‘But?’ Harriet asked, because clearly there was one.
‘I don’t think this young girl is well at all, I’m not happy to discharge her, yet she doesn’t want to get undressed for a full examination,’ Ciro said grimly.
‘A lot of fifteen-year-olds wouldn’t,’ Harriet ventured, ‘especially…’ Her voice trailed off, but in the interests of patient care she cleared her throat and boldly continued, ‘Well, you’re a young man, good-looking—’
‘I have taken that into consideration,’ Ciro broke in, apparently not remotely embarrassed by Harriet’s rather personal observation. ‘She is swathed in legwarmers and a cardigan. All I have managed is to roll up her sleeve, check her blood pressure and take a small look at her ankles while I checked her reflexes. That was enough for me to see that this girl is not just thin, but I would say anorexic and severely malnourished. Her ankles are swollen and oedematous, which would suggest severe malnutrition, and her arms are very thin. Now, usually you would have the parent helping, telling the child not to worry, that it is a doctor examining her and this needs to be done, but instead the mother is agreeing with the daughter when she says that she doesn’t want to get undressed and loudly insisting that any further investigations are unnecessary and that she wants to take her home.’
‘OK.’ Harriet chewed her bottom lip as she realised the possible gravity of the situation, listening intently as Ciro continued.
‘I took her pulse for a full five minutes and she is having arrhythmias. I suggested that we put her on a monitor and do an ECG and some bloods, but the mother again refused. She said that she would take her to the family doctor tomorrow. It is my belief that the mother knows her daughter is grossly underweight, knows that if she is examined properly she will be kept in hospital, and is trying to avoid it.’
‘Have you managed to speak to Alyssa alone?’
‘No.’ Ciro shrugged, his shoulders moving just a fraction. ‘Sister…’
‘Harriet,’ she corrected automatically.
‘Harriet, I do not overreact.’ He stared unblinkingly at her. ‘I do not make problems when there are none. I have asked for the most senior nurse to come with me, as I am going to attempt again to examine Alyssa properly, and if the mother again refuses then I am going to have to get…’ Again he paused, again Harriet guessed he was trying to find the right word—only this time she attempted to help him.
‘Heavy?’ Harriet suggested, and from his slightly bemused expression clearly that wasn’t the word he’d been searching for!
‘If the mother doesn’t comply, then the polite requests and friendly small talk ends and I will call the mother into the interview room and tell her that unless the daughter is examined and treated properly tonight, not only will I be consulting with the paediatrician but also the Department of Community Services, because, although it may be unusual circumstances, Alyssa is at risk.’
‘You’ll get heavy!’ Harriet summed up for him with a smile.
‘Very!’ Briefly he smiled back as the alternative meaning of the word dawned on him, but it faded quickly, his voice slightly urgent when he spoke. ‘Harriet, this is not good.’
She believed him.
Despite the fact she hadn’t even observed him with a patient, had only known him for a few moments, Harriet knew, as nurses just did, that this was a voice of experience talking, knew to go along with his hunch in the knowledge it would be reciprocated; that one day when it was Harriet that was concerned, that when everything on paper told her that the patient was fine, she’d be able to turn to him and tell him that today or tonight or whenever the time came to follow a hunch, she was worried about a patient.
And he would listen.
‘Let’s go and get Alyssa examined and speak with Mrs Harrison, shall we?’
‘Are you OK, Harriet?’ He was still frowning. ‘You look a bit…flushed.’
She felt a bit flushed, only, unlike earlier, it had nothing to do with six feet four of Mediterranean hunk and everything to do with her stomach pain which, despite a hot-water bottle and some painkillers, was still making itself known, but she certainly wasn’t about to tell Ciro that.
‘I’m fine.’ Harriet shook her head dismissively, walking briskly towards the cubicles, ignoring the griping pain in her stomach and mentally preparing for the potentially unpleasant task ahead.
But Ciro clearly hadn’t quite finished. One hand caught her arm as she went to go, those observant eyes staring down at her, narrowing slightly as he took in the pale lips in her flushed face and the tiny grimace of pain as she swung around to face him.
