Czytaj książkę: «The Doctor's Secret Family»

CHAPTER ONE

IT JUST wouldn’t go away.

The nasty prickle of premonition had been stalking senior paediatric registrar Hannah Campbell ever since she had first woken that morning, and she had been unable to shake it off despite a busy few hours on ward duty. At least now Hannah thought she had identified its origin.

‘I have a horrible feeling I’m not going to get it.’

‘Of course you will.’ Junior registrar William Price sounded surprised. ‘I wish I had a fraction of your skill in getting IV access in kids.’

Hannah glanced up from the tiny hand she was holding, bent over to stretch the skin between wrist and knuckles in the hope of revealing the exact whereabouts of a vein. ‘I’m not talking about IV access, Will. I’m talking about the job.’

‘Ah…’ William rearranged his hold on the infant lying on the treatment bed. ‘It’s OK, Jamie,’ he said soothingly. ‘It’ll all be over in a minute or two.’ He turned his gaze back to his senior colleague. ‘They’ve closed the applications for the consultancy position now, haven’t they?’

‘Yeah.’ Hannah was using an alcohol wipe in a circular motion to clean Jamie’s hand and hopefully stimulate a tiny vein into making an appearance. ‘They closed yesterday.’ Which had to be why this feeling of premonition had started first thing this morning. The countdown to the interviews was on.

‘Do you know how many applicants there were?’

‘Not exactly. But I do know that one of them is from a guy in Auckland who is already a consultant and has years more experience than me. He wants to get out of the rat race up there and move his family to Christchurch.’

‘You have the advantage of being known. How long have you worked here now?’

‘I was a junior registrar here nearly six years ago. I had a year off before I got the senior registrar position. That was three and a half years ago now.’

‘You had the year off because of Olivia?’

‘Mmm.’ Hannah had selected the finest gauge of cannula available. ‘Sorry about this, sweetie,’ she murmured as she pierced the skin on Jamie’s hand.

The eleven-month-old boy’s grizzles increased in volume and William had to hold his arm more firmly to prevent any movement. The child’s mother had elected not to watch the procedure so the two young doctors were alone in the treatment room of Christchurch Central Hospital’s paediatric ward.

‘I wouldn’t worry about it.’ William’s reassuring tone was intended to benefit the baby as much as Hannah. ‘Peter thinks you’re marvellous and as head of department he’ll have significant input into deciding who gets the job.’

‘I hope so.’ The worry wasn’t going to evaporate easily, however. Hannah wanted this position she had waited a long time to apply for. She wanted it badly.

She also wanted to find IV access in this severely dehydrated infant. IV fluid resuscitation was urgent and she wasn’t going to allow any niggling personal fears to interfere with her performance. She should also be using this opportunity to help consolidate William’s skills, not discuss her future employment options.

‘What percentage dehydration would you estimate Jamie to have?’ Hannah was advancing the fine needle in a new direction now. Anatomically, there had to be a vein somewhere close.

‘His skin’s a bit mottled and the capillary return isn’t great,’ William answered promptly. ‘His fontanelle and eyes are markedly sunken but his level of consciousness isn’t too depressed. I’d say about seven per cent.’

Hannah nodded. She drew the needle back towards the surface of the skin and a tiny spot of red appeared in the flashback chamber of the cannula mechanism.

‘Got you,’ she said in satisfaction. ‘Keep him really still for a second, Will.’ Dropping the angle of the needle and advancing it just fractionally, Hannah held her breath as she pushed the plastic cannula off the end of the needle. A smooth entry indicated effective placement and Hannah unsnapped the tourniquet fastening before swiftly removing the introducing needle and attaching a syringe to the end of the cannula.

‘What tests are you going to order on these bloods, Will?’

‘CBC and differential. Urea, creatinine, sodium and potassium levels.’

‘What’s the most likely cause for the gastroenteritis?’

‘Rotavirus.’

‘And how are we going to treat it?’

‘Initial fluid resuscitation with normal saline at 20 mil per kilogram. Then 10 mil per kilogram per hour until we get the serum electrolyte results. We’ll adjust the solution depending on sodium levels after that.’

