Toxin

SEVEN

Tuesday, January 20th

The OR door burst open, and Kim and Tom entered the scrub area outside OR number 20. As they did so, they untied their face masks and let them drop down over their chests. They rinsed off the talc from their hands.

"Hey, thanks for lending a hand on such short notice," Tom said.

"Glad to help," Kim said flatly.

The two men started walking up the corridor toward the recovery room.

"You seem down in the dumps," Tom said. "What happened? Did your accountant just call you about your bottom line in response to the new Medicare reimbursement rates?"

Kim didn't laugh. He didn't respond at all.

"Are you all right?" Tom asked, seriously this time.

"I suppose," Kim said without emotion. "Just a lot of aggravation." Kim then told Tom what had happened in the ER the night before.

"Whoa!" Tom commented when Kim was finished. "What a God awful experience! But don't be down on yourself for taking a poke at that Barclay Bradford character. I had a mini run-in with him myself. Administrators! You know, I read in a journal last night that in the United States there's currently one administrator for every one and a half doctors or nurses. Can you believe that?"

"Yeah, I can," Kim said. 'That's a big part of why our healthcare costs are so high."

"That was exactly the point of the article," Tom said. "But anyway, I can understand why you popped Bradford. If it had been me, I know I would have been bullshit. Three hours! Hell, I'd a punched him out as a minimum."

"Thanks, Tom," Kim said. "I appreciate your support. But the worst part of the whole episode is that after all that wait and aggravation, I never got a chance to talk with the doctor who examined Becky."

"How's she doing today?"

"I don't know yet," Kim said. "It was too early for me to call when I got up, and Tracy hasn't called me. But she's got to be doing better. Her bloodwork was fine, and she's been afebrile."

"Dr. Reggis!" a voice called.

Kim turned to see Deborah Silverman, the OR head nurse, beckoning toward him. Kim detoured to the OR desk.

"Dr. Biddle called while you were in surgery," Deborah said. "He left a message for you to stop into his office as soon as you were out."

Kim took the message slip. It was punctuated with a number of exclamation points. Apparently it was serious.

"Uh-oh!" Tom commented over Kim's shoulder.

"Sounds to me like the chief is planning on adding to your aggravation."

Kim and Tom parted ways at the recovery-mom door. Kim went into the surgical locker room. Despite the implied urgency of Forrester Biddle's message, Kim took his time. It wasn't hard to guess what Forrester wanted to see him about. The problem was that after a point, Kim wasn't sure he understood his own behavior.

Kim took a shower and mulled over in his mind the previous evening's experience. He didn't reach any epiphany beyond admitting he'd been unduly stressed. After dressing in a clean set of scrubs, Kim used the phone in the surgical lounge to call Ginger at the office to discuss the afternoon schedule. Only then did he make his way over to the chief's office in the administration wing.

Dr. Forrester Biddle was the quintessential New England conservative. He had the gaunt look of a Puritan preacher and the acerbic personality to go with it. His only redeeming quality was that he was an excellent surgeon.

"Come in and close the door," Forrester said as Kim stepped into his cramped, journal-filled office. "Take a seat."

Kim sat down. Forrester made him wait while some paperwork was being completed. Kim's eyes roamed the room. Kim noted he'd had a much better office as chief over at the Samaritan.

After adding his signature with a flourish, Forrester slapped down his pen on his desk top so that it sounded like a distant report of a firearm.

"I'll get right to the point," he said, assuming an expression more stern than usual. "Your behavior last night in the emergency room is an embarrassment to this department as well as to the entire medical staff."

"My daughter was in pain," Kim said simply. It was an explanation not an excuse. He was not inclined to sound remorseful.

"There's no excuse for violence," Forrester remarked. "Mr. Bradford is considering filing charges, and I wouldn't blame him if he did."

"If anybody gets sued it should be AmeriCare," Kim said. "I waited over three hours mostly so that AmeriCare can maximize profits."

"Assaulting an administrator is no way to make social commentary," Forrester said. "Nor, I might add, is appealing directly to the media. I wasn't going to say anything about your quote Kelly Anderson gave during the Friday night news until this inexcusable episode of battery. Saying publicly that the rationale for the merger of the University Medical Center and the Samaritan was to benefit AmeriCare's bottom line hurts the reputation of this hospital."

