by Randy Singer
“Occupation?” the intake clerk asked. She sat on the other side of a large Formica countertop. Thomas juggled Tiger on his knee, while Stinky stayed in the waiting room watching television.
“Self-employed.”
“Insurance?”
“None.”
“Excuse me?” She stopped writing, looking up from her paperwork for the first time, an eyebrow raised in condemnation. “You have no health insurance?”
“No, we’ll pay for it ourselves.”
She shook her head slightly, disapprovingly, her lips pursed. “Who is your child’s primary-care physician?”
“He doesn’t have one,” Thomas said defensively. He watched the look flash on the lady’s face again. She made no effort to hide it. She might as well have said the words. White trash.
“Maybe this wasn’t such a good idea bringing him here,” Thomas mumbled.
“Why in the world would you say that?” the bureaucrat asked as she reached in her top right drawer and pulled out a stack of Medicaid forms.
Dr. Sean Armistead stopped outside Emergency Intake Room 4 to study the assessment from the triage nurse. He always studied the chart before talking to a patient, even on nights like tonight when they were crazy busy. Armistead wanted to know what he was up against. A doctor should exude confidence; patients always felt better if a doctor knew what he was talking about right from the beginning.
He had been working since three in the afternoon and, in addition to the usual parade of ER illnesses, had already been in emergency surgery twice. A knife fight and a shooting. Virginia Beach was rapidly becoming big-city America.
The surgeries had wreaked havoc on his already crowded ER schedule. Now he and his partner had them stacked up and waiting. This one had better be quick, and the chart had better be perfect. He had no time for anything less.
Time of admission: 9:04. It was now 9:30. The patient had been waiting a few minutes, but that was unavoidable. Patient’s name: Joshua Hammond. Age: 20 months. He glanced down to the patient complaint section of the chart. Pt w/ fever 106, activity,—playfulness, generalized achiness, n, v, x 3 days, sore and distended abdomen.
This child was in acute distress.
The temperature of 106 would have been taken rectally, and rectal temperatures were always a degree high. Still, even a temp of 105 was in the danger zone. The kid had no energy, no zip. According to the note, he showed decreased activity and negative playfulness. He hurt all over—thus the notation for generalized achiness—but was particularly sore and swollen in the abdomen. This kid had been nauseated and vomiting for three days. Three days! What kind of parent would allow these symptoms to persist for three days before seeking medical help?
Just from reading the chart, Armistead formed a working diagnosis. Peritonitis. Poison in the system. Not literal poison but just as deadly. It could lead to a total breakdown of the nervous system and vital organs as a result of a severe bacterial infection. In this case, a likely culprit was the appendix, possibly ruptured and spewing the contents of the intestines into the abdominal cavity and ultimately the bloodstream of tiny Joshua.
It would not have been life threatening on day one. Or even day two. But now, with Joshua lethargic, running a high-grade fever, an elevated pulse of 118, dangerously low blood pressure, and a respiratory rate of 28, there were no guarantees.
Armistead knew what to expect. They would open the child up to remove the appendix and find all kinds of inflammation caused by pus and fecal matter in the lining of the abdomen. He had seen some bad cases of peritonitis straggle into the emergency room, but none this bad. The child was hypotensive and in acute distress. Three days fighting a losing battle against the bacteria had taken its toll.
Armistead tucked the chart under his right arm, shook his head, and prepared to enter Intake Room 4. He pushed open the door and extended his hand to a mother who had waited three long days before bringing her dying baby to him for help.
He forced himself to smile.
Theresa looked up as the door opened.
“I’m Dr. Armistead; how are we doing here?” the doctor asked, pleasantly enough.
Theresa was sitting on the examining table with Joshie on her lap. Her son was listless and lying on his left side against her, knees pulled up to his chest. Theresa shook hands with Dr. Armistead and did her best to return the doctor’s thin smile.
