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 2008.
Author’s Note: 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. RK
MAXIMUS
“Maximus, Reagan needs
you. It's urgent.”
“Emily?” I heard my daughter's name leave my lips; my
throat was suddenly dry, and my voice was hoarse, little more than a
whisper. Terry nodded.
“Your paediatrician
from Ennis is coming with them …they're on their way to Children's by ambulance. They'll be there within half-an-hour. Come on, Mate, I'll drive you. You don't need to go it alone.” I nodded and stood, leaving my computer on
and my briefcase on the floor beside my desk as I left my office. Terry spoke to Sooze on our way past her.
“Emily's crook, and
they're bringing her into Children's.
Let Diana and Dino know, would you?”
Her eyes widened as she nodded, and we walked into the corridor.
REAGAN
Max's private line had
been busy when I called; I called the office line and asked Sooze to put me
through to Terry. I didn't waste time on
explanations, telling him only that Emily was ill, and we were on our way to
Children's Hospital. Would he tell Max
and have him meet us there? I closed my
phone and looked back at my child.
I’d been holding Emily
until the paramedics arrived; one of them took her from my arms, cuddling her
and talking softly in an effort to soothe her as she screamed. Drew Spicer and I followed them to the
ambulance and once in the bay, the young man placed her on the stretcher for
transport. She was so tiny and looked
even more vulnerable now as the paramedic inserted an oxygen line into one
nostril and taped it to her tiny face. She
wailed in fear and dismay. They were
monitoring her respiration and heart rate and I watched as the switched her to a
pure oxygen feed. Dr. Spicer reached
over and took one of my hands in his; he gave it a squeeze as he looked into my
eyes.
“Reagan, she's not in
extremis, but there's something going on, and we need more care for her
than is available at the regional medical center. Have you called her paediatrician yet?” I nodded and tried to smile.
“I don't need to call
anyone else. You're with her, and you're
her paediatrician now. Do you have
emergency privileges at Children's?”
“I have full
privileges; we have enough children transferred there to warrant having applied
for them years ago.” He pulled his own
phone from his pocket and dialled.
“Krista? It's Drew Spicer from Ennis. Would you put me through to Dave,
please?” He put his thumb over the
microphone as he waited and spoke to me.
“Dave Kinsey …paediatric haematologist. I've worked with him in the past, and he's
excellent. If it's a blood disorder –
and I suspect it is – he'll find it.”
Kinsey must have answered because Spicer spoke into the phone.
“Dave, Drew Spicer
here. I'm inbound to Children’s with an
infant …white female, approximately six months of age, history of idiopathic
bruising, rash on face and trunk with some evidence on arms and legs, dark
malodorous urine, some vomiting …approximately two months
duration. Her mother brought her in again
today, and she's now running a temp of 102°.
She's not convulsing, her white count's normal, but her red count is
below three million.” I could hear Dr.
Kinsey's voice because Spicer was holding his phone out so I could.
“I'll meet you in the ER …what's the
mother's name?”
“Reagan Kavanagh …father’s name is
Max Espan. He's on his way from his
office in Dallas and will meet us there.
Mom's a clinical and forensic psychology professor at SMU; Dad's in risk
management. They're strong people, and
you can talk to them as you would to me; Reagan has a background in an allied
medical field.”
“Got it. I'm out the door.” Spicer closed his phone and looked at me.
“Let's find out what's wrong with
Emily.”
DREW SPICER
I didn't know what was wrong with
Emily Espan, but I sure as Hell intended finding out and as quickly as was
feasible. I had several thoughts, none
of them good. Thalassemia …a genetic
disorder commonly found in those of Mediterranean
and Asian Indian, South Asian, and Chinese ancestry. Max Espan was Spanish, of Mediterranean
ancestry. More than two million people
in the United States
are carriers; most have no idea. If
Emily had thalassemia, she'd be in for blood transfusions every two or three
weeks for the rest of her life unless we found a cure. Thalassemia is another of those genetic
disorders for which stem cell research would be a God send.
Two months ago I'd considered the
possibilities of either aplastic or megaloblastic anaemia and tested for
both. The tests were negative. I'd considered the possibility of Fifth
Disease, a form of parvovirus. One
strain of parvovirus kills canines unless it's rapidly treated, but the form
that dogs have isn't zoonotic; it isn’t transmissible to humans. I'd not tested for Fifth Disease, but Dave
Kinsey certainly would. Any of the
various forms of leukaemia was also a possibility, but so far nothing had shown
up indicating that. It was time to call
up the heavy artillery, and that's what Kinsey is.