‘Cool.’ Hannah attached the giving set leading to the bag of IV fluid already set up on the drip stand. She taped the line to Jamie’s arm and then protected the IV cannulation site with a thick layer of crêpe bandaging. When finally satisfied that the fluids were running well, Hannah relaxed and scooped the baby from the table into her arms.

‘There you go, darling,’ she murmured. ‘All done. Let’s get you back to Mummy for a cuddle.’

William grinned. ‘You must be one heck of a substitute. That’s the closest to being happy I’ve seen him look since he arrived. What is it with you and babies?’

Hannah kissed the top of the downy head. ‘I’m just the maternal type, I guess. There’s got to be some reward for the awful things we need to do to the poor wee mites sometimes.’

‘Mind you don’t take a dose of rotavirus home to Olivia.’

‘I’ve been taking things home since she was even younger than Jamie. I reckon we’ve both got fantastic immune systems by now. Livvy never gets sick.’

Hannah’s pager sounded as they walked back to Jamie’s room. ‘I’ll leave you to get those bloods away and chase up the results, Will. Keep a close eye on things. If Jamie’s condition deteriorates any further, we’ll need to transfer him to Intensive Care.’

There was a phone on the wall just outside the room Jamie would share with his mother for the next day or two. William emerged just as Hannah finished taking the call her pager message had requested.

‘You don’t look very happy,’ he commented. ‘What’s up?’

‘I have to get up to Theatre. A woman who’s thirty-five weeks pregnant has just come in with a placental separation following an MVA. They’re rushing her up for an emergency Caesar and it seems I’m the most senior paediatrician available at the moment.’ Hannah was already moving swiftly towards the lifts at the end of the wide corridor. Maybe the cause of that premonition had been some instinct that she might be faced with a particularly challenging case. Thanks to Hannah’s determination to excel in everything she did in the run-up to the decision on appointing the department’s new consultant she had a new pressure and a whole new set of nerves to contend with.

‘You’ll be fine.’ William’s confident words floated through the closing lift doors. ‘Peter will be proud of you, you’ll see.’

* * *

Consultant Peter Smiley was living up to his name when he sat down at the table in the cafeteria Hannah was occupying nearly two hours later. It was far too late to be considered part of any normal lunch-break and the huge room was largely deserted.

‘I’ve been hearing great things about you, Dr Campbell.’

Hannah grinned. If that emergency case had been responsible for the nameless fear stalking her earlier then she had managed to prove her instinct very wrong. Her grin faded as she shook her head.

‘I have to admit I was pretty nervous when I got to Theatre. I had no idea how long the baby might have been hypoxic for. I had the feeling that even if the resuscitation was successful the parents might not thank me for it.’ Hannah bit her lip. ‘What are the precise criteria for deciding not to take an aggressive approach? Have you ever done a resus and left parents to cope with bringing up a badly handicapped child, Pete?’

‘It happens.’ Peter nodded. ‘But there are no hard and fast rules. Even when you get a baby born at the limits of viability, like twenty-two to twenty-four weeks’ gestation, it’s tricky. You have to look at the weight and degree of bruising, along with the baby’s condition at birth, the presence or absence of a heartbeat and any efforts to breathe.’

Hannah nodded. ‘This one had an Apgar score of zero initially. White, flaccid, undetectable heartbeat and no spontaneous breathing.’

‘What gestation?’

‘Thirty-five weeks.’

‘How badly injured was the mother?’

‘She had a fractured tib-fib and seat-belt bruising. It was probably the position of the seat belt that caused the placental separation. She’d begun bleeding heavily by the time she reached the emergency department. They did a quick ultrasound and got her straight up to Theatre. The baby was delivered within thirty minutes of her arrival, which was pretty amazing.’

‘I’ll say. They must have had a theatre ready to go.’

‘They were setting up an elective Caesar. The patient had had her epidural and was on the way. I bet she wasn’t too happy about being sent back to the ward for another couple of hours.’

‘No.’ Peter sat back in his chair, his gaze curious. ‘So, what did you do with this flaccid baby?’

‘Put her under the lights and used gentle suction to clear the upper airway. Inflating her lungs with the bag mask initiated a gasp but no spontaneous breathing so I intubated.’

