She moved her spoon around in her coffee.
“Or maybe I’m just denying— trying to make myself feel better for not seeing the Munchausen thing sooner. Which is why I called you in— I need some direction, Alex. Tell me which way to go with this.”
I thought for a while.
Munchausen syndrome.
A.k.a. pseudologia fantastica.
A.k.a. factitious illness disorder.
An especially grotesque form of pathological lying, named after Baron von Munchausen, the world-class prevaricator.
Munchausen is hypochondriasis gone mad. Patients fabricating disease by mutilating and poisoning themselves, or just lying. Playing mind games with physicians and nurses— with the health-care system itself.
Adult Munchausen patients manage to get hospitalized repeatedly, medicated needlessly, even cut open on the operating table.
Pitiful, masochistic, and perplexing— a twist of the psyche that still defies comprehension.
But what we were considering here was beyond pity. It was an evil variant:
Munchausen by proxy.
Parents— mothers, invariably— faking illness in their own offspring. Using their children— especially daughters— as crucibles for a hideous concoction of lies, pain, and disease.
I said, “So much of it fits, Steph. Right from the beginning. The apnea and passing out could be due to smothering— those movement artifacts on the monitor could mean she was struggling.”
She winced. “God, yes. I just did some reading, found a case in England where movement artifacts tipped them off to the baby being smothered.”
“Plus, with mom being a respiratory tech, breathing could be the first system she’d choose to mess with. What about the intestinal stuff? Some kind of poisoning?”
“Most likely, but it’s nothing the tox panel could come up with when they tested.”
“Maybe she used something short-acting.”
“Or an inert irritant that activated the bowel mechanically, but passed right through.”
“And the seizures?”
“Same thing, I guess. I don’t know, Alex. I really don’t know.” She squeezed my arm again. “I’ve got no evidence at all and what if I’m wrong? I need you to be objective. Give Cassie’s mom the benefit of the doubt— maybe I’m misjudging her. Try to get into her head.”
“I can’t promise a miracle, Steph.”
“I know. But anything you can do will be helpful. Things could get really messy with this one.”
“Did you tell the mother I’d be consulting?”
She nodded.
“Is she more amenable to a psych consult now?”
“I wouldn’t say amenable, but she agreed. I think I convinced her by backing away from any suggestion that stress was causing Cassie’s problems. Far as she’s concerned, I think the seizures are bona fide organic. But I did press the need for helping Cassie adjust to the trauma of hospitalization. Told her epilepsy would mean Cassie can expect to see a lot more of this place and we’re going to have to help her deal with it. I said you were an expert on medical trauma, might be able to do some hypnosis thing to relax Cassie during procedures. That sound reasonable?”
I nodded.
“Meanwhile,” she said, “you can be analyzing the mother. See if she’s a psychopath.”
“If it is Munchausen by proxy, we may not be looking for a psychopath.”
“What then? What kind of nut does this to her own kid?”
“No one really knows,” I said. “It’s been a while since I looked at the literature, but the best guess used to be some kind of mixed personality disorder. The problem is, documented cases are so rare, there really isn’t a good data base.”
“It’s still that way, Alex. I looked up sources over at the med school and came up with very little.”
“I’d like to borrow the articles.”
“I read them there, didn’t check them out,” she said. “But I think I still have the references written down somewhere. And I think I remember that mixed personality business— whatever that means.”
“It means we don’t know, so we’re fudging. Part of the problem is that psychologists and psychiatrists depend on information we get from the patient. And taking a history from a Munchausen means relying upon a habitual liar. But the stories they tell, once you expose them, do seem to be fairly consistent: early experience with serious physical illness or trauma, families that overemphasized disease and health, child abuse, sometimes incest. Leading to very poor self-esteem, problems with relationships, and a pathological need for attention. Illness becomes the arena in which they act out that need— that’s why so many of them enter health professions. But lots of people with those same histories don’t become Munchausens. And the same history applies both to Munchausens who abuse themselves and the proxies who torment their kids. In fact, there’s some suggestion that Munchausen-by-proxy parents start out as self-abusers and switch, at some point, to using their kids. But as for why and when that happens, no one knows.”
“Weird,” she said, shaking her head. “It’s like a dance. I feel I’m waltzing around with her, but she’s leading.”
“Devil’s waltz,” I said.
She shuddered. “I know we’re not talking hard science, Alex, but if you could just dig your way in there, tell me if you think she’s doing it. . . .”
“Sure. But I am a bit curious why you didn’t call in the hospital Psych department.”