We pulled into the emergency
entrance at Children's, and the driver cut the siren. It was eerily quiet after hearing the noise
for so long a time. There's a rumor that
you can't hear the siren if you're inside the ambulance; that's patently
incorrect. Emily had been crying when we
loaded her into the ambulance at my office; she'd stopped within five minutes
and had remained silent since then, alternately seeming to sleep or to open her
huge green-blue eyes to look at her mother who had been leaning forward and
over her child for the entire trip.
Reagan would have one Hell of a backache tonight.
The paramedics opened the doors to
the back of the ambulance and pulled out the stretcher with Emily on it; Reagan
and I followed as they ran for the doors.
I saw Reagan's mouth open as she looked toward the ER’s entrance. Two men were standing there. Max Espan was swarthy, with black hair and a
beard; the man beside him was fairer, clean shaven, and with chestnut hair. They looked enough alike to be brothers. Max spoke as he pulled his wife into his
arms.
“Cara, ….” The second man was right behind him. Reagan spoke into her husband's chest.
“Dr. Spicer's called in a paediatric
haematologist; I think he's already here.”
He was; I could see Dave Kinsey waiting just inside the door, and I
walked toward him with Emily's chart in one hand as the paramedics rolled the
tiny child inside. He nodded to me and
held out his hand to the Espans.
“Dave Kinsey.” Max Espan held out his hand in return.
“Max Espan; this is my wife
Reagan.” He turned to me – hand out once
more – and spoke.
“I thank you once more for your care
of our child, Dr. Spicer.” I shook his
hand firmly as I spoke.
“No need for thanks, Max. Let's just try and find out what Emily's
problem is and see if we can fix it.” He
nodded once, a brief, almost clipped action and turned to the man with him.
“Allow me to introduce my colleague,
Terry Thorne. Terry, this is Emily’s
paediatrician, Drew Spicer.” A nod from
Thorne, a gesture almost identical to Espan's.
There had to be a blood relationship there somewhere.
“You two related?” Thorne nodded again.
“Cousins. Nice to meet you.”
TERRY
The bad thing about standing beside
Max with people who haven't known us for yonks and seem to have forgotten our
resemblance is that one of us always has to come up with an explanation. We’d finally settled on cousins a while back;
that didn't elicit any questions about the difference in surnames.
We followed Ems' stretcher straight
to the lifts as Kinsey explained he'd pre-admitted her after speaking with
Spicer earlier; we were going directly to the paediatric neonatal intensive
care unit. Max could go to Admissions
later and sign the requisite paperwork.
My phone rang just as we entered the lift …Diana. I stepped away from the others to speak
quietly to her.
“Terry! Sooze called and said you'd taken Max to the
hospital because Reags was bringing Emily in by ambulance! Is it because of the weird bruises?”
“True about the ambulance. Apparently Ems
has been unwell on and off for some time, so it’s a bit more than the bruising. The paediatrician felt she needed to be at
Childrens' for a more thorough evaluation.”
“I can be there in an hour.”
“Diana, it's likely best you
wait. They're getting admissions sorted
and will be ordering more tests. I'm
heading back to the office in a tic. If
you like, take the train in, and we'll drop by here before going home. Max and Reags have all they can handle just
now in dealing with the doctors and nurses.
They wouldn't have time for us – even for comfort – until a bit
later.” She was silent for a tic as she
mulled that over. I have no doubt she’s
mentally putting together a food basket for Max and Reags from what we have in
the pantry and what she can pick up on the way in.
“All right. I'll see you in a couple of hours.” I closed my phone just as the doors to the
lift opened.
“That was Diana. She's taking the train in, and we'll stop by
before going home tonight. I'll keep
Sooze and Dino away until at least tomorrow.”
Reags took a deep breath.
“Thanks …we need to concentrate on
Emily right now.”
“Right. I'll be going back to the office. We'll give you a lift back to the car park if
you need it tonight. I know Max has
clothes at the loft – we all do – and if necessary, Diana can run down to The
Gate early tomorrow and get clothing for you.”
She nodded wearily as Max and I gripped hands, and I gave her a quick
hug and kiss on the cheek.
“Call if you need me.” Max's voice was firm when he spoke.
“We shall …and thank you,
Terry.” I was back at my desk within
half-an-hour though Sooze, Dino, and I got no work accomplished. We only managed to frighten ourselves with looking
up medical terminology on Web MD and the possible outcomes that fit Ems’ symptoms.