He was younger than Theresa expected. And shorter. He had receding light blond hair, sharp cheekbones, penetrating eyes, and a prominent jaw. His smile displayed rows of perfect white teeth and created quite a contrast with the narrow gray eyes that stared intensely out from behind small wire-rimmed glasses.
His impeccable presentation, ramrod posture, and pressed lab coat made Theresa self-conscious of her own appearance. She had not thought about how miserable she looked until this very moment, confronted with a doctor who exuded confidence and composure.
“Not real well,” Theresa admitted. “He’s been running a fever for a couple of days, and now he’s pretty . . . lifeless, I guess.” She grimaced at her own choice of words. Something about Armistead intimidated her, made her feel inadequate.
He bent down and started poking at Josh. He checked ears, nose, and throat. He took Josh’s pulse himself and confirmed a 116. He put a cold stethoscope on bare skin and listened to the lungs.
“Rapid respirations, difficulty breathing,” the doctor confirmed. He put pressure on the lower right abdomen and elicited a moan.
“Hey, buddy,” Armistead said as he poked and prodded. “Can you tell me where it hurts? Does this hurt? . . . How ’bout this? . . .” Joshie winced at times and remained stoic at others. “Man, you’re a tough little guy.” He rubbed Joshie’s head, tousling already disheveled hair, and then looked over Joshie’s head and directly at Theresa.
“When did you first notice the fever?”
“Um . . . it seems like maybe three days ago.”
“You know we’ve got a pretty elevated fever here. One-oh-six rectally. Anytime that fever gets up over a hundred and two, you ought to get him checked out, okay?”
“Yes, sir. It was only about a hundred and three earlier today. I tried everything I knew to keep it down.”
Armistead scribbled a few notations on the chart. He stopped for a moment and glanced at Theresa, said nothing, then went back to writing.
“How long has he been listless and lethargic like he is now?”
“That just started today, maybe yesterday. . . . I mean, whenever he runs a fever, he’s not himself, you know, but it was just this morning that I noticed we couldn’t get any reaction out of him at all.”
Theresa stared down at the top of Joshie’s head, unwilling to look at the doctor with the accusing eyes.
“I think we’ve got a case of appendicitis here,” Armistead continued, studying the chart. “He hurts in all the right places. We should have a CBC and a urinalysis done just to get a read on the white blood cell count and to rule out other possibilities.” He was writing again, mumbling more to himself than Theresa. “I don’t know why she didn’t suggest that lab work already; I’d like to have it in process by now.”
He then turned back to Theresa, replacing his plastic smile with a frown. He pulled up a stool in front of her so they were sitting eye to eye. “Appendicitis is not generally life threatening at Joshua’s age if it’s treated soon enough,” he lectured. The absence of emotion made the words even more condemning. “But when a child’s appendix bursts, it spews poison into his system. If that goes untreated long enough, it can lead to peritonitis and ultimately to septic shock. It can affect the circulatory system and central nervous system if the cause of the peritonitis is not treated.
“Joshua is showing classic signs of septic shock. We’ll probably have to operate as soon as possible. But first we’ve got to try and resuscitate him with some IV fluids, start him on some antibiotics, and build up his strength for the operation. Once we get the fluids and drugs in him, you and I will
talk again about the risks of surgery. But believe me, the risks of not having surgery, of not treating this problem, are infinitely greater.”
Armistead stopped and let the silence linger. The unspoken accusation hung in the air and screamed for an answer. It was obvious that this doctor had no intention of speaking until Theresa answered his charge.
Why? Why had she waited so long?
“Our church teaches that healing comes from the hand of God, not the hand of man.” She spoke softly, feeling the depth of her own guilt while holding Joshie and patting his back. “My husband and I knew we should come earlier, but we also knew that our church would forbid it. These last few days have been incredibly hard . . .” Her voice trailed off. She had said enough.
