Blood Work - Part One

This work of adult fiction, loosely based on characters portrayed by Russell Crowe, includes adult language and experiences; you have been warned. No copyright infringement on the original work is intended. Copyright Reagan Kavanagh 2007.

MAXIMUS
“Maximus, Reagan needs you. It's urgent.”

Terry had entered my office and was standing in front of my desk. It was unnecessary to tell me the situation was urgent. He had addressed me as Maximus rather than Max; he had used my wife's given name rather than Reags. It was as if my heart had ceased to beat, and I felt the blood drain from my head.

One month earlier

“Max, could you come here, please?”

I was in the media room watching the DVR of a Souths' game that had played late the night before. They were about to score, and I stood, watching the play and smiling when they made the try before hitting the pause button and walking next door to the nursery. Cassandra was standing over Emily's cot; there was a look of concern on her face. She pointed to a large bruise on our daughter's leg.

“Did you notice that bruise when you were playing with her earlier in the evening?” I looked closely and shook my head.

“No. It was not there. Has she fallen?”

“Not to my knowledge, and she certainly hasn't cried out as if she'd fallen or somehow injured herself.” She pulled Emily's nightdress down and the covers up, shaking her head as we walked to the door. Emily was asleep and had not wakened whilst we spoke. “I don't like that bruise, Max. It worries me.” I put my arm round her shoulders as we went to sit on the couch in front of the television.

“So large a bruise is cause for concern in any child, particularly one so young. Have you any notion as to how she managed such a nasty mark?” She shook her head.

“Haven't a clue. That's the second bad bruise she's had in a week, and I can’t account for either of them; obviously, neither can you. I'll call Dr. Harbin first thing tomorrow and make an appointment for her.”

REAGAN
“This is the second bad bruise she's had in a week – the other one is on her back – and neither Max nor I are aware of any falls or other possible injuries that could have caused them. She's virtually never alone unless she's asleep, and we've never found her with an arm or leg caught in the bars of her crib. We've never dropped her, and she's never cried as if something had hurt her.”

He nodded as he continued checking her.

“She's a fair-skinned baby, but she looks a bit paler than usual to me today. Have you or your husband noticed that?” I hadn't, but as I see her day in and day out, I'd likely not notice a gradual change.

“No, but then I probably wouldn't unless it was an overnight thing.” He nodded again.

“Anything else out of the ordinary?”

“She had a cold a few weeks back and ran a low grade temperature for several days; I gave her baby Tylenol. The temp subsided, and she was snuffly for about a week then seemed to get over it.”

“That's common enough. Anything else?” I thought for a minute.

“She did throw up a couple of nights ago. I'd been fighting allergies and hay fever for a week and figured that was her problem, too …sinus drainage and concomitant nausea isn't uncommon for me, so I wrote her upchucking off as the same.”

“You're probably right. Nothing since then?”

“Nothing until this second bruise.” He straightened, picked up Emily, and handed her off to me.

“It's probably nothing. Keep an eye on her, and if you notice anything else bring her back, and we'll look further.” I was dissatisfied with what I considered his laissez faire attitude but didn’t know another paediatrician I could take Emily to immediately. I’d start looking for a replacement for Harbin, one who seemed a bit more concerned with his infant charges.

Max had gone to put Emily down for the night. That process necessarily includes changing her nappy and putting on the super thick, ultra absorbent, in reality three nappies folded as one and requiring multiple nappy pins to hold the lot in place. Over that bundle of cloth went the plastic knickers that in theory would keep her from floating herself out of her crib during the night. Max and I don't use disposable diapers; we're both a bit too old-fashioned and purist for that. We'd engaged a nappy service prior to Emily's birth; you cannot imagine how difficult it is in this day and time to find a service that brings clean cloth nappies to your door three times a week and collects the soiled ones in the nappy pails provided by the service.

Cloth nappies were still in use by some women when I was an infant, and my mum had used them. As an adolescent interested in childbearing and all things related to babies, Mum had carefully schooled me in the advantages of cloth over disposable nappies. Cloth is far softer and less likely to irritate a baby's tender skin. Yes, you do have to change them as soon as possible after the baby urinates or defecates because they simply don't have the absorptive power of disposable nappies, but I think it's worth the extra effort. Given that I wasn't planning to return to teaching until the fall term, I had the time and interest required for the task. To say that Max agreed and was a willing participant was likely the understatement of the decade. He would have stayed home to care for Emily had it been necessary; he truly is that devoted a father.