Peter raised his eyebrows. Intubation of a newborn required considerable skill. Clumsy insertion of the tube could damage the upper airways, and over-vigorous inflation could damage the lungs. ‘Any problems?’

‘No. I ventilated at a rate of thirty per minute with a nice gentle pressure but she still didn’t pink up. Heart rate was less than sixty per minute so then I started cardiac massage.’ Hannah’s smile was a little grim. She had thought she was fighting a losing battle at that point. She had encircled the baby’s chest with both hands, positioning her thumbs to exert pressure on the lower half of the tiny sternum and directing the nurse assisting her to deliver one inflation of the lungs to every three to five compressions.

‘Did you need any adrenaline?’

‘I had it drawn up as I cannulated the umbilical vein but then things started to improve.’ Hannah’s smile was much brighter now. ‘The Apgar score at five minutes was 7. She had facial grimaces, gasping respiration, heart rate greater than a hundred, some flexion and she was finally pink!’

Peter smiled at Hannah’s obvious pleasure. ‘Pretty satisfying, then?’

‘You bet. Apgar was 9 at ten minutes. I still wasn’t happy enough with her muscle tone to give her a ten but I’m pretty confident she’ll be OK. It’s hard to know, though, isn’t it?’ Hannah’s brow furrowed. ‘She could have been without oxygen for long enough to have permanent repercussions.’

‘Some people put all sorts of things down to a mild hypoxic insult—anything from hyperactivity to learning problems. But there’s not much in the way of good evidence. Babies can recover remarkably well from what seems like a dire start to life. We’ll keep an eye on this one for the next few days for any sign of neurological compromise but I doubt we’ll find anything. You sound like you managed a difficult case extremely well, Hannah. Well done.’ The consultant’s face creased into a familiar expression of approval. ‘I’m proud of you.’

‘Thanks.’ Hannah returned the fond smile. ‘If I’m good at what I do a lot of credit needs to go to you, you know.’

‘It’s always been a pleasure to work with you, Hannah. A pleasure that I hope will continue for a long time.’

‘So do I.’ Hannah toyed with her almost empty cup of coffee. ‘I’m going to be biting my nails waiting for this consultancy to be decided.’

‘You really want this job, don’t you?’

‘It’s exactly what I want, Pete.’

‘But it’s only a seven-tenths position and you don’t want to do any private practice, do you?’

‘Will that make a difference?’ Hannah asked anxiously. ‘Do you really need someone else in your practice?’

‘I will eventually. I’m not getting any younger, in case you hadn’t noticed.’

Peter was nearly sixty years old but Hannah grinned. ‘I hadn’t. You’ll need to develop some more crinkles, as Livvy calls them.’

‘I’ve got plenty of ‘‘crinkles’’.’ Peter’s face brightened. ‘How is Livvy?’

‘She’s great. She can write her own name now. She drew the most amazing picture yesterday and signed it for me. I think I’ll get it framed.’

‘What’s it a picture of?’

‘Joseph.’

‘That’s your…donkey, yes?’’

Hannah laughed. ‘That’s the one.’

‘It’s a bit difficult remembering all the names of your pets. Every one of those hens has a name, doesn’t it?’

‘Yes. And the goat and cats. We’d love to get a puppy some time as well.’

‘How on earth do you look after them all?’

‘It’s not difficult. And if I get this consultancy I’ll have a bit more time at home so maybe we could think about getting a dog.’

‘Is that why you’re so keen?’

‘Of course not. Having more time with Livvy is the main appeal. On a consultant’s salary I would be paid as much for seven-tenths as I am for this registrar position, which feels like twelve-tenths a lot of the time. Plus I’d be able to stay in Christchurch on a permanent basis. Neither Livvy nor I want to leave our property. I’ve spent years turning that old house into something worth living in and I’d hate to move. We’d never find land so close to town that we could afford now either. The prices for lifestyle blocks have gone through the roof in the last few years.’

‘So the department doesn’t really rate, then?’

‘Come off it, Pete.’ Hannah’s admonishing tone was negated by the smile she bestowed on her boss. ‘You’ve been far more than a boss, or even a colleague, to me and you know it. I might never have come back after having Livvy if it hadn’t been for your encouragement, and thanks to you, the paediatric department of Christchurch Central is probably more sought after as a place to work in than anywhere else in this country.’ She sighed. ‘That’s the problem. I’m going to be up against some pretty stiff competition for this position, aren’t I?’

