A Mother's Trial (4 page)

But because Mindy’s illness was beginning to look suspicious, because it might somehow be related to her intake, Sara had ordered a stool sodium test. And the results were indeed significant.

Sara had already calculated Mindy’s known sodium intake. In the period preceding the time the stool sample had been collected on Wednesday, Mindy had received 14 milliequivalents of sodium: 10 by IV and 4 by Cho-free formula. There should have been an equal amount coming out.

But the lab test result was astonishing. On the sample collected Wednesday afternoon, Mindy’s stool sodium level had reached an incredible 251 milliequivalents. This was totally unexplainable.

Nothing in medical school had prepared Sara for this. As late as this afternoon, before she had received these results, she’d still been trying to find a medical cause for Mindy’s condition. She had telephoned Dr. Applebaum at Kaiser-San Francisco and asked him again about secretory diarrhea. He had not ruled it out. And as long as a diagnosis was still possible, Sara could put off thinking about the other cause, the nonmedical one, the one she preferred not to face.

She remembered the afternoon meeting with Priscilla and Debby Roof on the ward. Debby’s concern was apparent. Mindy was stooling heavily, and was lethargic, just like Tia.

“It’s not like with Tia, is it, Dr. Shimoda?” the nurse had asked. “After all, Tia had all those high serum sodiums.”

Priscilla had nodded and smiled. “That’s right,” she agreed.

And Sara had said nothing, had not contradicted her. Because by this time, something was entering her consciousness, and it was certainly nothing she could say to soothe Priscilla. She was starting to know it in a place in her heart: whatever was happening to Mindy had happened to Tia, too.

She took out a copy of the current issue of the
JAMA
that Dr. Arnhold had given her after Wednesday’s staff meeting. She had read and reread the editorial he had pointed out.

It commented on a British article about Munchausen Syndrome by Proxy, a variation on Munchausen Syndrome itself. Sara knew about Munchausen Syndrome. They all did. There were always jokes floating around every hospital about famous cases they had had of this person or that who came in with massively scarred bodies from procedures they had fooled doctors into performing on them.

People with Munchausen Syndrome craved the type of warm care and attention they felt they could receive only in a hospital setting. They would do anything, make up any symptom, to remain hospitalized. They would submit to—and welcome—any hospital procedure. They might rub feces into open wounds to cause infection, or pour blood into urine specimens to throw off a diagnosis. When their deceptions were discovered, they often left in a huff to try another hospital. Some hospitals even published lists of these people to look out for. They were sad psychological messes in Sara’s opinion.

But Munchausen Syndrome by Proxy was a little different. Apparently patients suffering from this caused their own children to undergo unnecessary hospital procedures by giving false histories and tampering with test results. One of the two children mentioned in the
JAMA
article had died after having been repeatedly dosed with salt. The two mothers involved had both appeared to be loving and concerned, and only after their roles in the children’s illnesses had been discovered did their psychopathic traits become obvious. The mother of the baby who died had attempted suicide afterward. The other mother’s mental stability was also questioned when it turned out that she had tampered with her own specimens on an earlier occasion.

It was almost incredible that any mother would deliberately and repeatedly poison her child. Yet this fit with a case cited in a
Clinical Pediatrics
article that Evelyn had read, and if the mother were really mentally ill... Sara shook her head. It was too much to think about right now.

Sara replaced the journal on her desk and rose. She was suddenly struck by a tiredness so overwhelming that it frightened her. She welcomed the weekend, away, out of reach of all this.

8

It was the kind of morning characteristic of the Bay Area in February, overcast and foggy. A thick dew had settled on the grass outside Evelyn’s house, and a mist had dampened the windshield of her car. It was impossible to predict how the day would turn out. The fog might clear by mid-morning, permitting thin, filtered sunlight to touch the dull pink of the hospital walls, or the fog might turn to heavy cloud and deep, mushy rain. Evelyn hugged her coat to her as she made her way up from the doctors’ parking lot to the side entrance of the hospital where the Emergency Room was located.

She was already tired. She had hardly slept. Beside her last night, her husband had lain dreamless. Mindy was not his problem—but hers.