‘You are unwell.’ His statement was delivered as fact, his eyes holding hers as Harriet’s mind raced for some witty response, desperate to shrug off his attention. Sympathy was the very last thing she wanted or needed right now if she was going to get through the night but, given that she had no choice but to get through the night, Harriet decided to swallow her pride and ask this relative stranger for a bit of help.
‘I’m feeling a bit nauseous,’ she admitted. ‘Would you mind writing a script for some Maxalon for me?’ She watched as his eyes narrowed slightly. ‘I don’t usually ask things like this, anyone will tell you that, if I could just have something to get rid of the nausea…’
‘Fine.’ He gave a short smile and Harriet gave a relieved one. ‘After I’ve examined you.’
‘Examined me?’ Horrified, her mouth dropped open. ‘I just asked you to write me up for two anti-emetics, Dr Delgato. Most doctors—’
‘Are you saying that doctors here are prepared to prescribe drugs without examining their patients?’ Ciro questioned, his frown deepening.
‘I’m not your patient, Dr Delgato,’ Harriet pointed out. ‘I’m your colleague.’
‘Well, in that case,’ Ciro answered in the same tight vein, ‘the answer is no.’
‘Then we’d better get on with our work,’ she responded tersely, reclaiming her arm from his grip and walking towards the cubicle more determinedly now. ‘If you can give me a couple of minutes alone with her before you come in, I’ll see if I can get Alyssa undressed so that you can examine her.’
‘You won’t get anywhere with the mother,’ Ciro warned.
‘Just watch me.’
Smiling, Harriet breezed into the cubicle, introducing herself to the patient who lay on the trolley. As Ciro had said, she was swathed in legwarmers and a thick cardigan. Her dark hair was drawn back in a small bun and gorgeous velvet-brown eyes, huge in her face, were blinking in confusion as Harriet produced a gown. Without pausing for breath, as if the entire conversation with Ciro hadn’t happened, as if she had no idea that the mother and patient were resisting treatment, Harriet explained in clear terms what was going to happen.
‘Mrs Harrison.’ Smile still in place, Harriet faced the well-groomed, heavily made-up woman. ‘We’re concerned that Alyssa’s heartbeat is rather irregular at times, so I’m just going to pop her into one of our gowns and then the doctor can examine her properly.’
‘No!’ Mrs Harrison’s voice was firm, her bracelets jangling as she went to grab at the gown, rouged lips furious, but Harriet’s smile remained intact. ‘I’ve already been through all this. I want to take my daughter home.’
‘Of course you do,’ Harriet replied sweetly, ‘but it really is imperative that Alyssa be examined thoroughly. Hopefully it’s nothing serious, but, as I’m sure you’ll understand, Mrs Harrison, we can’t just ignore an irregular heartbeat.’
‘As I’ve explained,’ Mrs Harrison snarled, ‘on several occasions, I’d rather my daughter was seen by our family doctor. I’ll take her there first thing tomorrow—’
‘This can’t wait till tomorrow.’ Harriet’s smile was still intact, but the slightly dizzy air to her tone had gone. Her voice was firm, holding the woman’s gaze as she spoke. ‘Your daughter has a cardiac arrhythmia.’ Still she stared directly at Mrs Harrison. ‘It has to be dealt with tonight. I’m going to get Alyssa into a gown and put her onto one of o
ur monitors so we can keep a closer eye on her.’
And something in her unequivocal stance, something in her voice, must have told the woman that this was non-negotiable, and even though Harriet would never have forced Alyssa to undress, she demanded the mother’s co-operation, told her with her eyes that this had to be confronted. Finally, after the longest time, she felt an inward sigh of relief as Mrs Harrison gave a tiny reluctant nod and turned to her daughter.
‘Listen to the sister, Alyssa.’
‘Harriet,’ she offered, her smile softer now, her eyes kind as she approached the young girl. If Alyssa was, as Ciro suspected, suffering from anorexia nervosa then being undressed and exposed would be traumatic for her, and Harriet was determined to make the entire procedure as gentle and as unintrusive as possible, covering the young girl with a blanket as she helped her out of her clothes. Harriet had to keep her own emotions firmly in check as she briefly witnessed the stick-thin limbs. She talked in gentle soothing tones as she gently leant her patient forward to tie up the gown and even though there hadn’t been much room for doubt, any that might have lingered was quashed as she saw the length of Alyssa’s spinal column, vertebrae protruding, dry, flaky skin hanging off. Glancing up at Mrs Harrison, Harriet saw a flash of shock on the woman’s face but she didn’t comment.