‘I wouldn’t worry too much about that. I was just discussing you with Tom Berry, in fact.’

‘Oh?’ Tom Berry was one of the paediatric surgeons at Central. He would also be on the committee that would decide the position. Hannah widened her eyes anxiously but Peter simply grinned.

‘He had very nice things to say about you.’ Peter glanced at his watch. ‘And that reminds me. I was supposed to be in Tom’s office ten minutes ago for an afternoon tea to welcome their new appointee.’ He stood up hurriedly. ‘I’ll have to disappear. Sorry, Hannah.’

‘That’s OK.’ Hannah followed his example and rose, collecting her empty plate and cup. ‘I’m due back in the ward for an admission anyway.’

Her resigned expression made Peter smile. ‘Anyone I know?’

‘Jadine Milton,’ Hannah replied. ‘She looks set to become our latest frequent flyer.’

‘Abdominal pain again?’

‘Yep. And I’ve ruled out every obscure medical cause I can think of over the last three admissions.’

‘Crohn’s disease? Constipation? Lead poisoning?’ Peter was walking with Hannah as she left the cafeteria.

‘And intussusception, intestinal obstruction, appendicitis, pyelonephritis and pancreatitis.’

‘Diabetes?’

‘Blood sugars are normal. I’m sure there’s no organic cause. We even did an endoscopy last time to rule out peptic ulcers.’

‘Munchausen’s?’

‘It’s starting to look like that. Or Munchausen’s by proxy. The mother’s got a few problems.’

‘Who initiated today’s admission?’

‘The GP. I suspect she’s fed up.’

Peter turned off as they reached the lifts near the gift shop in the main foyer. ‘Get some input from Psych this time. And maybe Social Services.’

Hannah nodded wearily. ‘I’ll see if I can have a good talk to the mother myself as well.’ She headed for the stairs unsurprised that that vague feeling of premonition had returned. This was another challenging case but behavioural and social problems were veering away from any field of expertise Hannah had and it was hard to stay uninvolved when she liked her patient. Six-year-old Jadine was not unlike her own daughter to look at, with her blond curls and big, brown eyes. Her single mother was also struggling with the kinds of issues Hannah had dealt with herself. The case would be time-consuming, however, and there were a lot of loose ends on the ward that Hannah would need to deal with before she could leave for the day. She almost welcomed that familiar tension that came with the conflict between wanting to get home to Livvy and needing to do her job as best she could. She was used to coping with this and it was preferable to that formless fear still clouding her day.

* * *

Jadine Milton lay on a bed in Room 4, next door to where young Jamie was receiving IV fluids to correct his dehydration. The small girl’s face was pale but Hannah suspected this was quite a normal colour for her. Clutching a Barbie doll, Jadine was shaking her head vigorously as Hannah entered the room.

‘I don’t want a drink, Mummy. I hate water!’

‘Water’s good for you. You drink far too much cola. It’s probably got something to do with all these tummyaches you’re getting.’

‘Hi, there, pumpkin.’ Hannah smiled at her patient. ‘Fancy seeing you in here again.’

‘I’m so sorry about this.’ Jadine’s mother, Caroline Briggs, sighed theatrically. ‘I felt embarrassed enough turning up at the medical centre yet again. It’s even worse to have to come back into hospital. I know how busy you are and—’

‘It’s not a problem,’ Hannah interrupted. ‘What’s important is making sure that Jadine is fine.’

‘You haven’t found anything wrong with her the last three times she’s been in. You must be starting to think we just make a fuss about nothing.’

Hannah hoped her smile was reassuring. She could see the anxiety in Jadine’s face. No matter what the cause of the recurrent abdominal pain, a six-year-old child couldn’t be held responsible for any wastage of time and resources.

‘So your tummy’s sore again, Jadine?’

The little girl nodded.

‘Does it feel just the same as last time?’

She nodded again.

‘When did it start?’

‘It’s never really gone away completely,’ her mother answered. ‘She seems to get better and then it comes back again a few days later. It’s been going on for weeks.’

