Bloodstream (9 page)

“See that fuzziness there?” said Chapman, pointing to the movement artifact.

“We can’t make him hold still unless we put him under anesthesia.”

“Well, that’s an option.”

Claire shook her head. “His mentation’s cloudy enough. I don’t want to risk anesthesia right now. I’m just trying to rule out any mass shifts before I do the lumbar puncture.”

“You really think encephalitis could explain these symptoms?” Chapman looked at her, and she saw skepticism in his eyes. In Baltimore, she’d been a respected family practitioner. But here she still had to prove herself. How long would it take before her new colleagues stopped questioning her judgment and learned to trust her?

“At this point, I have no choice,” she said. “The initial screen for both methamphetamine and PCP came back negative. But Dr. Forrest thinks this is clearly an organic psychosis, not psychiatric.”

Chapman was obviously unimpressed by Dr. Forrest’s clinical skills. “Psychiatry is hardly an exact science.”

“But I agree with him. The boy’s shown alarming personality changes in just the last few days. We have to rule out infection.”

“What’s the white cell count?”

“Thirteen thousand.”

“A little high, but not all that impressive. What about the differential?”

“His eosinophil count is high. Way off the scale, in fact, at thirty percent.”

“But he has a history of asthma, right? That could account for it. It’s some sort of allergic response.”

Claire had to agree. Eosinophils were a type of white blood cell that proliferated most commonly in response to allergic reactions or asthma. High eosinophil counts could also be caused by a variety of other illnesses such as cancer, parasitic infections, and autoimmune diseases. In some patients, no discernible cause was ever found.

“So what happens now?” asked the Maine state trooper, who’d been watching the procedure with a look of growing impatience. “Can we move him to the Youth Center or not?”

“We have more tests to run,” said Claire. “The boy could be seriously ill."

“Or he could be faking it. That’s what it looks like to me.”

“And if he’s sick, you could find him dead in his cell. I wouldn’t want to make that mistake, would you?”

Without comment, the trooper turned and stared through the CT viewing window at his prisoner.

Taylor was lying on his back, wrists and ankles restrained. His head was hidden inside the CT cradle, but they could see the movement of his feet, twisting against the restraints.
Now comes the hard part,
she thought.
How do we hold him in position long enough for the lumbar puncture?

“I can’t afford to miss a CNS infection,” said Claire. “With an elevated white blood count and changes in mental status, I have no choice but to do the spinal tap.”

Chapman at last seemed to agree. “From what I see here on the scan, it looks safe enough to proceed.”

They wheeled Taylor out of X-ray and into a private room. It took two nurses and a male orderly to transfer the struggling boy to the bed.

“Turn him on his side,” said Claire. “Fetal position.”

“He’s not going to lie still for this.”

“Then you’ll have to sit on him. We need this spinal tap.”

Together they rolled the boy on his side, his back to Claire. The orderly flexed Taylor’s hips, forcibly pushing the knees toward the chest. One nurse pulled the shoulders forward. Taylor snapped at her hand, almost catching her finger in his jaws.

“Watch his teeth!”

“I’m trying to!”

Claire had to work fast; they couldn’t keep the boy immobilized much longer. She lifted the hospital gown, exposing his back. With his body curled into a fetal position, the vertebral spines poked out clearly under the skin. In rapid order she identified the space between the fourth and fifth spinous processes in the lower back, and swabbed the skin with Betadine, then alcohol. She snapped on sterile gloves and picked up the syringe with local anesthetic.

“I’m putting in the Xylocaine now. He’s not going to like this.”

Claire pricked the skin with the twenty-five-gauge needle and gently injected the local anesthetic. At the first sting of the drug, Taylor shrieked with rage. Claire saw one of the nurses glance up, fear in her eyes. None of them had ever dealt with anything like this, and the violence coursing through this boy’s body was frightening them all.

Claire reached for the spinal needle. It was three inches long, twenty-two-gauge gleaming steel, the hub end open to allow cerebrospinal fluid to drip out.

“Steady him. I’m doing the tap now.”

She pierced the skin. The Xylocaine had numbed the area, so he didn’t feel any pain—not yet. She kept pushing the needle deeper, aiming the tip between the spinous processes, toward the dura mater of the spinal cord. She felt a slight resistance, then a distinct pop as the needle penetrated the protective dura.

