"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 you 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."
"Stop it, Kim!" Tracy said, fighting tears. As anxious as she was about Becky, she didn't want to have to deal with Kim's contentiousness.
"Stop what?" Kim challenged.
"Your bickering!" Tracy managed. "This constant fighting with the doctors and the nurses is not helping. It's driving me to distraction."
Kim glared at Tracy. He couldn't believe that she could turn on him so quickly, especially since the issue involved Becky's care.
"Dr. Reggis, come with me!" Kathleen said suddenly. She made a motion with her hand as she started toward the nurses' station.
"Go!" Tracy encouraged. "Get a grasp on yourself."
As Tracy went back into Becky's room, Kim caught up with the striding Kathleen. She had her mouth set and was moving at a surprising clip with her relatively short legs.
"Where are you taking me?" Kim questioned.
"To the chart room behind the nurses' station," Kathleen said. "I want to show you something, and I think we should talk, just you and me, doctor to doctor."
The nurses' station was a beehive of activity. The day shift was preparing to leave and the evening shift was just coming on duty. Kathleen walked through the congestion with practiced ease. She held open the chart-room door and motioned for Kim to step inside.
Once the door closed against the hubbub, relative quiet ensued. The chart room was a windowless nook with built-in desks and X-ray view box. The communal coffeemaker stood on the countertop in the corner.
Without speaking, Kathleen slipped some X-rays from their folder and snapped them up onto the light box. She turned the unit on. The films were of a child's abdomen.
"Are these Becky's?" Kim asked.
Kathleen nodded.
Kim leaned forward to study the details as he allowed his trained eye to scan the X-rays. He was more adept at reading chest films, but he knew the basics.
"The bowel looks uniformly edematous," he said after a moment.
"Exactly," Kathleen said. She was impressed. She'd thought she'd have to point out the pathology. "The mucosal lining is swollen for most of its length."
Kim leaned back. "What does that tell you?" he asked. He did not like what he was seeing but had no way of relating it to clinical symptoms.
"It makes me worry specifically about E. coli 0157:H7," Kathleen said. "You could see about the same X-ray with shigella dysentery, but the patient would probably have fever. As you know, Becky doesn't have any fever."
"What about antibiotics?" Kim asked. "Claude Faraday advised against them for fear of disturbing the normal flora. Do you agree?"
"I do," Kathleen said. "Not only so as not to disturb the normal flora, but they might very well be useless. With no fever, there is a good chance the offending organisms are already gone from Becky's gut."
"If we're dealing with a potential toxemia," Kim said, "how do we make the diagnosis then?"
"There is the possibility of testing for the toxin itself," Kathleen said. "Unfortunately AmeriCare has not authorized our lab to do the test."
"Don't tell me it's a money issue," Kim warned.
"I'm afraid so," Kathleen said. "It's one of those tests which is not used often enough for AmeriCare to justify its expense. AmeriCare feels it is not cost-effective."
"Jesus H. Christ!" Kim exploded. He pounded the countertop with his fist in frustration. "If I hear that phrase 'not cost-effective' one more time I'm going to have a fit. From the moment Becky became sick, AmeriCare's bottom line seems to be haunting me."
"Unfortunately managed care is a reality we all must face," Kathleen said. "But in this case I took it upon myself to have a sample sent out to Sherring Labs. We'll have the results in twenty-four to forty-eight hours."
"Hallelujah!" Kim commented. "Thank you, and I apologize for saying you weren't doing anything. I mean, money should not be a consideration when Becky's health is concerned."
"What do you know about this particular E. coli and its toxin?" Kathleen asked. "Assuming that it is indeed what Becky has."
"Not much," Kim said. "I didn't even know antibiotics weren't helpful. E. coli isn't something I've had to deal with in my practice. But vancomycin-resistant enterococcus is another matter. We cardiac surgeons are terrified of it."
"I get your point," Kathleen said. "I'm not familiar with the enterococcus problem, but I am with E. coli 0157:H7.Maybe even a little too familiar. I think you and your wife should know that it can be a very bad bug."
"How so?" Kim asked nervously. He didn't like the sound of Kathleen's voice nor the implications of what she was saying. Kim didn't even bother to correct her misconception that he and Tracy were still married.
"Maybe you should sit down," Kathleen said. She was struggling with how best to explain her fears without unduly unsettling Kim. She could sense he was only in marginal control of his emotions.
Kim dutifully sat down in one of the desk chairs. He was afraid not to.
"If E. coli is involved with Becky's current problem," Kathleen said, "I'm concerned about the drop in platelets she's had. There was only a slight drop last night, but after she's been rehydrated, the drop is more apparent and statistically significant. It makes me worry about HUS."
"HUS?" Kim questioned. "What in devil's name is HUS?"
"It's the acronym for the Hemolytic Uremic Syndrome," Kathleen said. "It's associated with the shigella-like toxins E. coli 0157:H7 is capable of producing. You see, this type of toxin can cause intravascular platelet coagulation as well as red-cell destruction. That, in turn, can lead to multiple-organ failure. Kidneys are the most commonly affected and hence the name uremic syndrome."
Kim's lower jaw slowly dropped. He was stunned. For a moment all he could do was look at Kathleen in a vain hope that she would suddenly smile and say it was all a bad joke. But she didn't.