Devil's Waltz (2 page)

A door at the rear of the clinic opened to a stairway. We descended to the first basement level. Stephanie moved fast, almost jogging down the steps.

The cafeteria was nearly empty — one orange-topped table occupied by a male intern reading the sports section, two others shared by slumping couples who looked as if they’d slept in their clothes. Parents spending the night. Something we’d fought for.

Empty trays and dirty dishes cluttered some of the other tables. A hair-netted orderly circulated slowly, filling salt shakers.

On the eastern wall was the door to the doctors’ dining room: polished teak panels, finely etched brass nameplate. Some philanthropist with a nautical bent. Stephanie bypassed it and led me to a booth at the far end of the main room.

“Sure you don’t want coffee?” she said.

Remembering the hospital mud, I said, “Already filled my caffeine quota.”

“I know what you mean.”

She ran her hand through her hair and we sat.

“Okay,” she said. “What we’ve got is a twenty-one-month-old white female, full-term pregnancy, normal delivery, APGAR of nine. The only significant historical factor is that just before this child was born, a male sib died of sudden infant death syndrome at age one year.”

“Any other children?” I said, taking out a note pad and pen.

“No, there’s just Cassie. Who looked fine until she was three months old, at which time her mother reported going in at night to check on her and finding her not breathing.”

“Checking because she was nervous about SIDS?”

“Exactly. When she wasn’t able to rouse the baby, she administered CPR, got her going. Then they brought her into the E.R. By the time I arrived she looked fine, nothing remarkable on exam. I admitted her for observation, did all the usual tests. Nothing. After discharge we set the family up with a sleep monitor and an alarm. Over the next few months the bell went off a few times but they were always false positives — the baby was breathing fine. The graphs show some tracings that could be very brief apnea but there are also lots of movement artifacts — the baby thrashing around. I figured maybe she was just restless — those alarms aren’t foolproof — and put down the first episode to some quirky thing. But I did have the pulmonologists look at her because of her brother’s SIDS. Negative. So we decided just to keep a close eye on her during the high-risk period for crib death.”

“A year?”

She nodded. “I played it safe — fifteen months. Started with weekly outpatient checkups, tapered off so that by nine months I was willing to let them go till the one-year exam. Two days after the nine-month checkup they’re back at E.R., middle-of-the-night respiratory problems — the baby woke up gasping, with a croupy bark. More CPR by mom and they bring her in.”

“Isn’t CPR kind of extreme for croup? Did the baby actually pass out?”

“No, she never lost consciousness, just gasped a lot. Mom may have been overreacting, but with her losing the first child, who could blame her? By the time I got to the E.R., the baby looked fine, no fever, no distress. No surprise, either. Cool night air can clear up croup. I ran a chest X-ray and bloodwork, all normal. Prescribed decongestants, fluids, and rest and was ready to send them home but the mother asked me to admit her. She was convinced there was something serious going on. I was almost certain there wasn’t, but we’d been seeing some scary respiratory things recently, so I admitted her, ordered daily bloodwork. Her counts were normal and after a couple of days of getting stuck, she was going hysterical at the sight of a white coat. I discharged her, went back to weekly outpatient follow-up, during which the baby would have nothing to do with me. Minute I walk into the exam room she screams.”

“The fun part of being a doctor,” I said.

She gave a sad smile, glanced over at the food servers. “They’re closing up. Want anything?”

“No thanks.”

“If you don’t mind, I haven’t had breakfast yet.”

“Sure, go ahead.”

She walked briskly to the metal counters and came back with half a grapefruit on a plate and a cup of coffee. She took a sip of the coffee and grimaced.

“Maybe it needs some steamed milk,” I said.

She wiped her mouth with a napkin. “Nothing can save this.”

“Least it doesn’t cost anything.”

“Says who?”

“What? No more free coffee for the docs?”

“Them days are gone, Alex.”

“Another tradition bites the dust,” I said. “The old budgetary blues?”

“What else? Coffee and tea are forty-nine cents a cup now. Wonder how many cups it’ll take to balance the books.”

She ate some grapefruit. I fiddled with my pen and said, “I remember how hard you guys fought to get the interns and residents in on the freebie.”