Hannah nodded. The first admission had been six weeks ago now. ‘Is there any pattern to it?’

‘How do you mean?’

‘Is it more likely to happen, say, on a Monday? Or a weekend?’

‘I don’t know. She’s been missing an awful lot of school, though.’

‘Do you like school, Jadine?’

Jadine nodded again. ‘My friend Georgie and me play Barbies at lunchtime.’

It was not the kind of response she would have expected from a child who might be experiencing problems like bullying at school. Hannah glanced up at Caroline.

‘Have you noticed anything that seems to make any difference?’

‘Like what?’

‘Changes in her diet, maybe?’

‘The only real change she gets is when she goes to stay with my mum.’ Caroline sighed. ‘For some reason she’ll always eat her veggies when she’s staying with Grandma. She never does it at home.’

‘Don’t you like veggies, Jadine?’

‘I like Grandma’s veggies.’

‘I cook them exactly the same way,’ Caroline protested.

‘They don’t taste the same. And you don’t make pudding. I have to eat veggies for Gran or I don’t get the pudding.’

‘I don’t have time to make puddings. And, anyway, they’re not good for you.’

‘Gran’s puddings are good for me. They make my tummy stop being sore.’

Hannah stayed silent, observing the undercurrent between mother and daughter. The significance of another family member being involved was not something she had thought of pursuing in this case but there was clearly something going on here that could be important. She made a mental note to follow it up.

‘Have you been back to your GP before today?’

‘We’ve been at the medical centre every other day. They’re getting sick of seeing us turn up and it’s costing me a fortune.’

Hannah smiled sympathetically. The referral note from the GP had suggested that Jadine’s mother needed more reassurance than they were able to supply. ‘Is she eating all right?’

‘She’ll eat anything that looks like a hamburger or chips. Her appetite seems to vanish in front of a plate of vegetables, though.’ Caroline sighed again. ‘I do try.’

Hannah smiled as she sat on the edge of the bed close to Jadine. ‘My little girl likes chips, too.’ She leaned forward. ‘She’s got a Barbie doll as well, only she left hers in the water trough out in our paddock the other day and now Barbie keeps leaking.’

Jadine stared at Hannah. ‘What’s a troff?’

‘A big drinking bowl. Like cows or horses need.’

‘Have you got a cow?’

‘No. I haven’t got a horse either, but I do have a donkey.’

‘What’s its name?’

‘Joseph.’

Caroline was also staring at Hannah. ‘Why do you have a donkey?’

Hannah laughed. ‘Just for a pet. I’d always wanted one.’

‘Why?’

‘They’re lovely animals. Very gentle and friendly and they’re kind of peaceful to be around.’

‘Really?’ Caroline still looked unconvinced. ‘I thought they made a horrible noise.’

‘Joseph is very quiet. Except for when he sees us coming and wants to say hello.’ Hannah pulled her stethoscope from its position around her neck. Chatting with her patient might make for a relaxing atmosphere but it was time she got on with her job.

‘Can I have a look at you now, Jadine? I need to check all those things like your blood pressure and temperature and heart and then I’ll need to feel your tummy.’

Jadine’s eyes filled with tears. ‘Do I have to have a needle again?’

Her mother grabbed a tissue from the box on the locker and was ready to mop her daughter’s face. ‘You’ve got to be brave, Jadie. Dr Hannah’s here to make you better.’

‘You don’t have to have a blood test right now,’ Hannah said soothingly. ‘And if you need one later we’ll make sure we put that special cream on your skin to make it go all numb so it doesn’t hurt.’

Hannah went through the motions of a full physical examination. Consciously trying not to allow any bias towards a psychosomatic cause for the abdominal pain probably made her examination even more thorough than normal. As the commonest acute surgical emergency of childhood and usually seen in children over five years of age, appendicitis was still at the forefront of possible diagnoses but, as with the previous three admissions, there was no associated low-grade fever and no history of vomiting or anorexia. Whilst Jadine seemed to have genuine discomfort on palpation, Hannah could find no ‘guarding’, where the muscles became protectively rigid, when she pressed on the lower right quadrant of the abdomen.

‘Bowel habits normal?’ she queried.

