by Kate Hardy
So it was better not to let his thoughts even go there. Whatever his libido might like to hope, it wasn’t going to happen.
* * *
Georgie had a case that worried her. Baby Jasmine was a day and a half old, and had been feeding well so she’d gone home with her mum the day before; but, unlike most newborns, she’d slept completely through the first night. This morning she was lethargic, not opening her eyes. When the midwife arrived for her follow-up visit, Jasmine still wouldn’t feed and then she started trembling. On the midwife’s advice, Jasmine’s parents had brought her straight into the paediatric assessment unit at St Christopher’s.
Small babies could get very sick, very quickly; and Georgie really wasn’t happy when she noticed Jasmine’s breathing becoming more rapid.
It could be dehydration, it could be a blood sugar level problem, or it could be a virus. But, most importantly, she needed to keep Jasmine’s breathing supported. She called up to the special care baby unit to get Jasmine ventilated and monitored, and ordered a battery of tests.
But later that morning all the tests came back clear. No dehydration, no blood sugar problems, and none of the other obvious things.
What was she missing? Some kind of allergy, perhaps?
She really needed input from someone with more experience. Even though the person she needed help from wasn’t the easiest to deal with, her patient’s needs came first. So she went to find Ryan in his office. ‘Dr McGregor, do you have a moment, please?’
He looked up from his desk. ‘What can I do for you?’
‘I’ve got parents in with a very sick baby and I can’t work out what’s wrong. As you have more experience than I do, I was hoping you might see what I’m missing,’ she said.
He nodded. ‘Run me through it.’
She explained Jasmine’s symptoms. ‘I’ve got her on prophylactic antibiotics, in case it’s a bacterial infection, but the SCBU says she’s unresponsive, her face is swollen, she’s deteriorating, and there just doesn’t seem to be a reason for it because all the tests have come back clear.’
‘A swollen face,’ he said thoughtfully. ‘Given that she’s a newborn and there’s progressive lethargy, it might be a urea cycle disorder. It’s pretty rare—maybe one in a hundred thousand babies suffer from it, so that’d be six or seven each year in the UK—but try checking her for argininosuccinic aciduria.’
‘So get her blood tested for ammonia?’ she asked. At his nod, she added, ‘I’m on it. Thanks.’
‘Let me know how it goes,’ he said. ‘And it’s nearly lunchtime, so would you like to grab a sandwich with me?’
That was the very last thing she’d expected. He’d done his best to avoid her at the cottage. Had he had some kind of sea-change and decided to make her feel welcome in Edinburgh? Or was this the real Ryan, the man she hadn’t met yet—the man Parminder had said all the team adored?
She decided to give him the chance. ‘If you could tell me everything you know about argininosuccinic aciduria, then yes, please,’ she said. ‘Otherwise, I’ll be spending my lunchtime online, researching it.’
‘Come and get me when you’ve ordered the tests,’ he said. ‘You’ve enough time for a sandwich and coffee before the results come back, and I’ll fill you in.’
She sorted out the tests, then went to the canteen with him.
‘How are you settling in, other than having a case that would make anyone panic slightly?’ he asked.
‘OK. I’m starting to understand more of the accent up here, provided I can persuade people to slow down a bit when they talk.’ She gave him a rueful smile. ‘And I think I’m going to have to learn a lot about football.’
He grinned, surprising her—and she was also shocked to feel as if her heart had just done an anatomically impossible somersault. When he was nice, he was very nice indeed. Then again, she knew his flip side: Grumpy McGrumpface.
Behave, she told her libido silently. He’s off limits.
‘Be very careful about which team you pick,’ he said.
‘London?’ she asked hopefully.
He laughed. ‘Which gives you at least fifteen to choose from.’
‘I think,’ she said, ‘I’ll have to find a list of them and toss a coin.’ And she needed to concentrate on work, before her libido got the chance to have control of her tongue and came out with something inappropriate. ‘So can you run me through argininosuccinic aciduria?’