She shook her head. “Amazing what seemed important back then.”

“Money problems worse than usual?”

“Afraid so.” She frowned, put her spoon down and pushed the grapefruit away. “Anyway, back to the case. Where was I?”

“The baby screaming at you.”

“Right. Okay, again things start to look good, so again I taper off and terminate, set up an appointment in two months. Three days later, back in the E.R., two
A
.
M
. Another croup thing. Only this time the mother says the kid
did
pass out — actually turned blue. More CPR.”

“Three days after you terminated,” I said, making a note. “Last time it was two.”

“Interesting, huh? Okay, I do an E.R. checkup. The baby’s blood pressure is up a bit and she’s breathing rapidly. But getting plenty of oxygen in. No wheeze, but I was thinking either acute asthma or some sort of anxiety reaction.”

“Panic at being back in the hospital again?”

“That, or just the mother’s distress rubbing off on her.”

“Was the mother showing a lot of overt distress?”

“Not really, but you know how it is with mothers and kids — the vibes. On the other hand, I wasn’t ready to rule out something physical. A baby passing out is something to take seriously.”

“Sure,” I said, “but it could also have been a tantrum gone too far. Some kids learn young how to hold their breath and pass out.”

“I know, but this happened in the middle of the night, Alex, not after some power struggle. So I admit her again, order allergy tests, complete pulmonary functions — no asthma. I also start thinking of rarer stuff: membrane problems, an idiopathic brain thing, an enzyme disorder. They’re up on
Five
for a week, real merry-go-round, consults by every specialty in the house, lots of poking and probing. Poor little thing’s freaking out as soon as the door to her room opens, no one’s coming up with a diagnosis, and the whole time she’s in, there are no breathing difficulties. Reinforcing my anxiety theory. I discharge them and the next time I see them in the office, I do nothing but try to play with her. But she still won’t have anything to do with me. So I gently raise the anxiety issue with mom but she’s not buying.”

“How’d she take that?” I said.

“No anger — that’s not this lady’s style. She just said she couldn’t see it, the baby being so young. I told her phobias could occur at any age, but I clearly wasn’t getting through. So I backed off, sent them home, gave her some time to think about it. Hoping that as the baby approached one year and the SIDS risk dropped, mom’s fears would diminish and the baby would start to relax too. Four days later they were back in the E.R., croup, gasping, mom’s in tears,
begging
for an admit. I put the baby in but ordered no tests. Nothing even remotely invasive, just observation. And the baby looked perfect — not even a sniffle. At that point I took the mom aside and leaned more heavily on the psychological angle. Still no sale.”

“Did you ever bring up the first child’s death?”

She shook her head. “No. I thought of it but at the time it just didn’t seem right, Alex. Overloading the lady. I figured I had a good feel for her — I was the attending doc when they brought the first child in dead. Handled the whole post-mortem… I carried him to the morgue, Alex.”

She closed her eyes, opened them but focused away from me.

“What hell,” I said.

“Yeah — and it was a chance thing. They were Rita’s private patients, but she was out of town and I was on call. I didn’t know them from Adam but I got stuck doing the death conference, too. I tried to do some basic counseling, gave them referrals to grief groups, but they weren’t interested. When they came back a year and a half later, wanting me to take care of the
new
baby, I was really surprised.”

“Why?”

“I would have predicted they’d associate me with the tragedy, a kill-the-messenger kind of thing. When they didn’t, I figured I’d handled them well.”

“I’m sure you did.”

She shrugged.

I said, “How’d Rita react to your taking over?”

“What choice did she have? She wasn’t around when they needed her. She was going through her own problems at the time. Her husband — you know who she was married to, don’t you?”

“Otto Kohler.”

“The famous conductor — that’s how she used to refer to him: ‘My husband, the famous conductor.’ ”

“He died recently, didn’t he?”

“Few months ago. He’d been sick for a while, series of strokes. Since then, Rita’s been gone even more than usual and the rest of us have been picking up a lot of the slack. Mostly, she attends conventions and presents old papers. She’s actually going to retire.” Embarrassed smile. “I’ve been considering applying for her position, Alex. Do you see me as a division head?”