I was in the media room – we'd been watching “Notes on a Scandal” and I wanted to strangle Cate Blanchett's character for her idiocy whilst simultaneously loathing the scheming and manipulative older woman portrayed by Dame Judi Dench. It really is a compelling film, and the suggestion of closet Lesbianism in Dench's character was exceedingly well done. I'd put the film on pause when Max went to put Emily down; I was jolted to my feet by his voice.

“Cassandra! I need your counsel!” I sprinted the 15 feet into the nursery to find my husband bundling Emily into her nightly armour; he nodded to the nappy he'd just taken off her.

“Her urine is abnormally dark. Do you think it important?” It was dark, quite so, and had a stronger and more acrid odour than is common in infants. Her urine is usually so pale it can scarcely be seen on the white cloth; this was an almost brownish hue, and I could smell it from where I stood.

“She is also running a temperature; I have not taken it, but she is quite warm and seems fretful. Should we call Dr. Harbin?” My hand went first to her head, then to her belly; she was very warm. I'd guess her temp was around 101°. She was fussing, and that was unusual, as she's what is termed “an easy baby.” When Max changes her, he blows on her belly, and she usually burbles with baby laughter. Tonight there were tears streaming from her eyes, and she was not a happy child.

“Harbin's in Dallas …let's bundle her up and take her to Ennis. The hospital there's a regional trauma centre; they should be able to deal with an infant. If they think it's necessary, we can hit the road for Dallas, and call Harbin to meet us at Children's.” He nodded as I ran to pull on jeans and a sweater; I'd been in my night shift, as we'd planned on going to bed as soon as the film was done. We were in the car in less than five minutes.

I'd learnt years ago that the fastest way to be seen in trauma was to tell the clerk at the admissions desk that you were “Doctor” whomever, and it works if you've enough medical knowledge to follow through; fortunately for our child on that night, I had that knowledge. Unless you present with an obvious stroke or heart attack, you'll wait for hours to get into a trauma room and hours more to be seen and assessed by medical staff. We had a sick child and waiting wasn't on our agenda tonight. I was out of the car and getting Emily out of her car seat almost before Max had us in a parking space. We sprinted through the door and to the desk with Max holding Emily close in his arms. The clerk looked up from her Harlequin romance novel and gave me a vacant look; I spoke before she could.

“I'm Doctor Kavanagh, and my child is ill. Who's the paediatrician on call?”

“You're a doctor?”

“Yes. The paediatrician, please?”

“Ummm, I guess that would be Doctor Spicer, but he isn't in the hospital right now.” God help me.

“I should imagine that's why he's the on call paediatrician. Please get him on the phone for me …NOW!” That got me a look, but she did pick up the phone, consulted her list of numbers, and dialled. Good job, too, as Max looked ready to go over the desk at her. Someone answered seconds later.

“Doctor Spicer? This is Corinne at the ER. I have a Doctor …,” she paused and looked at me.

“Kavanagh.”

“I have a Doctor Kavanagh here, and she says her baby's sick. She wants to talk to you.” I had my hand out for the phone.

“Doctor Spicer? Dr. Kavanagh here. My daughter is running a temp, her urine is abnormally dark and malodorous, and she's very fretful. She's just going six-months-old, and my husband and I are more than a bit concerned.” He asked the obvious question, and I answered.

“Brett Harbin in Dallas. My husband works in Dallas, and that's where my practice is.” It had been in Dallas when I'd maintained a clinical practice. “Until now it's been more convenient for us to have her see a physician there.” He spoke again.

“Yes, and thank you so much. We'll get her into a room, and wait for you there.” I handed the phone back to Corinne who put it to her ear and listened.

“Yes, Sir. Yes, Sir. Yes, Doctor. We'll have them waiting for you.” She hung up the phone and picked up a clipboard with admissions paperwork before standing and looking at us with ill-concealed annoyance. We had interrupted her reading after all.