‘It’s an autosomal recessive trait where the child lacks the enzyme argininosuccinic lyase,’ he said, ‘so that means either both her parents are carriers, or one of them maybe has the late onset form.’
‘So between them they would have a one in two chance of a child being a carrier, a one in four chance of the baby having the condition, and a one in four chance of the baby not being affected at all,’ she said.
He nodded. ‘Symptoms usually start at birth, but might not be noticed for a few days. If it’s less severe, it might start later in childhood or even adulthood. The lack of the enzyme causes excess nitrogen in the blood, in the form of ammonia.’
‘Which damages the central nervous system. So that’s why she’d be lethargic, refusing to eat, and her breathing’s too fast,’ Georgie said thoughtfully.
‘I’d check her liver, too,’ he said. ‘And there’s also a risk of neurological damage.’ He paused. ‘If it is argininosuccinic aciduria, would you like me to talk to the parents with you?’
‘As I’ve never come across a case before, yes, please,’ she said.
‘I’ve only seen one case,’ he said, ‘when I was a student. But the baby was fine and he still comes in to see us regularly, so that should help reassure Jasmine’s parents.’
‘Is there a support group?’ she asked.
‘Yes, so we can give her parents the details.’
‘Thank you.’ She finished her coffee. ‘Sorry to be rude, but I’d better get back. I won’t be happy until I get those test results.’
The results provided the answer: there were indeed raised levels of ammonia in Jasmine’s blood. Georgie went to the SCBU to update them and start treatment for Jasmine, then went to find Ryan. ‘Thank you. Your diagnosis was spot on,’ she said.
‘Let’s go and see her parents,’ he said.
She introduced him to Jasmine’s parents. ‘Dr McGregor’s the acting consultant in the department, and thankfully he’s seen a case like Jasmine’s before, so he was able to suggest different tests and we know what’s wrong now,’ she said.
‘So is she going to d—be all right?’ Jasmine’s dad corrected himself, looking anxious.
It was the big fear of every parent with a newborn, and her heart went out to him.
‘We’re treating her now, so hopefully she’ll start turning a corner today,’ Ryan said reassuringly.
‘So what’s wrong with her?’ Jasmine’s mum asked.
‘It’s something called argininosuccinic aciduria,’ Georgie said. ‘It’s caused by an enzyme deficiency.’
‘When your body digests protein, the protein is broken down by enzymes into amino acids, and some of the acids turn into ammonia,’ Ryan explained. ‘Usually ammonia is excreted from the body when you urinate, but the enzyme deficiency means that Jasmine’s body can’t do that so the ammonia builds up in her blood.’
‘Can you treat it?’ Jasmine’s mum asked.
‘Yes. She’s still very poorly and it’s going to take a couple of weeks before she’ll be able to come home again,’ Georgie said, ‘but we know what it is now, so we can give her the right treatment.’
‘First of all, we need to filter her blood to get rid of the ammonia,’ Ryan said, ‘and then we need to find the right balance of milk protein feeds and medication to keep her ammonia levels under control.’
‘And she’ll be all right?’ Jasmine’s dad asked.
‘There ca
n be complications, but she should be fine,’ Ryan said.
‘Argin—’ Jasmine’s mum shook her head.
‘Argininosuccinic aciduria,’ Georgie repeated.
‘I’ve never heard of it,’ Jasmine’s mum said.
‘It’s rare—about one in a hundred thousand babies get it—but there are children living perfectly normal lives with the same condition,’ Ryan reassured her. ‘When I was a student, I treated a baby with it here, and he’s doing just fine. He’s at high school now.’
‘Is there a family history of any urea cycle disorders for either of you?’ Georgie asked.
Jasmine’s dad shook his head. ‘Not that I know of—though my parents had a little boy about six years before I was born, and he died when he was a couple of days old. They thought it was cot death.’ His face filled with terror. ‘Oh, no. Does this mean he had the same thing that Jasmine has, this argino thing?’
