The ambulance attendants wheeled in a gurney bearing five-year-old Drew Harrison, straps across his blue Star Trek pajamas securing him to a spinal board, his head between padded blocks, a C collar stabilizing his neck. Shrouded in fear, Sarchi rushed to his side and cupped his cheeks in her hands. “Baby, it’s Aunt Sarchi. Everything’s going to be fine. Don’t be scared. I’ll take care of you.”
“His vitals are basically fine,” one of the ambulance attendants said. “He’s just limp. Can’t stand or move his major muscle groups. His airway is clear, and, as you can see, he can breathe on his own. And he can swallow okay.”
Sarchi raised Drew’s limp arm a few inches and let go. It flopped back onto the gurney. Probing his arms with her fingers, she found the flesh abnormally compliant, indicating he had lost muscle tone as well as voluntary motion. She slipped her finger into Drew’s hand and curled his fingers around it. “Drew, baby, try to squeeze my finger.”
Nothing happened.
“Can you hear me, Drew?”
His eyes appeared to respond, but he made no attempt to speak. “If you can hear me, Drew, blink your eyes twice.”
Drew’s lids closed and opened twice in rapid succession.
“Squeeze my finger, Drew.”
Nothing.
She felt his legs and noted the same loss of tone there. An inventory of his reflexes with her tapping hammer produced no response. She lifted his right leg and stroked the sole of his foot with the edge of a tongue depressor. Again, there was no reaction.
“Let’s get him out of the hallway,” Kornberg said, grabbing hold of the gurney.
They wheeled Drew into an examining room where, as soon as the gurney stopped moving, Sarchi reached for an ophthalmoscope and looked into his eyes. Thankfully, his pupils were of equal diameter and reactive to light. There was also no papilledema—protrusion of the optic nerve into the eye—which would have indicated a buildup of cranial pressure.
Although Drew appeared to be paralyzed over a large part of his body, Sarchi had seen him move his eyes. She now tested the extent of that ability by asking him to track her finger as she moved it from side to side, then from corner to corner.
All those movements were intact.
From the moment she’d received Marge’s call, Sarchi’s heart had been hammering in her ears. Now, because of the obvious severity of Drew’s condition, she was fighting panic. Kornberg was great at stabilizing patients who were crashing, but he wasn’t someone to turn to in a situation like this. For now, it was all on her shoulders.
And the burden was huge, not just because Drew was her nephew and she loved him fiercely, but because she hadn’t taken him when Carolyn died. With Bill’s parents too infirm physically to care for a child, and her father’s mental state deteriorating, Sarchi had been the logical choice. But she’d procrastinated over the decision, stalled by being a medical student with no time for herself, let alone a child. And there was the matter of money. Carolyn and Bill were just getting started and had left more debts than assets. So there was no money for Drew from their estate. How could someone existing on student loans and already tens of thousands in debt for her education take on the additional financial responsibility of raising a little boy?
Then Marge, Carolyn’s best friend, had stepped forward, taking the pressure off Sarchi. For a while, Drew’s new parents seemed the ideal solution, but then, with Marge’s divorce, she became a single mother struggling with her own finances. The whole episode had left Sarchi with a smoldering sense of guilt. Now she held Drew’s life in her hands. She just couldn’t fail him again.
Stay calm, she thought. Use your training.
“Drew honey, can you talk?”
Once again he just looked at her without speaking.
“If you can’t talk, blink your eyes twice.”
Still, he just stared back.
Sarchi turned to Marge, who had just joined them. “Has he said anything since it happened?”
“He hasn’t made a sound.”
“Drew, say your name for me.”
No response.
“I’m trying to make you better, Drew. You can help me by saying your name. Will you do that?”
He still seemed to be making no attempt to speak.
