by Janet Dawson
As his head came up his eyes appraised Dr. Helvig and the girl’s mother. Then his attention—and mine—was caught by a child’s steady wail. I looked around for its source and saw a room, walled by glass, where several hospital workers were gathered around a child I could only glimpse.
“What’s going on in there?” I asked as he joined me.
His face took on an expression of clinical detachment. “In Isolation? Ah, that. Eighteen-month-old kid with diarrhea. His cousin died two weeks ago of massive sepsis. There may be some connection. Family brought this kid in yesterday, then wouldn’t wait for the lab work. They took him home AMA—that means against medical advice—and brought him back several hours later when the kid got worse.”
“Is he going to make it?”
“I don’t think so,” he said quietly. “Why don’t you wait for me here? I’ll only be a few minutes.”
I took a seat at a small table he’d indicated, behind the counter in a central work station. I tried not to think about the child in Isolation whose wails were fast becoming background music in what I assumed was the normal chaotic cacophony of the intensive care unit. Dr. Pellegrino moved over to one of the high cribs, near the wall. It was occupied by a child with the now-familiar tubes leading to nose and arm. The doctor joined two blue-clad ICU nurses. They surrounded the bed, doing something to the child. To one side of the bed I saw a girl, no more than eighteen, if that, seated in a chair. Standing behind her was a boy of the same age. Both of them seemed mesmerized by the screen of the television set suspended from the ceiling.
I heard a thump behind me and turned to find the source. I heard it again and saw a pneumatic tube drop into a receptacle. All around me I heard noise, high-pitched electronic whines and beeps, a steady bing-bong, the conversations of doctors, nurses, family members, the child wailing behind that glass door.
“That’s the little girl whose X rays I was looking at.” Dr. Pellegrino had stepped up to a nearby sink to wash his hands after examining the child in the crib near the wall. “Probably toxic shock syndrome. She came in with an infection of the chest wall.” He dried his hands on a paper towel, discarded it in a waste bin with a lid, and walked over to a computer terminal on the work station counter. “We’ve got all the patient information on a database,” he explained. “It makes delivery of care much easier. I can access information about meds, lab tests, all that stuff.” By now he’d punched up the information on the little girl. “She’s had both staph and strep infections.”
While the doctor made some notes in the child’s chart, my eye went back to the girl who sat in the chair. I assumed she was the child’s mother. Perhaps the boy with her was the father. Yet during the entire time the nurses worked over the little girl in the crib, both teenagers’ eyes never left the television set. Did they simply not care? Or were they overloaded by the sights and sounds around them?
Dr. Pellegrino got up from the computer terminal and now stood at my elbow. He followed the direction of my eyes but he didn’t say anything else about the child he’d just examined.
“Let’s go to my office,” he said.
Twenty-nine
“I’LL APOLOGIZE IN ADVANCE FOR THE MESS,” DR. Pellegrino said as he led the way down a corridor, into what seemed like relative quiet after my sojourn in Pediatric ICU. “We’re getting ready to move into that new building across the street, so I’ve got a lot of stuff in boxes.”
The office was an older wing of the hospital, a small square that looked as though it had once housed patients. As we entered I saw two doors on the wall to my left, with a sink in between, and I guessed that one door led to a closet and the other to a bathroom. A desk stuck out from the opposite wall, with one chair behind it and another in front. The room was crowded with cardboard cartons, some with the flaps open to reveal books and binders. The low bookcase near the window had been emptied out, but the top held a small CD player with two speakers. I glanced at the stack of CDs next to it. The doctor’s taste, at least here at work, ran to the standards—Cole Porter, Glenn Miller, Tony Bennett, Sinatra.
“Want some coffee?” he asked as he closed the door behind us. He gestured toward a drip coffee maker on a small cabinet in the corner.
“Yes, thank you. I take it black.”