“He wants you in an exam room, and he'll be here in about ten minutes. He said you can fill out the paperwork while you wait for him.” I looked at Max and held out my arms for Emily; he took the clipboard, and we followed the nitwit to a treatment room. He waited until she'd left and raised one eyebrow before speaking.

“I believe she may be annoyed with you.”

“I believe I don't give a flying fuck.” We both laughed, and Emily began to cry again.

Drew Spicer, M.D., FACP, was likely in his mid 50s, calm, collected, and seemed genuinely concerned about our child.

“You said she's had some unexplained bruising lately? When was that?” We gave him the specifics and told him about her having thrown up, and the fact that Dr. Harbin thought she seemed a bit pale.

“Um hmmm …all right. Let's take a look.” We got her out of her nighty – not an easy thing to accomplish when your child is screaming at the top of her lungs and rigid as a board, something infants tend to do when you're trying to dress or undress them. The rigidity is exponentially worse when the infant is unhappy.

“Okay, little lady …hey, Emily, what's going on with you, Honey?” I liked his manner and from a glance at Max surmised he also approved. Spicer held Emily as he listened to her chest before returning her to the exam table. We indicated where the bruises had been – they were almost non-visible now – and he frowned as he turned her to look at the spot where the one on her back had been. There was a new one; neither Max nor I had seen it earlier, and Max actually paled under his tan.

“Doctor, I put her into her nightdress and changed her nappy less than two hours ago. That bruise was not present at that time.” The doctor nodded and continued his exam. I could read Max's anger beginning to build; he thought the paediatrician felt we were abusing our child. Spicer removed her nappy and checked the colour of the urine as well as its odour. He smiled as he looked up at us.

“We don't have cloth diapers, but there's a box of Pampers in the cabinet over there. If you'll grab one, I'll get it on her.” I did, and he did, looking up at both of us before focusing on Max.

“Mr. Espan, I know you think you know what I'm thinking, but don't get your bowels in an uproar. This child isn't abused. If I even remotely suspected that, I'd already be on the phone to Children's Protective Services and the police. The bruises she has aren't from being hit or dropped, or thrown against something; they're idiopathic. If one of you had hit this baby or dropped or thrown her against something, there would be paetechial haemorrhaging into the surrounding tissue …there would be clearly visible, minute red spots from the force of your knuckles or hands or whatever you hit her with or whatever she bounced off of; you couldn't hide them. There's nothing to indicate that anyone's intentionally hurt this little girl.” I imagine the relaxation in both of us was visible. It's sad when a parent fears that any bruising might result in a charge of child abuse, but I've seen it happen more than once and to completely innocent parents.

“I don't know what's wrong with your daughter, but I'd like to get a blood panel before we go any further. We can do full body x-rays if you want, but I don't think that's necessary at this point. I can't appreciate any fractures, and she doesn't show any signs of pain when I palpate the bruised areas or the rest of her body; the bruises aren't sore, so they aren't what we think of as a classic bruise. There's something else going on here.” I felt a cold spasm of fear start in my gut and reached for Max's hand as his arm went round my shoulders. Spicer smiled softly before continuing.

“Folks, there are a lot of reasons your daughter could have any or all of these symptoms. I want to be sure she doesn't have an infection that we aren't aware of before I start treating her for anything. This could as easily be an immune system disorder as anything else, so let's be safe. I'll admit her to the neonatal unit overnight, get the labs, and then decide where we go. You stay here, and I'll get Admitting on the phone. Be back in a minute. You can go on and get her dressed.”

MAXIMUS
The doctor was most kind, and I regretted having leapt to the conclusion that he might think we had injured Emily. Someone from the laboratory came and took blood for analysis, and we were taken to the neonatal unit and placed in a private room. The doctor called his wife from Emily's room to say that he did not know what time he would return home; it was his wish to stay at hospital and wait for the results from Emily's tests. He asked many questions of us whilst we awaited the laboratory report.

“Let's start by eliminating possibilities. It's almost never found in female children, but is there any history of haemophilia in either of your families?” I thought it best for Cassandra to respond to his questions, as my knowledge of things medical is rather confined in scope and limited to battle wounds and the plagues that swept through our camps like wildfire.

