Chapter 18: Dead on My Feet

July 7, 1989, McKinley, Ohio

"Doctor Mike?" I heard through the fog of waking from sleep. "Doctor Varma needs you."

I groaned, removed my mask, and saw Nurse Kellie in the dim light. I looked at my watch and saw that I'd only been asleep for about fifteen minutes.

"Giant grasshoppers?" I asked, sitting up.

"What?" she asked.

"Nothing. What's going on?"

"Some joker at Taft spiked brownies with Ex-Lax."

"That's a shitty thing to wake me up for," I deadpanned.

Kellie laughed, "You do have a good sense of humor, after all!"

"Who said I didn't?" I asked.

"Don't worry about it. There are patients on gurneys who need exams before we give them IVs."

"OK," I said, getting up. "How many altogether?"

"Eleven."

"Awesome," I said sarcastically.

I got up and Kellie handed me a stack of charts, then accompanied me to the first patient, who was on a gurney in the corridor. It took an hour to work through all six patients on gurneys, with each one receiving an IV with Ringer's. None of them had any symptoms other than diarrhea and stomach cramps, so I filled out discharge forms but didn't sign them, as we wouldn't send them home until they no longer had cramps and had at least one bag of IV fluid.

"Doctor Mike?" Kellie said. "Detective Kleist wants to speak with you. She's in the consultation room."

"Me?"

"You."

"OK. None of the patients are in any danger. Once their IV bags are empty, if they've had no cramps, bring me their chart to sign."

"By your command!" Kellie said with a smirk.

"Battlestar Galactica fan?"

"Season one, not two."

"A wise woman!"

I left and went to the consultation room.

"Detective Kleist? Doctor Mike Loucks."

"Come in, Doc. This will be quick, I suspect."

"What questions can I answer?" I asked.

She smiled, and her eyes twinkled, "Are you married?"

"Yes."

"Too bad. About the students — are any of them seriously ill?"

"No. All of them have IVs with Ringer's lactate to ensure they aren't dehydrated."

"Will you give me permission to speak to them?"

"Sure. I take it you want to arrest someone for this?"

"The Dean of Students certainly wants us to."

"Do you know who made the brownies?"

"Nobody in the dorms is talking so far, and everyone who ate one is here."

"They're all fine, so as long as you aren't using inappropriate interrogation techniques, they're all yours."

"Maybe they like being tied up!" Detective Kleist said with a smirk.

"Somehow, I don't think the answer to that question is relevant to your investigation," I said with a smile.

"Do you?"

"Same answer."

She nodded, and I left the room, and remembered I was supposed to have called Clarissa at 11:00pm, but had been busy, then slept briefly. I decided it was better not to wake her and decided to lie down again, but Kellie stopped me to sign a chart for the first patient I'd seen. I did that, and before I could go back to the on-call room, Jay, the midnight to 8:00am clerk, waved me over.

"Paramedics are five minutes out with a toddler found unresponsive in his bed. Trauma 2 is open."

"Where is Mary?"

"She just went into the lounge."

"Thanks."

I let Mary know we had a patient coming in, then asked for a nurse as I'd sent Tom home, thinking it might have been a good idea for me to go home, too. I felt dead on my feet, and I still had over thirteen hours to go on my shift. Kellie was free, so she was assigned to help, asking Nurse Vickie to watch the remaining gurney patients in the corridor.

"Non-responsive toddler at 2:45am?" Kellie asked.

"That's what Jay said," I replied. "I wondered about that, too."

"Is that cop still here?"

"I think so."

"If we see any signs of abuse, just say something about me not seeing toddlers aboard Nimitz."

"Why do you two suspect abuse?" Mary asked as we stepped out into the ambulance bay.

"While my experience is limited to my daughter," I said, "by the time she was toddling, she was sleeping through the night, and I sure wasn't awake just before 3:00am on Thursday nights. Sure, it might be that one of the parents works second shift, or whatever, but even then, you check on the kid, and so long as they're breathing, you don't try to rouse them."

"Doctor Mike is exactly right," Kellie said. "During nursing school, we had two cases like that. I'm not saying that's the case, but you know we have to check, and hospital policy is to call a social worker if there are signs of neglect and the police if there are signs of abuse."

