always!”

“I'll accept that, provided we go back inside,” Tracy said with a smile. “I'm freezing.”

“Sure, I'm sorry,” Kim said. “I just needed a breath of cold air.”

• • •

“
D
oes the IV bother you?” Kim asked Becky.

Becky raised her left hand which was taped to a flat wristboard. A length of clear plastic tubing dove into the gauze covering the back of her hand. “I can't feel it at all,” she said.

“That's the way it's supposed to be,” Kim said.

“Does it feel cold?” Tracy said. “That's what I remember when I was in the hospital having you.”

“It does feel cold!” Becky remarked. “I didn't know it until you said it. My whole arm is cold.”

David had carefully examined Becky, had started the IV, had done routine bloodwork and urinalysis, and had a flat plate and an upright X-ray taken of her abdomen. Although he'd yet to see the X-rays since they were not yet available, the blood and urine results were all normal, suggesting the blood loss had been minimal. At that point, he'd sent for Kim and Tracy to keep Becky company while they waited for Dr. Claude Faraday.

The infectious-disease specialist arrived a few minutes later. He introduced himself to Kim and Tracy, and then to Becky. He was a slender, dark-complected man with an intense manner. He listened to a full recounting of Becky's problem, from the very first symptoms Saturday morning until the episode of hemorrhage that evening. He nodded every so often, especially when Becky herself added specific details.

“Okay, Miss Reggis,” he said to Becky. “Would you mind if I looked you over a bit?”

Becky looked at Tracy as if she had to get permission.

“Dr. Faraday is asking you if it's all right for him to examine you,” Tracy translated for Becky.

“It's okay,” Becky said. “I just don't want any more needles.”

“No more needles,” Claude assured her.

Claude started his rapid but thorough examination by feeling Becky's pulse and checking the turgor of her skin. He looked into her mouth and ears. He used an ophthalmoscope to peer into her eyes. He listened to her chest and checked her skin for rashes. He gently poked into her abdomen, which was tender. He searched for enlarged lymph nodes.

“You seem okay to me, except for that slightly sore belly,” he said at last. “Now, I'm going to step outside and talk to your parents. Okay?”

Becky nodded.

Tracy leaned over and gave her daughter a kiss on the forehead before following Claude and Kim out through the curtain. The corridor was busy, so the group drew to the side to avoid the bustle. David happened to see them and walked over. He introduced himself to Claude.

“I was just about to give a summary to the parents,” Claude said to David.

“Mind if I listen in?” David asked.

Claude looked at Kim and Tracy.

“That's fine,” Tracy said.

“All in all, she looks good to me,” Claude began. “She's a little pale, of course, and a bit dehydrated. There's also some generalized abdominal tenderness. Otherwise, on physical exam she's quite normal.”

“But the hemorrhage?” Tracy questioned. She was afraid Claude was about to dismiss the case.

“Let me finish,” Claude said. “I also went over her laboratory work. Compared to last night, there is a slight drop in her hemoglobin. It's not statistically significant, but in view of the mild dehydration, it might be important, considering the history of the hemorrhage. There's
also a slight drop in her platelets. Otherwise, everything is within normal limits.”

“What's your presumptive diagnosis?” Kim asked.

“I'd have to say food-borne bacterial illness,” Claude said.

“Not viral?” Kim asked.

“No, I think it's bacterial,” Claude said. He looked at David. “I believe that was your feeling last night as well, wasn't it?”

“Yes it was,” David said.

“But why no fever?” Kim asked.

“The fact that there has been no fever makes me think this has been more a toxemia than an infection,” Claude said. “Which also goes along with the normal white count.”

“What about last night's culture?” Kim asked. “Is there a preliminary twenty-four-hour reading?”

“I didn't see a culture,” Claude said. He looked at David.

“We didn't do a culture last night,” David said.

Kim shook his head in disbelief. “What the hell are you talking about?” he demanded. “I even gave you the sample.”

“We don't do routine stool cultures for simple diarrhea here in the ER,” David said.

Kim slapped his hand to his forehead. “Wait a sec! You just said you'd made a presumptive diagnosis of a bacterial infection. Why wouldn't you do a culture? It just stands to reason, much less being good medicine. How else could you treat rationally?”

“AmeriCare utilization rules proscribe routine cultures in this kind of case,” David said. “It's not cost-effective.”

Kim's face reddened. Tracy was the only one who
noticed. She reached out and gripped Kim's arm. He pulled it free. “Cost-effective! What kind of screwball excuse is that? What the hell kind of emergency room are you running here? You're telling me that to save a few measly dollars you failed to do a culture?”

“Listen, you prima donna,” David snapped. “I just told you, it's standard operating procedure not to do them. Not for you, not for anybody.”

