Christmas on the Children's Ward

by Carol Marinelli

  ‘I’ll be fine,’ Eden assured her, consoling herself that Lily would no doubt be asleep. She was determined not to let her personal life interfere with her work. ‘You go. Enjoy your break.’

  As Eden had predicted, Justin awoke a couple of minutes later and because she was the most senior RN on the ward Eden put on a gown and bought him to the desk, cuddling him as she gave him his bottle.

  ‘He’s been here for ages,’ Rochelle said, peering at her notes. ‘Why has he been kept in so long? There doesn’t seem to be anything wrong with him.’

  ‘It’s complicated,’ Eden replied warily, smiling down at the baby as he guzzled his bottle. ‘Justin was bought in a few weeks ago with failure to thrive. He was losing weight and not taking his feeds well.’

  ‘Well, that’s certainly improved.’

  ‘That’s exactly the problem,’ Eden responded. ‘He put on weight and was discharged, only to present to his GP a couple of weeks later with further weight loss. He’s been in all this time having tests to see what the problem could be.’

  ‘But they’ve all come back as normal,’ Rochelle said, staring down at her notes. ‘Clearly he’s taking his feeds well now, so why don’t they just send him home?’

  ‘Here’s perhaps not the best place to talk about it,’ Eden said tactfully, ‘but when Becky gets back from her break, if we get a chance we can go into the office.’

  ‘Oh.’ Rochelle’s eyes widened, staring from Eden to Justin and shaking her head. ‘But his mum adores him,’ Rochelle said.

  ‘We’ll talk later,’ Eden said again, because the nurses’ station, even if it was in the middle of the night, wasn’t the place to discuss such things.

  Jenny did love Justin, there wasn’t any doubt on that score, but for so far inexplicable reasons whenever the child had been left in her care, he had not only failed to thrive but had actually lost weight and was suffering from malnutrition to the point where he had rickets from a vitamin D deficiency. After exhaustive investigations the medical and social workers were coming to the unpalatable conclusion that young Justin might be a victim of a rare and controversial syndrome by the name of Munchausen’s by proxy—that his mother was somehow using Justin as a tool to satisfy her own attention-seeking needs, causing harm to her child to fill whatever it was that was missing in her own life.

  The nurses’ station certainly wasn’t the place to talk about it.

  ‘Do you want me to do the oxygen saturations on the baby?’ Rochelle offered as Eden rose to take Justin back to his cot. ‘And then I can do the neuro obs.’

  ‘I’ll do the neuro obs,’ Eden said, tactfully not adding that Nick would rather one of the more experienced staff members looked after his niece. Given the fact that he was the consultant on the ward, Eden could understand the unspoken request.

  Never had she been more grateful for that split-second decision as she crept into the room to perform Harriet’s neurological observations. A gnawing sense of foreboding niggled at her as she flicked on the overhead light and saw the awkward angle of her head on the pillow, but Eden didn’t let it show. Instead, she smiled as an exhausted Lily stretched in the reclining chair by the bed and yawned a greeting.

  ‘Hi, Lily,’ Eden said. ‘I’m just going to do Harriet’s neuro obs and then I’ll let you get back to sleep.’ Gently she shook Harriet on the shoulder, calling her name a couple of times until Lily herself intervened, rousing her daughter from her deep sleep. ‘Come on, honey,’ Lily called. ‘You remember Eden. She’s just going to do your obs again. Remember how they shine that light in your eyes and you have to answer some questions?’

  ‘Hi, Harriet,’ Eden said softly as those familiar green eyes stared back at her. ‘Do you remember me?’

  A confused look flickered across the child’s face and she shook her head slightly.

  ‘It’s the uniform,’ Lily said firmly. ‘Harriet, it’s Eden. Remember she was with us for Christmas?’

  ‘Do you know where you are, Harriet?’ Eden asked, that niggling feeling increasing as the same confused eyes stared back at her.

  ‘What’s your name?’ Eden asked, desperate to hear the little girl speak, her breath stuck in her throat until finally Harriet softly mouthed the word.

  ‘She’s tired,’ Lily said quickly. ‘She was at her father’s all day. I think he took them to the beach. She’ll be much brighter by the morning.’