Armistead let the punishing silence remain a bit longer. At last he spoke. “These last few days have been hard not just for you and your husband but for Joshua as well. A burst appendix is extremely painful. With today’s medical advances, no child should have to live through the pain of an untreated ruptured appendix for three days. But you’re here now, and it was right for you to come. Let’s try to help Joshua with the pain and get him back on the road to healing.”
He tousled Josh’s hair again and stood up to leave.
“Will he be okay?” Theresa asked. It was more of a plea than a question.
“We’ll do our very best,” Armistead promised. “Nurse Pearsall will be with you shortly.”
And with that, he picked up the chart and left.
In the hallway Armistead quickly scratched out his diagnosis and orders.Dx: Appendicitis, w/ onset of peritonitis and sepsis. R/O urinary tract infection. Prep for surgery. Orders: CBC, UR, antibiotics and hyperal.
He needed to prepare Joshua for surgery, build the child’s antibodies, and rule out any other potential causes of lower right abdominal pain, such as a urinary tract infection. All of this was basic stuff. Emergency Room Medicine 101.
But it was the order he did not put in the chart that gave Armistead reason to pause before moving on to the next patient. Should he keep this child at Tidewater General or order a transfer to Norfolk Children’s Hospital?
Conventional wisdom dictated a transfer. Norfolk Children’s Hospital specialized in pediatric care and surgery. They had all the latest technology and the certified specialists who could pull a child through even the most difficult cases. And from everything Armistead could tell, Joshua would be a very challenging case, the sepsis potentially affecting all the major organs.
Just from a pure liability standpoint, which was no small factor, it would make sense to transfer the kid to a hospital like Norfolk Children’s, a hospital with the premier reputation for pediatric care in southeast Virginia. But Armistead personally believed its reputation was not justified. There were good surgeons at Tidewater General, better than most at Norfolk Children’s Hospital. And he hated the thought of transferring this kid to those prima donnas at the big city hospital who would later take all the credit for saving a child that the doctors at Tidewater General couldn’t handle.
And what if the specialists at Norfolk Children’s lost the child? They would certainly blame it on the half hour or so that Joshua sat in the ER examining room before being seen. After three days of total neglect, the hotshots in Norfolk would say it all came down to that extra half hour. Or they would find something else to nitpick, something about Armistead’s orders, something about the transfer.
No, there was no sense in transferring this patient. Armistead would keep the kid here. Joshua would get virtually the same level of treatment, and Armistead would not open himself up to all the second-guessing.
Transfers took time, and this patient didn’t have much time. Putting aside all of his resentment for the place, putting aside all of the arrogance of the Norfolk Children’s doctors, looking at it solely from the vantage point of the best interest of the patient, it still made sense.
They would operate here. No way would Armistead order a transfer to the same hospital that had five years ago rejected him for its residency program. Twice.
6
WHOEVER DESIGNED emergency room waiting areas obviously knew nothing about kids. Tiger had already been told three times by his dad to sit still, each time louder than the last. He had really tried. But the magazines for kids had simply failed to keep his attention, and so his running around the room had earned him a long stretch of sitting in the same chair. Worse, despite some rather loud noises generated when Tiger cleared his throat, his dad seemed to forget all about Tiger being confined to the chair. The possibilities for getting up anytime soon seemed pretty dim.
Just when Tiger was about to give up hope, a chance for escape presented itself when his dad stepped into the men’s bathroom. Tiger looked left and right, ignoring the accusing looks from Stinky, then decided to get up from his seat and take advantage of the momentary lull in supervision to test the operation of the automatic doors at the ER entrance.
Step on the pad, the doors open. Jump off the pad, the doors close. They seemed to be working fine.
“You’re a-posed to be sitting down,” Stinky warned, nervously eying the door of the men’s room.
But Tiger had not exhausted all the options. Jump on quick and off quicker, and you can get the doors to open and close only partway. In fact, just a tap from the heel of a cowboy boot would send the doors springing open. What power! What fun!
Open . . . close . . . open . . . close . . .
“Tiger!” Dad was out of the bathroom. He didn’t sound happy.