"Mary, do you know what to look for?" I asked.

"Besides the obvious, no."

"Old injuries, especially broken bones that weren't properly set and previous, unexplained injuries that resulted in the child being brought to the hospital."

"Couldn't the kid be accident-prone?" Mary asked.

"One thing I heard from nurses on military bases," Kellie said, "is that 'accident prone' is often a cover for abuse. Not always, but often."

"We're not jumping the gun here, either," I said as I saw the EMS squad turn into the driveway. "We're just on heightened alert, if you will."

The EMS squad rolled to a stop, and Julie, the lone female paramedic in the county, hopped out of the driver's seat.

"Tommy Mcinnis, twenty-two months, found unresponsive in his crib. BP 130/90; pulse 80; PO₂ 98% on nasal cannula; temp 38.3C; no obvious injuries. Parents should be right behind us."

"Trauma 2," I said.

"Mary, I'll want an EKG and monitor; Kellie CBC, Chem-20, ABG, LFT, and glucose panel. And we'll dip a urine."

They both acknowledged my orders, and we quickly moved Tommy to Trauma 2, where Julie simply lifted him onto the treatment table. Kellie switched the oxygen to the hospital feed, and the paramedics left. We quickly set about our tasks, and upon exam, I appreciated a bit of guarding in his abdomen, as well as sluggish pupils. He had a normal Babinski, and other than elevated blood pressure, there were no other signs.

"EKG looks normal," Mary announced. "BP 130/84, pulse 84; PO₂ 99%."

"Kellie, once you draw the blood, have a nursing student take it to the lab and see if Tommy's parents are in the waiting room."

"Yes, Doctor," she responded.

"Mary, what would you do next?" I asked.

"You appreciated guarding, so an ultrasound."

"Differential?"

"For abdominal guarding? It's a long list, even eliminating the ones that are female-only."

"Top three things you'd look for in a two-year-old?"

She thought for a minute.

"Bowel obstruction, appendicitis, and ... well, more likely for a girl, but a UTI."

"And based on what we discussed before?"

"Blunt force trauma."

"I'd add one more — incarcerated hernia. Not all that common in kids, but it does happen. Who does the ultrasound?"

"You, right? You're a surgical Intern."

"First lesson about treating kids?"

"They aren't miniature adults. Pediatric consult, right?"

"Make the call, please."

She did, then reported, "Doctor Olson will be down in five minutes. What if you suspected something immediately life-threatening?"

"Then I'd do it, but other than the mild hypertension, there's nothing obviously wrong with Tommy except that he's unconscious. Get the ultrasound so it's ready when Doctor Olson arrives."

"Mike?" Nurse Kellie said. "The parents are here. Do you want to bring them in or come out?"

"Let me come out there, please. You stay with Tommy. Matt Olson from Pedes will be down to do an ultrasound."

"OK. And I hope I wasn't out of line calling you by your given name."

"No, you weren't. I'm OK with informality, though we do want to be careful in front of patient families."

"Yes, of course! His parents are the young couple in jeans and white T-shirts in the waiting room."

"Thanks."

I left the trauma room and went out to the waiting room.

"Mr. and Mrs. Mcinnis? I'm Doctor Mike."

"How is Tommy?" Mrs. Mcinnis asked.

"I've examined him, and we're going to run some tests. I have a few questions for you."

"OK."

"When's the last time Tommy ate?"

"A snack before bed, so around 8:30pm. Milk and a cookie."

"How has his appetite been?"

"Good, I think. He eats his meals without fights."

"Have his bowel movements been regular?"

"Yes, I think so," Mrs. Mcinnis said. "I mean, they're like they normally are."

"No diarrhea or constipation?"

"No diarrhea and he seems regular."

"Is he on any medications?"

"No."

"When was his last pediatric visit?"

"At eighteen months, so about four months ago."

"And he's had all his vaccinations?" I inquired.

"Whatever the doctor recommended, yes."

"Has he been sick recently?"

"He had chickenpox in May," Mrs. Mcinnis said, "but otherwise, no."