The window was open, letting in a chill breeze from the gray morning outside. I heard freeway noise coming from Highway 24, and then the sound of wheels on track as a BART train moved down the elevated portion of its route, over Martin Luther King Jr. Way. Dr. Pellegrino scooped ground coffee into the filter and walked to the sink to fill the carafe with water. I stepped out of his way and watched him pour the water into the coffee maker.
Then my eyes were drawn to a color snapshot taped to the back of the door he’d shut. It showed a teenage boy, maybe fourteen, curly dark hair over a smiling face. He wore a snowy white T-shirt with large black letters that read “HIV-Positive.” Next to the photograph were several articles from local newspapers, detailing the youngster’s battle with AIDS. He’d lost. The columns of newsprint were obituaries.
“One of your patients?” I asked.
“Yeah. He was really a special kid.”
I watched emotions flicker over his face as he looked at the photograph on the door. Then he turned his attention to the coffee, which had finished trickling into the carafe. I could smell it now, as the doctor took a couple of mugs from a desk drawer, filled them, and handed one to me. I sipped the coffee. Good stuff, a rich dark roast, better than one would get in the hospital cafeteria or from a vending machine.
“Now, what’s this about?” He settled into the chair behind his desk and motioned me to the one in front.
“I guess you could call it a missing persons case,” I began, once seated. Although Naomi Smith hadn’t really hired me to find her granddaughter Dyese, that was how the case had evolved.
“The missing person is a two-year-old girl. Her mother’s body was found up in the Oakland hills several weeks ago. The police are investigating her death as a homicide. The coroner seemed to be having some trouble coming up with a cause of death, given the condition of the body when it was found. Yesterday the investigating officer told me the dead woman was positive for HIV. What are the chances that the child is also HIV-positive?”
“Twelve to twenty-five percent,” Dr. Pellegrino said. “But it’s not as simple as that.” He set the mug on the desk and leaned forward in the chair, fixing me with those bright blue eyes. “How did the mother contract the virus?”
“I have no idea. She ran away from home three years ago. I’ve had limited success tracing her movements since then. Most likely she got it through heterosexual contact. That could have happened before or after she ran away. I can check with her mother to see if she’d ever had any transfusions. I haven’t come across any indication of intravenous drug use but I wouldn’t rule it out. At various times she was homeless, living on the streets over in Berkeley. I understand AIDS is cutting a swath through the homeless population.”
“And adolescents. They don’t know anything about AIDS and what little they do know is misinformation. They’re sexually active and they think the bullet won’t hit them.” Dr. Pellegrino shook his head. “A teenage mother who has been homeless is doubly at risk. Besides, Alameda County has the highest rate of HIV infection anywhere in California. Those aren’t good odds. You said the mother’s dead. If the child is still alive, she needs to be tested for antibody.”
“It’s possible that whoever killed the mother also killed the child,” I said slowly. “But I have a hunch she’s still alive. My hunches—well, I like to play them out I do have some leads. Explain the antibody test to me. I’ve read the occasional newspaper article, but I need more information.”
“If you are exposed to a disease, like chicken pox,” Dr. Pellegrino said, “your body makes a protein called an antibody. This enables you to recover from the disease and protects you from further infection. But HIV antibody is different. It’s not protective.
” He paused and picked up his coffee.
“You don’t get rid of HIV. But the antibody provides us with a marker. The only way you get that particular antibody is if the virus triggers you to make the antibody. So if we test your blood for antibody and find it, that means the virus is present. No doubt that’s what the pathologist found when he tested the mother’s blood.”
“Babies get protective antibodies from their mothers,” I said, recalling some long-ago biology class. “In normal circumstances, I mean.”
“Right.” The doctor swallowed another mouthful of coffee. “In the first six months of life, most babies don’t get very sick with the common childhood infections because they get antibodies from their mothers. These antibodies disappear by the time the kids are six to twelve months old. Then the children are more vulnerable. They have to start making antibodies on their own.”
“But it’s different with HIV?”