Losing control as he'd done the night before, Kim grabbed David by the lapels of his white jacket. “Prima donna, am I? Well, your goddamn screwed-up operating procedure has lost us a whole damn day!”

Tracy grabbed Kim's arm. “No, Kim!” she cried. “Not again!”

“Take your hands off me, you arrogant son-of-a-bitch,” David growled.

“Calm down!” Claude said as he insinuated himself between the two much larger men. “It's okay. We'll run some cultures stat. We haven't lost that much, because I doubt we'd treat anyway.”

Kim let go of David. David smoothed his jacket. Each man glared at the other.

“What would you expect to see in the culture?” Tracy asked, hoping to defuse the situation and get the conversation back on track. “What kind of bacteria do you think is involved?”

“Mainly salmonella, shigella, and some of the newer strains of E. coli,” Claude said. “But it could be a lot of other things as well.”

“The blood scared me,” Tracy said. “I guess it looked like more than it was. Will she be admitted?”

Claude looked at David. “It's not a bad idea,” he said. “But it's not my call.”

“I think it is a good idea,” David said. “She needs fluids. Then we can evaluate the possibility of anemia and make sure there's no more bleeding.”

“What about antibiotics?” Tracy asked.

“I wouldn't recommend it,” Claude said. “Not at this juncture. Not until we have a definitive diagnosis.”

“Which is why the goddamn culture should have been done last night!” Kim growled.

“Please, Kim!” Tracy urged. “We have to deal with the current situation. It would be nice if you'd try to be helpful?”

“All right,” Kim said resignedly. “If we don't have a culture, why not use a broad-spectrum antibiotic. It can always be changed once the organism and its sensitivities are known.”

“It would not be my recommendation,” Claude repeated. “If the offending agent turns out to be one of the aberrant strains of E. coli, antibiotics can make the situation worse.”

“Now, how can that be?” Kim said. “That's ridiculous.”

“I'm afraid not,” Claude said. “Antibiotics can decimate the normal flora and give the renegade E. coli more room to flourish.”

“Will she be admitted to your care?” Tracy asked Claude.

“No, that's not possible,” Claude said. “AmeriCare requires a gatekeeper. But I'll be happy to look in on her, especially if whoever handles the case requests an infectious-disease consult.”

“Since Becky does not have a staff pediatrician, she'll be admitted under the care of Claire Stevens,” David said. “It's her rotation. I can give her a call.”

“You can't do much better than Claire,” Claude remarked.

“You know her?” Tracy asked.

“Very well,” Claude said. “You're lucky it's her rotation. She takes care of my kids.”

“Finally something seems to be going right,” Kim said.

Wednesday, January 21
st

K
im turned into the hospital parking lot a little after six in the morning. He'd skipped stopping at his office, as he normally did. He was eager to look in on Becky and make sure everything was okay.

The previous night things had gone well after the unpleasant episode with David Washington. Dr. Claire Stevens had come into the ER within a half hour of being paged. In the interim, Kim had phoned George Turner for the second time that evening. This gave him a chance to ask George's opinion about the pediatrician. George had echoed Claude's sentiments, and both Kim and Tracy had felt relieved.

Claire was a tall, thin woman—nearly Kim's height. Her features were sharp but they were belied by her gentle, reassuring manner. Kim's personal impressions of her added to the professional testimonials. She was about his age, which suggested years of clinical experience under her belt. What's more, her competence was immediately
apparent and reassuring. Of equal importance, she established immediate rapport with Becky.

Kim pushed into Becky's room. There was a night-light near the floor that reflected off the ceiling, casting a gentle glow over the entire room. Kim advanced silently to the bedside and looked down at his sleeping daughter. Her halo of dark hair made her face appear the color of ivory. Its translucency gave her a fragile look as if she were made of porcelain.

Kim knew that under the circumstances it was appropriate for Becky to be in the hospital. At the same time her being there gave him great anxiety. His vast experiences in hospitals reminded him that it was an environment where horror could lurk.

Becky's breathing was regular and deep. Her IV was running slowly. Happy to see her resting so well, Kim quietly backed out. He did not want to disturb her.

Back at the nurses' station, Kim withdrew Becky's chart. He glanced through the admitting notes that Claire had dictated, then turned to the nurses' notes. He noticed Becky had been up twice during the night with continued diarrhea. There had been some blood reported but only by Becky. None of the nurses had seen it.

Kim then turned to the order sheet and was pleased to see that Claire had followed up on her word: she'd requested a pediatric gastroenterology consult for that day.

“Now, that's one delightful child,” a lilting voice said.

