Chapter 1: Acute

Diane Thibault eased herself into bed. She was on-call, which meant that she should get to sleep as early as possible. The odds on being awakened during the night were fairly high. Back in med school, a fellow student with dreams of going into research had laid it out:

“At Johns Hopkins, we read about the debilitating effects of high blood pressure, diabetes, and obesity. The debilitating effects of sleep deprivation, on the other hand, we study by the experimental method.”

Well, that had been in med school, which now seemed to be the good old days. With her pediatric residency, she spent twelve hours a day dealing with sick kids. Every other night, she stayed and slept at the hospital ready to be called in an emergency. And, since nurses couldn’t prescribe, a sleepless teen asking for a sleeping pill was an emergency.

Twelve hours out of forty-eight remained for getting a full night’s sleep, shopping, laundry, eating something other than hospital food, and social life. Somehow, she seldom got down that list as far as social life.

Still, she was a medical doctor, and she was independent. She loved her family in Minneapolis, but what she loved most about them was that they were in Minneapolis. Well, if they were scattered now, none of the rest of them had scattered to San Francisco. Her brother, Norm, claimed that she had been free from pressure as a girl not expected to go into the family business. But she had been in the orbit of her family all her life. Her home had been stifling with two older brothers supervising her social life.

She had felt free at first at Radcliffe, her own person able to make her own decisions and her own mistakes. If Vaughan had been a mistake, he had definitely been Diane’s mistake. But, then, she had realized that she had been admitted to Radcliffe as a legacy. She had so wanted to go to Radcliffe as Mom had. She had gone to Radcliffe, but not at all as her Mom, the scholarship student, had.

Med school admission had, at least, had nothing to do with her family. The tuition payments had, of course. Still, others got there by other routes. You couldn’t ask for a scholarship on the grounds that you wanted to be independent of the inheritance which was paying your way. Scholarships were for those who actually needed them.

Now, at last, she was paying her own way. The inherited stock was still paying dividends, but she only used those dividends to pay taxes and to buy gifts. The cost of the gifts to her brothers and sisters in law were influenced by the size of the dividends as much as the taxes were. She was her own woman. Okay, she was always at the hospital’s beck and call. At least she wasn’t her damned family’s woman.

Eric Barnes was just shutting off his alarm when his cell sounded. It was the particular ring tone of his housekeeper.

“Yes, Madeleine,” he said.

“Mr. Barnes, I’m with Sparky.” He could tell his daughter was listening. Madeleine always said “Val” unless Sparky was within hearing distance. “She is sick. I don’t think it’s malingering.”

“I’ll be there in minutes.” It was probably not even one minute before he was in Sparky’s room. “What seems to be wrong, darling?”

“Hurts.” Sparky pointed to her stomach. He opened her pajamas and looked. He couldn’t see any special sore or boil, but the abdomen looked rigid.

“Stay here a moment,” he said. Madeleine followed him out the door.

“She’s running a fever,” Madeleine told him when the door was shut and they were down the hall. “It may be nothing, but it might be appendicitis, too.”

“Okay,” he said. “I’ll go back in. You get dressed. When you’re ready to travel, come back and relieve me. Know when Dr. Kleinfeld gets to his office?”

“I think eight o’clock,” she said heading out the door. He was still carrying his cell, and he scrolled down to the Doctor immediately. He hit the number. The answering machine told him that Madeleine was right. This was one of his mornings in the office, too.

“This is Valerie Barnes’s father, Eric Barnes. We think that Valerie may have something serious. We’ll be at your office shortly after eight. We don’t have an appointment, but we would appreciate Dr. Kleinfeld seeing her long enough to make a diagnosis. It looks like appendicitis to two amateurs. The patient’s name is Valerie Barnes.” He spelled the last name. He didn’t leave his number; he would be in the car before the office got that message.