Kim stood up. The meeting was not going to be a discussion, and there was no way Kim would sit there and absorb reprimands like a delinquent schoolboy. "If that's all, I have patients to see.

Forrester pushed his chair back and stood up as well. "I think you should keep in mind, Dr. Reggis," he said, "this department seriously considered hiring a full-time, salaried surgeon to cover your area of valve replacement prior to the merger. Your behavior of late is making us reevaluate that issue."

Kim turned around and left without responding. He wasn't about to validate such a comment. It was hardly the threat that Forrester intended. In reality Kim was being repeatedly recruited to take over a number of prestigious departments around the country. The only reason he was still at the University Medical Center was because of shared custody of Becky and the fact that Tracy couldn't move because of her matriculation in the liberal arts college.

But Kim was again angry. Of late it seemed to be his constant state of mind. Striding out of the administrative area of the hospital, he practically ran head-on into Kelly Anderson and her cameraman, Brian.

"Ah!" Kelly squealed with apparent delight. "Dr. Reggis! Just the man I've been hoping to see."

Kim flashed a nasty glance at the TV journalist and continued down the corridor at a brisk pace. Kelly reversed directions and ran after him. Brian kept pace despite his burden of equipment.

"My God, Dr. Reggis," Kelly panted. "Are you in training for a marathon? Slow down. I need to talk with you."

"I've no intention of talking with you," Kim said.

"But I want to hear your side of last night's ER episode," Kelly said.

Kim pulled up short, forcing Brian to collide with him. Brian apologized effusively. Kim ignored him and peered at Kelly in surprise. "How in God's name did you hear about that and so quickly?"

"Surprised you, huh!" Kelly remarked with a sly, self-satisfied smile. "But I'm sure you understand that I can't reveal my sources. You see, I do so many medical-related stories that I've developed a kind of fifth column here at the med center. You'd be surprised about the gossip I get. Unfortunately it's usually as prosaic as who's screwing whom. But once in a while, I get a real tip, like your episode in the ER last night. Cardiac surgeon punches out administrator: that's news!"

"I don't have anything to say to you," Kim responded. He recommenced walking.

Kelly caught up to him. "Ah, but I think you do," she said. "Having to wait three hours in an emergency room with a sick child must have been a major aggravation that I'd love to discuss."

"Too bad," Kim said. "Among other things I was just reprimanded for giving you that bottom-line quote. I'm not talking with you."

"So the administration hates the truth," Kelly said. "That in itself is interesting."

"I'm not talking to you," Kim repeated. "You might as well save your breath."

"Oh, come on!" Kelly said. "Your having to wait hours to be seen in the emergency room will strike a familiar chord with my viewers, especially with the ironic twist that it's a doctor doing the waiting. We don't even have to discuss the assault and battery part if you don't want."

"Yeah, sure, as if I could trust you," Kim said.

"You can," Kelly said. "You see, I think having to wait so long relates to the merger story. I believe it has something to do with AmeriCare's interest in profits. What do you think?"

Kim looked at Kelly as they walked. Her bright blue-green eyes sparkled. Kim had to admit that although she was a pain in the neck, she was also smart as a whip.

"You said it, not me," Kim remarked. "So no quotes. My life right now is sufficiently screwed up that I don't need you to make it worse. Goodbye, Miss Anderson."

Kim went through a pair of swinging doors leading back into the operating area. Kelly pulled to a stop to the relief of Brian. Both were out of breath.

"Well, we tried." Kelly said. "The sad irony is that this time I'm sincerely sympathetic. A month ago I had to wait almost the same amount of time with my own daughter."

Kim entered his office complex by the back door. It gave him a chance to get into his private office without having to go through the waiting room. As he struggled out of his suit jacket he picked up his phone and got Ginger at the reception desk.

"I'm back," Kim said. With the receiver caught in the crook of his neck, he walked over to his closet. The telephone wire was just long enough.

"You've got a waiting-room full of patients," Ginger said. "Thanks to Tom's emergency surgery, you're about two hours behind schedule."

"Any phone messages of import?" Kim asked. He managed to get his jacket hung up and grabbed his short white doctor's jacket.

"Nothing that can't wait," Ginger said.

"No calls from Tracy?"

"No," Ginger said.

