Priscilla watched as an Unusual Incident form was filled out. Approximately two cubic centimeters of quinacrine had entered Mindy’s vein instead of her gastrointestinal tract. This kind of thing happened in hospitals. Priscilla had seen it several times before, and that was one reason why she so carefully checked all of the procedures. She knew medical personnel were fallible. But that didn’t help her deal with this mistake despite Dr. Arnhold’s assurance that it was unlikely to cause a problem.
And there was a problem. Mindy had become confused and hysterical. She screamed and struggled and twisted until Priscilla thought her arms would burst with the effort of holding her. Priscilla talked to her and bounced her to no effect. Mindy suddenly started tearing at the dressing over the cut-down in her elbow in an attempt to rip the needle out of her vein. And then she began to pull at the NG tube, fighting it, trying to tear it out.
Finally Priscilla called out for help. Dr. Arnhold was summoned. Priscilla knew him well. He had been the pediatrician for Erik and Jason before he had left the country on a long sabbatical and she had changed to Sara.
“Priscilla, if she doesn’t stop doing that, we’re going to have to tie her down. You know that cut-down is too precious to lose, and her stomach is in no shape to deal with bottle feedings, so we need the NG drip, too. We can’t have her pulling that out.”
Priscilla reacted instantly. “My God, Dr. Arnhold! First you half kill her with the quinacrine in the IV, and now, when she gets upset about it, you want to tie her down?” The tears were tracking unnoticed down her face.
“Well—” began Arnhold.
“I’ll stay with her!” Priscilla interrupted, her voice echoing throughout the ward. “Let me stay with her! I’ll see that she doesn’t pull out the lines!”
“Well, if you think you can, all right,” Arnhold relented. So she had stayed.
Now it was midnight and Mindy was throwing up and stooling and deteriorating noticeably. Finally the nurse phoned the doctor on call. Mindy was ordered NPO. Nil per os. The medical shorthand for nothing by mouth. Even all the medications, for the time being, would be held. The nurse clamped off the NG tube, leaving it in place. NPO was a standard medical procedure for a patient suffering from diarrhea. Tia had once gone for weeks NPO. In Mindy’s case, sometimes it seemed to work to make her NPO, sometimes it didn’t.
This time it was successful. The rest of the night passed without incident. At 6:45 A.M. that Friday morning, just as the day nurses came on shift, Priscilla watched the nurse draw Mindy’s blood to check her electrolytes. This, too, had become regular procedure. Still, Mindy screamed as the needle entered the vein. The night nurse went off duty, and Priscilla fell into Debby Roof’s arms as she came on the ward to start her shift. Priscilla had not talked to Debby since the birthday lunch the day before. She told Debby all about the wrong medication and the change in Mindy’s treatment. How she had fought to keep Arnhold from tying Mindy down. About Mindy’s deterioration.
“This is just like it was with Tia,” she sobbed. “It’s happening again, and I can’t control it, or stop it. And Sara’s worried now. I can tell!”
“But Mindy’s better, Priscilla,” Debby protested. “See, she hasn’t had any stool since she was made NPO. It’ll be all right.”
At eight-thirty, Mindy’s NG tube was unclamped and the formula drip resumed. She was given another dose of cholestyramine through the tube. It might help prevent the diarrhea.
Priscilla, as she customarily did after spending a night at the hospital in her clothes, went home for breakfast and to change.
“I’ll be back later,” she promised Debby.
7
At five-thirty that Friday afternoon, Dr. Sara Shimoda planned to meet with Drs. Arnhold, Callas, and Estol Carte. She was on the point of leaving for the weekend with her husband and daughter to visit her parents near Fresno. Arnhold would be on call that night, with Carte and Callas to share hospital duties over the weekend. Sara needed to talk to them.
Mindy’s deterioration remained uppermost in her mind. She was also concerned about the results of the test for sodium that had been run on Mindy’s stool sample collected on Wednesday, the same day Sara had presented Mindy’s case at the staff meeting.