“I’m Sparky,” she said when he turned back to her. If her belly was sore, he shouldn’t hug her middle. He cuddled her head against his side instead.

“Yes, darling. But you are listed as ‘Valerie’ on their records. We want the good doctor to have all the information as easily as possible. After all, we are asking a favor of them. They would prefer us to make an appointment long in advance.” She didn’t even argue with that. That worried him as much as the temperature. Sparky was a sweet girl, but she did like to argue. And, as Murphy had asked him once, should he credit that to heredity or environment? Thinking of Murphy, he made another call. It was the direct land line, and he waited through the message.

“Murphy, it’s me. Sparky has a problem and we’re taking her to the doctor. I don’t know when I’ll be in. I don’t know whether.” Madeleine came back, and he went to dress.

Madeleine fixed breakfast for the two adults. Sparky wasn’t hungry, and they didn’t think it was wise to push her. Dr. Kleinfeld’s office was in a not-very-distant part of Sausalito, and he parked before eight and was in the office a few minutes later. Dr. Kleinfeld was already seeing a patient, but the nurse took Sparky into another examination room. She took her temperature, looked at the abdomen, and went out for a minute. When she came back, she took Sparky’s weight and blood pressure. He looked at her blankly, and she must have noticed.

“Well, the doctor will be in momentarily. This is routine for a visit. What else should I be doing?”

“Sorry,” he said. “Nerves.”

“Perfectly justified in this case. Oh, here’s the doctor.” Dr. Kleinfeld’s examination was very brief, though he touched Sparky’s belly so hard she winced.

“I want you to take her to Children’s hospital in San Francisco. I have admitting privileges, and I’ll call them and tell them that you’re coming. You came in your car?”

“Yes.”

“Go in through the emergency room. Miss Brand will give you the address.”

Everyone was talking in a calm voice, but when he got out his checkbook, Miss Brand said, “I’ll send a bill. You really want to get to the hospital as soon as possible.”

It was not the best time of day to cross the bridge, but they got to the hospital before nine. In the emergency room, he and Madeleine split duties. She went with Sparky, and he dealt with the desk about payment. He had his insurance card in his hand. He asked for a private room and agreed to pay a surcharge for that and anything that the insurance company didn’t pay. They didn’t take credit cards, but he displayed them to demonstrate his creditworthiness. Between Dr. Kleinfeld’s calling ahead, his insurance and his obvious willingness and ability to pay, and Sparky’s state, there wasn’t all that much delay. Still, every second had him boiling inside. Luckily, the nurses were taking Sparky’s blood pressure and not his.

Diane usually followed the admitting physician around and let him tell her about the patient. This one, though, had an admitting physician still stuck on the other side of the Bay seeing other patients. The girl, Valerie Barnes, was six from the chart and looked it. The diagnosis was acute appendicitis, and the girl didn’t look happy.

“Shall I call you Valerie or Val?” she began. There was so much out of the patients’ control -- where they were, what they wore, whether they were going to be put to sleep and have a perfect stranger slice their abdomens open -- that Diane tried to give them as much control as possible.

“Valerie, please.” A polite little girl.

“Pull up the gown please. I’d like to take another look at your tummy. How many people have looked at it already?” Yeah, it looked like appendicitis to her. She checked the heartbeat with her stethoscope. The girl was trying to look brave, but her heart was racing.

“What can you tell me?” asked a black woman followed her out of the room. “I’m Madeleine Grant, the Barnes’s housekeeper. Is it appendicitis?”

“It certainly looks like it. I imagine they will do more tests and operate tomorrow. This is fairly serious, Mrs. Grant. Miss Grant? Are the parents leaving it in your hands?” Some parents made you wonder why driving required a license and parenthood did not. She supposed that the children who had somebody else who cared were luckier than the others, and Valerie appeared to be one of these.