“Sure.”

“Really?”

“Sure, Steph. Why not?”

“I don’t know. The position’s kind of… inherently authoritarian.”

“To some extent,” I said. “But I’d imagine the position can adapt to different styles of leadership.”

“Well,” she said, “I’m not sure I’d make a good leader. I don’t really like telling people what to do…. Anyway, enough about that. I’m getting off track. There were two more passing-out episodes before I brought up the psych thing again.”

“Two more,” I said, looking at my notes. “I’ve got a total of five.”

“Correct.”

“How old’s the baby by now?”

“Just under a year. And a hospital veteran. Two more admits, negative for everything. At that point I sat mom down and
strongly
recommended a psych consult. To which she reacted with… here, let me give you the exact quote.”

She opened the chart and read softly: “‘I know that makes sense, Dr. Eves, but I just
know
Cassie’s sick. If you’d only seen her — lying there, cyanotic.’ End of quote.”

“She phrased it that way? ‘Cyanotic’?”

“Yup. She has a medical background. Studied to be a respiratory tech.”

“And both her kids stop breathing. Interesting.”

“Yes.” Hard smile. “At the time I didn’t realize how interesting. I was still caught up in the puzzle — trying to arrive at a diagnosis, worrying when the next crisis was going to be and if I’d be able to do anything about it. To my surprise it didn’t happen for a while.”

She looked at the chart again. “A month passes, two, three, still no sign of them. I’m happy the baby’s okay but I’m also starting to wonder if maybe they’ve just found themselves another doc. So I called the home, talked to mom. Everything’s fine. Then I realized that in the heat of everything, the baby had never had her one-year exam. I schedule it, find everything intact, with the exception that she’s a little slow vocally and verbally.”

“How slow?”

“No retardation or anything like that. She just made very few sounds — in fact I didn’t hear anything from her at all, and mom said she was pretty quiet at home, too. I tried to do a Bailey test, but couldn’t because the baby wouldn’t cooperate. My guesstimate was about a two-month lag, but you know at that age it doesn’t take much to tip the scales, and given all the stress the poor thing’s been through, no big deal. But brilliant me. Bringing up language development got mom worried about
that
. So I sent them over to ENT and Speech and Hearing, who found her ears and laryngeal structure one hundred percent normal and concurred with my assessment: possible mild delay in reaction to medical trauma. I gave the mom suggestions about stimulating speech and didn’t hear from them for another two months.”

“Baby’s fourteen months old,” I said, writing.

“And back in the E.R., four days later. But not with breathing probs. This time she’s spiking a temp — a hundred and five. Flushed and dry, and breathing fast. To be honest, Alex, I was almost
happy
to see the fever — at least I had something organic to work with. Then the white count came back normal, nothing viral or bacterial. So I ran a toxicology. Clean. Still, lab tests aren’t perfect — even our error rates are running ten to twenty percent. And that spike was real — I took the temp myself. We bathed her and Tylenoled her down to a hundred and two, admitted her with a fever-of-unknown-origin diagnosis, pushed fluids, put her through some real hell: spinal tap to rule out meningitis, even though her ears were clear and her neck was supple, because for all we knew she had one heck of a headache she couldn’t tell us about. Plus twice-daily bloodwork — she went bananas, had to be held down. Even with that, she managed to dislodge the needle a couple of times.”

She exhaled and pushed the grapefruit farther away. Her forehead had moistened. Swabbing it with a napkin, she said, “First time I’ve told it like this from the beginning.”

“You haven’t had any case conferences?”

“No, we don’t do much of that anymore. Rita’s basically useless.”

I said, “How did the mother react to all the procedures?”

“Some tears, but basically she stayed composed. Able to comfort the baby, cuddling her when it was over. I made sure she never was involved in holding the baby down — integrity of the mother-child bond. See, your lectures stuck, Alex. Of course the
rest
of us felt like Nazis.”

She wiped her brow again. “Anyway, the blood tests kept coming back normal but I held off discharge until she’d had no fever for four days running.”

Sighing, she burrowed her fingers through her hair and flipped through her chart.