One
Vicki Shea came into Gunnison Memorial Hospital through the Emergency Room entrance, thinking that she could go through the waiting room incognito and, as she passed by her, get a look at the patient's mother. It was raining and cold and a small hospital, so she didn't expect there would be many people waiting at three A.M. There weren't. The one woman sitting and staring at the carpeting had to be the mother.
The young woman glanced up as Vicki came through the door, seemed to decide Vicki was not who she was looking for, and then looked away. Even in a lined trench coat over her sweatshirt and jeans Vicki was small and slight enough to be mistaken, at a quick glance, for one of her pediatric patients. Her blaze of red hair was half combed, still flattened by her pillow on one side, making her a little wild-looking, an effect that was not diminished by the blood in her eye as she scowled at the woman in the waiting room and then down at the floor when their eyes met. Vicki didn't stop.
The mother's appearance barely registered as young-looking, blonde, frightened, and tired. No one was attending the triage desk and Vicki didn't bother the nurses she could hear at the back, near the microwave. Popcorn smell. She was looking for Tom Boyle, the ER doc that had this shift, or Magdalena, the nurse who had called her. She found Magdalena first.
"In here, Dr. Shea. I'm sorry. I know you're not on call tonight."
"Forget it." Vicki scowled into the newborn warmer, pulling off her coat and reaching for the box of disposable gloves. "Where's Tom?"
"Radiology. He knows you're coming."
The baby girl in the warmer was naked, on her back, limp. There were blue marks on both upper arms and another, high in the center of her forehead, right at the hairline. There was a small catheter plugged into the femoral vein, slow-dripping normal saline, waiting for Vicki's orders. As Vicki watched, the right hand twitched, then twitched twice more.
Vicki didn't move her eyes from the baby, taking in all the marks, watching the hands and feet for spontaneous movement. "Like this since she came in?"
"No change. Got here about two-thirty. She's seventeen weeks old, normal gestation, vaginal delivery. Mom says she slipped and fell while she was carrying her."
Vicki snorted. "Right."
Vicki's hands were small and the gloves universal, so there were boggy tips on her fingers as she reached through the portals on the warmer. Oh-so-gently, she probed the little abdomen, felt the ribs, the long bones in the arms and legs, the shoulders, the hips and ankles. Nothing obviously abnormal or out of place so far, except the baby didn't respond. The twitch was not connected to anything in the outside world, it was in response to a spontaneous firing of motor neurons that shouldn't have been firing. Vicki touched the area around the mark on the front of the scalp. Nothing much there, to palpation anyway. She slid her fingers around the cranium until she felt the soft, spongy texture of swelling at the back of the head. Okay, there it is. Wait for radiology.
Magdalena pushed an instrument tray near Vicki's elbow and opened a sterile package, exposing a tiny clear plastic catheter. Vicki lifted the tent from the incubator and, with deft, smooth maneuvers, drained the bladder into a sterile cup. Dark yellow. No obvious pink. She passed the specimen to the nurse. "Look for occult blood along with the regular panel."
"Sure."
Using a funduscope, Vicki looked carefully at the retina in each eye. The eyes reacted to light equally. The retina on the left looked hemorrhagic. She looked again. Yes, a small but definite retinal hemorrhage. Using two hands now, she felt the phalanges behind the spinal column on the back of the neck. Grossly normal.
Vicki stood over the warmer and stared at the little girl. From what Magdalena had told her this had been a normal baby. Just yesterday, this child had been squawling, smiling, reacting to faces, gripping toys, turning her head to noises. A little girl.
Vicki couldn't let it show but it was impossible for her not to react. A little girl. A brain injury. She'd seen her own Mary like this, the seizures, the unresponsiveness. It was just like it was yesterday. Twenty-five years and it was still that clear—so clear that if she let up just a little she would be in tears now over this new baby. She would not let up. It had taken her twenty years to be able to take these problems on, to be able to look at them as she thought a doctor should. Mary had been born with the mysterious injury built into her brain. This one had not.
Vicki could hear Tom Boyle snapping films into the view box behind her in the examining room. She glanced at him and then continued watching the baby, watching for the twitching. She pulled off the gloves.
"What'd you find, Tom?"
"AP and lateral of the spine look okay, but there's a stellate skull fracture in the occiput."
"Left side?"
"Yes, left side. That ecchymosis you see in front seems to have a little epidermal hematoma under it. There's probably a subdural clot under the fracture in back. Can't see it here, but that's my guess." He kept staring at the films. He glanced at Vicki and then looked back at the view box. "Want me to call for transport to Moffett?"
"Yes, thank you. I'll call Neurosurgery, tell 'em we're on the way."
"Transport's waiting in the hall, Neurosurg is expecting you, got an MRI open in twenty minutes. They'll hold it for you if they can." Magdalena's voice was decisive, firm, with maybe a little defensive anger behind it.
Vicki looked at her, saw the defiant look back. "Don't worry about it, Mag. You did right. Who's on call?"
"Dr. Jacobs."
"Oh. Who's the baby's regular pediatrician?"
"It was Dr. Holmes."
Vicki looked at her again. "Mike Holmes? The guy who died last week?"
"Yes." She nodded for emphasis. "Dr. Jacobs will miss the chance to pick her up as a regular, now."
Vicki waved it off. "Don't worry about it. I'll call him right after I talk to the mother. He'll understand."