Like most doctors, Sara almost never ordered stool sodium tests. Serum sodium tests were valuable, and often essential, diagnostic tools. But stool sodiums were rarely significant because a test of the amount of sodium in a patient’s stool simply reveals what the person has eaten. If a patient has consumed a high-sodium meal of ham and potato chips, the excess sodium in his gastrointestinal tract will be thrown off in the urine and the stool. So the level of sodium in a person’s excretions will vary quite a bit depending on his day’s menu. In a normal, healthy child, a stool sodium might range between 20 and 90 milliequivalents per liter, with 20 or 30 as a good average. When a child is suffering from diarrhea, the level of sodium concentrated in the stool can go higher. Every doctor knew this, and knew a stool test would reveal this. So there was usually no point in testing stool sodium. Most doctors, no matter how long they had practiced, never had occasion to order the test.
But because Mindy’s illness was beginning to look suspicious, because it might somehow be related to her intake, Sara had ordered a stool sodium test. And the results were indeed significant.
Sara had already calculated Mindy’s known sodium intake. In the period preceding the time the stool sample had been collected on Wednesday, Mindy had received 14 milliequivalents of sodium: 10 by IV and 4 by Cho-free formula. There should have been an equal amount coming out.
But the lab test result was astonishing. On the sample collected Wednesday afternoon, Mindy’s stool sodium level had reached an incredible 251 milliequivalents. This was totally unexplainable.
Nothing in medical school had prepared Sara for this. As late as this afternoon, before she had received these results, she’d still been trying to find a medical cause for Mindy’s condition. She had telephoned Dr. Applebaum at Kaiser-San Francisco and asked him again about secretory diarrhea. He had not ruled it out. And as long as a diagnosis was still possible, Sara could put off thinking about the other cause, the nonmedical one, the one she preferred not to face.
She remembered the afternoon meeting with Priscilla and Debby Roof on the ward. Debby’s concern was apparent. Mindy was stooling heavily, and was lethargic, just like Tia.
“It’s not like with Tia, is it, Dr. Shimoda?” the nurse had asked. “After all, Tia had all those high serum sodiums.”
Priscilla had nodded and smiled. “That’s right,” she agreed.
And Sara had said nothing, had not contradicted her. Because by this time, something was entering her consciousness, and it was certainly nothing she could say to soothe Priscilla. She was starting to know it in a place in her heart: whatever was happening to Mindy had happened to Tia, too.
She took out a copy of the current issue of the JAMA that Dr. Arnhold had given her after Wednesday’s staff meeting. She had read and reread the editorial he had pointed out.
It commented on a British article about Munchausen Syndrome by Proxy, a variation on Munchausen Syndrome itself. Sara knew about Munchausen Syndrome. They all did. There were always jokes floating around every hospital about famous cases they had had of this person or that who came in with massively scarred bodies from procedures they had fooled doctors into performing on them.
People with Munchausen Syndrome craved the type of warm care and attention they felt they could receive only in a hospital setting. They would do anything, make up any symptom, to remain hospitalized. They would submit to—and welcome—any hospital procedure. They might rub feces into open wounds to cause infection, or pour blood into urine specimens to throw off a diagnosis. When their deceptions were discovered, they often left in a huff to try another hospital. Some hospitals even published lists of these people to look out for. They were sad psychological messes in Sara’s opinion.
But Munchausen Syndrome by Pro
xy was a little different. Apparently patients suffering from this caused their own children to undergo unnecessary hospital procedures by giving false histories and tampering with test results. One of the two children mentioned in the JAMA article had died after having been repeatedly dosed with salt. The two mothers involved had both appeared to be loving and concerned, and only after their roles in the children’s illnesses had been discovered did their psychopathic traits become obvious. The mother of the baby who died had attempted suicide afterward. The other mother’s mental stability was also questioned when it turned out that she had tampered with her own specimens on an earlier occasion.
It was almost incredible that any mother would deliberately and repeatedly poison her child. Yet this fit with a case cited in a Clinical Pediatrics article that Evelyn had read, and if the mother were really mentally ill… Sara shook her head. It was too much to think about right now.
Sara replaced the journal on her desk and rose. She was suddenly struck by a tiredness so overwhelming that it frightened her. She welcomed the weekend, away, out of reach of all this.