Kim looked up. Glancing over his shoulder was a plump nurse with a face red from exertion. Her blond hair was permed into a multitude of tight ringlets. Her cheeks were dimpled. Her name tag indicated she was Janet Emery.

“Have you been looking in on her?” Kim asked.

“Yup,” Janet said. “Her room's in my area. Cute as a button, that one.”

“How has she been doing?” Kim asked.

“Okay, I guess,” Janet said without a lot of conviction.

“That doesn't sound too positive,” Kim said. A minute sliver of fear eked its way up his spine, giving him an involuntary shiver.

“The last time she was up, she seemed weak,” Janet said. “Of course, it might have been because she was sleeping. She rang for me to come help her back to bed.”

“I understand from the chart that you didn't get to see how much blood she might have passed,” Kim said.

“That's right,” Janet said. “The poor thing is embarrassed to beat the band. I tried to tell her not to flush after she uses the toilet, but she does anyway. What can you do?”

Kim made a mental note to talk to Claire about that problem and to Becky as well. It would be important to know if the blood was mere spotting or worse.

“Are you a consult on the case?” Janet asked.

“No,” Kim said. “I'm Dr. Reggis, Becky's father.”

“Oh my goodness,” Janet said. “I thought you were a consult. I hope I didn't say anything out of line.”

“Not at all,” Kim said. “I certainly got the feeling you care for her.”

“Absolutely,” Janet said. “I just adore children. That's why I work this floor.”

Kim went off to see his inpatients and then attend the series of hospital conferences scheduled for that morning. Like Mondays, Wednesdays were particularly busy with respect to his administrative responsibilities. Consequently, he didn't get back to Becky's floor until almost
ten. When he did, the ward clerk informed him that Becky was off to X-ray. He was also told that Tracy had come in and was with her.

“Can you tell me about the status of the gastroenterology consult?” Kim asked.

“It's been ordered,” the clerk said. “If that's what you mean.”

“Any idea when it will be?” Kim asked.

“Sometime this afternoon, I'd guess,” the clerk said.

“Would you mind giving me a call when it does happen?” Kim asked. He handed the clerk one of his cards.

“Not at all,” the clerk said.

Kim thanked him and hurried off to his office. He would have preferred to see Becky and talk to her, even if for a moment, but he didn't have the time. He was already behind schedule, a fact that he was philosophical about, since it tended to happen more often than not.

 

“
W
ell, Mr. Amendola,” Kim said, “do you have any questions?”

Mr. Amendola was a heavyset plumber in his early sixties. He was intimidated by modern medicine and horrified by Kim's verdict: he needed a valve in his heart replaced. A few weeks earlier, he'd been blissfully unaware he even had valves in his heart. Now, after experiencing some scary symptoms, he knew that one of them was bad and had the potential to kill him.

Kim ran a nervous hand through his hair as Mr. Amendola pondered the last question. Kim's eyes wandered out the window to the pale wintery sky. He had been preoccupied ever since Tracy had called an hour earlier to say she thought Becky didn't look good, that she was glassy-eyed and listless.

With a waiting-room full of patients, Kim's response had been to instruct Tracy to page Claire and to tell her Becky's status. He also told Tracy to remind the clerk to call him when the gastroenterology consult arrived.

“Maybe I should talk to my children,” Mr. Amendola said.

“Excuse me?” Kim said. He'd forgotten what he'd asked the man.

“My children,” Mr. Amendola said. “I got to ask them what they think the old man should do.”

“Good idea,” Kim said. He stood. “Discuss it with your family. If you have any questions, just call.”

Kim walked Mr. Amendola to the door.

“You're sure the tests you've done are right?” Mr. Amendola asked. “Maybe my valve isn't so bad.”

“It's bad,” Kim said. “Remember, we got a second opinion.”

“True,” Mr. Amendola said with resignation. “Okay, I'll get back to you.”

Kim waited in the corridor until it was certain Mr. Amendola was on his way to reception. Then Kim lifted the heavy chart of the next patient out of the chart rack on the back of the door to the second examining room.

Before Kim had even read the name, Ginger appeared at the end of the corridor. She had to move out of the way for Mr. Amendola to pass.

“I just got a call from the ward clerk on Becky's floor,” she reported. “I'm supposed to tell you that the gastro something-or-other doctor is seeing Becky at this very moment.”

“Then I'm out of here,” Kim said quickly. He replaced the chart into its rack and stepped into his private office. While he was getting his suit jacket from the closet, Ginger came in.

“Where are you going?” she asked.

“Back to the hospital,” Kim said.

“When will you be back?” Ginger asked.

“I don't know,” Kim said. He pulled on his winter coat. “Let Cheryl know, so that the patient doesn't sit and wait in the examining room.”