"Okay, have Cheryl start moving the patients into the examining rooms," Kim said.

After slipping on the white jacket and collecting the pens and other paraphernalia he kept in his pockets, Kim dialed Tracy 's number. While the call went through. he draped his stethoscope around his neck.

Tracy answered on the first ring as if she were right next to the phone.

"Well, how's the patient doing?" Kim asked. He tried to sound upbeat.

"Not a lot of change," Tracy said.

"Any fever? How about cramps?" Kim asked.

"Some' Tracy said. "But I was able to get her to take some chicken broth."

Kim was tempted to say that Ginger had tried to get her to eat chicken broth on Sunday, but then he thought better of it. Instead he said: "It sounds like you're making progress. I'll bet Becky will be feeling herself in no time."

"I certainly hope so," Tracy said.

"It stands to reason," Kim said. "With no fever and no elevated white count, her body's obviously handled the infection. But keep me posted, okay?"

"I will," Tracy said. Then she added: "I'm sorry if I was mean last night."

"You don't have to apologize," Kim said.

"I feel I said some nasty things," Tracy said. "I was very upset."

"Please," Kim said. "I was the one out of line, not you."

"I'll call if there's any change," Tracy said.

"I'll either be here or at home," Kim said.

Kim hung up the phone. For the first time all day he felt relatively content. Walking out into the corridor, he smiled at Cheryl and took the first chart.

When Kim turned off the headlights of his car in front of his garage door, he found himself in pitch dark. It was only eight o'clock, but it could have been midnight. There was no moon, and the only light was a slight smudge on the eastern horizon, where the city lights reflected off the low cloud cover. The house was so dark it appeared like a hunk of rock.

Kim opened the car door, and the interior lights came on. That gave him an opportunity to collect the cartons of Chinese takeout he'd picked up on the way back from his office. The last patient had left at seven-fifteen.

With his arms full of food containers and paperwork he hoped to complete that evening, Kim made his way from the driveway toward the front door. He had to move by feel along the flagstone walkway. As dark as it was, it was difficult to comprehend that during the summer at that very time of the evening, the sun would have still been in the sky.

Kim heard his phone even before he got to the door. It was jangling insistently in the darkness. Without knowing why, Kim felt a stab of panic. In the process of getting his keys out, he dropped the paperwork. Then he couldn't find the right key, which forced him to put down the food cartons so that he could use both hands. Finally he got the door open and rushed inside.

With the help of the foyer light, Kim dashed into the cavernous, mostly empty living room and answered the phone. He was irrationally terrified that whoever was calling would hang up before the connection went through. But it didn't happen. It was Tracy.

"She's worse," Tracy blurted. She sounded desperate and on the verge of tears.

"What's happened?" Kim demanded as his heart skipped a beat.

"She hemorrhaged," Tracy cried. "The toilet's full of blood."

"Is she lucid?" Kim asked quickly.

"Yes," Tracy said. "She's calmer than I am. She's on the couch."

"Can she walk?" Kim asked. "Is she dizzy?"

"She can walk okay," Tracy said, getting more in control of herself. "I'm glad you answered the phone. I was about to call 911."

"Get her into the car and back to the ER," Kim said. "Provided you think you can drive okay. Otherwise, we can call 911 for an ambulance."

"I can drive fine," Tracy said.

"I'll meet you there," Kim said. He hung up the phone. Then he raced into the library and tore open the central drawer of his desk. Roughly he searched through the contents, looking for his address book. When he found it, he opened it to the T's and ran his finger down until he came to George Turner. Taking out his cell phone, he entered the number and pressed SEND.

With the phone pressed to his ear, Kim retraced his route to the car. He stepped over the Chinese takeout, leaving the cartons and the paperwork strewn over the doormat.

Mrs. Turner answered just as Kim opened the car door. Without any pleasantries, he asked if George were available. By the time George was on the line, Kim was already backing out the driveway.

"Sorry to bother you," Kim said.

"No bother," George said. "What's up? Nothing, I hope."

"I'm afraid so," Kim said. "I mean it's nothing earth-shattering. It's just that Becky's sick with dysentery-like symptoms: cramps, diarrhea, and now some bleeding, but no fever."

"I'm sorry to hear that," George said.