‘Absolutely.’ Jadine’s mother nodded. ‘Colour and everything’s just the same as usual. I always check.’

Hannah hid her surprise. She might not have blinked if an infant’s mother knew more about her baby’s bowel habits than her own but it was a little unusual for a six-year-old not to be demanding some privacy in the toilet. Her own daughter was four and a half now. She might not bother to shut the door and she sometimes forgot to flush but she had been independent as far as toileting went for some time now.

‘Has Jadine had any bugs recently? Coughs or colds?’ An upper respiratory tract infection could cause inflammation of the mesenteric lymph nodes leading to nonspecific abdominal pain but Jadine’s lungs sounded as clear as bells, which fitted with Caroline’s denial of any viral illnesses.

‘You don’t have a family history of migraine, do you, Caroline?’

‘You asked me that last time. I get headaches.’ Caroline’s huff was resigned. ‘Usually when the bills are due to be paid. Wouldn’t call them migraines, though.’

Hannah nodded. Children who went on to have classical migraines commonly presented with recurrent episodes of prolonged abdominal pain but they usually had nausea or other symptoms accompanying the discomfort. As Caroline had pointed out, she was covering the same ground she had been over before.

‘We’ll need to get a urine sample again.’ She smiled at Jadine. ‘Do you remember that test, sweetie? The nurse takes you to the toilet and gives you a wash and you have to wee into the little jar. You don’t mind doing that again for us, do you?’

Jadine shook her head.

‘Good girl. That way we can do another check to make sure there’s no bugs hiding in your waterworks that might be making your tummy sore.’ And it might give Hannah a chance to have a talk to Jadine’s mother privately. ‘You tell me when you think you might be ready to go to the toilet.’

‘I want to go now.’

‘Do you? That’s great.’ Hannah stood up. ‘I’ll call Nina to come and look after you. She’s your nurse today, isn’t she?’

Jadine smiled. ‘Nina’s nice. She likes Barbies.’

‘She looks a bit like Barbie, doesn’t she, with that pretty blond hair?’ Hannah smiled. ‘It’s just like yours, isn’t it?’

Jadine returned the smile happily, which only reinforced Hannah’s impression that there was nothing seriously wrong with this child. ‘I’m going to take Mum off for a cup of tea while Nina’s looking after you,’ she told Jadine. ‘Is that OK?’

‘Sounds good to me,’ Caroline said. ‘I’d love a cup of tea.’ She eyed the notes Hannah was carrying anxiously, however, as the two women took their tea into Hannah’s office a few minutes later. ‘You’ve found something wrong with her, haven’t you? Something you didn’t want to talk about in front of Jadie.’

‘Not at all,’ Hannah said promptly. ‘It was time I had a break and I’m sure you could use one. It’s pretty stressful having your child unwell.’

Caroline sat down on the spare chair in the office. ‘How old is your daughter?’

‘Four and a half.’

‘Ah…nice age.’ Caroline’s smile was poignant. ‘Make the most of it.’ She caught Hannah’s glance. ‘It won’t be long till she starts school,’ she added. ‘And that’s when you really lose your baby.’

‘It’s a big milestone,’ Hannah agreed. ‘But we’re both looking forward to it.’

‘Are you?’ Caroline sounded surprised. ‘I cried for days. It wasn’t until I started being a mother help at school every day that things started to get better.’

‘Oh?’ The sound was intended to be encouraging but a warning bell was going off for Hannah. Just how deeply centred on her child was Caroline Briggs’s life? Munchausen syndrome by proxy was an unusual and bizarre form of child abuse that could possibly be triggered by a parent’s need for some form of attention. Was Jadine Caroline’s primary source of relationships with others?

Given Caroline’s concern about a prolonged and unexplained illness in her child, the syndrome needed consideration. And hadn’t Jadine said her symptoms disappeared when she stayed with her grandmother? It was highly unlikely that she was being cured by some magic ingredients in the puddings. Hannah would need to seek assistance from other medical professionals, as Peter had suggested. A conversation with the grandmother was probably overdue as well but now seemed like a good opportunity to gather some more background history.

‘Tell me about Jadine when she was a baby,’ Hannah invited. ‘Did everything go well with your pregnancy and her birth?’