Now wasn’t the time.
‘Well done,’ Harriet reassured the girl. ‘Now, these sticky things just go onto your chest, and it lets us keep an eye on your heartbeat.’ Placing the dots and leads on Alyssa’s frail chest, Harriet quickly covered her back up, before turning on the cardiac monitor. As Ciro made his way in he gave Harriet a brief appreciative nod when he saw that the family was now being more co-operative.
‘Alyssa, Mrs Harrison.’ Ciro smiled warmly. ‘I know you are both keen to go home, but first we need to ensure that Alyssa is well enough. Now, I know you’ve already been through this, but, given the doctor that first treated you has gone home now, can you tell me again what happened this evening when you cut your head?’
‘I was at rehearsal—we’ve got the first performance next Saturday.’ It was the first time Harriet had heard Alyssa speak, her voice, small and breathless, almost drowned out by the busy background noise of the emergency department.
‘She’s the lead,’ Mrs Harrison explained. ‘That’s why I want to get her home. She needs her sleep so she can practise tomorrow. It’s a very demanding role—’
‘Alyssa,’ Ciro broke in, ‘why did you fall?’
‘She landed awkwardly…’ Mrs Harrison started, but her voice trailed away as Ciro and Harriet both looked at Alyssa for the answer.
‘I was halfway through my routine and I just got a bit dizzy. It only lasted a second, but I was in the middle of a jump, so I fell awkwardly.’
‘How often do you get dizzy?’ Ciro asked, and Harriet could only admire his questioning, assuming, as was probably rightly so, that this was probably fairly normal for Alyssa.
‘A bit…’ She gave a tiny shrug.
‘OK.’ Ciro nodded. ‘Alyssa, I’m going to examine you, it’s nothing to worry about, and then I’m going to take some blood from you. Harriet has put you onto one of our heart monitors so that we can see what your heartbeat is doing and maybe find out why you’ve been getting dizzy.’
Infinitely reassuring, still he was commanding, his voice firm but somehow soothing. His hands were gentle as he first pulled down Alyssa’s lower eyelids, examining the conjunctiva, then her hands and nail beds. Lifting the blanket and checking her reflexes, his middle finger probed the swollen ankles that looked out of place on such thin legs.
‘You have some fluid retention. Does this happen often?’
‘Sometimes,’ Alyssa answered, ‘but Mum gives me—’
‘Just some vitamins,’ Mrs Harrison said quickly. ‘I get them at the chemist.’
‘OK.’ Ciro didn’t push for any further details, acted as if the information barely merited a comment, but Harriet knew, just knew, it had been noted, but that for now he was focussed on the important task of gaining Alyssa’s trust.
He listened to her chest, warming the stethoscope in his palms first, all the while keeping as much of Alyssa covered as possible. When he’d finished listening he probed her abdomen for a moment before replacing the blanket.
‘Thank you, Alyssa. I know that wasn’t pleasant for you, but it was necessary. I’m going to take some blood now. I’m going to insert a small cannula and leave it there, but from that I can take blood, and if we need to give you any fluids or medication we can do it all through there, so at least you’ll only get one needle. I’ll try not to hurt you.’
He didn’t. Slipping the needle in neatly, he collected several vials of blood before unclipping the tourniquet and flushing the bung to keep it patent with the heparin flush Harriet had pulled up. Only when the blood had been taken, when the IV was in and Alyssa attached to a monitor did he approach the most difficult part of the whole subject. ‘How much do you weigh, Alyssa?’
‘I’m not sure…’
‘Would you get the scales?’ Ciro asked Harriet.
‘Alyssa knows her weight,’ Harriet responded without looking up at him, keeping her eyes on Alyssa. It would be easy to go and get the scales, but Harriet also knew that the delay and interruption could ruin the relatively compliant mood that they had somehow managed to foster, and it would be far better to forge ahead while the going was good. So instead she broached her patient, knowing, somehow knowing, this was what Ciro wanted her to do. Effective interview skills in Emergency required as much teamwork and synchrony as a surgeon and scrub nurse required, and with some doctors it took for ever—if ever—to perfect, yet with Ciro they fell into it easily, Harriet handing him the metaphoric scalpel without him needing to ask for it. ‘How much do you weigh, Alyssa?’