"We never got another pediatrician after you left," Kim explained guiltily. "And the few I knew, including yourself, all left town. Last night we took her to the emergency room at the University Med Center and ended up waiting for three hours."

"God! That's terrible," George said.

"I'm embarrassed to say I punched out one of the AmeriCare administrators over it," Kim said. "Anyway, Becky was sent home with nothing. No medications. Tracy just called me to tell me she hemorrhaged. I don't know how much, but Tracy was a bit hysterical. I'm on my way to meet them at the ER. Who should I have see her?"

"Hmmmm." George intoned. "I don't think a pediatrician would be best. I guess I'd recommend either an infectious-disease specialist or a GI person."

"Well, which?" Kim asked. "And would you recommend one? The consults I deal with don't see kids as a rule."

"You've got a lot of superb people," George said. "I guess I'd recommend an infectious-disease guy, at least initially. Try to get Claude Faraday. You can't do better than Claude anyplace."

"Thanks, George," Kim said.

"My pleasure," George said. "Sorry I'm not around."

"Me too," Kim said.

"Keep me posted," George said.

"I will," Kim said.

Kim disconnected, then used speed-dialing to get the hospital. He had the hospital operator patch him through to Claude Faraday. To Kim's relief, the man was at home.

Kim explained the situation much as he did to George. Claude listened, asked a few pertinent questions, and then graciously agreed to come to the ER directly.

Kim pulled into the hospital. On this occasion he drove directly around to the parking area reserved for the emergency room. He looked briefly for Tracy 's Volvo. When he didn't see it, he went up the steps to the ER platform and pushed inside.

The emergency room appeared to Kim nearly as busy as it did the night before, although he saw some empty chairs in the waiting room. He bypassed the reception and went directly to the nurses' desk. Both Molly and Monica happened to be sitting there as he came in. They exchanged nervous glances.

"Has my daughter come in yet tonight?" Kim asked.

"I haven't seen her." Molly said. She seemed disinterested and a tinge wary at the same time.

"Nor I," Monica said.

"Is she supposed to come in again?" Molly asked.

Kim didn't bother to answer. He left the desk and headed directly back into the emergency room proper.

"Hey, where are you going?" Molly demanded. She stood up with the idea of coming around the edge of the desk to bar Kim's passage as she'd done the previous night, but Kim was already beyond. Molly hurried after him.

Monica snapped her fingers to get the security man's attention. When he looked over, she pointed frantically at Kim's disappearing figure. The security man nodded and started after him as well. As he trotted, he slipped his two-way radio out from its holster.

Kim walked the length of the first room, sticking his nose into each cubicle as he went along. Molly caught up to him. "Just what do you think you are doing?" she demanded.

Kim ignored the woman, who was joined by the security man. They trailed after Kim. "What should I do?" the security man asked Molly. "I mean, he is a doctor."

"I haven't the slightest idea," Molly said.

Kim ran out of cubicles on one side of the room and started on those on the opposite side. Finally he found David Washington suturing a laceration on a child's hand. A nurse was assisting him. David was wearing two-plus oculars, and he regarded Kim over the top of them.

"My daughter's on her way in," Kim announced. "Now she's apparently passing frank blood."

"I'm sorry to hear that," David said. "What's her blood pressure and pulse?"

"That I don't know," Kim said. "My ex-wife is bringing her in. I haven't seen her yet."

With his sterile, gloved hands raised in the air, David turned to Molly and asked her to get a mom ready with a crash cart and plasma expanders in case they were needed. Molly nodded and disappeared.

"I want my daughter seen immediately," Kim ordered. "And I want her to have an infectious-disease consult."

"Dr. Reggis," David said. "Let's try to be friends. It would help if you recognize I'm in charge here,"

"I've already talked with Dr. Claude Faraday," Kim said as if he'd not heard David. "He's on his way. I presume you know him?"

"Of course I know him," David said. "That's not the point. The usual protocol is for us to order the consults if the patient does not have an AmeriCare gatekeeper. AmeriCare is very clear on this issue."

"I want Dr. Faraday to see her," Kim averred.

"All right," David said. "But at least understand we are doing you a favor. This is not the way things are usually done here."

"Thank you," Kim said. He turned and walked back the length of the room. He scanned the reception area, and when he didn't see Tracy and Becky he went out onto the receiving platform. He stood waiting just as he'd done the evening before.