“No.”

“Any hereditary disorders of which you're aware? Sickle cell disease? We used to only consider that with children of Black heritage, but with interracial children and the natural tide of genetic drift, we're now seeing it in all ethnic groups.”

Cassandra shook her head in the negative, and Dr. Spicer continued.

“Are either of you of Eastern European or Judaic heritage? I can't imagine these symptoms representing Tay-Sachs, but I want to rule out as much as possible.”

“No. My husband is Spanish by birth, and if there were any Eastern European or Judaic lineage in his family, it would have been watered down centuries ago. My own heritage is pure Celt; I'm Irish on both sides of my family. We can rule that out definitively.”

“What about cancer …leukaemia? Anything there?” Another shake of her head.

“Not in my family, and I'd know. I don't know about Max's family ….” I shook my head.

“Deaths in my family not attributable to wounds suffered in battle or accidents – the men in my family were either soldiers or farmers – were due to old age or in the case of the women – death in childbirth or having borne too many children too close in succession. I am aware of nothing that might have been passed down to our daughter.”

“She's current on all her immunizations?”

“The only things she hasn't had are her MMR, influenza, varicella, hepatitis A, and meningococcal vaccinations, and those aren't due until she's six-months-old; she’s actually scheduled for them next week. Everything else is current.”

“I think we can rule out meningococcal infections; she'd have to come in direct contact with someone with meningitis, and from what you've told me, that's not likely. Her temp isn't high enough for meningitis, and there's no apparent stiffness or tenderness of her neck or shoulders. The same is true for the other illnesses, so I think you're home free there.” I took a deep breath before speaking.

“Doctor, you mentioned leukaemia …do you think that likely?” I asked the question because I did not think Cassandra capable of it; she had blinked back tears when the doctor first mentioned it. Of the realistic possibilities, that was the one we most feared. Even with my limited knowledge of things medical, I knew leukaemia to be a not uncommon disease of childhood, and our daughter's symptoms were among those often observed in that malady.

“I don't know, Mr. Espan. It's within the realm of possibility; I can't speak as to probability. Let's try not to get ahead of ourselves, and wait for the labs. We'll talk about the next step after that.”

We had been standing near the door of Emily's room, and now the doctor returned to her bedside, reaching down to stroke her cheek as he smiled at her.

“I know you two won't leave her tonight, and one of you can sleep in that chair over there …it opens out and pretty much makes a single bed. I'll ask the floor supervisor to call housekeeping and have a cot brought in for the one of you that doesn't take the chair. Try and get a little rest. I'm going down to the lab and wart the technicians …maybe I can speed them up, and get the results to you a little faster.” He shook our hands and left the room, closing the door softly as he departed. I felt the scalding heat of tears in my eyes as I pulled Cassandra into my arms, and we wept.

REAGAN
I like Dr. Harbin, but I like Drew Spicer much more. He may be a small town doctor, but he knows paediatrics and he knows – and obviously likes – children. That obvious concern likely means more to the parents of a sick child than anything else possibly could. He had been so gentle with Emily, and she'd responded to him better than she has to anyone other than Max or me. That isn't easy for a sick and frightened baby, and she was frightened. Who wouldn't be? She was in a strange place with strange smells, bright lights, and a lot of noise. She was being poked and prodded and handled by people she didn't know; she was sick and wanted to be left alone. So would I; so would any of us.

I managed to control my tears within a couple of minutes, and Max led me to the chair, sat, and pulled me to his lap.

“She's so tiny, Max, so fragile.” As a mother, I suppose my question was inevitable. “How could God allow her to be ill?” I knew my husband had no answer for me, but I also knew he needed to talk; perhaps my question and its expression of my fears would give him the freedom he needed to express his own.

“I do not know, Cara. Is it blasphemy to pray for mercy for our child to our ancient gods as well as to your Christian one?”

“I don't think so, and I suspect He'll forgive us if it is. Frankly, I believe that it doesn't really matter which 'god' we pray to because, despite my Catholic faith, I think they're all the same. We just call him or her by different names.” That got me a smile.

“I suspect you are correct. It makes perfect sense to me.”