He nodded. “The HIV marker antibody is passed from an infected mother to her baby and can last for fifteen to eighteen months. All babies born to infected mothers have a positive antibody. The challenge with these kids is to make the diagnosis of HIV infection despite the misleading antibody test. We have to follow these kids until they lose their mother’s antibody. But that’s assuming we know from the start the mother is infected. Your missing kid is a different situation entirely.”
I cradled the coffee mug in my hands. “I have so many gaps in my knowledge of the mother. I do know she was living on the streets while she was pregnant, then she hooked up with some people from Sonoma County. Her baby was born on their farm, two years ago.”
“Two years,” he repeated. “If the child got the marker antibody from her mother, it should be gone now. You find her, we do an antibody test. If she’s positive, it means she has HIV. We also confirm that diagnosis with a more sophisticated test called a PCR. That means polymerase chain reaction.”
“Say she’s positive. What does that mean?” I glanced to my right, at the snapshot of the dead boy taped to the back of the door. “Ultimately she’ll die of AIDS?”
“Again, it’s not that simple.” Dr. Pellegrino set his coffee mug on the desk and rummaged around in a pile of papers near his left elbow. “Just because she’s infected doesn’t mean she has AIDS. There’s a time line that can stretch over many years.”
He unearthed what he was looking for, a photocopied work sheet that appeared to be some sort of instructional material. “According to the Centers for Disease Control, you have AIDS if you have these complications of HIV infection.” He flipped pages and I leaned forward to examine the list.
“If you had the virus,” he continued, “you could stay healthy, or you could have damage to your immune system or blood system, or you could have mild nonspecific health problems. If you had a combination of all these things—and you were in a population we consider at risk—that should make me suspect AIDS.”
“Is it the same pattern with children?”
He flipped to another page in the work sheet. “Basically, but in children the diseases we call AIDS are slightly different. The time line is different too. A mother with HIV can still be healthy, while her child deteriorates fast.”
“How long would it be before the child showed symptoms of AIDS?” I asked, thinking of what little—so little—I knew about Dyese Smith.
“About twenty percent of the kids we see get really sick in the first year or two of life and are diagnosed early,” he said. “The other eighty percent do fairly well. For example, we’re following a hundred twenty HIV-positive kids right now. About half are actively infected. The only one who is hospitalized right now is Mary, the little girl you just saw in ICU. Most of what we do is outpatient care. We see the kids every three, four months. There are ways of treating HIV infection like a chronic disease, similar to diabetes or rheumatoid arthritis.”
“I thought this diagnosis was an automatic death sentence,” I said.
“I don’t look at it that way. Treatment prolongs life. You know, more than anything else, these children want to be treated like other kids. They often lead normal lives for five or ten years.” He picked up his coffee mug and moved it in a salute, directed toward the photograph on the door. “He did. He was a fighter.”
I followed his eyes, then looked back at the work sheet, so many black words on white paper, then frowned. “Assuming I can find this child, what kind of symptoms might she show?”
“We had one patient who died several months ago,” he said slowly. “A five-year-old girl. She was fine until she was about fifteen months old. She lost what we call developmental milestones. Those milestones mean she grew and gained weight as we would expect a child of her age group to do. Then she just stopped growing, lost weight. She dropped off the growth curve.”
He stopped, sipped his coffee in silence for a moment, then began again. “Symptoms. You’re looking for symptoms. As in an adult, the child could be healthy, yet have damage to the blood or the immune system. If I were doing a physical on the kid, I might find big lymph nodes, a big liver, an enlarged spleen. Recurrent serious infections, like ear infections or pneumonia.”
“I need to find this kid,” I said. The urgency I already felt now doubled, tripled.
No one seemed to want Dyese Smith, except her mother. Now her mother was dead. A very large deck of cards was stacked against the little girl I’d only seen in that snapshot which had been hacked in two by her grandmother, wielding a pair of scissors the way she’d wielded her neglect of her own daughter. I thought of Naomi Smith in her empty Piedmont house, drinking vodka in the middle of the day. She didn’t much care for the fact that her granddaughter was of mixed race. I wondered how a possible HIV diagnosis would penetrate the alcoholic fog.