He didn't have long to wait. Within minutes Tracy 's station wagon appeared and drove practically up to the platform itself. Kim jumped down and was at the back door by the time Tracy was pulling on the emergency brake.

He opened the door and leaned in. Becky was lying on the backseat on her side. Kim could see her face with the help of the floodlights on the receiving platform. Although she appeared pale, she smiled at him, and he felt relieved.

"How do you feel, Pumpkin?" Kim asked.

"Better now," Becky said. "The cramp went away."

"I'm glad," Kim said. "Come on, let me carry you."

"I can walk," Becky said.

"I'll carry you just the same," Kim said.

He got his right arm under her knees and slid her out so that he could get his left arm under her upper body. He hoisted her up. She put her own arms around his neck and buried her face under his chin.

"Okay," Kim said soothingly. "Daddy has you."

"She's not too heavy, is she?" Tracy asked.

"Not at all," Kim said.

Kim led the way: first up the stairs and then bucking through the swinging doors. As he walked past reception with Tracy directly behind him, one of the clerks called out that they had to check-in. Kim ignored her. Although Tracy felt uncomfortable, she didn't say anything.

Monica was sitting at the nurses' desk when she heard the clerk call out. Looking up, she saw Kim approaching. Immediately she leaped to her feet and stepped into the hall to bar the way. But she was not Molly.

"No, you don't," Monica said. "You're not bringing that child in without a sign-in sheet."

Kim continued walking. Monica took several steps backward. "You can't do this," she protested.

Tracy tugged on Kim's arm. "Let's not have a scene," she said.

Relentless as a steamroller, Kim continued forward. Monica did not have Molly's bulk and was forced to the side.

"You can get the information from last night's sign-in sheet," Kim called over his shoulder.

Monica rushed back into the desk area to page David Washington.

Kim carried Becky into the first available cubicle. He laid her on the gurney. Tracy came in to stand on the opposite side and hold Becky's hand. Kim took the blood-pressure cuff and wrapped it around her other arm. Monica reappeared after putting in her page and tried to take over, but Kim would not hear of it. He put a stethoscope in his ears and started to inflate the cuff.

David Washington and Molly McFadden entered. David had a white jacket thrown over his scrubs. He nodded a greeting to Tracy and waited for Kim to finish taking the blood pressure. He also motioned to Monica that she could leave.

"You have no respect for protocol," David commented as Kim took the stethoscope from his ears.

"Her blood pressure is ninety over fifty," Kim said. "Let's get an IV going. I want her typed and cross-matched just in case. Also…"

"Hold up!" David yelled. raising his hand for emphasis. Then in a calm voice he added: "Dr. Reggis, with all due respect, you've already forgotten that you are not in charge here."

"I'm just covering the basics," Kim said. "Miss McFadden, how about getting me a twenty-one-gauge catheter, and I'll need a tourniquet and some tape."

David motioned for Molly to stay where she was, while he went up to Kim. He wrapped one of his sizable hands around Kim's forearm.

"I'm only going to ask you once," David said in his calm but commanding voice. "I want you to walk out of here and wait outside. It's in your daughter's best interest. I'm sure that if you just stop and think for a moment, you'll understand."

Kim's eyes narrowed as he stared at David. Slowly he looked down at David's hand clasped around his arm. For a moment no one said a word. The only sound came from a cardiac monitor in another cubicle.

Tracy sensed the electricity in the air. For her it was like the explosive calm just prior to a sudden summer thunderstorm. To avert an undoubtedly unpleasant scene, she dashed around the foot of the gurney and put her arm over Kim's shoulder and tugged on him. "Please, Kim!" she pleaded. "Let's let them do their thing."

Gradually Kim responded to Tracy 's urging, and he visibly relaxed a degree. David took his hand away.

Kim nodded to Tracy. "Okay," he said. Then, turning back to Becky, he gripped her tiny arm. "Daddy will be right outside, Pumpkin."

"I don't want any needles," Becky said plaintively.

"They want to give you some fluid," Kim said. "But it will be only one stick. It will be over in a second. I know it's no fun, but you've got to be strong so you can get back to normal. Okay?"

"Okay," Becky said reluctantly.