That meant Reye Syndrome was possible.

"No vomiting or rashes?" I asked.

"No."

"Did he complain about headaches or have nightmares?"

"No."

Which mostly ruled out Reye Syndrome, assuming they were telling the truth.

"Has he fallen recently?"

"No more than a normal toddler, I think. He scraped his knees about two weeks ago, but no broken bones or anything."

"Has he been irritable or fussy?"

"No more than normal," Mrs. Mcinnis said. "All toddlers get fussy now and then."

"Is your home childproofed?"

"What do you mean?" Mr. Mcinnis asked, speaking for the first time.

"Locks on cabinets, outlet covers, anything that might be dangerous locked away or out of reach? Mainly, I'm thinking about cleaning supplies, pesticides, fertilizer, and things like that."

"Nothing is in his reach," Mr. Mcinnis said. "And Sarah is home with him all the time."

"What do you do?" I asked.

"Plumber, but all my stuff is locked in my van."

"Has Tommy been to the hospital at all?"

"Not since I brought him home after he was born," Mrs. Mcinnis said.

"OK. That's all the questions for the moment. I've asked a pediatric specialist to assist, and as soon as we know something, one of us will come to speak with you."

"Can we see him?" Mrs. Mcinnis asked.

"He's in a trauma room at the moment, and those aren't really designed for visitors," I replied. "One of you could come in for a moment, but that's it."

"Go, Sarah," Mr. Mcinnis said.

"Follow me, please."

I led Mrs. Mcinnis to the trauma room and allowed her to stay until Matt Olson arrived. After he introduced himself, I had Kellie escort Mrs. Mcinnis back to the waiting room.

"What do you have, Mike?" Matt Olson asked.

I went over the results of my exam and my questioning of the parents.

"Let's see what we can figure out," he said.

He repeated the physical exam, confirming what I'd told him, then used the ultrasound to examine Tommy's abdomen.

"What do you see, Mike?" he asked.

I looked closely and saw a moderate dilation of the small bowel that indicated an obstruction along with a possible mass, and said so.

"And the rule?" Matt asked.

"Never let the sun rise or set on a small bowel obstruction," I replied. "Mortality rates increase rapidly every twelve hours for untreated obstructions. But that doesn't explain his lack of consciousness nor his sluggish pupils."

"No, it doesn't, but we need to treat that first. It's a surgical case, so you can certify it. They'll have to wake up Pete Barton, so you should call up."

Pete Barton was the on-call pediatric surgeon. I moved to the phone and dialed the surgical ward.

"Mike Loucks in the ED," I said. "I have an unresponsive pediatric small bowel obstruction, confirmed by Matt Olson. We'll send the patient up shortly."

The nurse asked for Tommy's basic details, which I gave her, and let her know the labs had all been ordered. Once everything was confirmed, I hung up.

"He won't start without labs, and we probably have fifteen to twenty minutes before those are back," I said. "I'm concerned about the other symptoms."

"Me, too," Matt said. "The parents claimed he wasn't fussy or crying?"

"Yes."

"I don't believe it. He must have been in pain, and there's a good chance he vomited and had irregular bowel movements. I think we should get a head CAT. Will you sign off?"

"You're thinking 'Shaken Baby Syndrome'?" I asked.

"It does fit the circumstances because there is no way this little boy was asymptomatic."

"I'll sign off, but we wait for the results before we make any accusations or involve the police."

"Agreed."

"Mary, call for an orderly, and you can take Tommy upstairs. No need for a portable monitor, and he should be fine on room air for transport."

"Right away," she confirmed.

"Shall we update his parents?" I suggested to Matt.

He agreed, and we went to the waiting room as we couldn't use the consultation room because Detective Kleist was still using it.

"Tommy has a bowel obstruction," I said. "He's going to need surgery to relieve it."

"Surgery?" Mrs. Mcinnis asked.

"Yes," Doctor Olson said. "It's a very simple procedure, and there are minimal risks compared to doing nothing, which could lead to serious complications or even death."

"And that's why he won't wake up?"