“Never liked the hospital Psych department,” she said. “Too Freudian. Hardesty wanted to put everyone on the couch. It’s a moot point, anyway. There is no Psych department.”
“What do you mean?”
“They were all fired.”
“The whole department? When?”
“Few months ago. Don’t you read your staff newsletter?”
“Not very often.”
“Obviously. Well, Psych’s dissolved. Hardesty’s county contract was canceled and he never wrote any grants, so there was no financial backup. The board decided not to pick up the cost.”
“What about Hardesty’s tenure? The others— weren’t Greiler and Pantissa tenured, too?”
“Probably. But tenure, as it turns out, comes from the med school, not the hospital. So they’ve still got their titles. Salaries are a whole other story. Quite a revelation for those of us who thought we had job security. Not that anyone fought for Hardesty. Everyone thought he and his guys were deadwood.”
“No more Psych department,” I said. “No more free coffee. What else?”
“Oh, plenty. Does it affect you, there being no Psych department— in terms of your staff privileges, I mean?”
“No, my appointment’s in pediatrics. Oncology, actually, though it’s been years since I’ve seen any cancer patients.”
“Good,” she said. “Then there won’t be any procedural hassles. Any more questions before we go up?”
“Just a couple of observations. If it is Munchausen by proxy, there’s some time pressure— the usual picture is an escalating pattern. Sometimes kids die, Steph.”
“I know,” she said miserably, pressing her fingertips to her temples. “I know I may need to confront the mother. That’s why I have to be sure.”
“The other thing is the first child— the boy. I assume you’re considering him a possible homicide.”
“Oh, God, yes. That’s really been eating at me. When my suspicions about the mother started to gel, I pulled his chart and went over it with a fine-tooth comb. But there was nothing iffy. Rita’s ongoing notes were good— he was perfectly healthy before he died and the autopsy was inconclusive, as so many of them are. Now here I am with a living, breathing child and I can’t do a thing to help her.”
“Sounds like you’re doing everything you can.”
“Trying, but it’s so damned frustrating.”
I said, “What about the father? We haven’t talked about him.”
“I don’t really have a good feel for him. Mot
her’s clearly the primary caretaker and it’s her I’ve been dealing with most of the time. Once I started to think of it as a possible Munchausen by proxy, she seemed especially important to focus on, because aren’t mothers always the ones?”
“Yes,” I said, “but in some cases the father turns out to be a passive accomplice. Any sign he suspects something?”
“If he has, he hasn’t told me. He doesn’t seem especially passive— nice enough. So is she, for that matter. They’re both nice, Alex. That’s one of the things that makes it so difficult.”
“Typical Munchausen scenario. The nurses probably love them.”
She nodded.
“What’s the other?” I said.
“The other what?”
“Thing that makes it so difficult.”
She closed her eyes and rubbed them and took a long time to answer.
“The other thing,” she said, “and this may sound horribly cold-hearted and political, is who they are. Socially. Politically. The child’s full name is Cassie Brooks Jones— set off any buzzers?”
“No,” I said. “Jones isn’t exactly memorable.”
“Jones, as in Charles L. Junior. Hotshot financier? The hospital’s primary money manager?”
“Don’t know him.”
“That’s right— you don’t read your newsletters. Well, as of eight months ago he’s also chairman of the board. There was a big shake-up.”
“The budget?”
“What else. Anyway, here’s the genealogy: Charles Junior’s only son is Charles the Third— like royalty. He goes by Chip— Cassie’s daddy. The mom is Cindy. The dead son was Chad— Charles the Fourth.”
“All Cs,” I said. “Sounds like they like order.”
“Whatever. The main thing is, Cassie is Charles Junior’s only grandchild. Isn’t that wonderful, Alex? Here I am with a potential Munchausen by proxy that could explode in everyone’s face, and the patient’s the only grandchild of the guy who took away the free coffee.”
3
We got up from the table and she said, “If you don’t mind, we can take the stairs up.”
“Morning aerobics? Sure.”
“You hit thirty-five,” she said, smoothing her dress and buttoning her white coat, “and the old basal metabolism goes to hell. Got to work hard not to be lumpy. Plus, the elevators still move on Valium Standard Time.”
We walked toward the cafeteria’s main exit. The tables were completely empty now. A brown-uniformed maintenance worker was wet-mopping the floor, and we had to step gingerly to maintain traction.
I said, “The elevator I took to your office was converted to key lock. Why the need for all the security?”
“The official line is crime prevention,” she said. “Keeping all the street craziness out of here. Which to some extent is valid— there have been increased problems, mostly during the night shift. But can you remember a time when East Hollywood didn’t get bad after dark?”
