Toxin

EIGHT

Wednesday, January 21st

Kim turned into the hospital parking lot a little after six in the morning. He'd skipped stopping at his office, as he normally did. He was eager to look in on Becky and make sure everything was okay.

The previous night things had gone well after the unpleasant episode with David Washington. Dr. Claire Stevens had come into the ER within a half hour of being paged. In the interim, Kim had phoned George Turner for the second time that evening. This gave him a chance to ask George's opinion about the pediatrician. George had echoed Claude's sentiments, and both Kim and Tracy had felt relieved.

Claire was a tall, thin woman – nearly Kim's height. Her features were sharp but they were belied by her gentle, reassuring manner. Kim's personal impressions of her added to the professional testimonials. She was about his age, which suggested years of clinical experience under her belt. What's more, her competence was immediately apparent and reassuring. Of equal importance, she established immediate rapport with Becky.

Kim pushed into Becky's room. There was a night-light near the floor that reflected off the ceiling, casting a gentle glow over the entire room. Kim advanced silently to the bedside and looked down at his sleeping daughter. Her halo of dark hair made her face appear the color of ivory. Its translucency gave her a fragile look as if she were made of porcelain.

Kim knew that under the circumstances it was appropriate for Becky to be in the hospital. At the same time her being there gave him great anxiety. His vast experiences in hospitals reminded him that it was an environment where horror could lurk.

Becky's breathing was regular and deep. Her IV was running slowly. Happy to see her resting so well, Kim quietly backed out. He did not want to disturb her.

Back at the nurses' station, Kim withdrew Becky's chart. He glanced through the admitting notes that Claire had dictated, then turned to the nurses' notes. He noticed Becky had been up twice during the night with continued diarrhea. There had been some blood reported but only by Becky. None of the nurses had seen it.

Kim then turned to the order sheet and was pleased to see that Claire had followed up on her word: she'd requested a pediatric gastroenterology consult for that day.

"Now, that's one delightful child." a lilting voice said.

Kim looked up. Glancing over his shoulder was a plump nurse with a face red from exertion. Her blond hair was permed into a multitude of tight ringlets. Her cheeks were dimpled. Her name tag indicated she was Janet Emery.

"Have you been looking in on her?" Kim asked.

"Yup," Janet said. "Her room's in my area. Cute as a button, that one."

"How has she been doing?" Kim asked.

"Okay, I guess," Janet said without a lot of conviction.

"That doesn't sound too positive," Kim said. A minute sliver of fear eked its way up his spine, giving him an involuntary shiver.

"The last time she was up, she seemed weak," Janet said. "Of course, it might have been because she was sleeping. She rang for me to come help her back to bed."

"I understand from the chart that you didn't get to see how much blood she might have passed," Kim said.

"That's right," Janet said. "The poor thing is embarrassed to beat the band. I tried to tell her not to flush after she uses the toilet, but she does anyway. What can you do?"

Kim made a mental note to talk to Claire about that problem and to Becky as well. It would be important to know if the blood was mere spotting or worse.

"Are you a consult on the case?" Janet asked.

"No," Kim said. "I'm Dr. Reggis, Becky's father."

"Oh my goodness," Janet said. "I thought you were a consult. I hope I didn't say anything out of line."

"Not at all," Kim said. "I certainly got the feeling you care for her."

"Absolutely," Janet said. "I just adore children. That's why I work this floor."

Kim went off to see his inpatients and then attend the series of hospital conferences scheduled for that morning. Like Mondays, Wednesdays were particularly busy with respect to his administrative responsibilities. Consequently, he didn't get back to Becky's floor until almost ten. When he did, the ward clerk informed him that Becky was off to X-ray. He was also told that Tracy had come in and was with her.

"Can you tell me about the status of the gastroenterology consult?" Kim asked.

"It's been ordered," the clerk said. "If that's what you mean.

"Any idea when it will be?" Kim asked.

"Sometime this afternoon, I'd guess," the clerk said.