"We don't know the cause of that at the moment," I said. "But we need to fix his small bowel right away, and we'll continue to investigate why he won't wake up. The lab tests aren't back yet, and there are some other tests we'll run after surgery."

"I'll take you upstairs," Doctor Olson said. "They'll have consent forms for you to sign, and you can see Tommy before he goes into surgery."

"Thank you, Doctors!" Mrs. Mcinnis gushed.

"Come with me, please," Doctor Olson said.

He led them towards the elevators, and I returned to Trauma 2.

"I have $10 that says one of his parents shook him because he was crying," Kellie said. "My money is on the mom."

"Why?" Mary asked.

"Call it a gut feeling," Kellie replied. "Mom's stay-at-home, right Mike?"

"Yes. And I agree with Doctor Olson that he had to have been symptomatic, given he has an obstruction and a small mass. Matt's taking the parents upstairs to fill out the consent paperwork."

The phone rang, and Mary answered it, then announced the labs were back. She went to get them, and while she was gone, the orderly arrived. Once Mary returned, I reviewed the labs and saw nothing out of the ordinary except a very slight elevation of Tommy's white blood cell count, though it was only marginally high and might be normal for him.

"I'm going to try to get a nap," I said to Kellie. "I'm dead on my feet."

"Down from the 'I almost died' adrenaline high?"

"I don't have ice water in my veins like some people!"

"Military service will do that to you," she said.

"What was your rank?"

"Lieutenant. If I'd have stayed in, I was up for Lieutenant Commander and would have been assigned as a supervisor at a shore billet."

"Why'd you get out?"

"Naval careers aren't conducive to having children," she said. "Not all that different from how it is for women doctors."

"Are you married?"

"Nobody has asked! I'm dating, but haven't found 'Mr. Right' just yet. How long have you been married?"

"Since January."

"And you have a toddler?" she asked with a slight smile.

"Rachel's biological mom died shortly after giving birth to her."

"Oh, my!" she gasped. "I'm so sorry!"

"It's OK. You weren't here two years ago and had no way to know."

"Now I have to ask..."

"Rachel needed a mom, and whatever feelings or emotions I had, that was a priority."

"I can see that," Kellie said. "Single dad in med school would have been tough."

"It was. I had a ton of help from my friends and family. If you don't mind, we can continue this talk later. I'm going to sack out."

We left the trauma room, and before I made it to the on-call room, I was approached to sign four more charts for discharge of the Ex-Lax patients. I fell asleep almost as soon as my head hit the pillow.

"Mike?" I heard Kellie call out.

I groaned, removed my eye mask, and sat up, seeing only ten minutes had passed.

"Yeah," I said.

"Drunk driving MVA with three victims. Ghost said to wake you."

"How long?"

"Four minutes."

"I'm going to take a leak," I said. "Meet you in the ambulance bay."

As I got up, she handed me a Styrofoam cup of coffee.

"Thanks. Have Mary meet me in the ambulance bay."

She left, and I drank some of the hot liquid, then went to the locker room to use the urinal and made it to the ambulance bay just before the first EMS squad rolled to a stop.

"Mike, I'll take patient one, you take patient two, and Naveen will take patient three. Doctor Taylor is available for anyone who needs help."

Kellie, Mary, and I took our patient to Trauma 2, the room we'd just cleared, for treatment. Fortunately, other than a contusion and laceration on his head, he had no injuries. His passenger, who had been on the side of the car the drunk driver had t-boned, didn't fare nearly as well and had been sent for emergency surgery by Doctor Casper to repair significant internal injuries. The drunk driver, as happened disgustedly often, was uninjured and was on a banana bag with Deputy Schmidt guarding him.

I contemplated trying to take another nap and had decided I would, when Jay said there was a call for me.

"Doctor Mike Loucks," I said when I picked up the phone.

"Doctor Clarissa Saunders. You stood me up!"

"You don't want to know, Lissa. Breakfast?"

"Sure. Now?"

"I think I can make a break for it."

"On my way."

We ended the call, and I let Jay know I was going to the cafeteria for breakfast. I trudged there, more tired than I'd ever been, and I still had more than twelve hours before the end of my shift.

"You look like death warmed over," Clarissa observed when she saw me.