She had realized something would have to be done yesterday afternoon, after she had met with Sara and Rainer Arnhold and Estol Carte and heard about the results of Mindy’s stool sodium tests.

They had decided that Mindy’s intake and output would have to be carefully monitored. Sara planned to repeat the tests when she came back, and they had agreed this was necessary. They had discussed poisoning. Evelyn continued to believe that a sodium cathartic was responsible for Mindy’s condition. Probably Epsom salts. They still had to research a method of testing for sulfates. Would a stool sample reveal magnesium? she wondered. Maybe Boyd Stephens would know. Sara planned to call him on Monday.

After the meeting, Evelyn had hurried back to her office and looked up the stool sodium values for cholera, the only illness she could think of that might produce anything close to the 251 milliequivalents per liter of sodium at which Mindy’s stool sample had been measured. Not that Mindy could possibly
have
cholera, she realized. There was no possibility of that. It was simply a basis for comparison of sodium levels. There were no higher sodium levels in an illness than those that cholera could produce.

She could not believe the values she found. She rushed out of her office to find someone, anyone, she could tell. Jim Levine, another pediatrician, was still in his office at the other end of the hall. She jumped at him with her news.

“Jim, Jim!”

“What? My God, Evelyn! What’s wrong?”

“It’s Mindy Phillips. She’s had a stool sodium of two hundred fifty-one; and you know what?” Her words tumbled over each other.

“What?”

“That’s
twice
the level of the worst case of cholera I could find recorded.”

“Good God!”

“Exactly, Jim. Exactly,” Evelyn said.

Later she realized something else. Mindy’s stool sodium was higher than the concentration of sodium in her blood. And Evelyn knew of no way that this could happen. Not naturally.

If they couldn’t control the diarrhea and if they lost the use of her veins for the IV, Mindy would die. It was as clear-cut as that.

Sara was away. Dr. Stein, who had been the Chief of Pediatrics until just a few weeks ago and was now the Assistant Physician-in-Chief, was away. The Physician-in-Chief himself was away. Evelyn knew what she had to do, and if Carte, who was in charge of the ward today and thus officially Mindy’s doctor, would not agree with her plan, she had decided to override him. She had the ultimate responsibility for the care of the patients on the ward. She didn’t want to exercise her authority, but if she had to, she would.

Evelyn had maintained to her colleagues, laughing because she was a little embarrassed at her new position, that her appointment to Chief of Pediatrics meant that she was now merely some strange combination of secretary, agenda maker, and mother hen. But in fact, she realized there were added responsibilities of being what was essentially the first among equals.

And now she had certainly been plunged straight into the crucible. She had a sudden insight that what she did these next few days would either temper her or completely burn her out.

When Evelyn arrived at the ward, it was quiet, the doors to the rooms on Five West shut tight. Even room 503 was closed and darkened. Mrs. Phillips might be in there, she might not, Evelyn thought as she crossed to the nurses’ station. It didn’t matter. Evelyn nodded at the young, dark-haired nurse on duty, Christine King. She was not a regular pediatrics nurse, but a floater, assigned where she was needed, but Evelyn had seen her around.

Evelyn checked Mindy’s most recent lab sheets and then pulled her chart. The nurse’s progress notes confirmed what she knew in her heart she’d find.

After a few moments, Evelyn replaced the chart. She made some quick calculations on the back of a progress note. Mindy, she thought bluntly, was going down the tubes. In the past 24 hours, she’d lost 1,000 cubic centimeters of watery stool. This amounted to almost 15 percent of her body weight. Without the IV she would be dead. Evelyn was sure that the 7:00 A.M. sodium samples to be run on Mindy’s blood, urine, and stool would confirm the deterioration. But she would not wait for the results. All she had to do was look at the lab results on the 1 o’clock samples. The concentration of sodium in Mindy’s urine had been measured at 252 milliequivalents. And the stool was 159 milliequivalents. There was no doubt that both were much too high.

Evelyn pressed a long-fingered hand against her graying hair and looked up. Down the hall she saw the meager figure of Dr. Estol Carte approaching her. Herculean Pirate, as she liked to call him to herself.