  ‘Harriet, can you squeeze my hands for me?’ Eden said, placing her hands in the little girl’s and feeling the pressure that she applied. ‘Good,’ she said, pulling back the sheet. ‘Can you wiggle your toes for me? That’s a good girl,’ Eden encouraged her. ‘Now, I want you to lift your legs up for me.’ Putting her hand on Harriet’s calf, she encouraged her further, noticing with growing disquiet that Harriet had already fallen back to sleep. ‘Come on, Harriet, push my hand away.’

  ‘She’s exhausted,’ Lily insisted. ‘Look, I really think that she needs to sleep, Eden. I know you have to do these obs but surely, given that it’s three a.m….’

  ‘I’m nearly finished,’ Eden replied. ‘I’m just going to shine a light in your eyes, Harriet, and then I’ll let you rest.’

  Shining the torch into Harriet’s eyes, Eden didn’t comment as Lily replaced the sheet around her daughter.

  ‘Can I turn off the light?’ Lily asked, and Eden nodded, slightly taken back by Lily’s lack of concern.

  ‘Sure,’ Eden answered, frowning as she left the room and heading straight for the telephone. But even before she’d put out the page for Dr Timms’s registrar, Nick was at the desk, obviously having set his watch alarm. He asked her how Harriet’s obs had been.

  ‘I’m just paging Dr Timms’s registrar to discuss them,’ Eden answered carefully, unsure how she should proceed, acutely aware that in this instance Nick was far from objective but wanting a doctor’s opinion all the same.

  ‘What’s wrong Eden?’ Nick’s voice was not to be argued with. ‘I’m not going to jump in with all guns blazing, I just need to know what’s going on. Why are you paging the registrar? What’s the problem with Harriet?’

  ‘I’m not sure,’ Eden admitted. ‘I didn’t actually see her on admission because she’s Becky’s patient, but she’s at supper break now. I’ve just gone to do Harriet’s two-hourly obs and…’ Her voice trailed off, and she chewed her bottom lip as she attempted to voice her concern. ‘On paper she seems fine, and admittedly it’s the first time I’ve really seen her since she arrived from Emergency, but to me she seems altered.’

  Nick gave her a worried look. ‘Altered’ was exactly that—an altered state of consciousness, a slight inappropriateness that wasn’t always definable. ‘She’s answering questions, and she’s obeying commands, but she just doesn’t seem right. There’s also a slight nystagmus.’

  Nick’s concerned frown deepened a fraction—nystagmus was a flickering of the eyes that was often a normal presentation in people but it could also indicate a neurological problem. ‘I’ve had a quick look at the admission notes and it hasn’t been recorded.’

  ‘Because there wasn’t one,’ Nick said, dragging in a deep breath. ‘What does Lily say?’

  ‘I didn’t mention the nystagmus to her but she didn’t seem concerned at all. Lily seems to think that she’s just tired. Perhaps she was the same on admission,’ Eden offered, but privately she doubted it. Becky had given no indication of concern. ‘Maybe I’m just overreacting.’

  ‘I hope so,’ Nick said. ‘I’m going to check on her.’

  ‘I’ll come with you,’ Eden said, calling Rochelle away from the saturations she was checking. ‘Rochelle, I’ve just paged Dr Timms’s registrar. When he calls back, can you ask him to come and review Harriet Mason?’

  ‘What shall I say is wrong?’

  ‘Just say that Dr Watson is in with Harriet now and that he’d like a doctor to come and assess her.’ Eden called over her shoulder, and headed off to Harriet’s room. But midway she halted, a gut feeling that couldn’t be
explained stopping her in her tracks. Heading back to the desk, she summoned Rochelle again.

  ‘Go and knock on the staffroom door and ask Becky to come back from her break.’

  ‘She’s just gone back to sleep, Nick,’ Lily was saying as Eden slipped into the room. ‘Can’t we just let her rest?’

  ‘We need to check her,’ Nick said firmly, running a careful eye over Harriet who was seemingly dozing on the bed.

  But Eden just knew Nick was seeing the same as her, the awkward position that she was lying in, her head rotated awkwardly on the pillow. Lily was clearly less than impressed with the further intrusion and sucked in her breath, in irritation as Nick pulled back the sheet, gently rousing the little girl and noting her reaction to verbal stimulation.

  ‘Hi, Harriet.’ His voice was far less formal and he repeated the greeting a couple of times before gently shaking Harriet’s shoulder.