Without catching his dad’s eye, the little guy scampered quickly to his seat and hopped up in it. Stinky started furiously reading her magazine. As usual, Tiger was on his own.
For a long moment Tiger just sat there looking down. He sensed a large shadow hovering over him.
“Doggone it,” the shadow huffed. “Didn’t I ask you to stay in your seat?”
Even while looking down, he could sense the other two families in the emergency room watching this showdown. They were probably thinking that the little pistol would finally get what he deserved. They didn’t know they were the only thing saving him.
“Yes, sir,” came his squeaky reply. His voice never worked just right when he was in trouble. Tiger was scared but thought he would probably get by without a spanking. After all, this was a public place, and Dad didn’t usually spank in public, not with others watching. And sometimes, if Tiger was especially lucky, Dad would forget all about the need for a spanking once they got home.
“Then why did you disobey and git outta your seat?” It seemed the shadow had a point.
“I dunno,” Tiger said. It felt like a good idea at the time. In hindsight, he was starting to have second thoughts. “Sorry, Dad.”
“Well, you’ve done earned yourself a time-out, young man.”
And without another word, Tiger climbed out of his seat in the middle of the room, pulled a chair into the corner, and turned it facing the wall. He climbed into it and scootched back so his feet and cowboy boots were swinging freely. He was secretly relieved; it could have been a lot worse.
Then he heard a few soft words of pity from the others in the room, and it almost made him smile. “Aw . . . ,” one of the moms whispered. “He’s sooo cute.”
But cute wouldn’t get him off time-out any faster, that much Tiger knew for sure. And so he simply stared at the wall and began serving his sentence. He was a repeat offender; he had been in for worse. He could do this time standing on his head.
In fact, he thought, that’s not such a bad idea. If I could just slide forward far enough, lean down, get my hands on the floor . . .
Across town a first-time offender wondered if he would make it through the night.
Charles Arnold had been fingerprinted and booked. They took his mug shots, one from the front and one from each side. The deputies took his cargo shorts, T-shirt, socks, and sneakers and replaced them with a bright orange jumpsuit and slippers. He felt like . . . well, he felt like a crimin
al. He supposed that was the whole point.
A deputy grabbed Charles’s arm and yanked him down a tight and dingy hallway, ignoring the catcalls from the jail cells they passed. At the end of the hallway, the deputy opened the door of a large holding cell, shoved Charles inside, then backed away and swung the heavy door shut. It closed with a solid clang.
“Have fun, Professor,” the deputy said as he disappeared back down the hallway.
Charles took a quick inventory of the rough-looking bunch. About a dozen men. Most of them younger than Charles. A handful of blacks, a handful of whites, a couple of Hispanics. Tattoos, dreadlocks, and scowls seemed to be in vogue. The cell was segregated, blacks on one side, whites on the other. The two Hispanics took up residence close to the whites.
The odor hit him first. And the thought that his own oily, slick sweat, brought about by the suffocating humidity of this place, now contributed to it. The cell reeked of unwashed and grungy men—the stench of defeat, frustration, and anger.
The inmates regarded the new fish with looks of disinterested disdain. Nobody spoke for a few moments as Charles shuffled to the African American side of the cell. It was moments like this that Charles wished he were a darker member of the darker nation. For these men, his light brown skin might trigger less than full-fledged membership among the brothers, making him an outcast on both sides of the cell.
“What you in for?” one of the brothers asked. He was a wiry young man, no more that eighteen or nineteen, Charles guessed, with a grotesque network of bulging veins and tattoos covering every inch of his exposed forearms.
“Cop killin’.” Charles decided to make a good first impression.
“You bustin’ me? You didn’t pop no five-O.”
“Thought about it,” Charles responded, taking a few steps toward the black side of the holding cell. He touched closed fists with one of the brothers. “So they Rodney Kinged me for resistin’ arrest.”
“Shut up, woman. Don’t need no comics in here.”