We reached the door. Another maintenance man was locking it and when he saw us, he gave a world-weary look and held it open for us.
Stephanie said, “Reduced hours— another budget cut.”
Out in the hallway, things had gotten frantic. Doctors blew past in boisterous groups, filling the air with fast talk. Families traipsed through, wheeling doll-sized veteran journeyors to and from the ordeals wrought by science.
A silent crowd was assembled at the elevator doors, clumped like human droplets, waiting for any of three lifts that had settled simultaneously on the third floor. Waiting, always the waiting . . .
Stephanie moved through deftly, nodding at familiar faces but never stopping. I followed close behind, avoiding collision with I.V. poles.
When we entered the basement stairwell, I said, “What kind of crime problems have there been?”
“The usual, but more so,” she said, climbing. “Car thefts, vandalism, purse snatchings. Some muggings out on Sunset. And a couple of nurses were assaulted in the parking lot across the street a few months ago.”
“Sexual assaults?” I said, taking two steps at a time in order to keep up.
“That was never made clear. Neither of them came back to talk about it. They were night-shift floats, not regular staff. What I heard was that they were beaten up pretty badly and had their purses stolen. The police sent a community relations officer who gave us the usual personal safety lecture and admitted that, bottom line, there was little anyone could do to guarantee safety unless the hospital was turned into an armed camp. The women on the staff screamed a lot and the administration promised to have Security patrol more regularly.”
“Any follow-through?”
“Guess so— you see more uniforms in the lots and there’ve been no attacks since then. But the protection came with a whole bunch of other stuff no one asked for. Robocops on campus, new badges, frequent hassles like the one you just went through. Personally, I think we played right into the administration’s hands— gave them an excuse for exercising more control. And once they get it, they’ll never relinquish it.”
“C students getting revenge?”
She stopped climbing and looked down at me over her shoulder, smiling sheepishly. “You remember that?”
“Vividly.”
“Pretty mouthy back then, wasn’t I?”
“The fire of youth,” I said. “And they deserved it— talking down to you in front of everyone, that ‘Dr. Ms.’ stuff.”
“Yeah, they were a pretty cheeky bunch, weren’t they.” She resumed the climb, but more slowly. “Banker’s hours, martini lunches, sitting around shmoozing in the caf and sending us memos about increasing efficiency and cutting costs.”
A few steps later she stopped again. “C students— I can’t believe I actually said that.” Her cheeks were aflame. “I was obnoxious, wasn’t I?”
“Inspired, Steph.”
“More like perspired. Those were crazy times, Alex. Totally crazy.”
“Sure were,” I said. “But don’t dismiss what we accomplished: equal pay for female staff, parents rooming in, the playrooms.”
“And let us not forget free coffee for the house staff.”
A few steps later: “Even so, Alex, so much of what we obsessed on seems so misdirected. We focused on personalities but the problem was the system. One bunch of C students leaves, another arrives, and the same old problems go on. Sometimes I wonder if I’ve stayed here too long. Look at you— away from it for all these years and you look better than ever.”
“So do you,” I said, thinking of what she’d just told me about trying for the division-head position.
“Me?” She smiled. “Well, you’re gallant to say so, but in my case, it’s not due to personal fulfillment. Just clean living.”
• • •
The fifth floor housed children aged one to eleven who were not in need of high-tech care. The hundred beds in the east ward took up two thirds of the floor space.
The remaining third was set aside for a twenty-bed private unit on the west side, separated from the ward by teak doors lettered THE HANNAH CHAPELL SPECIAL UNIT in brass.
Chappy Ward. Off limits to the hoi polloi and trainees, maintained by endowments, private insurance, and personal checks; not a Medi-Cal form in sight.
Private meant Muzak flowing from concealed ceiling speakers, carpeted floors instead of linoleum, one patient per room in place of three or more, TVs that worked almost all the time, though they were still black-and-white antiques.
This morning, nearly all twenty rooms were empty. A trio of bored-looking R.N.’s stood behind the counter at the nursing station. A few feet away a unit clerk filed her nails.
“Morning, Dr. Eves,” said one of the nurses, addressing Stephanie but watching me and looking none too friendly. I wondered why and smiled at her anyway. She turned away. Early fifties, short, chunky, grainy-skinned, long-jawed, sprayed blond hair. Powder-blue uniform trimmed with white. Atop the stiff hair, a starched cap; I hadn’t seen one of those in a long
time.
Devil's Waltz Page 3