Tracy gave Becky's hand a squeeze and told her that she would be with Kim and that they would be back in to see her in a few moments. Becky nodded but she clearly wasn't happy. She looked scared.

Tracy followed Kim out through the curtain surrounding Becky's gurney. She could hear that he was breathing fast. She didn't say anything until they had passed the nurses desk.

"Kim, you have to calm down," Tracy said. She put her hand gently on his arm. "You're so tense."

"David Washington drives me up a wall," Kim snapped.

"He's doing his job," Tracy said. "If the situation were reversed and you were taking care of his child, I'm sure you'd act the same way he has. You wouldn't want him giving orders."

Kim pondered this as he pushed through the swinging doors to the outside. The blast of cold air felt good on his face. He stopped on the platform and took a deep breath. He slowly let it out. Tracy still had a hold of his arm.

"I guess you're right," he said finally. "It's hard for me to see Becky lying there and so vulnerable."

"I can imagine," Tracy said. "It must be very difficult."

Their eyes met.

"You can understand?" Kim asked. "Seriously?"

"Absolutely," Tracy said. "You're a surgeon. You are trained to act. And who would you want to take care of more than your own child. For you the hardest thing in the world is to see Becky in need and not do something."

"You're right," Kim said.

"Of course I am," Tracy said. "I'm always right."

In spite of himself, Kim smiled. "Now, I'm not going to go that far. Frequently maybe, but not always!"

"I'll accept that, provided we go back inside," Tracy said with a smile. "I'm freezing."

"Sure, I'm sorry" Kim said. "I just needed a breath of cold air."

"Does the IV bother you?" Kim asked Becky.

Becky raised her left hand which was taped to a flat wristboard. A length of clear plastic tubing dove into the gauze covering the back of her hand. "I can't feel it at all," she said.

"That's the way it's supposed to be," Kim said.

"Does it feel cold?" Tracy said. "That's what I remember when I was in the hospital having you."

"It does feel cold!" Becky remarked. "I didn't know it until you said it. My whole arm is cold."

David had carefully examined Becky, had started the IV, had done routine bloodwork and urinalysis, and had a flat plate and an upright X-ray taken of her abdomen. Although he'd yet to see the X-rays since they were not yet available, the blood and urine results were all normal, suggesting the blood loss had been minimal. At that point, he'd sent for Kim and Tracy to keep Becky company while they waited for Dr. Claude Faraday.

The infectious-disease specialist arrived a few minutes later. He introduced himself to Kim and Tracy, and then to Becky. He was a slender, dark-complected man with an intense manner. He listened to a full recounting of Becky's problem, from the very first symptoms Saturday morning until the episode of hemorrhage that evening. He nodded every so often, especially when Becky herself added specific details.

"Okay, Miss Reggis," he said to Becky. "Would you mind if I looked you over a bit?"

Becky looked at Tracy as if she had to get permission.

"Dr. Faraday is asking you if it's all right for him to examine you," Tracy translated for Becky.

"It's okay," Becky said. "I just don't want any more needles."

"No more needles," Claude assured her.

Claude started his rapid but thorough examination by feeling Becky's pulse and checking the turgor of her skin. He looked into her mouth and ears. He used an ophthalmoscope to peer into her eyes. He listened to her chest and checked her skin for rashes. He gently poked into her abdomen, which was tender. He searched for enlarged lymph nodes.

"You seem okay to me, except for that slightly sore belly," he said at last. "Now, I'm going to step outside and talk to your parents. Okay?"

Becky nodded.

Tracy leaned over and gave her daughter a kiss on the forehead before following Claude and Kim out through the curtain. The corridor was busy, so the group drew to the side to avoid the bustle. David happened to see them and walked over. He introduced himself to Claude.

"I was just about to give a summary to the parents," Claude said to David.

"Mind if I listen in?" David asked.

Claude looked at Kim and Tracy.

"That's fine," Tracy said.

"All in all, she looks good to me," Claude began. "She's a little pale, of course, and a bit dehydrated. There's also some generalized abdominal tenderness. Otherwise, on physical exam she's quite normal."

"But the hemorrhage?" Tracy questioned. She was afraid Claude was about to dismiss the case.