Evelyn was an Agatha Christie fan, and it was an obvious comparison once you saw it, she thought. Estol, with his balding, egg-shaped head and his
moustaches,
all set on a precise five-foot-three frame, was detective Hercule Poirot to the life.

As she drew him aside, she could not know how apt a description it was.

“Estol,” she said with a calm she didn’t feel, “I’ve got to talk with you.”

9

Priscilla had not intended to spend the night. She and Steve had decided earlier to take the boys to a promised dinner at McDonald’s, despite the fact that Mindy needed to be tied down while Priscilla was gone to prevent her from pulling out the NG. Priscilla did not like to alter plans, especially not when her children were expecting some special activity. In any case, she intended to be gone only a short time, and she thought that Mindy seemed stable when they all left for dinner. But later that evening, Mindy’s condition began to deteriorate. Priscilla phoned Steve to tell him she wouldn’t be coming home. She still hoped that Mindy would improve by morning. She wanted Steve to bring the boys up in the afternoon to visit their sister, as they had arranged, and she never liked them to see Mindy when she was really sick. It frightened them. She had started this policy during Tia’s illness. And sometimes with Tia, days had gone by before she was well enough for the boys to visit.

Shortly before nine, Dr. Carte entered Mindy’s room. He was not Priscilla’s favorite doctor. She thought he was weird, and so did most of the nurses, as far as she could tell.

Dr. Carte glanced at Mindy in her walker and at her chart that he held in his hand.

“She seems to be doing okay,” he remarked.

“Yes, she’s better,” said Priscilla. “But it was a pretty rocky night.”

With a nod, Carte left the room. Through the window in the door, Priscilla could see him at the nurses’ station working with Mindy’s chart. At that moment, Nurse King walked in. She had to refill Mindy’s metriset with formula every two hours. Priscilla had never met her, and she and the nurse introduced themselves and talked for a moment, first about Mindy’s condition, then about Tia.

“You know I lost another child a year ago,” Priscilla confided.

“Yes, I heard,” Christine King answered. “It must have been just terrible. I have a child of my own; he’s just a baby, too. I just can’t conceive of losing Michael. How did you cope?”

“I don’t know. Sometimes I really don’t know how I lived through the last year. My friends helped—and my minister. And I had my boys. And then Mindy—I was so excited to hear about her, I just about burst.”

“When did you get her?”

“In November. It was just nine months after Tia died—she was born the same week Tia died. Like a new life to replace the one we had lost. We had a new baby—it felt like it could have been our own,” Priscilla said.

“What a strange coincidence.”

“Oh, there have been a lot of those. Debby Roof and I talked about it, too. You know Mindy was admitted here a year to the day after Tia died—it was horrible.” Tears came to her eyes and she brushed at them.

“I’m so sorry. I’m sure she’ll be better soon.”

“Yes,” agreed Priscilla, turning to pick up Mindy.

Shortly after eleven, Christine King returned to Mindy’s room looking puzzled. Priscilla glanced up as the door opened. Mindy was back in her bed.

“Do you know the recipe for Mindy’s formula?” the nurse asked.

“Sure. Why? There’s plenty of formula already mixed.”

“Yeah, well it’s gone now. We need some more and I can’t find the recipe written down anywhere. I called the nursing supervisor and she didn’t know either. It’s supposed to be written in the cardex, but it isn’t there.”

Priscilla rattled off the recipe for the Cho-free formula plus the polycose that Mindy was receiving. When Sara had recently changed the percentage of polycose to be added, Priscilla and Debby had figured out the new recipe together—it was the kind of thing Priscilla liked to help with on the ward.

In a few minutes, Christine was back with the newly mixed formula and some fresh NG tubing.

“Why new tubing?” Priscilla wanted to know.

“Oh, Dr. Carte told me to,” Christine answered. “Apparently he’s testing the formula for sodium levels and to be on the safe side, he told me to change the tubing, too.”

Priscilla shrugged. It did not seem important, she would later claim. But of course later, when Priscilla was to go over the events of that Saturday, February twenty-fifth, again and again, trying to reconstruct everything that had happened, every word, every nuance of expression and action, then it would seem terribly important, and its significance clear.