DAVE KINSEY
I scanned Drew's notes on the Espan
child. He'd done everything possible
given the constraints of a small town medical center. Emily Espan had presented two months
previously with low-grade temperature, pallor, moderate anaemia, slight jaundice,
idiopathic bruising, and dark urine.
There were no red blood cells in her urine, but that could have
changed. I didn't like the low red blood
cell count. Add to that the facts that
the child had been vomiting and had a history of recent infection, and I'd
order a complete blood panel, to include testing for thalassemia as the father
was of Mediterranean descent. I'd be
looking for that as well as any possible form of anaemia and the various leukaemias. In years past we only looked at African Americans
for sickle-cell disease, but with genetic drift, we now looked at everyone as
being a potential carrier or possibly having the disease.
The mother had given her child baby
Tylenol for temperature regulation during the infection a few months past. Based on that, I'd also be looking for Fifth
Disease; you don't see it often – or at least don’t recognize it as that - but
it was possible. We'd do a complete body
scan for any signs of tumour. Again, you
don't often find cancer in a child this young, but it does happen. We needed to find out what was wrong with
this child, and do it fast. Thank God
the parents didn't seem to be the hysterical type as is often the case with
very young, first-time parents. This
couple was in their forties, and this was their only child. They might not display overt indicators of
hysteria, but it was obvious they were worried sick for their daughter.
We got Baby Espan into the NICU and
into a crib; one of the nurses pulled the screens around us, and I turned to
the parents. A quick glance said they
could afford the fare, even if it had to come from their own pockets rather
than being completely covered by insurance.
“I'd suggest we line up
round-the-clock, private duty nurses for your daughter. We don't know what's wrong, and I want her
observed constantly. Twelve hours in
this place will have both of you at the breaking point from exhaustion.” Mr. Espan nodded once.
“Do whatever you deem most
appropriate for our daughter's care, Doctor.
Her care is all that is important.”
I turned toward the door, speaking as I walked.
“I'll write the orders.”
*
An hour later we'd drawn all the
blood samples and taken urine specimens; they were on their way to the lab with
STAT labels on everything. Emily Espan
was scheduled in diagnostic radiology in half-an-hour; I'd already administered
the sedative that would keep her still and quiet during the MRI. I'd also ordered full-body x-rays and a
spinal tap for tomorrow morning. Drew
Spicer hadn't been able to appreciate any fractures – nor had I on examination
– but I'd rather be sure. We could be
looking at osteogenesis imperfecta, commonly known as fragile bone syndrome,
and I don't like surprises. Unexplained
bruising is very common in such infants.
Further, if she did have osteogenesis imperfecta, we could do one Hell
of a lot of damage just in our various examinations of her. I’d seen that happen more than once.
I walked with Drew and the Espans as
Emily's stretcher was rolled to the radiology lab, watched as the infant was
transferred to the table that would slide into the MRI, and then settled in
with the other three to watch as the MRI proceeded. An hour later we had the images; no tumours,
no soft tissue pathology of any sort that was discernible. Her spleen was a bit enlarged, but that was
common with an infectious process and, thus, unremarkable. We were still waiting on some of the blood
work. The results on the test for Fifth
Disease wouldn't be ready until sometime tomorrow because it takes longer to look
for antibodies than for red or white blood cells. STAT orders not withstanding, some tests just
take time.
REAGAN
Dave Kinsey and Drew Spicer walked
into the NICU just after seven that evening.
Terry and Dee were in the waiting room; policy wouldn't allow any other
than parents or siblings over the age of six into the unit.
“Reagan, Emily's under constant
observation; Dave and I need to talk to you in the family waiting area.” I felt my heart sink, and my gut clenched
into a hard, tight ball. I could tell
from the look on Max's face when he took my hand that his reaction was the
same. We nodded and silently followed
them, sitting on the sofa beside Terry and Dee.
“These are our dearest friends and
our daughter's godparents. You may speak
freely in their presence.” Drew smiled.
“You beat us to the punch, Max. Okay, so far the tests are negative, but we
don't have all of them back, and Emily still has that date for full body x-rays
and her appointment with the paediatric neurologist tomorrow. At this point, we're both leaning toward
Fifth Disease. Dave? Your turn.”
“Drew tells me you indicated that
Emily had a cold a while back. Is that
correct, Dr. Kavanagh?”
“Yes, she came down with it a week
or so after I'd had a really nasty cold …it was the closest I've ever felt to
having influenza without actually doing so.”
“That's when you gave her the Baby
Tylenol?” I nodded.
“Did you notice anything after the
cold disappeared?” He was going
somewhere with this line of questioning, but at the moment I'd no idea where
that might be. I shook my head.