"Let me finish," Claude said. "I also went over her laboratory work. Compared to last night, there is a slight drop in her hemoglobin. It's not statistically significant, but in view of the mild dehydration, it might be important, considering the history of the hemorrhage. There's also a slight drop in her platelets. Otherwise, everything is within normal limits."

"What's your presumptive diagnosis?" Kim asked.

"I'd have to say food-borne bacterial illness," Claude said.

"Not viral?" Kim asked.

"No, I think it's bacterial," Claude said. He looked at David. "I believe that was your feeling last night as well, wasn't it?"

"Yes it was," David said.

"But why no fever?" Kim asked.

"The fact that there has been no fever makes me think this has been more a toxemia than an infection," Claude said. "Which also goes along with the normal white count."

"What about last night's culture?" Kim asked. "Is there a preliminary twenty-four-hour reading?"

"I didn't see a culture," Claude said. He looked at David.

"We didn't do a culture last night," David said.

Kim shook his head in disbelief. "What the hell are you talking about?" he demanded. "I even gave you the sample."

"We don't do routine stool cultures for simple diarrhea here in the ER," David said.

Kim slapped his hand to his forehead. "Wait a sec! You just said you'd made a presumptive diagnosis of a bacterial infection. Why wouldn't you do a culture? It just stands to reason, much less being good medicine. How else could you treat rationally?"

"AmeriCare utilization rules proscribe routine cultures in this kind of case," David said. "It's not cost-effective."

Kim's face reddened. Tracy was the only one who noticed. She reached out and gripped Kim's arm. He pulled it free. "Cost-effective! What kind of screwball excuse is that? What the hell kind of emergency room are you running here? You're telling me that to save a few measly dollars you failed to do a culture?"

"Listen, you prima donna," David snapped. "I just told you, it's standard operating procedure not to do them. Not for you, not for anybody."

Losing control as he'd done the night before, Kim grabbed David by the lapels of his white jacket. "Prima donna, am I? Well, your goddamn screwed-up operating procedure has lost us a whole damn day!"

Tracy grabbed Kim's arm. "No, Kim!" she cried. "Not again!"

"Take your hands off me, you arrogant son-of-a-bitch," David growled.

"Calm down!" Claude said as he insinuated himself between the two much larger men. "It's okay. We'll run some cultures stat. We haven't lost that much, because I doubt we'd treat anyway."

Kim let go of David. David smoothed his jacket. Each man glared at the other.

"What would you expect to see in the culture?" Tracy asked, hoping to defuse the situation and get the conversation back on track. "What kind of bacteria do you think is involved'?"

"Mainly salmonella, shigella. and some of the newer strains of E. coli," Claude said. "But it could be a lot of other things as well."

"The blood scared me," Tracy said. "I guess it looked like more than it was. Will she be admitted?"

Claude looked at David. "It's not a bad idea," he said. "But it's not my call."

"I think it is a good idea," David said. "She needs fluids. Then we can evaluate the possibility of anemia and make sure there's no more bleeding."

"What about antibiotics?" Tracy asked.

"I wouldn't recommend it," Claude said. "Not at this juncture. Not until we have a definitive diagnosis."

"Which is why the goddamn culture should have been done last night!" Kim growled.

"Please, Kim!" Tracy urged. "We have to deal with the current situation. It would be nice if you'd try to be helpful."

"All right," Kim said resignedly. "If we don't have a culture, why not use a broad-spectrum antibiotic. It can always be changed once the organism and its sensitivities are known."

"It would not be my recommendation," Claude repeated. "If the offending agent turns out to be one of the aberrant strains of E. coli. antibiotics can make the situation worse."

"Now, how can that be?" Kim said. "That's ridiculous."

"I'm afraid not," Claude said. "Antibiotics can decimate the normal flora and give the renegade E. coli more room to flourish."

"Will she be admitted to your care?" Tracy asked Claude.

"No, that's not possible," Claude said. "AmeriCare requires a gatekeeper. But I'll be happy to look in on her, especially if whoever handles the case requests an infectious-disease consult."

"Since Becky does not have a staff pediatrician, she'll be admitted under the care of Claire Stevens," David said. "It's her rotation. I can give her a call."

"You can't do much better than Claire," Claude remarked.

"You know her?" Tracy asked.

"Very well," Claude said. "You're lucky it's her rotation. She takes care of my kids."

"Finally something seems to be going right," Kim said.