‘It’s a possibility,’ Georgie said, wanting to reassure him, ‘but the difference is that we know what it is, so we’re treating her and she’s not going to die. If your brother had it, it sounds as if nobody picked up on it and he didn’t get treatment.’
Jasmine’s mum looked awkward. ‘I’m adopted, so I don’t know if there’s anything in my blood line. I’m not in touch with my birth family.’
Georgie squeezed her hands. ‘It’s fine. We can offer you some tests to see if either of you is a carrier or has a problem with the enzyme, and if that’s the case then if you have more children we’ll know to test the baby straight after the birth.’
‘I’m just so...’ Jasmine’s mum dragged in a breath to cut off the words.
‘Of course it’s scary,’ Georgie said. ‘She’s a day and a half old. But she’s in the right place and you both did all the right things. You brought her here in good time.’
‘We’re giving her the right treatment and we’re expecting a good outcome,’ Ryan said, ‘but I do need to tell you that sometimes argininosuccinic aciduria can cause neurological damage. Right now it’s early days so we can’t give you a definitive answer, but it might be that because of what’s happened Jasmine takes a little bit longer than average to reach the baby milestones—rolling over, sitting up, that sort of thing.’
‘But we’re keeping a very close eye on her,’ Georgie said. ‘Once we’ve got her stabilised, we can work with a dietician to find out the right amounts of protein and medication she needs. You can give her the medicine with an oral syringe, just as you would with infant paracetamol. Though you’ll need to monitor every single thing she eats, and she’ll need regular follow-up appointments as she grows to make sure that she’s still getting the right amount of protein and medication.’
‘It sounds a bit daunting,’ Ryan added, ‘but it’s workable.’
‘We’ll do everything we need to, to keep her well,’ Jasmine’s mum said.
‘Everything,’ Jasmine’s dad agreed.
‘That’s great. We can also give you an emergency plan to follow if she picks up a bug that makes her sick or gives her diarrhoea, which will obviously affect what she eats and how her body processes it,’ Georgie said. ‘The main thing is, you’re not alone. We’re here, and we can put you in touch with a support group so you can talk to other parents whose families have been through exactly what you’re all going through, and they can reassure you and give you practical advice.’
‘We really appreciate that,’ Jasmine’s mum said. ‘So can we see her now?’
‘Of course you can. She’s got a lot of tubes and cannulas in,’ Georgie said, ‘but you can sit by her and talk to her and stroke her head and hold her hand. I know it’s not quite the same as cuddling her, but she’ll know you’re there and it’ll comfort her.’
‘And our nurses are more than happy for parents to be involved in their babies’ care, so you’ll be able to help with things like washing her face and changing her nappy,’ Ryan added.
‘I’ll take you up and introduce you properly,’ Georgie promised.
‘Thank you,’ Jasmine’s parents said, looking relieved.
‘It looks scarier than it actually is,’ Ryan said. ‘But just remember that Jasmine will get a little bit better every day. Before you know it, she’ll be back home.’
* * *
Georgie popped into the special care baby unit after her shift, too, just to see how Jasmine was getting on; and then she drove back to the cottage, pleased that her second day had gone well. Even though it was raining again, everything was fine until she was heading up the track to the cottage; then she felt a jolt, and after that the car started to pull strongly to the left-hand side.
Oh, no.
She was pretty sure that meant the car had a puncture. She’d never actually been in the car with a puncture before. Her dad had shown her how to change a tyre, but that had been years ago and she could barely remember how. The middle of a muddy track, in the rain, when it was starting to get dark and there was no place for anyone to pass her so she was completely blocking the road, wasn’t exactly the best place to change a tyre for the first time.
Not that she had any other options. She’d just have to get on with it.