Taylor screamed again and began to thrash.

“Hold him! You have to hold him!”

“We’re trying! Can you hurry it up?”

“I’m already in. It’ll just be another minute now.” She held a test tube under the open hub of the needle and caught the first drop of CSF as it slid out. To her surprise, the fluid was crystal clear with no blood, no telltale cloudiness of infection. This was not an obvious case of meningitis.
So what am I dealing with?
she wondered as she carefully collected CSF in three different test tubes. The fluid would be sent immediately to the lab, where it would be analyzed for cell count and bacteria, glucose and protein. Just by looking at the fluid in the tubes, she knew that the results would be normal.

She withdrew the needle and applied a bandage to the puncture site. Everyone in the room seemed to give a simultaneous sigh of relief; the procedure was over.

But the answer was no closer.

Later that evening, she found Taylor’s mother downstairs in the tiny hospital chapel, gazing numbly at the altar. They had spoken earlier, when Claire had requested the mother’s consent for the lumbar puncture. At the time, Wanda Darnell had been a bundle of nerves, all jittery

hands and trembling lips. She had been on the road all day, first the two-hundred mile drive to Portland to visit her divorce attorney, and then the harrowing drive back, after the police had contacted her with the terrible news.

Now Wanda seemed exhausted, all her adrenaline depleted. She was a small woman, dressed in an ill-fitting skirt suit that made her look like a child playing grown-up in her mother’s clothes. She looked up as Claire came into the chapel and barely managed a nod of greeting.

Claire sat down and gently placed her hand on Wanda’s. “The lab results have come back on the spinal tap, and they’re completely normal. Taylor doesn’t have meningitis.”

Wanda Darnell released a deep sigh, her shoulders slumping forward in the oversize suit jacket. “That’s good, then?”

“Yes. And judging by the CT scan, he has no tumors or signs of hemorrhage in his brain. So that’s good, too.”

“Then what’s wrong with him? Why did he do it?”

“I don’t know, Wanda. Do you?”

She sat very still, as though struggling to come up with an answer. “He hasn’t been
...
right. For almost a week.”

“What do you mean?”

“He’s been out of control, angry at everyone. Cursing and slamming doors. I thought it was because of the divorce. He’s had such a hard time of it
. .

Claire was reluctant to bring up the next subject, but it had to be addressed. “What about drugs, Wanda? That could change a child’s personality. Do you think he’s been experimenting with anything?”

Wanda hesitated. “No.”

“You don’t sound sure.”

“It’s just that She swallowed, tears flashing in her eyes. “I feel like I hardly know him anymore. He’s my son, and I don’t even recognize him.”

“Have you seen any warning signs?”

“He’s always been a little difficult. That’s why Dr. Pomeroy thought he might have attention deficit disorder. Lately, it seems he’s gotten Worse. Especially since he started hanging out with those awful boys.”

“Which boys?”

“They live up the road from us. J.D. and Eddie Reid. And then there’s that Scotty Braxton. All four of them got into trouble with the police back in March. Last week, I told Taylor he had to stay away from the Reid brothers. That’s when
we
got into our first really big fight. That’s when he slapped me.”

“Taylor
did?”

Wanda’s head drooped, the victim ashamed she’d been abused. “We’ve hardly spoken to each other since then. And when we do talk, it’s so obvious that Her voice slid to a whisper. “That we hate each other.”

Gently Claire touched Wanda’s arm. “Believe it or not, disliking your own teenager isn’t all that abnormal.”

“But I’m also afraid of him! That’s what makes it even worse. I dislike him
and
I’m scared of him. When he hit me, it was like having his father back in the house.” She touched her fingers to her mouth, as though remembering some long-faded bruise. “Paul and I are still in a custody fight. Two of us battling over a boy who doesn’t like either of us.”

Claire’s beeper went off. She glanced at the digital readout and saw the lab was paging her. “Excuse me,” she said, and left the chapel to make the call from the hospital lobby.

Anthony, the lab supervisor, answered the phone. “The Bangor lab just called with more of Taylor’s results, Dr. Elliot.”

“Did anything turn up positive on the specific screens?”

