Toxin

TEN

Thursday, January 22nd

Kim ended up going home, but as he expected he had not been able to sleep much, and the sleep he did get was marred by disturbing dreams. Several of the dreams he found incomprehensible; they were about being ridiculed for poor performance on tests in college. By far the most horrible nightmare had been about Becky, and it was easy for him to understand. In the dream she had fallen from a jetty into a surging sea. Although Kim was on the jetty. he couldn't reach Becky no matter what he did. When he had awakened, he had been covered with perspiration.

Despite getting little rest, Kim's going home did afford him an opportunity to shower and shave. With at least an improved appearance, he was back in his car just after five in the morning. He drove on mostly deserted streets slick with a dusting of wet snow.

In the hospital he found Becky as he'd left her. She appeared deceptively peaceful in her slumber. Tracy was fast asleep as well, curled in the vinyl chair and covered with a hospital blanket.

At the nurses' station Kim came across Janet Emery dutifully doing her chart work.

"I'm sorry if I was rude last night," Kim said. He sat down heavily in the seat next to Janet. He pulled Becky's chart from the rack.

"I didn't take it personally," Janet said. "I know what kind of stress it is to have a child in the hospital. I experienced it with my own son."

"How was Becky's night?" Kim asked. "Anything I should know?"

"She's been stable," Janet said. "Most important, her temperature has stayed normal."

"Thank God," Kim said. He found the operative note that James had dictated and which had been put into the chart over night. Kim read it but didn't learn anything he didn't already know.

With nothing else to do, Kim went to his office and busied himself with the mountain of paperwork that had accumulated. As he worked, he eyed the clock. When he thought the time appropriate, taking into account the hour difference on the East Coast, Kim gave George Turner a call.

George was enormously sympathetic when he heard about the perforation and the resultant surgery. Kim thanked him for his concern and quickly came to the point of the call: he wanted to ask George's opinion of what to do if the diagnosis of HUS secondary to E. coli 0157:H7was confirmed. Kim was particularly interested in knowing if Becky should be transferred elsewhere.

"I wouldn't recommend it," George said. "You've got an excellent team with Claire Stevens and Kathleen Morgan on board. They've had a lot of experience with this syndrome. Perhaps as much as anybody."

"Have you had any experience with HUS?" Kim asked.

"Just once," George said.

"Is it as bad as it's described?" Kim asked. "I've read just about everything I could find on it, including what's on the Internet. The problem is there's not a lot."

"The case I had was a very unnerving experience," George admitted.

"Could you elaborate?" Kim asked.

"It was unpredictable and relentless," George said. "I'm going to hope that Becky's problem turns out to be something else."

"Can you be more specific?" Kim asked.

"I'd rather not," George said. "It's a protean syndrome. Chances are that even if Becky has it, it will not be anything like my case. My case was quite depressing."

After a few more minutes, Kim brought the conversation to a close. Before hanging up, George asked to be kept informed about Becky's progress. Kim promised to do so.

After disconnecting from George, Kim phoned the nurses' station on Becky's floor. When he got Janet, he asked about Tracy.

"She's up and about," Janet said. "I saw her last time I was down that way taking vital signs."

"Would you mind putting her on the phone," Kim asked.

"Not at all," Janet said agreeably.

While he waited, Kim thought about George's comments. He didn't like the sound of "relentless and unpredictable" and that George's case had been depressing. Such descriptions reminded Kim of his nightmare, and he could feel himself perspire.

"Is that you, Kim?" Tracy asked as she came on the line.

They talked for a few minutes about how they had each passed the previous five hours. Neither had slept well. Then they got around to Becky.

"She seems a bit better than last night," Tracy said. "She's more lucid. I think she's slept off the rest of the anesthesia. Her main complaint is the nasogastric tube. When can that come out?"

"As soon as her whole GI system seems to be working," Kim said.

"Let's hope that can be soon," Tracy said.

"I spoke to George this morning," Kim said.

"What did he say?" Tracy asked.

"He said Claire and Kathleen were a good team, especially if HUS is confirmed. He told me that we couldn't do any better anyplace else."

"That's reassuring," Tracy said.

"Listen, I'm going to stay here," Kim said. "I'll see a few patients, including the pre-ops for tomorrow. I hope you don't mind."

"I don't mind in the slightest," Tracy said. "In fact I think it's a good idea."

"It's hard for me to sit there and do nothing," Kim explained.

"I understand completely." Tracy said. "You do what you have to do. I'll be here, so don't worry."

"Call me if there is any change," Kim said.

"Of course!" Tracy said. "You'll be the first to know."

When Ginger arrived just before nine, Kim told her to cancel whatever patients she could, because he wanted to get back to the hospital sometime in the afternoon.

Ginger asked about Becky, saying she was disappointed Kim hadn't called her the night before. She'd been worrying all night but had been afraid to phone.

Kim told her Becky was doing better following the surgery. He also explained that he'd not gotten home until after midnight and thought it much too late to call.

At first Kim found seeing patients was not easy under the circumstances, but he forced himself to concentrate. Gradually the effort paid off. By noontime, he felt slightly more relaxed although his heart would race every time the phone rang.

He wasn't hungry at lunchtime, and the takeout sandwich Ginger had brought in sat untouched on his desk. Kim preferred to immerse himself totally in his patients' problems. That way he didn't have to deal with his own.

In the middle of the afternoon, Kim was on the phone with a cardiologist from Chicago when Ginger stuck her head in the door. From her expression alone Kim could tell something was wrong. Kim covered the mouthpiece with his palm.