“No, …wait. Yes, I did, and so did Max.” I turned to my husband. “Remember the night you asked me if I'd
slapped her face and how angry I got at your implication?” He rubbed his cheek in remembrance; it
was somewhat amusing now, but at the time I'd been livid with rage and
indignation.
“Indeed I do. I went to check on Emily shortly after my
wife changed her nappy and noted a red mark on her face. It looked remarkably like the flush one notes
in an individual who has just been slapped.
I called to my wife, and when she entered the nursery, I asked if she
had slapped our daughter. I could not
imagine that she would do so but could think of no other explanation. Her response was to slap me with all
her strength. She took the greatest
possible umbrage at my question and its implications.”
“Do you recall if both Emily’s cheeks
were red?” Max shook his head.
“In truth, I did not look. I was too busy with my efforts to placate my
wife. In the end we both decided that
her temperature from her recent infection had returned.”
“Did you notice anything else?” I thought for a moment then nodded.
“Several days later there was a rash
all over her body. Over the next few
days, it took on a lacy pattern. Emily
was scratching at it, I put calamine lotion on it, and she stopped. It went away a few days later.” The doctors looked at each other and nodded,
and Drew Spicer spoke again.
“Have you noticed that her face is
red again?” Max and I looked at each
other in surprise and shook our heads.
“No …it's pretty dimly lit in the
unit, and I haven't noticed it.”
“Nor have I.”
“Both of us have, but we turn on the
over-the-bed fluorescent lamp when we check her. That flush or rash is the primary hallmark of
Parvovirus 19, commonly known as Fifth Disease, and Fifth's can cause every
symptom Emily has.”
Max's jaw dropped.
“Parvovirus? Is that not a disease of canines?” He looked at me before the doctors could
answer. “Cassandra, if our child has contracted
this malady from one of our dogs in spite of their having been appropriately
vaccinated, we must remove them – and find new homes for them – before Emily
returns home.” Dave Kinsey put one hand
on Max's arm.
“Take it easy, Mr. Espan. Yes, dogs are highly susceptible to one specific strain of parvovirus, and if not quickly and properly
treated, it kills them. The strain your
daughter has – assuming she has the disorder, and we don't have the lab reports
back yet – is not transmissible across species nor is the strain that so
often kills dogs. The fatal strain in
dogs is very different genetically from the strain that affects humans. Parvovirus 19 – Fifth Disease – is often
mistaken for measles, but it usually doesn't make a child this ill. Of course we usually see it in older children
– five and up – with a better immune system than an infant, and they don't get
as sick. It's probable that your wife
contracted the disease accidentally and passed it on to your daughter. She'd have thought she had a cold and would
have drawn the same conclusion when your daughter became ill.” I finally found my voice.
“What are the other symptoms? Can all of her symptoms be explained by this
one disorder? Why have I never heard of
it? I thought I'd read everything
available on diseases and disorders of infants and children, and so has
Max!”
“Relax, both of you. It's actually very common, but as it
resembles a cold so closely most parents never take their children to the
doctor for it. By the time the rash
appears, the fever accompanying the disease is gone, and parents usually think
their child has gotten into something that caused a skin allergy.” That made sense; I'd noted Emily's rash – we
both had – but I'd thought perhaps she was allergic to the laundry detergent I
used. I'd changed detergents, the rash
had disappeared, and I'd been content.
Spicer and Kinsey stood, and we joined them. Terry and Dee hadn't said a word as Kinsey
spoke again.
“Well, we both think that's the
problem. It accounts for the anaemia,
the bruising as a result of the anaemia, the cold-like symptoms, and Emily's
malaise. Let's wait and see if we get
the results back before we do the spinal tap tomorrow. If so, and the test is positive for antibodies,
I'll cancel the tap. I'm not putting an
infant through that procedure without a damned good reason. If we get results early enough, I'll cancel
the x-rays, but that won't be uncomfortable for her so if the results are late,
we'll go ahead with that just as a safeguard.
Any questions?” Max looked at me,
and I shook my head.
“Not at the moment and thank you.”
TERRY
Fifth Disease. Parvovirus 19. Who in bloody hell would think a variation of
a disease often fatal to the family dog could make a child so ill? Diana and I looked at each other, and I shook
my head. She moved toward Reags and put
one arm round her.
“Honey, do you and Max want to go to
the loft and get a few hours sleep? If
you do, Terry and I’ll stay here. You
can be back over here in less than half-an-hour if you’re needed.” Reags smiled wanly as Max shook his head.
“Thank you, but no. We will remain here. We have both lost sleep on occasion in the
past; it will not harm us to do so this night.”