Giving up for now on that point, she continued her exam. First, she rechecked Drew’s vital signs and verified that, allowing for the fear he was experiencing, they were all within normal limits, just as the ambulance attendant had said. Over the next few minutes, she determined that his heart rhythm and sounds were normal—no murmurs, gallops, or rubs. The lungs were clear, and the liver and spleen were normal in size. There was no guarding of the abdomen and no tenderness.
“What is it, Sarchi?” Marge said, from the other side of the bed. “What’s wrong with him?” She had obviously been crying, and her eyes were red and swollen. Normally, Marge was beautiful even without makeup. In its absence now, her skin was blotchy and raw.
“It’s too soon to say,” Sarchi replied.
“Doctor Kornberg, we’ve got an asthmatic infant out here who’s in a desperate state,” a second nurse said from the doorway.
“I’ve got to go,” Kornberg said to Sarchi. He touched Marge’s shoulder lightly. “Your son is in excellent hands with Doctor Seminoux.”
Sarchi could not remember when Marge wasn’t in total command of whatever situation arose around her. But tonight, she looked frail and lost.
Speaking to the nurse who’d accompanied the gurney into the room, Sarchi said, “Sallie, let’s get him on the monitors, but turn the sound off so we can talk.” When she’d cupped Drew’s cheeks in her hands, he hadn’t felt hot, but she still added, “And get his temperature.”
Turning to Marge, she gestured toward a couple of nearby chairs. “Come over here and tell me exactly what happened.” Marge took a long look at Drew, then went with Sarchi and sat down.
“I was just reading to him . . . he was next to me on the sofa, alert and interested. Then his chin dropped to his chest and he got limp. I thought he was asleep. But when I picked him up, I saw his eyes were open. But he couldn’t move. What the hell is it?”
“In the last few days, has he fallen and hit his head?”
“Not unless it was at school. But I’m sure they would have told me if something like that happened.”
“Has he been sick . . . fever . . . cough?”
“No.”
“Has he had any blisters lately around his mouth or anywhere else?”
“I haven’t seen any.”
“Any recent immunizations?”
Marge shook her head.
“Vomiting or a rash?”
“No.”
“What did he have for dinner tonight?”
“I made him his favorite . . . spaghetti.”
“How was his appetite?”
“He ate like a little horse.”
“Did you have the same thing?”
“Yes.”
“You haven’t seen any evidence he’s been into the medicine cabinet or any cleaning chemicals?”
“He knows to stay away from those places.”
“Has he been around any animals?” Thinking of cat scratch fever, Sarchi added, “Kittens in particular.”
“Not that I know of. But I suppose some stray cat could have wandered into the backyard. And there are a lot of raccoons in midtown.”
“He’s never out alone after dark?”
“No.”
“Raccoons are nocturnal. It’s not likely he’d encounter one during the day. And I don’t see any fresh scratches on him. I wonder if any of his classmates are sick?”
“I can try to contact his teacher.”
“She could tell us who missed school today, but I’d also like to know i
f any became ill tonight.”
“That’ll be tougher to find out, but I’ll try.”
“If you do reach his teacher, ask her if Drew hit his head anytime in the last day or two. Cell phones aren’t allowed on the ward, but there’s a landline at the nursing station you can use.”
Marge got up to leave but paused and took a long look at her son. Lips trembling, she looked at Sarchi. “He’ll get better, won’t he?”
This part was hard. Without knowing what was wrong, it was impossible to venture a prognosis. But right now, Marge needed support and encouragement, not accuracy. So Sarchi lied. “I’m sure we’ll get to the bottom of this, and he’ll be home in no time, whole and happy.”
Before showing Marge to the phone, Sarchi wrote orders for a battery of blood tests and gave them to the nurse.
The paramedics who’d brought Drew in had correctly treated him as though he might have a broken neck. Fractured vertebrae do not always shift and damage the spinal cord at the time of the bony injury but may do so later. This meant that even though Drew’s paralysis had begun when he was merely listening to a story, a broken neck was certainly a possible, albeit terrible, explanation for his condition. So when Sarchi saw one of the radiology techs at the nurses’ station as she took Marge to the phone, she asked him to move the mobile X-ray unit to Drew’s room and get some neck films.