8
It was the kind of morning characteristic of the Bay Area in February, overcast and foggy. A thick dew had settled on the grass outside Evelyn’s house, and a mist had dampened the windshield of her car. It was impossible to predict how the day would turn out. The fog might clear by mid-morning, permitting thin, filtered sunlight to touch the dull pink of the hospital walls, or the fog might turn to heavy cloud and deep, mushy rain. Evelyn hugged her coat to her as she made her way up from the doctors’ parking lot to the side entrance of the hospital where the Emergency Room was located.
She was already tired. She had hardly slept. Beside her last night, her husband had lain dreamless. Mindy was not his problem—but hers.
She had realized something would have to be done yesterday afternoon, after she had met with Sara and Rainer Arnhold and Estol Carte and heard about the results of Mindy’s stool sodium tests.
They had decided that Mindy’s intake and output would have to be carefully monitored. Sara planned to repeat the tests when she came back, and they had agreed this was necessary. They had discussed poisoning. Evelyn continued to believe that a sodium cathartic was responsible for Mindy’s condition. Probably Epsom salts. They still had to research a method of testing for sulfates. Would a stool sample reveal magnesium? she wondered. Maybe Boyd Stephens would know. Sara planned to call him on Monday.
After the meeting, Evelyn had hurried back to her office and looked up the stool sodium values for cholera, the only illness she could think of that might produce anything close to the 251 milliequivalents per liter of sodium at which Mindy’s stool sample had been measured. Not that Mindy could possibly have cholera, she realized. There was no possibility of that. It was simply a basis for comparison of sodium levels. There were no higher sodium levels in an illness than those that cholera could produce.
She could not believe the values she found. She rushed out of her office to find someone, anyone, she could tell. Jim Levine, another pediatrician, was still in his office at the other end of the hall. She jumped at him with her news.
“Jim, Jim!”
“What? My God, Evelyn! What’s wrong?”
“It’s Mindy Phillips. She’s had a stool sodium of two hundred fifty-one; and you know what?” Her words tumbled over each other.
“What?”
“That’s twice the level of the worst case of cholera I could find recorded.”
“Good God!”
“Exactly, Jim. Exactly,” Evelyn said.
Later she realized something else. Mindy’s stool sodium was higher than the concentration of sodium in her blood. And Evelyn knew of no way that this could happen. Not naturally.
If they couldn’t control the diarrhea and if they lost the use of her veins for the IV, Mindy would die. It was as clear-cut as that.
Sara was away. Dr. Stein, who had been the Chief of Pediatrics until just a few weeks ago and was now the Assistant Physician-in-Chief, was away. The Physician-in-Chief himself was away. Evelyn knew what she had to do, and if Carte, who was in charge of the ward today and thus officially Mindy’s doctor, would not agree with her plan, she had decided to override him. She had the ultimate responsibility for the care of the patients on the ward. She didn’t want to exercise her authority, but if she had to, she would.
Evelyn had maintained to her colleagues, laughing because she was a little embarrassed at her new position, that her appointment to Chief of Pediatrics meant that she was now merely some strange combination of secretary, agenda maker, and mother hen. But in fact, she realized there were added responsibilities of being what was essentially the first among equals.
And now she had certainly been plunged straight into the crucible. She had a sudden insight that what she did these next few days would either temper her or completely burn her out.
When Evelyn arrived at the ward, it was quiet, the doors to the rooms on Five West shut tight. Even room 503 was closed and darkened. Mrs. Phillips might be in there, she might not, Evelyn thought as she crossed to the nurses’ station. It didn’t matter. Evelyn nodded at the young, dark-haired nurse on duty, Christine King. She was not a regular pediatrics nurse, but a floater, assigned where she was needed, but Evelyn had seen her around.
Evelyn checked Mindy’s most recent lab sheets and then pulled her chart. The nurse’s progress notes confirmed what she knew in her heart she’d find.