“I’m afraid not. There’s no alcohol, cannabis, opioids, or amphetamines in his blood. That’s a negative for every drug you wanted screened?’

“I was so sure,” she said in bewilderment. “I don’t know what else could cause this behavior. There must be some drug I’ve forgotten to test for.”

“There
may
be something. I ran his blood through our hospital gas chromatography machine, and an abnormal peak showed up at one minute, ten seconds’ retention time.”

“What does that mean?”

“It doesn’t pinpoint any particular drug. But there is a peak, which indicates something out of the ordinary is circulating in his blood. It could be completely innocuous—an herbal supplement, for instance.”

“How do we find out what it is?”

“We’d need more extensive analysis. The Bangor lab isn’t equipped to do that. We have to draw more blood and send it to our reference lab in Boston. They can simultaneously screen for hundreds of different drugs.”

“Then let’s do it.”

“Well, here’s the problem. It’s the other reason I paged you. I just got an order to cancel any and all remaining drug tests. It’s signed by Dr. DeIRay.”

“What?” She shook her head in disbelief.
“I’m
Taylor’s doctor.”

“But DelRay’s writing orders, and his are contradictory to yours. So I’m not sure what to do.”

“Look, let me talk to the mother and I’ll clear this up right now” She hung up and returned to the chapel.

Even before she opened the door, she could hear a man’s voice, raised in anger.

never exerted any control! Completely useless, that’s what you are. No wonder he’s so screwed up!”

Claire pushed into the chapel. “Is there a problem here, Wanda?”

The man turned to her. “I’m Taylor’s father.”

Personal crises bring out the worst in people, but Paul Darnell was probably not likable even at his best. A partner in the largest accounting firm in Two Hills, he was far more stylishly garbed than his wife, who seemed to shrink to inconsequential size in her ill-fitting suit. The brief interaction Claire had witnessed between these two ex-spouses told her what this marriage must have been like: Paul the aggressor, full of demands and complaints. Wanda always appeasing, retreating.

“What is this about my son taking illegal drugs?” he asked.

“I’m trying to find a reason for what happened today, Mr. Darnell. I was just asking your wife—”

“Taylor hasn’t been taking any drugs. Not since you stopped the Ritalin.” He paused. “And he was fine on the Ritalin. I never understood why you took him off it.”

“It’s been two months since I discontinued it. This personality change is more recent.”

“Two months ago, he was fine.”

“No he wasn’t. He was tired and listless. And that diagnosis of ADD was never really established. it’s not the same as diagnosing hypertension, where there are definite parameters to go by.”

“Dr. Pomeroy was certain of the diagnosis.”

“ADD has turned into a catchall for all childhood misbehavior. When a student’s failing in class, or he gets into mischief, parents want to find a reason. I didn’t agree with Pomeroy’s diagnosis. When in doubt, I prefer not to push pills on children.”

“And look what’s happened. He’s out of control. He’s been out of control for weeks?’

“How would you know, Paul?” said Wanda. “How long has it been since you actually spent time with your own son?”

Paul turned to his ex-wife with such a look of hatred, Wanda shrank back. “You’re the one who’s supposed to be in charge,” he said. “I knew you couldn’t handle him. You screwed it up as usual, and now our son’s going to end up in jail!”

“At least I didn’t provide him with the gun,” she said softly.

“What?”

“It was your gun he brought to school. Did you ever notice it was missing?”

He stared at her. “The little
shit!
How did he get—”

“This isn’t helping!” Claire cut in. “We need to focus on Taylor. On how to explain his behavior.”

Paul turned to his wife. “I’ve asked Adam DelRay to take over. He’s upstairs looking at Taylor now.”

Paul’s blunt announcement left Claire speechless. So this was why DelRay had written orders; he was the new attending. She’d just been fired from the case.

“But Dr. Elliot’s his doctor!” Wanda protested.

“I know Adam, and I trust his judgment.”

Meaning he doesn’t trust mine?

“I don’t even like Adam DelRay,” said Wanda. “He’s your friend, not mine.”

“You don’t have to like him.”

“If he’s taking care of my son, I do.”

Paul’s laughter was grating. “Is that how you choose a doctor, Wanda? Pick whoever gives you the most warm fuzzies?”