by Robin Cook
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.”
“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 O157: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 c
onsideration 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 O157: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 O157: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.
“You think Becky has HUS?” Kim asked quietly with a calmness he did not feel.
“Let’s put it this way,” Kathleen said, trying to ease the impact. “It’s my concern. There’s no proof as of yet. At this moment, it’s my clinical intuition that is suggesting it.”
Kim swallowed loudly. His mouth had gone dry. “What can we do?” he asked.
“Not a lot, I’m afraid,” Kathleen said. “I’ve sent the sample to the lab looking for the toxin. Meanwhile I will suggest hematology and nephrology consults. I don’t think it is premature to get their opinions.”
“Let’s do it!” Kim blurted.
“Hold on, Dr. Reggis,” Kathleen said. “Remember I’m only a consult. Any other consult requests have to go through Claire Stevens. It’s her decision. AmeriCare is very clear on this.”
“Well, let’s call her for chrissake,” Kim sputtered. “Let’s get the ball rolling.”
“You want me to call her this minute?” Kathleen asked.
“Absolutely,” Kim said. He reached for the phone and pushed it in front of Kathleen.
While Kathleen used the phone, Kim cradled his head in his hands. He felt weak with sudden anxiety. What had been a nuisance, albeit a bothersome, scary nuisance requiring Becky to suffer and come into the hospital, had now become something else entirely. For the first time in his life, he was on the patient side of a major medical problem; one that he didn’t even know much about. He was going to have to learn and learn fast. He quickly thought of ways he could do it.
“Claire’s in full agreement,” Kathleen announced as she replaced the receiver. “You are lucky to have her. She and I have handled several cases of HUS in the past.”
“When will the consults see Becky?” Kim asked urgently.
“I’m sure as soon as Claire can arrange them,” Kathleen said.
“I want them right away,” Kim stated. “This afternoon!”
“Dr. Reggis, you have to calm down,” Kathleen said. “That’s why I brought you down here, so that we could talk calmly, one professional to another.”
“I can’t calm down,” Kim admitted. He breathed out noisily. “How common is HUS?”
“Unfortunately it’s become relatively common,” Kathleen said. “It’s usually caused by E. coli O157:H7 of which there are about twenty thousand cases a year. It’s become common enough to be the current major cause of acute kidney failure in children.”
“Good Lord!” Kim commented. He nervously massaged his scalp. “Twenty thousand cases a year!”
“That’s the CDC estimate of the E. coli O157:H7 cases,” Kathleen said. “It’s only a percentage that go on to HUS.”
“Is HUS ever fatal?” Kim forced himself to ask.
“Are you sure we should be talking about this aspect?” Kathleen questioned. “Remember the E. coli diagnosis has not been definitively made. I’ve just wanted to prepare you for its possibility.”
“Answer the question, goddamn it!” Kim said hotly.
Kathleen sighed with resignation. She’d hoped Kim would be smart enough not to want to hear the disturbing details. The fact that he did, left her with no choice. She cleared her throat. “Between two hundred and five hundred people, mostly kids, die from E. coli O157:H7 every year,” she said, “and it’s usually from HUS.”
Perspiration broke out on Kim’s forehead. He was stunned anew. “Two to five hundred deaths a year,” he repeated. “That’s unbelievable, especially since I’ve never heard of HUS.”
“As I said, these are CDC estimates,” Kathleen said.
“With that kind of mortality, how come all this isn’t better known?” Kim asked. Intellectualization had always been a coping mechanism for Kim in dealing with the emotional burdens of medicine.
“That I can’t answer,” Kathleen commented. “There’s been a couple of high-profile episodes with this E. coli strain, like the Jack-in-the-Box outbreak in ’ninety-two and the Hudson Meat recall in summer ’ninety-seven. Why these and other episodes haven’t raised general awareness and concern, I don’t know. It is rather mystifying.”
“I remember those two episodes,” Kim said. “I suppose I just assumed the government and the USDA took care of the problems.”
Kathleen laughed cynically. “I’m sure that’s what the USDA and the beef industry hoped you’d believe.”
“Is this mostly a problem with red meat?” Kim asked.
“Ground meat, to be precise,” Kathleen said. “Ground meat that is not cooked through and through. But it’s also true that some cases have been caused by such things as apple juice and apple cider and even unpasteurized milk. The key problem is contact with infected cow feces.”
“I don’t remember this problem as a child,” Kim said. “I used to eat raw hamburger all the time.”
“It’s a relatively new situation,” Kathleen said. “It’s thought to have originated in the late seventies, perhaps in Argentina. The belief is that a shigella bacterium gave an E. coli bacterium the DNA necessary to make a shigella-like toxin.”
“By bacterial conjugation,” Kim suggested.
“Precisely,” Kathleen said. “Conjugation is bacteria’s answer to sexual reproduction, a method of genetic shuffling. But if conjugation was involved, it’s curious since conjugation usually only happens within a species. But the truly surprising aspect is that once this new strain of E. coli was formed, it spread extraordinarily rapidly around the globe. Today it exists in about three percent of bovine intestines.”
“Are the infected cows sick?” Kim questioned.
“Not necessarily,” Kathleen said. “Although it can cause a bovine diarrheal disease, cows seem to be generally immune to the toxin, at least systemically.”
“Strange!” Kim commented. “And ironic! Back when molecular biology was in its infancy, a doomsday scenario was envisioned that scared everybody: a researcher would give an E. coli bacterium the ability to manufacture the botulism toxin,
and then bacteria would inadvertently get released into nature.”
“It’s a good analogy,” Kathleen said. “Especially considering that with the emergence of E. coli O157:H7 nature probably didn’t do it on its own. Man helped.”
“How so?” Kim asked.
“I believe E. coli O157:H7 has come from the intense farming techniques that are in use today,” Kathleen said. “The need for cheap protein to feed the animals has resulted in creative but disgusting solutions. Cows are fed rendered animals, including themselves. Even chicken manure is being widely used.”
“You’re joking!” Kim said.
“I wish,” Kathleen said. “And on top of that, the animals are given antibiotics. It creates a soup within the animals intestines that fosters new strains. In fact the E. coli O157:H7 was created when the shigella toxin DNA was transferred along with the DNA necessary for a particular antibiotic resistance.”
Kim shook his head in disbelief. He was hearing about an issue of considerable interest, but then, all of a sudden, he remembered the case in point: Becky’s situation. The realization was instantly sobering.
“The bottom line of all this is bovine fecal material particularly in ground beef,” Kim said. His voice returned to its previous anxious intensity.
“I think that’s fair to say,” Kathleen said.
“Then I know how Becky got it,” Kim said angrily. “She had a rare hamburger at the Onion Ring restaurant Friday night.”
“That would be consistent,” Kathleen said. “Although the incubation period for E. coli O157:H7 is usually longer, sometimes as much as a week.”
The door to the chart room banged open, causing both Kim and Kathleen to start. One of the nurses leaned in. She was flushed.
“Dr. Morgan!” she said urgently. “There’s an emergency with your consult Rebecca Reggis!”
Kim and Kathleen raced out of the room and ran headlong down the corridor toward Becky’s room.
NINE
Wednesday afternoon, January 21st
As Kim came through Becky’s door, he saw a nurse on either side of his daughter’s bed. One was taking her blood pressure, the other her temperature. Becky was writhing in pain and whimpering. She appeared as pale as a ghost. Tracy was standing off to the side, with her back against the wall and a hand pressed to her mouth. She was almost as pale as Becky.