  ‘She’s exhausted, Nick,’ Lily argued, and Eden turned to the irritated woman, confused as to why, when Lily was a doctor herself, she would argue the point over something so that was obviously necessary. Then Eden realised that it was fear talking, that Lily quite simply didn’t want to admit to the possibility that Harriet was really unwell. ‘That’s why she’s not waking up—the poor kid is worn out.’

  ‘Perhaps,’ Eden conceded, ‘and Nick will take into consideration the fact that Harriet is very tired, but it is imperative that he does a full examination on your daughter before we leave her to rest.’

  A tiny nod from Lily indicated her consent and, knowing it was better for the young patient if her mother was included, Eden guided her closer to the bedside as Nick commenced his examination. Even though not by even a flicker did Nick betray his anxiety, as he moved the little girl’s head to her chest Eden could tell that he was concerned. She’d worked alongside Nick for a long time now and could read from the tiny subtle shifts in his expressions, the way the lines that fanned around his eyes deepened, that Nick wasn’t at all happy with what he was seeing.

  ‘How are you feeling, Harriet?’ He smiled down at his niece, who just stared back at him.

  ‘Harriet, I need for you to talk to me. Are you sore anywhere?’

  Again Harriet didn’t answer, just stared back at her uncle with confused, anxious eyes.

  ‘She answered you before?’ Nick checked, and Eden gave a worried nod. ‘Yes, well, when I say she answered, she just mouthed her name.’

  ‘Harriet.’ Lily’s voice wobbled slightly. ‘Answer Nick for me, honey.’

  ‘Nick.’ Something in Eden’s voice dragged his attention away from the child. He watched where Eden’s finger was pointing—a tiny red patch of skin no bigger than a pinhead with a small clear blister above it.

  ‘That wasn’t there before?’ Nick asked, and there was definitely an urgent note to his voice now.

  ‘No.’ Eden shook her head. ‘When I did her obs I checked for any rash. Let’s sit you forward, Harriet,’ she said immediately, not waiting for Nick, knowing he would want to examine Harriet’s torso. ‘There’s another one,’ she said, pointing to a small blister on her back as Nick looked behind Harriet’s ears. ‘And a few coming out here.’

  ‘What going on?’ Lily asked, staring at the faint rash on Harriet’s body. ‘What have you found…?’ Her voice trailed off as she saw the emerging rash on her daughter, a hand smothering a sob as Nick flashed a torch in Harriet’s eyes and repeated the reflex response check with a tendon hammer, gently reassuring the little girl when she let out a moan of protest.

  ‘It’s OK, Harriet, you can rest now. I’m just going to have a word with your mum and then I’ll be back. Eden, can you get some acyclovir IV started?’

  ‘She’s got chickenpox, hasn’t she?’ Lily gulped. ‘And if she’s having this type of reaction it means that—’

  ‘We’ll talk outside,’ Nick broke in quickly. Lily’s tension could only upset Harriet further and Eden bit hard on her lip as he guided the frantic woman outside, pressing the buzzer on the wall three times in a code that told the ward that a member of staff required some rapid assistance. The emergency bell was only used when the situation was extremely serious.

  ‘What’s happening?’ ‘Rochelle asked.

  ‘Have you called Becky?’ Eden asked, barely able to disguise her irritation when Rochelle shook her head.

  ‘I was on the phone with Dr Timms’s reg. He’s at home but he’s going to come in soon.’

  ‘What do you need?’ Becky was back, summoned by the emergency bell and awake in a second.

  ‘Her neuro obs are decreasing. Nick just examined her and it looks as if she’s got chickenpox. Could you get me some acyclovir and a flask of saline? Nick will write it up when he gets back. And could you get the lab on the phone for Nick? He’s going to want to speak to them.’

  ‘Chickenpox?’ Rochelle questioned, clearly bemused at her colleague’s behaviour, but Eden didn’t have the time to enlighten her. ‘I’ll explain later. Tell the switchboard to urgently page Dr Timms’s registrar and let him know he needs to be here now!’

  Even though it had only been fifteen minutes since Eden had done a set of observations she repeated the process, checking Harriet’s vital signs. Though her pulse and blood pressure were relatively stable, Eden noted a marked decrease in her respiratory rate.

  ‘Harriet!’ Eden’s voice was sharp, attempting to rouse the girl verbally. When the child responded to neither her voice nor a shoulder shake, she tweaked Harriet on her earlobe, calling her name in an urgent voice.