Then, as difficult as it was to concentrate on another case, she shifted her attention to the asthmatic that had come in. By the time that child was stabilized, and Sarchi had written up the admitting orders allowing him to be sent to the ICU, Drew’s X-rays were waiting for her on the ward computer.
Finding every vertebra intact, she went to Drew’s room and gently removed his C collar, hoping to make him more comfortable. His neck wasn’t broken, but Sarchi’s heart still felt as heavy as a deck plate on the Titanic. Among the many possible diagnoses remaining was some kind of acute encephalopathy, an abnormality in his brain. As hard as she fought it, the image of Gilbert Klyce kept bulling into her mind.
No . . .
That was not going to happen to Drew. She would find the problem and make him better.
She had to.
She just had to.
4
“YOU TOOK OFF his collar,” Marge said.
“His neck is fine, so we don’t need it,” Sarchi replied. “What did you find out?”
“I got hold of the woman who runs Drew’s kindergarten, and she gave me the phone numbers of his teacher and the parents of his classmates. His teacher says she has no knowledge of Drew hitting his head. One of the other kids has a sore throat, but her mother says she gets that every couple of months. None of the others are sick. Where does that leave us?”
Where indeed, Sarchi thought, a dozen possibilities tumbling in her head: Guillain-Barré syndrome, a tumor, cat scratch fever, bacterial or viral meningitis. But the onset was so sudden, and there was no fever. He could have had a stroke, or maybe it was multiple sclerosis. But how often do you see those in a five-year-old? If he’d had an immunization recently, she’d have suspected the disease he was being inoculated against. God knows that’s not unheard of. But he’d had no shots. Possibly some kind of electrolyte imbalance?
“Sarchi, where does that leave us?” Marge repeated.
“We’ll know better when we get the labs.”
“When will that be?”
Sarchi checked the time. “Twenty minutes, maybe.”
“Isn’t there anything we can do now?”
An idea popped into Sarchi’s head. “As a matter of fact, there is. There’s a disease called tick paralysis that lasts as long as the tick is attached and clears up within minutes after its removal.”
Marge’s face lit up. “Do you think that’s what it is?”
Actually, the chances were so remote, Sarchi was sorry she’d given Marge that hope. But it was something to do while waiting for the labs. “Let’s check,” Sarchi said, heading back to Drew’s room.
Sarchi spent the next fifteen minutes searching every inch of Drew’s body for ticks, most of that time prowling through his hair. As expected, she found nothing.
Marge was obviously disappointed.
“You stay here with Drew,” Sarchi said, trying to hide the continuing sense of dread she felt. “I’m going to see if any of the lab results are back.”
There was only so much you could learn from a physical exam. Sometimes it pointed you in the right direction, but often it didn’t. In either case, without the lab, medicine was just a lot of guesswork. So, as she walked to the chart room, Sarchi hoped at least some of the tests were done.
In the chart room, Sarchi sat at one of the computers and logged in her password and Drew’s name. After a short pause, the screen filled with data.
Her eyes hurried down the chem 20 results, looking for aberrant values, but everything was within usual limits. That neither Marge nor any of the other kids in Drew’s school were ill made botulism an unlikely possibility. Even so, she’d ordered a test to determine if the toxin was present in Drew’s blood. It wasn’t.
Moving on to the hematology data, she found Drew’s hematocrit normal. His distribution of white cells, the so-called diff count, was also what you’d expect in a normal, active five-year-old. If he’d had an elevated neutrophil count, it would have suggested a possible bacterial infection. More lymphocytes than normal would have turned her thoughts to a virus. But there was no support for either of those diagnoses. Although the full panel wouldn’t be complete until tomorrow, the preliminary results of the drug screen she’d ordered were negative.