I snuggled into his arms, and we napped for a while. We were awakened by an orderly bringing in the promised cot. Predictably, for my husband, he insisted I take the cot; he would stay in the chair. We stood at Emily's bedside and watched her for a time. She slept quietly, temporarily unaware of her illness, the strange surroundings, and her parents' fears.

Dr. Spicer's soft knock on the door as he entered the room woke us; he motioned us out into the hallway, pulling the door closed as he followed.

“I didn't see any point in taking the chance on waking Emily by our talking in there. We have the results on her first round of blood work.” The first round …that meant the results were inconclusive, and there would be more tests to come.

“There's no real indication of any infectious process, so we can definitely rule out something like meningitis; that would have her white count off the chart. That also eliminates something like a urinary or respiratory tract infection or an inner ear infection. This is all good.

“I'm not as happy about her red blood cell count. It's lower than I'd like to see it, and that could signal any one of a dozen things. The normal range for an infant of her age is around five to seven million; hers is sitting just below four million. You see diminished red counts in lead poisoning, haemorrhage – though I don't see any indication of internal bleeding – iron deficiency, or any of the various anaemias; unfortunately, you also see them in the various leukaemias.” He gave us a sharp look.

“I don't want either of you jumping to conclusions, because it probably isn't leukaemia, but if I didn't tell you it's a possibility, I wouldn't be doing my job of being completely honest with you. Even worse, I'd keep you from investigating all the possibilities, and I want to find out what's wrong with this baby as much as you do.”

MAXIMUS
Leukaemia. Cancer of the blood. Though I know that was not the only possibility, it was the one Cassandra and I most feared.

To be Continued

NOTES

Children's	Children's Medical Centre in Dallas, Texas. North Texans refer to it generically as “Children's.”
FACP	Indicates membership as a Fellow in the American College of Paediatricians, a speciality certification requiring study beyond the usual residency and passing of “board” exams developed and administered by the College.
Idiopathic	Of unknown or undetermined origin, often disease-based.
Paetechial haemorrhage	Minute, round, nonraised haemorrhages – bleeding - into the skin or in a mucous or serous membrane. These are the tiny red spots typically surround a spot where someone has been hit with a fist. The same indicators are a clue to suffocation, as well.
Neonatal Unit	Though Emily is in a small regional medical centre, such facilities do commonly have neonatal units. The term neonatal refers to a child of less than one month of age; because of their small size and lack of a mature immune system, they are isolated and treated differently than older infants who have had all their immunizations. In some hospitals, older infants are taken to the Neonatal Unit if they are small for their age or if their diagnosis or potential diagnosis is suggestive of a possible immune system dysfunction.
Genetic drift	In instance of “selective mating,” genetic drift is the statistical effect resulting from the influence that chance has on the survival of variations in genes. The effect may cause an allele and the biological trait that results to become more common or more rare over successive generations. This has accounted for an increase in sickle cell disorder in populations where it was not previously observed.
Tay-Sachs Disease	A fatal genetic lipid storage disorder in which harmful quantities of a fatty substance called ganglioside G_M2 build up in tissues and nerve cells in the brain. Infants with Tay-Sachs disease appear to develop normally for the first few months of life. Then, as nerve cells become distended with fatty material, a relentless deterioration of mental and physical abilities occurs. The child becomes blind, deaf, and unable to swallow. Muscles begin to atrophy and paralysis sets in. Other neurological symptoms include dementia, seizures, and an increased startle reflex to noise. The incidence of Tay-Sachs is particularly high among people of Eastern European and Ashkenazi Jewish descent. Patients and carriers of Tay-Sachs disease can be identified by a simple blood test that measures beta-hexosaminidase A activity. Both parents must carry the mutated gene in order to have an affected child. In these instances, there is a 25 percent chance with each pregnancy that the child will be affected with Tay-Sachs disease. Prenatal diagnosis is available if desired. There is no cure for Tay-Sachs.
MMR	Measles, Mumps, Rubella. This isn't given until the child reaches six months of age.
Leukemia vs. Leukaemia	We DO know how to spell, but our convention is to spell terms in the way the SPEAKER would spell them based on his or her nationality and educational background. The exception here is that medical terms, most of which are Latin-based, are generically spelled the same irrespective of nationality of the physician.

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