After a few moments, Evelyn replaced the chart. She made some quick calculations on the back of a progress note. Mindy, she thought bluntly, was going down the tubes. In the past 24 hours, she’d lost 1,000 cubic centimeters of watery stool. This amounted to almost 15 percent of her body weight. Without the IV she would be dead. Evelyn was sure that the 7:00 A.M. sodium samples to be run on Mindy’s blood, urine, and stool would confirm the deterioration. But she would not wait for the results. All she had to do was look at the lab results on the 1 o’clock samples. The concentration of sodium in Mindy’s urine had been measured at 252 milliequivalents. And the stool was 159 milliequivalents. There was no doubt that both were much too high.
Evelyn pressed a long-fingered hand against her graying hair and looked up. Down the hall she saw the meager figure of Dr. Estol Carte approaching her. Herculean Pirate, as she liked to call him to herself.
Evelyn was an Agatha Christie fan, and it was an obvious comparison once you saw it, she thought. Estol, with his balding, egg-shaped head and his moustaches, all set on a precise five-foot-three frame, was detective Hercule Poirot to the life.
As she drew him aside, she could not know how apt a description it was.
“Estol,” she said with a calm she didn’t feel, “I’ve got to talk with you.”
9
Priscilla had not intended to spend the night. She and Steve had decided earlier to take the boys to a promised dinner at McDonald’s, despite the fact that Mindy needed to be tied down while Priscilla was gone to prevent her from pulling out the NG. Priscilla did not like to alter plans, especially not when her children were expecting some special activity. In any case, she intended to be gone only a short time, and she thought that Mindy seemed stable when they all left for dinner. But later that evening, Mindy’s condition began to deteriorate. Priscilla phoned Steve to tell him she wouldn’t be coming home. She still hoped that Mindy would improve by morning. She wanted Steve to bring the boys up in the afternoon to visit their sister, as they had arranged, and she never liked them to see Mindy when she was really sick. It frightened them. She had started this policy during Tia’s illness. And sometimes with Tia, days had gone by before she was well enough for the boys to visit.
Shortly before nine, Dr. Carte entered Mindy’s room. He was not Priscilla’s favorite doctor. She thought he was weird, and so did most of the nurses, as far as she could tell.
Dr. Carte glanced at Mindy in her walker and at her chart that he held in his hand.
“She seems to be doing okay,
” he remarked.
“Yes, she’s better,” said Priscilla. “But it was a pretty rocky night.”
With a nod, Carte left the room. Through the window in the door, Priscilla could see him at the nurses’ station working with Mindy’s chart. At that moment, Nurse King walked in. She had to refill Mindy’s metriset with formula every two hours. Priscilla had never met her, and she and the nurse introduced themselves and talked for a moment, first about Mindy’s condition, then about Tia.
“You know I lost another child a year ago,” Priscilla confided.
“Yes, I heard,” Christine King answered. “It must have been just terrible. I have a child of my own; he’s just a baby, too. I just can’t conceive of losing Michael. How did you cope?”
“I don’t know. Sometimes I really don’t know how I lived through the last year. My friends helped—and my minister. And I had my boys. And then Mindy—I was so excited to hear about her, I just about burst.”
“When did you get her?”
“In November. It was just nine months after Tia died—she was born the same week Tia died. Like a new life to replace the one we had lost. We had a new baby—it felt like it could have been our own,” Priscilla said.
“What a strange coincidence.”
“Oh, there have been a lot of those. Debby Roof and I talked about it, too. You know Mindy was admitted here a year to the day after Tia died—it was horrible.” Tears came to her eyes and she brushed at them.
“I’m so sorry. I’m sure she’ll be better soon.”
“Yes,” agreed Priscilla, turning to pick up Mindy.
Shortly after eleven, Christine King returned to Mindy’s room looking puzzled. Priscilla glanced up as the door opened. Mindy was back in her bed.
“Do you know the recipe for Mindy’s formula?” the nurse asked.
“Sure. Why? There’s plenty of formula already mixed.”
“Yeah, well it’s gone now. We need some more and I can’t find the recipe written down anywhere. I called the nursing supervisor and she didn’t know either. It’s supposed to be written in the cardex, but it isn’t there.”
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