It would not be all right, of course. Jacobs would be pissed that somebody else got his call, but Vicki was the only pediatrician who had also been an assistant DA in her past life, before she went back to medicine late and completed her residency. Not all of the nurses, but certainly a veteran like Magdalena, would call Vicki first when there was any suspicion of child abuse. Five years earlier, as a new resident at San Francisco General, Vicki had caused a stir by calling in a child abuse report on her own without waiting for the attending faculty pediatrician. Nobody criticized her because of her background, and besides, she was older than the attending. She had called in two more on her own, and then other residents called her if they thought they might have an abuse case, which turned out to be fine with the attending. He was squeamish about cops.
Tom was still staring at the films, his voice offhand over his shoulder. "Tell Jacobs I called you. He can't stand me anyway, so it won't hurt a thing."
"Okay." Vicki stood at his shoulder and looked at the skull series, immediately dismissing the concern about Jacobs's feelings. "Nondisplaced, huh?"
"Looks like it from here."
Vicki was already moving toward the door. "What's the mother's name?"
Magdalena handed her the newly minted and growing chart. Patient name: Charlotte Sanderson. Responsible party: Francis A. Sanderson. Scrawled in Magdalena's pen next to that typed entry: Julia Wilkins-Sanderson.
Great, thought Vicki, squeaking down the hall in her running shoes. Still don't know what to call her.
The mother was standing with her back to the ER, ostensibly looking at a poor reproduction of a good painting on the wall. Vicki noted that she was tall, but then everybody looked tall to Vicki. She was wearing an expensive, full-length, soft leather coat. She turned at the sound of Vicki's shoes and her face looked openly frightened for a second before she composed it with an effort.
"Ms. Sanderson?"
She nodded. "Julia."
"I'm Dr. Shea, Julia. I'm a pediatrician." Vicki heard her own voice sounding flat, shallow, unsympathetic. "Charlotte is very sick. We have to take her to UCSF, to Moffett Hospital, where we can do an MRI. She may have to have surgery."
Julia's hand was inside a slick black leather glove, clenched in a fist as she brought it up to her mouth and held it there. It was as though all of her tension was in her hands, acting independently, while her face remained wide-eyed but composed, calm, the expression of someone trying to be helpful. She was nodding her head, seemingly eager to agree to whatever was being told to her.
"All right. Will she be okay?"
"I can't tell, yet. I'm sorry." Vicki added that last almost involuntarily. In spite of the calm expression, the young woman was literally shaking with fear. Vicki immediately regretted her hard tone, her hard face. "Here. Sit down a minute, okay?"
Obediently, Julia lowered her backside to the very edge of a chair and quivered there, her eyes wide and moist, her mouth a white straight line. Vicki sat in the chair next to her and plopped the chart on her knee for something else to look at.
"She has a skull fracture—"
"Oh!" The word squeaked out of her and the hand opened to cover her mouth. The other hand, acting on its own, came up and crushed a car key against her upper lip. The tears she had been restraining seemed to pool in her eyes. She blinked them back, refused to give way to them while she continued to stare at Vicki, waiting for her to go on. Vicki was struck by how young she seemed. In spite of the grip she was trying to keep on herself she looked vulnerable and hurt. Then Vicki thought about the flaccid baby, the unconnected twitching that betrayed the damaged brain tissue. She had to make a conscious effort to soften her voice a little.
"That's not the real problem. Bones heal very quickly in a baby. The problem is, there seems to be a blood clot underneath the bone where the fracture is." Vicki put her own hand on the back of her head to show where she was talking about. "So, we need to use the MRI to see how big it really is and if it's pressing on the brain. If it is, they can take it out pretty quickly and see if that doesn't solve the problem. She might be just fine in a couple of days, but I can't really tell right now. Understand?"
The mother nodded, so tense she couldn't make her neck work smoothly. "I need to take her up to UC?"
"No, we're taking her by ambulance. You just need to meet us there." Vicki saw a minimal amount of relief that she didn't have to do it herself. "They won't let you ride in the ambulance but I'll be in the back with her, okay?"
Again, the jerky nod, agreeing to anything and everything. "Where do I go? I mean, I know how to get to the hospital . . . you said Moffett?"
"Yes, Moffett Hospital." Vicki fumbled in the pockets of the lab coat until she came up with a card with her name on it. "The nurse is going to make you sign some consent forms, then you can come on over. Have me paged and I'll tell you where we are, okay? Julia? Take a cab."
More vigorous nodding, then the recognition of what she'd been told. "Oh. Yes, I'll take a cab."
"Can your husband meet us there, too?"
"We're not living together—" She stopped herself, then went on. "I'll try, but I think he's out of the country."
Finally, Vicki couldn't control it. She had to reach out, put a reassuring hand on the woman's arm. "Forget what I said. Do what you want about that. Listen, they're the best in the world up there and we'll be doing everything that can be done, okay?"
Julia nodded, and again she seemed to struggle to control herself. Her whole being was concentrated on Vicki's face, staring at her eyes, trying to read real answers behind the words.
"Can you . . . do you have privileges at Moffett, too?" She was no dummy.
Vicki finally allowed herself a small smile. Whether this woman had caused these injuries or not—and Vicki thought it was likely that she had—she was still the mother of her patient and all Vicki's instincts were to help her as much as humanly possible to get through this circumstance. The old prosecutor buried in her somewhere wanted to toughen up and put the bitch away. The mother in her, not always so firmly buried, wanted to wipe away her suffering.
Through the small smile, Vicki said, "Actually, I teach a course up there. On babies' brains."
She knew it sounded good, but Vicki was not sure this baby would even make it to the other hospital. Probably she would. Pressures, pulse, and spontaneous respirations were holding up okay. All you could ever really do was to run with the probables and hope for the best.