  ‘Harriet!’ Rubbing her sternum, Eden watched as Harriet’s arms made only a small attempt to push her away, and Eden knew that her condition had deteriorated rapidly in just a few moments and that a rapid response was needed. Pushing the bell three times, she applied oxygen to the girl as Rochelle again dashed to the door.

  ‘Get Nick—now!’ Eden ordered. ‘Actually…’ She went over Harriet’s symptoms in her head. Even though there was a consultant on the ward, Eden made a rapid decision. ‘Get Nick in here and when you’ve done that call the medical emergency team and bring the crash trolley to the bedside,’ she ordered, realising that the team needed to be summoned as in a matter of seconds Harriet could further deteriorate and require intubation.

  ‘Shouldn’t you run it by Nick?’ Rochelle asked, but Eden flashed her a firm look. ‘Just do it now, and get someone to stay with the mother.’

  Attaching the oxygen saturation probe to Harriet she saw that despite the oxygen her saturation was only on ninety per cent, which was rather low. Flashing a torch into her eyes, Eden noted that her pupil responses were present but the little girl who had been talking only fifteen minutes ago, who had been celebrating Christmas and singing her heart out just a few days ago, was now slipping into unconsciousness. Eden felt her throat tighten as Harriet’s body stiffened beneath her. The seizure she had anticipated had begun. Rolling Harriet swiftly onto her side, Eden willed the overhead chimes to go off, for help to arrive, relief flooding her when she heard Nick’s footsteps and the door burst open as he rushed in.

  ‘She just started seizing,’ Eden explained. ‘I’ve called a MET.’ She held her breath for a second after she said it.

  Rochelle hadn’t been far off the mark when she’d queried whether Eden should run it by Nick first, given that he was on the ward. But Nick just gave a nod. He closed his eyes for a fraction of a second, as if willing his mind to clear, as if summoning the strength to push emotion aside and deal with this dire situation objectively. And even if she hated him for all he had done to her, Eden felt sorry for him now. To witness his own niece so desperately ill and to be the only doctor nearby would be a horrendous burden.

  As the chimes went off overhead Becky arrived with the large red crash trolley, pulling up diazepam for Nick to give intravenously. But despite the drug, Harriet’s seizure continued, and even though Eden knew the chimes that were ringing overhead were being played throughout the entire hospital, that at this very second the med
ical emergency team would be running towards the children’s ward right now, the alarm on Harriet’s oxygen saturation machine was going off too now. Her saturations were dangerously low and despite the diazepam, she continued to seize.

  Rochelle was swinging into action now, moving chairs and tables out of the way to make room for the large trolley that was being wheeled in. And even though the emergency personnel were beginning to arrive, the situation was becoming more dire as Harriet’s saturations dropped even lower. Nick started to pull off the bedhead and remove the pillows from under Harriet’s head as Eden pulled open the intubation tray. She was grateful when the anaesthetist arrived. Nick at least would be spared from having to intubate his own niece.

  ‘What’s the story?’ the anaesthetist asked, making straight to the head of the bed, assessing the situation with calm, knowing eyes and listening intently as Nick bought him up to speed.

  ‘Five-year-old, admitted with first seizure. Neuro obs have rapidly deteriorated and we noted a classic chickenpox rash. She started seizing again.’ Nick hesitated for a second. ‘She’s also my niece.’

  ‘Should you be in here, then, Nick?’ the anaesthetist asked, but didn’t wait for an answer, his mind solely on the patient.

  ‘How long has she been seizing now?’ the anaesthetist asked, his finger probing the pulse in Harriet’s neck then listening to her chest for air entry as Harriet’s tiny body continued to convulse.

  ‘Six minutes,’ Eden responded, glancing down at her watch. ‘She’s had three lots of diazepam.’

  ‘She can’t keep on like this,’ The anaesthetist was rummaging through the crash trolley, expertly pulling up the drugs of his choice. ‘Let’s paralyse and intubate. Sister, can I have some carotid pressure, please? Nick can you—?’

  ‘I’ll stay, thanks, Vince.’ Nick’s voice was calm and measured and completely in control but, glancing up briefly, Eden could see the sheer terror in his eyes and she was grateful when he stepped to the back of the room. He had realized that heroics weren’t needed now, that the best he could do for his niece was stand back quietly and trust her life to his colleagues.