" Tracy was on the other line," Ginger said. "She was very upset. She told me that Becky has taken a sudden turn for the worse and has been moved to the ICU."

Kim's pulse quickened. He quickly wound up the conversation with the Chicago doctor and hung up. He changed his jacket, grabbed his car keys, and ran for the door.

"What should I do with the rest of the patients?" Ginger asked.

"Send them home," Kim said tersely.

Kim drove with determination, frequently barreling along the shoulder to avoid afternoon traffic jams. The closer he got to the hospital the more anxious he became. Although he'd been lobbying to have Becky moved to the ICU, now that she had been he was terrified. Having become all too aware of AmeriCare's cost-saving attitudes, he was certain the move wasn't for prophylaxis; there had to have been a serious emergency.

Eschewing the doctors' parking area, Kim drove right up beneath the hospital's porte cochere. He leaped out and tossed his keys to a surprised hospital security guard.

Kim fidgeted as the elevator rose painstakingly slowly up to the ICU's floor. Once in the corridor crowded with visitors, Kim moved as fast as he could. As he came abreast of a waiting room built specifically for family members of ICU patients, Kim caught sight of Tracy. She stood up when she saw him and came forward.

Tracy threw her arms around Kim. pinning his to his side. For a moment she would not let go. Kim had to forcibly extricate his arms before gently pushing her back. He looked into her eyes, which were brimming with tears.

"What happened?" he asked. He was afraid to hear the answer.

"She's worse," Tracy managed. "Much worse, and it seemed to happen so suddenly, just like with the perforation."

"What was it?" Kim asked with alarm.

"It was her breathing," Tracy said. "All of the sudden she couldn't get her breath."

Kim tried to break away from Tracy, but she held on, clutching his jacket. "Kim, promise me you'll control yourself. You have to, for Becky's sake."

Kim broke Tracy 's hold and ran from the room.

"Kim, wait!" Tracy called, running after him.

Ignoring Tracy, Kim dashed across the hall and entered the ICU. Just inside the door, he held up for a moment while he scanned the room. Most of the beds were full. The occupants were all seriously ill patients. Nurses toiled at nearly every bedside. Banks of electronic monitoring equipment beeped and displayed vital data.

The most activity was in one of the small, separate rooms off to the side. Within its confines was a group of doctors and nurses attending to an acute situation. Kim walked over and stood in the doorway. He saw the respirator and heard its rhythmical cycling.

Judy Carlson, a nurse Kim knew, caught sight of him. She called out his name and all the people surrounding Becky's bed silently stepped back to afford Kim a view. Becky had been intubated. A large tube stuck out of her mouth and was taped to her cheek. She was being breathed by a respirator.

Kim rushed to the bedside. Becky looked up at him with terrified eyes. She'd been sedated but she was still conscious. Her arms were restrained to keep her from pulling out the endotracheal tube.

Kim felt a crushing feeling in his chest. He was revisiting the dream that he'd had the night before; only this time it was real.

"It's okay, Pumpkin, Daddy's here," Kim said, struggling to control his emotions. He was desperate to say something to reassure her. He gripped her arm. She tried to speak but couldn't because of the tube in her throat.

Kim looked around at the people present. He centered his attention on Claire Stevens.

"What happened?" he asked, keeping his voice calm.

"Perhaps we should go outside," Claire said.

Kim nodded. He gave Becky's hand a squeeze and told her he'd be right back. Becky tried to speak but couldn't.

The doctors filed out into the ICU proper and formed a group off to the side. Kim folded his arms to hide his trembling.

"Talk to me!" Kim commanded.

"First let me introduce everyone," Claire said. "Of course you know Kathleen Morgan. We have Dr. Arthur Horowitz, nephrologist; Dr. Walter Ohanesian, hematologist; and Kevin Blanchard, respiratory therapist."

Claire had pointed out each person in turn. All had nodded to Kim, who nodded in return.

"What's the story?" Kim asked impatiently.

"First I have to tell you we're definitely dealing with E. coli 0157:H7," Claire said. "We'll have an idea of the particular strain tomorrow after pulse field electrophores's."

"Why is she intubated?" Kim asked.

"The toxemia is affecting her lungs," Claire said. "Her blood gases suddenly deteriorated."

"She's also in kidney failure," Arthur said. "We've started peritoneal dialysis." The kidney specialist was a completely bald man with a full beard.

"Why not a dialysis machine?" Kim questioned. "Aren't they more effective?"

"She should do fine with the peritoneal dialysis," Arthur said.

"But she just had surgery for a perforation," Kim said.

"That was taken into consideration," Arthur said. "But the problem is AmeriCare only offers dialysis machines at Suburban Hospital. We'd have to transfer the patient there, which we surely don't recommend."

"The other major problem is her platelet count," Walter said. The blood specialist was a gray-haired older man who Kim guessed was in his seventies. "Her platelets have fallen precipitously to the point where we feel they must be replenished despite the inherent risks. Otherwise, we might have a bleeding problem on our hands."

"There's also the problem with her liver," Claire said. "Liver enzymes have risen remarkably, suggesting.."

Kim's mind was on overload. He was stunned to the extent that he was no longer absorbing the information being presented to him. He could see the doctors talking, but he didn't hear. It was the nightmare all over again, with Becky floundering in the dangerous, surging sea.

A half hour later, Kim stumbled out of the ICU into the ICU waiting room. Tracy got up the moment she saw him. He looked like a broken man.

For a moment they stared into each others eyes. Now it was Kim's turn for tears. Tracy reached out, and they locked in a hug of fear and grief.