She returned to Drew’s room and relayed what she’d learned to Marge. “All his blood work is normal.” Despite her irritation and disappointment at finding no clue to Drew’s illness in his lab work, she tried to spin it for Marge’s benefit. “So that’s good news.”
Marge’s brow furrowed. “In what way?”
“It narrows the possibilities.”
“To what?”
With Gilbert Klyce constantly hovering on the edge of her thoughts, Sarchi was even more concerned now that Drew’s problem was in his brain. Of all the prognoses a parent might hear from a doctor treating their child, brain damage is one of the most feared. Wanting to spare Marge from the torture that possibility was wreaking in her own head, Sarchi parried the question. “The list is still too long for us to discuss right now.” Seeing from the look on Marge’s face that she didn’t like this answer, Sarchi said, “Instead of talking about a lot of potential explanations, wouldn’t you rather we keep working to find the correct one?”
Unable to fault this logic, Marge nodded. “You’re right.”
“I’m going to have someone else look at Drew,” Sarchi said. “I’ll set it up and come back.”
Sarchi went to the nurses’ station, where Kornberg inquired about Drew’s status.
“So far I’m sucking wind,” Sarchi said. “I need a neurology consult, and then I’m sure we’ll be wanting a CT scan.”
Kornberg reached for the phone. “I’ll take care of it.”
At that moment, Sarchi’s own pager went off. The number displayed was Seven West, the surgical ward. She picked up the other phone and checked in.
As the senior resident on call, she was responsible not just for her own patients, but for every kid in the hospital. Had the call concerned one of hers, she might have been able to handle it without going upstairs. But it was an ulcerative colitis patient from someone else’s service, running a fever. Being unfamiliar with the case, she needed to look over his chart. “I’ve got to go to Seven West. If I’m not back by the time the neurology res gets here . . .”
Kornberg waved her away. “Leave him to me.”
When things would heat up and she barely had a moment to think between patients, Sarchi had often pictured her
self as Lucille Ball working the runaway chocolate line in that classic TV show. Though tonight was relatively slow, her wish to concentrate fully on Drew’s case sent chocolates speeding through her head as she headed up to Seven West.
Upon her return to the ER, she was surprised to find that the neurology resident had yet to show. He finally walked in five minutes later.
Charles Lanehart was old for a resident and overweight, with multiple chins. Rumor was he’d given up a successful law practice for medicine, which seemed to Sarchi an odd decision. “I was just about to page you again,” she said sharply.
Lanehart looked at her with an expression of incredulity. “I’m covering two hospitals tonight. I wasn’t even here when I got the page.”
“Sorry. I’m just particularly worried about this one. It’s my nephew. He’s in here.”
Sarchi led Lanehart to Drew’s room, where he looked at the neck X-rays and conducted pretty much the same examination she had. When he was finished, Sarchi gave Marge a reassuring squeeze of the hand and went into the hall with Lanehart to hear his views on the case.
“I don’t know if he can’t talk or just won’t, but assuming it’s the former, it looks like locked-in syndrome to me.”
“What’s that?”
“Destruction of the major motor pathways in the basilar pons.”
“From what cause?”
“Hard to say, a bleed maybe. We need a CT scan. I’ll make the arrangements.”
“I told Kornberg we’d be wanting one, so the tech should be waiting.” Sarchi went back to Drew’s room to find Marge pacing. “We’re going to give Drew a CT scan.”
“Why?”
Seeing what was coming, Sarchi tried to avoid it by a judicious use of words. “So we can get a direct look inside his head.”
“You think something’s wrong with Drew’s brain?” Marge asked with terror in her voice.
So there it was, out in the open. She should have known earlier she’d have to admit this possibility eventually. Sarchi put her hands gently on Marge’s shoulder and looked her in the eye. “It’s just a possibility at this point. And even if it is the source of his problem, that’s no reason to become pessimistic about the outcome. We’re going to stay positive. We’re not even going to think anything but complete recovery.”
The Killing Harvest Page 3