Reags returned Diana’s hug as she seconded Max’s comment.
“Neither of us wants to be more than
a minute away from Emily tonight. Let’s
see what tomorrow brings; we may let one of you spell us then.”
For all the concern I knew she felt,
Diana knew better than to argue with a Mother Tigress, and that’s what Reags
was just now.
“OK.
We just wanted you to know that we’re here, and we’ll be here as long as
is necessary.” She turned to me. “Terry, let’s go to the loft. We can be here quicker tonight if
necessary. Max and Reags just might get
40 winks if they didn’t feel the need to be civil to us. They’ll call if we’re needed.” That finally got a smile from Max.
“Thank you for your concern, and we
know it is heartfelt. I will call early
tomorrow as I likely will not be in the office until we have spoken with the
doctors.”
“No wurries, Mate. Take all the time you need.” This was one of the occasions on which I
could say that and mean it. It had been
eerily quite in the world of K and R for quite a while. I wondered how long that would last.
MAXIMUS
My wife and I spent the night in
chairs beside Emily’s cot; we were awake when the doctors appeared before seven
the next morning. Both men were smiling
as Cassandra and I stood to meet them.
“Doctors? You manner is less serious this day …have you
good news?” Drew Spicer nodded.
“Let’s all go get a cup of coffee –
you two look as if you could use one – and we’ll bring you up to date."
*
“That’s it? That’s what’s caused all the symptoms? The bruising, the vomiting, the rash? All of it?”
My wife was as incredulous as I, and we listened as Dr. Kinsey reassured
us.
“That’s it …Parvovirus B19, commonly
known as Fifth Disease. Roughly 50% of
adults have had it at some point in their lives, usually in middle to late
childhood. In older children it presents
with a few sniffles, perhaps a low grade temperature for a couple of days, and
that’s it. It’s more noticeable in an
infant because of the lack of a competent immune system. Dr. Kavanagh picked it up from someone – she
could have been sneezed on in an elevator because it’s a droplet infection –
and passed it on to Emily. I suspect
you’d also test positive for antibodies, Mr. Espan, as you probably have kissed her within the last six
months …kissing is one of the ways it’s spread.” I could not but laugh at his last statement,
and my wife joined me.
“What is the appropriate
treatment? How soon may we take our
daughter home?”
“That’s the easy part. Her rash is virtually gone, but calamine
lotion is a good topical if she seems itchy.
Her temperature is back to normal, and her blood work is
stabilizing. She’s going to be
fine. If Emily had been almost seven years of age rather than seven months,
you’d never have known anything was wrong.
I’ll write the discharge order, and you may take her home after lunch
…it will take Admissions and Discharge that long to process the notes.”
*
“That’s it? She’s fine?”
Diana and Terry were as incredulous as we had been. The four of us were sitting in the dining
room at the hospital waiting for Emily’s final paperwork to be delivered to the
nursing station in order that Cassandra and I might take her home.
“She is quite fine. The doctors believe all her symptoms will
subside within a week. Had she been a
bit older it is likely we would never have noticed anything was amiss.”
REAGAN
Emily had slept in her car seat all
the way home, waking only when Max plucked her from it as I went to unlock the
door. The dogs greeted us with
enthusiasm, and we let them out into the fenced yard. It was late afternoon – just after five – and
approaching the usual time for Emily’s bath and her dinner followed by bedtime
at six. Max raised an eyebrow at me, and
I nodded. He walked down the hall carrying
our child; I heard water running a few minutes later. He was bathing her in the garden tub in our
suite. She loves to splash about in an
inch or so of water, and we think it good practice for when we’ll teach her to
swim. He returned with her bundled into
her nightgown just as I was spooning her dinner onto a small plate, and popped
her into her high chair.
We fed our child together,
delighting in this most simple of parental tasks and grateful to whatever gods
there may be for her safety. A short
time later we stood over her crib as she lay sleeping quietly. My husband’s voice was low when he spoke.
“Welcome home, Emily.”
This Concludes
Blood Work
NOTES
|
LT six months
|
Physicians abbreviate everything, i.e., LT = less than
|
|
NICU
|
Neonatal Intensive Care Unit. Technically, the NICU is usually reserved
for neonates – infants of no more than 30 days of age. Exceptions are made on a case-by-case basis
depending on severity of symptomology, potential for crisis, and other
factors as determined by the attending physician at time of admission.
|
|
STAT
|
Latin for status or standing (amongst MANY other
definitions), used by the health care profession to indicate immediate
attention required.
|