She stopped the car, put her hazard lights on to warn anyone else who might need to use the track that she was there, and used her phone as a torch so she could inspect the wheels on the passenger side of the car. Just as she’d feared, there was a hole in the front tyre; clearly she’d damaged it when she’d bumped through the pothole. Changing the tyre it was, then.
But, when she looked in the well of the boot, the spare wheel she’d expected to see wasn’t there. All she could see was a repair kit with a compressor and a bottle of goo. According to the packaging, it would act as a temporary repair until she could get the car to a garage or tyre fitter to replace it, as long as the hole in the tyre was less than four millimetres in diameter and the side wall of the tyre was fine. Otherwise the kit wouldn’t work and the tyre would have to be changed.
She went back to measure the hole. Six millimetres. She blew out a breath. Great. The repair kit wouldn’t work and she didn’t have a spare wheel. Now what?
The rain was coming down a lot faster now, and the wind was getting up, driving the rain right into her. She was soaked to the skin—and she was stuck here until she could get that tyre changed.
Shivering, she climbed back into the car. Please let there be a signal for her phone, so she could call a roadside assistance service. She wasn’t sure if they’d come out to people who weren’t actually members, but she hoped at least they’d be able to put her in touch with someone who would come out and help.
Then she noticed the sticker on the corner of the windscreen: it seemed that the hire car came with membership of a roadside assistance service. One hurdle down.
Though her relief was short-lived. When she rang them, they advised that they couldn’t come out to rescue her for three hours.
Three hours.
She was tired, she was wet, she was cold, she was starting to get hungry, and right at that moment all she really wanted was a hot shower and a cup of tea. Clearly she was going to have to wait for a lot longer than she wanted to. But other people had much worse to contend with; she was lucky, she reminded herself, and she had a lot to be thankful for.
A few minutes later, she became aware of headlights travelling up the track behind her, and then she heard the sound of a car horn.
Time to upset the neighbours, she thought ruefully, and jumped out of the car, ready to apologise for the fact that she couldn’t move her car and it was still going to be another couple of hours before the assistance company could rescue her.
Then she recognised the car.
Ryan.
‘Georgie? Are you all right? What’s happened to your car?’ he asked, climbing out of the car to join her.
‘I’ve got a puncture—and the hole’s too big f
or the repair kit to work,’ she said. ‘Sorry, I know I’m blocking the track, but I’m afraid it’ll be another couple of hours before the assistance company can get to me.’
‘Do you want me to change the tyre for you?’ he asked.
‘Thanks for the offer, but there isn’t a spare—just a repair kit,’ she said.
‘Ah, the joys of modern cars.’ He rolled his eyes. ‘Which tyre?’
‘Front left.’
He went to inspect it, then came back. ‘You’re right—the repair kit definitely won’t work on that. Look, I know the track well so I can avoid the pot holes more easily. Do you want me to drive your car back to the cottage for you?’
She bit her lip. ‘Isn’t that going to—well—cause problems with the car if you drive it on a flat tyre?’
‘Not if I take it very slowly and carefully,’ he said. ‘Why don’t I drive it back and you follow me in my car? Then you can wait for the assistance guys at the cottage.’
The offer sounded genuine rather than grudging, and he wasn’t sneering; so it would be sensible to accept. It meant she could have a hot shower and dry clothes and a cup of tea. ‘Thank you. I accept.’ What she really wanted was a hug, but she was pretty sure that asking Ryan for a hug would be a step too far.
Without further comment, he handed her his car keys, then drove her hire car down the track.
Georgie followed him in his car—and discovered that Ryan listened to really loud rock music when he drove. He’d seemed so closed off that she’d expected him to drive in silence, or listen to podcasts on developments in paediatric medicine. But rock music... That was something they had in common, even though she preferred the poppier end of the spectrum. Maybe that would help them connect better and make the house-share easier.
Back at the cottage, she rang the assistance company to tell them she’d moved the car. When she came downstairs from the shower, Ryan was standing by the kettle.
‘Thank you for rescuing me,’ she said.