“What happens when you do find her?” As Dr. Pellegrino asked the question, his blue eyes scanned my face, as though he’d been reading my mind. “You didn’t say who hired you. Does this missing child have a family?”
“A grandmother who drinks too much. And a woman who works for her, who’d rather not discuss the possibility that her nephew fathered a runaway’s child.”
“Denial,” he said. “Something we see a lot in working with HIV. Sometimes denial is healthy. That boy who just died, his denial took the form of not letting the disease keep him at home, bedridden. He was active up to the end.”
Now he shook his head. “More often I see the kind of denial where the infected person denies having the illness, continues to have unsafe sex, doesn’t do anything to control the disease and gets sicker and sicker. As you can imagine, an HIV diagnosis in a child puts a tremendous amount of stress on the family. If the child is infected, she got it from her mother. If the mother has it, where did she get it? Was it her husband and his sexual contacts? Did the mother have another relationship? Was she raped? Is either parent using drugs? An HIV diagnosis means that a lot of things people would rather keep secret come to light.”
“People don’t like to talk about AIDS,” I said. “It makes them feel uncomfortable.”
“Don’t I know it.” He reached for the coffee and topped off his mug. When he raised the carafe in inquiry, I shook my head. “I had one kid,” he continued, “a ten-year-old girl who got the virus from a transfusion. Her family never talked about it. They never asked her how she was feeling. They’d bring her to the clinic and act as though it were just another doctor’s appointment. They ignored the fact that HIV was part of this child’s life. Their denial made it incredibly difficult for everyone involved. Especially the patient.”
He shrugged and shook his head. “Then there are the parents who call every time the kid has a headache. Sometimes it’s just a headache. And sometimes I just can’t do anything about it.”
“How do you maintain your balance?” I wondered. “All your patients die.”
“Everybody dies,” he said, raising the mug to his lips. “It’s just a matter of when and how. Look at it this way. Twelve to twenty-five percent of these kids get HIV fr
om infected mothers. That means seventy-five to eighty-eight percent who don’t. I do what I can. I try to find the rose, even if I have to look in a wasteland.” He set the mug on the desk. “You didn’t answer my question. What happens when you find this child?”
“I think it’s very likely that nobody will want her.” I felt a chill on my back as I said the words. It wasn’t because the window was open.
“Then we’re talking foster care.” He smiled at me with those blue eyes. “Some of my kids do very well in foster care.”
I finished the coffee in my mug and stood up to leave. “Thanks for the coffee, Doctor. And the information.”
“Call me Kaz. Everybody does.” He got to his feet, stepped around the desk, and took my hand in his. “You need anything else, Jeri, call me.”
Thirty
THE ORCHESTRA IN THE PARAMOUNT THEATRE PIT had been tuning up, seemingly random phrases of melody insinuating themselves under the thrum of voices as the audience talked. Now the lights dimmed in the auditorium. On either side of me the sculpted burnished figures on the theater walls darkened from gold to bronze. Musical instruments fell silent and people’s conversations lulled from full voice to sibilant whispers. I heard the conductor’s baton tap three times in rapid succession. Then Tchaikovsky’s music poured into the elegant space around us, soaring up to the silvery metal work of the ceiling high above. Friday evening’s performance of The Nutcracker began.
Duffy LeBard and I settled back into our seats in the grand tier, the front section of the balcony, where we looked down on the orchestra and the stage. The curtain parted, silver and gold trim glittering on the dark red fabric, and the performance began. Dancers moved gracefully across the stage, riding on the melody. While I watched Herr Drosselmeyer present his gifts to the family gathered in front of a huge Christmas tree that was really a painted backdrop, my mind went back over the past thirty-six hours. What kind of Christmas would Dyese Smith have—assuming she was still alive?