"Would you mind giving me a call when it does happen?" Kim asked. He handed the clerk one of his cards.

"Not at all," the clerk said.

Kim thanked him and hurried off to his office. He would have preferred to see Becky and talk to her, even if for a moment, but he didn't have the time. He was already behind schedule, a fact that he was philosophical about, since it tended to happen more often than not.

'Well, Mr. Amendola," Kim said, "do you have any questions?"

Mr. Amendola was a heavyset plumber in his early sixties. He was intimidated by modern medicine and horrified by Kim's verdict: he needed a valve in his heart replaced. A few weeks earlier, he'd been blissfully unaware he even had valves in his heart. Now, after experiencing some scary symptoms, he knew that one of them was bad and had the potential to kill him.

Kim ran a nervous hand through his hair as Mr. Amendola pondered the last question. Kim's eyes wandered out the window to the pale wintery sky. He had been preoccupied ever since Tracy had called an hour earlier to say she thought Becky didn't look good, that she was glassy-eyed and listless.

With a waiting-room full of patients, Kim's response had been to instruct Tracy to page Claire and to tell her Becky's status. He also told Tracy to remind the clerk to call him when the gastroenterology consult arrived.

"Maybe I should talk to my children," Mr. Amendola said.

"Excuse me?" Kim said. He'd forgotten what he'd asked the man.

"My children," Mr. Amendola said. "I got to ask them what they think the old man should do."

"Good idea," Kim said. He stood. "Discuss it with your family. If you have any questions, just call."

Kim walked Mr. Amendola to the door.

"You're sure the tests you've done are right?" Mr. Amendola asked. "Maybe my valve isn't so bad."

"It's bad," Kim said. "Remember, we got a second opinion."

"True," Mr. Amendola said with resignation. "Okay, I'll get back to you."

Kim waited in the corridor until it was certain Mr. Amendola was on his way to reception. Then Kim lifted the heavy chart of the next patient out of the chart rack on the back of the door to the second examining room.

Before Kim had even read the name, Ginger appeared at the end of the corridor. She had to move out of the way for Mr. Amendola to pass.

"I just got a call from the ward clerk on Becky's floor," she reported. "I'm supposed to tell you that the gastro something-or-other doctor is seeing Becky at this very moment."

"Then I'm out of here," Kim said quickly. He replaced the chart into its rack and stepped into his private office. While he was getting his suit jacket from the closet, Ginger came in.

"Where are you going?" she asked.

"Back to the hospital," Kim said.

"When will you be back?" Ginger asked.

"I don't know," Kim said. He pulled on his winter coat. "Let Cheryl know, so that the patient doesn't sit and wait in the examining room."

"What about the other patients?" Ginger said.

"Tell them there's been an emergency," Kim said. "I'll be back but probably not for an hour and a half or so."

Kim picked up his car keys and went to his rear door.

Ginger shook her head. She was the one who would have to face the patients. From past experience she knew how upset they were going to be, especially the ones coming from out of town.

"Just do the best you can," Kim said as if reading her mind.

Kim dashed to his car. He jumped in, started it, and drove out into the congested street. Leaning on his horn, he weaved in and out of the traffic. He felt desperate. Particularly after Tracy 's comments, he did not want to miss talking directly to the GI consult.

In the hospital lobby, Kim repeatedly hit the elevator button as if such action would bring a car sooner. Several visitors eyed him suspiciously.

Once on Becky's floor, Kim literally ran down the hall. When he entered Becky's room, he was panting. He saw Tracy standing off to the side, talking with a woman in a long, professorial white coat. Even a quick glance told him that Tracy was distraught.

Becky was in her bed on her back with her head propped up against the pillow. Her dark eyes stared ahead. At the moment, the only apparent motion was the relentless drip of fluid in the millipore chamber of the IV line.

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 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.

"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 0157: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 0157:H7cases," 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 0157:H7every 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 0157:H7nature probably didn't do it on its own. Man helped."

"How so?" Kim asked.

"I believe E. coli 0157: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 0157:H7was 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 0157: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.