“What about the other patients?” Ginger said.

“Tell them there's been an emergency,” Kim said. “I'll be back but probably not for an hour and a half or so.”

Kim picked up his car keys and went to his rear door.

Ginger shook her head. She was the one who would have to face the patients. From past experience she knew how upset they were going to be, especially the ones coming from out of town.

“Just do the best you can,” Kim said as if reading her mind.

Kim dashed to his car. He jumped in, started it, and drove out into the congested street. Leaning on his horn, he weaved in and out of the traffic. He felt desperate. Particularly after Tracy's comments, he did not want to miss talking directly to the GI consult.

In the hospital lobby, Kim repeatedly hit the elevator button as if such action would bring a car sooner. Several visitors eyed him suspiciously.

Once on Becky's floor, Kim literally ran down the hall. When he entered Becky's room, he was panting. He saw Tracy standing off to the side, talking with a woman in a long, professorial white coat. Even a quick glance told him that Tracy was distraught.

Becky was in her bed on her back with her head propped up against the pillow. Her dark eyes stared ahead. At the moment, the only apparent motion was the relentless drip of fluid in the millipore chamber of the IV line.

Kim stepped over to the side of the bed. “How are you doing, Pumpkin?” he asked. He grasped her hand and lifted it. There was little resistance.

“I'm tired,” Becky offered.

“I'm sure you are, dear,” Kim said. Instinctively he felt her pulse. Her heart rate was on the high side of normal. By gently pulling down one of her eyelids, he checked her conjunctiva. It was pale but not significantly paler than it had been. He felt her skin. It was not particularly hot or moist, and her level of hydration seemed better than it had been the night before.

Kim's own pulse began to race. He could tell what Tracy had meant. There had been a change in Becky, and Tracy's description of glassy-eyed and listless was accurate. It was as if part of Becky's incredible life force was in abeyance. She'd become lethargic.

“I'm going to talk to Mom,” Kim said.

“All right,” Becky answered.

Kim stepped over to Tracy. He could see she was subtly trembling.

“This is Dr. Kathleen Morgan,” Tracy said.

“Are you the GI specialist?” Kim asked.

“I am indeed,” Kathleen said.

Kim eyed the woman. In many ways she was the physical antithesis of Claire Stevens, although they were about the same age. Kim estimated that she couldn't have been much over five feet in height. Her face was round and her features were quite soft. She wore wire-rimmed glasses that gave her the aura of a schoolmarm. Her dark hair was prematurely streaked with silver.

“Dr. Morgan has told me she thinks Becky's case is serious,” Tracy managed.

“Oh, that's a great comment,” Kim remarked with obvious derision. “Serious, huh? I don't need someone to
tell me it's serious. She wouldn't be in the goddamn hospital if it weren't serious. I need someone to say what it is that she has and how to treat and cure it.”

“The lab will call me the moment they have a positive,” Kathleen said warily. She was taken aback by Kim's response. “Until then our hands are tied.”

“Have you examined her yet?” Kim demanded.

“Yes, I have,” Kathleen said. “And I've gone over the laboratory results that are available.”

“And . . . ?” Kim remarked impatiently.

“So far I agree with Dr. Faraday,” Kathleen said. “Food-borne bacterial illness.”

“She looks worse to me,” Kim said.

“To me too,” Tracy added. “She's changed just since last night. She's not herself; she's not as alert.”

Kathleen cast an uncomfortable glance over at Becky. She was relieved to see the child was not paying attention to their conversation. Nonetheless she suggested they move out into the hallway.

“Having just seen her, I can't comment on any change,” Kathleen said. “And there wasn't anything in the nurses' notes to that effect.”

“I want her more closely monitored,” Kim said. “How about moving her into one of the isolation rooms in the ICU?”

“I'm only a consult,” Kathleen said. “Becky is officially under the care of Dr. Claire Stevens, the pediatrician gatekeeper.”

“Then how about your convincing her?” Kim said. “Last night I suggested as much on admission, but I got the feeling she's on AmeriCare's side and worried about costs.”

“That doesn't sound like Claire to me,” Kathleen said.
“But, to be truthful, I don't think your daughter needs the ICU. At least not yet.”

“That's an encouraging statement,” Kim snapped. “In other words, you expect her to get worse while the lot of you sit around and do nothing.”

“That's unfair, Dr. Reggis,” Kathleen said, taking offense.

“The hell it is, Dr. Morgan,” Kim spat. He pronounced her name with more scorn than he felt. “Not from my point of view. As a surgeon I make a diagnosis, then I go in and I fix it. In other words, I do something, whereas now I have this sickening sense my daughter is slipping downhill in front of my eyes and no one is doing anything.”