“Mrs. Grant, please. Mr. Barnes is dealing with the hospital bureaucracy. Mrs. Barnes died when Val was only two. Here he comes now.” And here he came, striding down the hall and glancing at room numbers. A good-looking man, taller than average and walking very erect. The glasses made him look vaguely scholarly.

“Madeleine. Doctor.” At least he didn’t take a woman doctor for a nurse. “Is there any news?”

“Dr. umm...” Mrs. Grant began.

“Thibault,” Diane supplied.

“Dr. Thibault says they’ll operate tomorrow.” Diane was about to emphasize that this was a guess, not a promise, when Mr. Barnes interrupted her train of thought.

“Tomorrow? Is today impossible? I know that it’s your field, not mine, but I thought that a ruptured appendix was a threat.” His voice was pleasant but his words raised red flags.

“Well, there are all sorts of preparations that have to be made. Certainly, delay introduces a few risks.” She wasn’t going to assure him that the appendix would not burst. That was unlikely before the operation, but the only thing impossible about the human body was understanding it. “But rushing things introduces its own risks. We still have to do an ultrasound to make certain it’s appendicitis.”

“Ultrasound?” he asked. “I’ll guarantee that her problem isn’t related to a pregnancy.” She smiled.

“They do ultrasounds for all sorts of conditions. It gives you a picture of the soft tissues of the body. It’s not just for pregnant women.”

Eric said, “Well, I still have her first tucked away somewhere. I’ll see her now if I may.” The door was open, and he ducked in.

“Daddy.”

“Sparky. Sorry I didn’t come up with you, but the hospital people wanted somebody to fill in some forms. You wouldn’t have enjoyed that, I promise you.”

Eric stayed with Sparky. There wasn’t much he could do with her, but she seemed to want his company. Since her middle was sore, he spent some time holding her feet rather than hugging her. When she needed to use the bathroom, he left her with Madeleine and went out to the hall to call Murphy. This time, he called her cell.

“How’s Val” she answered.

“In the hospital. They think it’s appendicitis. The doctor thinks they’ll operate tomorrow. Thing is, I’m out for the duration -- today, tomorrow, probably the next day. Deal with my appointments, will you? This is the highest priority. If the place catches fire, call 911, not me.”

“Sure. Give her my love.”

“Another thing. We’re here without her toys, and I don’t want to bring them here and then take them back from the hospital. There are germs here. So, do you think you could pick up something? I think one toy. Plush -- she’s kind of down. I’ll give you the address.”

“Sure.”

Sparky’s lunch was soup and Jell-O. Even though she hadn’t had any breakfast, she wasn’t very hungry. Between him and Madeleine, they persuaded her to eat most of it, and it didn’t come back up. He suggested shifts for lunch to Madeleine, and she went down to the cafeteria first. While she was gone, Murphy came by with the toy.

“Mrs. Darling,” Sparky said. She looked more interested in her than in what she was carrying.

“Hello, Sparky,” said Murphy, “I’m sorry to hear you’re not feeling well.”

“I’m feeling awful,” said Sparky. When Murphy had gone, however, Sparky got interested in the toy. It was a pink plush monkey. Then Madeleine came back and Eric went down for lunch. True to Dr. Thibault’s prediction, Sparky was taken away for an ultrasound soon after he came back. He stayed up on the floor by her room.

While he was there, he saw Dr. Thibault going from one room to another. The doctor was admittedly an easy sight to watch, but what he felt was merely aesthetic appreciation. He was a widower still wearing his ring. He’d been off the market since he’d met Laura. That was more than a decade.

Diane might despise parents who were too busy to visit their kids when those kids were hospitalized, but a visit was one thing and staying there was something else. She would never consider appendicitis trivial, but Valerie wasn’t one of the more serious cases in the hospital right now.

That guy looked like he was camped out at his daughter’s room. Didn’t he have a job to go to? She was careful not to look at him too often, partly because she could feel his eyes on her. At least, he wasn’t causing problems by being in the way or getting into conversations with medical personnel.

