“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.
“Next fever spike: the kid’s fifteen months old, mother claims a hundred and six.”
“Dangerous.”
“You bet. E.R. doc records a hundred and four and a half, bathes and doses it down to a hundred and one and a half. And mom reports new symptoms: retching, projectile vomiting, diarrhea. And black stools.”
“Internal bleeding?”
“Sounds like it. That made everyone sit up. The diaper she had on did show some evidence of diarrhea, but no blood. Mom said she threw the bloody one out, would try to retrieve it. On exam, the kid’s rectal area was a little red, some irritation at the external edges of the sphincter. But no bowel distension that I can palpate— her belly’s nice and soft, maybe a bit tender to the touch. But that’s hard to gauge ’cause she’s freaking out, nonstop, at being examined.”
“Raw rectum,” I said. “Any scarring?”
“No, no, nothing like that. Just mild irritation, consistent with diarrhea. Obstruction or appendicitis needed to be ruled out. I called in a surgeon, Joe Leibowitz— you know how thorough he is. He examined her, said there was nothing that justified cutting her open but we should admit her and watch her for a while. We put an I.V. in—great fun— did a complete panel, and this time there was a slightly elevated white count. But still within normal limits, nothing that would jibe with a hundred and four and a half. Next day she was down to one hundred. Day after that, ninety-nine point two, and her tummy didn’t seem to hurt. Joe said definitely no appendicitis, call in GI. I got a consult from Tony Franks and he evaluated her for early signs of irritable bowel syndrome, Crohn’s disease, liver problems. Negative. Another tox panel, a careful diet history. I called in Allergy and Immunology again, to test her for some weird hypersensitivity to something.”
“Was she on formula?”
“Nope, a breast-fed baby, though by that time she was totally on solids. After a week she was looking perfect. Thank God we didn’t cut her open.”
“Fifteen months old,” I said. “Just past the high-risk period for SIDS. So the respiratory system quiets and the gut starts acting up?”
Stephanie gave me a long, searching look. “Want to hazard a diagnosis?”
“Is that all of it?”
“Un-uh. There were two other GI crises. At sixteen months— four days after an appointment with Tony in Gastro clinic— and a month and a half later, following his final appointment with them.”
“Same symptoms?”
“Right. But both those times, mom actually brought in bloody diapers and we worked them over for every possible pathogen— I mean we’re talking typhoid, cholera, tropical maladies that have never been seen on this continent. Some sort of environmental toxin— lead, heavy metals, you name it. But all we found was a little healthy blood.”
“Are the parents in some sort of work that would expose the child to weird pollutants?”
“Hardly. She’s a full-time mom and he’s a college professor.”
“Biology?”
“Sociology. But before we get off on the family structure, there’s more. Another type of crisis. Six weeks ago. Bye-bye gut, hello new organ system. Want to take a guess which one?”
I thought for a moment. “Neurological?”
“Bingo.” She reached over and touched my arm. “I feel so vindicated calling you in.”
“Seizures?”
“Middle of the night. Grand mal, according to the parents, right down to the frothing at the mouth. The EEG showed no abnormal wave activity and the kid had all her reflexes, but we put her through a CAT scan, another spinal, and all the high-tech neuroradiology video games, on the chance she had some kind of brain tumor. That really scared me, Alex, because when I thought about it I realized a tumor could have caused everything that had been happening, right from the beginning. A growth impinging on different brain centers, causing different symptoms as it grew.”
She shook her head. “Wouldn’t that have been a happy situation? Me talking psychosomatic and there’s an astrocytoma or something growing inside her? Thank God all her scans were totally clean.”
“Did she look post-seizural when you saw her in the E.R.?”
“In terms of being drowsy and listless, she did. But that’s also consistent with a little kid being dragged to the hospital in the middle of the night and put through the wringer. Still, it scared me— that there could be something organic I was missing. I asked Neurology to follow up. They did for a month, found nothing, terminated. Two weeks later—two days ago— another seizure. And I really need your help, Alex. They’re up in Five West, right now. And that’s the whole kaboodle, history-wise. Ready to give me some wisdom now?”
I scanned my notes.
Recurrent, unexplained illnesses. Multiple hospitalizations.
Shifting organ systems.
Discrepancies between symptoms and lab tests.
Female child showing panic at being treated or handled.
Mother with a paramedical training.
Nice mother.
Nice mother who might just be a monster. Scripting, choreographing, and directing a Grand Guignol, and casting her own child as unwitting star.
Rare diagnosis, but the facts fit. Up until twenty years ago nobody had heard of it.
“Munchausen syndrome by proxy,” I said, putting my notes down. “Sounds like a textbook case.”
> Her eyes narrowed. “Yes, it does. When you hear it all strung together like this. But when you’re right in the middle of it . . . even now I can’t be sure.”
“You’re still considering something organic?”
“I have to until I can prove otherwise. There was another case— last year, over at County. Twenty-five consecutive admits for recurrent weird infections during a six-month period. Also a female child, attentive mother who looked too calm for the staff’s peace of mind. That baby was really going downhill and they were just about ready to call in the authorities when it turned out to be a rare immunodeficiency— three documented cases in the literature, special tests that had to be done at NIH. Moment I heard about it, I had Cassie tested for the same thing. Negative. But that doesn’t mean there isn’t some other factor I haven’t caught. New stuff keeps popping up— I can barely keep up with the journals.”
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