‘Forty kilos.’ When still Harriet held her gaze, she answered again. ‘Thirty-eight and a half.’
Deliberately Harriet didn’t flinch and she was thankful that, when Ciro spoke, his voice was matter-of-fact.
‘We’ll need to check it before we give any medication,’ he said, more to Harriet, ‘but whatever way you look at it, this is very underweight.’
‘She’s a ballet dancer.’ Mrs Harrison’s voice was terse. ‘She has to watch her weight.’
‘Of course.’ Ciro nodded, smiling at the agitated woman. ‘But Alyssa is extremely underweight. I’m going to run some tests and then I’ll ask one of my colleagues to come down.’
‘And how long is that going to take?’
‘It might take a while,’ Ciro admitted, ‘but I will tell you that it is my belief that Alyssa needs to be admitted—’
‘No!’ Furiously Mrs Harrison shook her head. ‘This can all wait.’
‘I’m afraid not.’ Ciro shook his head. ‘Look, I understand—’
‘No, Doctor, clearly you don’t!’ Mrs Harrison angrily interrupted. ‘My daughter is dancing next week in a role that could see her getting into the most elite dancing school in Australia. She has to rehearse, she has to—’
‘Perhaps we could talk outside,’ Harriet suggested, anxious to move what could be a very emotional discussion well away from Alyssa’s bedside, but Mrs Harrison wasn’t going anywhere.
‘Perhaps we can’t!’ she smartly retorted, and Harriet knew that for now the conversation was over. ‘I’ll wait for those blood results, and then I’m taking my daughter home.’
‘Thank you for your help in there.’ Ciro caught up with Harriet at the nurses’ station as Harriet attempted to put to paper what had just taken place, knowing that a detailed record, though always required, was especially important in cases such as this, so that the staff that were involved later knew exactly what had been broached and what the response had been. ‘You were very good with Alyssa, the mother, too. It looked as if you actually knew what you were doing.’ He smiled as she frowned. ‘That came out wrong, forgive me. What I am trying to say is that you—’
‘I worked on a
n adolescent psychiatric unit when I did my training,’ Harriet explained, realising that no offence had been meant. ‘I really enjoyed it. For a while there I even thought of…’ Her voice trailed off, long-forgotten dreams briefly surfacing as she remembered the thrill of excitement at being accepted to study psychology and the thud of disappointment when her fledgling plans had been effectively doused. A part-time nursing wage, while she’d studied at uni, had been nowhere near enough to cover a very part-time actor, whose dreams had always somehow been more important than her own. But this was neither the time nor place for what could have been and, quashing memories, she concentrated instead on the matter in hand. ‘Mrs Harrison was shocked when she first saw Alyssa undressed,’ Harriet said. ‘I don’t think she knew, until then, just how thin her daughter was.’
‘Because she doesn’t want to know,’ Ciro responded. ‘At least, not until the concert is over and Alyssa has her scholarship. She wants her daughter to get into this dance school—that is her sole focus.’
‘I think you’re being a bit harsh.’ Harriet frowned, but Ciro stood unmoved.
‘I have worked with many athletes, and with their parents, too. Believe me, Mrs Harrison doesn’t want to hear anything that might compromise her daughter’s chances of performing next week, whatever the cost.’
His arrogant assumption annoyed her, and Harriet let it show, her forehead puckering into a frown, her mouth opening to speak, but Ciro got there first.
‘I don’t want them to leave the department.’
‘We can’t force them to stay—’ Harriet started, but Ciro halted her with a stern gaze, his voice clipped when he spoke.
‘I was not exaggerating earlier, Harriet. I will call Community Services if I have to. If Alyssa goes home, I can guarantee she will be back at the bar first thing tomorrow, rehearsing for her performance. And, from my clinical examination, it is my belief that that child is in danger of collapse and possibly sudden death if she exerts herself.
Spanish Doctor, Pregnant Nurse Page 2