Then, his daughter came back from ultrasound, and he went back into her room. When Dr. Kleinfeld started making the rounds of his patients, she followed. Valerie Barnes was third on his list. He came in, greeted the girl, and looked at her chart and the ultrasound.

“Well,” he said to Barnes, “it’s appendicitis. We say it’s appendicitis, and we make a slew of tests, and then we say it’s appendicitis. You ask ‘Why the tests? Didn’t you already say that?’ Well...”

“Well,” Barnes said, “when we burst into your office, we had already said that. We wanted better judgment to confirm or refute. You wanted more information to confirm or refute. I’m never opposed to more information. Even I know what the treatment is. When?”

“We have surgery scheduled for late tomorrow morning. Nothing by mouth after midnight. Are you hungry, Valerie?”

“I’m Sparky,” the girl said.

“Okay, Sparky,” Dr. Kleinfeld said. “Are you hungry?”

“No. My tummy hurts.”

“Well, we’re going to do something about that tomorrow.”

“Will it stop hurting?” That was a good question, and Diane neither liked to lie to kids nor to tell them that they would have more pain before they had less.

“Well,” Mr. Barnes began before the doctors could, “first they are going to put you to sleep. It’s a special kind of sleep, and you won’t feel anything. Then, while you’re asleep, they will take out the thing which is making you hurt. That hurt will be gone when you wake up, but there will be other hurts there. It will really ache. It will get better, though, after that.”

“And,” Dr. Kleinfeld put in, “the nurses will be able to give you medicines to deal with that pain.” Barnes followed her and Dr. Kleinfeld out the door. Dr. Kleinfeld was first at the sanitizer dispenser, and she turned to Mr. Barnes.

“That was the best summary of what will happen in an operation I’ve ever heard. Do you have a medical background?” Well, it was the best summary for a kid.

Eric was complimented. Dr. Thibault’s manners were as pretty as her face.

“I’ve had an operation. I’m a programmer, not a medico. I try not to lie to Sparky. Tell me that nothing is going to go wrong.”

“I try not to lie to parents.” Hoist by his own petard! “This is a routine operation. Things are not likely to go wrong. On the other hand, they can.”

“You have an excellent surgeon,” Dr. Kleinfeld said. “And, if something does go wrong, you have Valerie in a first-class medical institution. They are equipped to deal with emergencies.”

“I’ll keep praying, but I’ll stop bugging you.” Barnes went back into his daughter’s room.

Eric was strangely reassured by the statement that things could go wrong. Was anyone more aware of that than he was? You could be driving down the street and have another car crash into you. Well, Sparky was in more danger through tomorrow than she was in the car, but it sounded like the doctors were taking what precautions they could.

“It hurts, Daddy,” Sparky said.

“I know it does honey,” he said. “It hurts because there is something wrong down there. They are going to fix that wrong thing tomorrow.”

“Tomorrow? Why not today?”

“They need to do some complicated things to fix it. They are setting up and getting the man to do that, the surgeon, ready. That’s why they’ll do it tomorrow.”

“I wish they would hurry,” she said.

“So do I, honey, but more than that I wish that they would do it right when they do it.” She didn’t seem to like that answer. She tried to hug the plush monkey. When that seemed to cause worse pain, she hugged it to her face. That took care of her top half, and he reached for her foot and held it.

They had TV in the room, and she started watching it. The controls were a little complicated, but she mastered them. She did a lot of channel surfing while he sat there. When dinner came, she ate a little. He didn’t know whether to urge her to finish it or not. When visiting hours were over, he couldn’t see a reason to fight them to let him stay. When he drove Madeleine home, she said that she would take her own car to the hospital in the morning.

“And, Mr. Barnes, the cleaners are due tomorrow.” There was more house than Madeleine could take care of by herself, well, more than she could take care of and tend to Sparky’s needs, too. There were two women who came in for one day a week to do the heavy cleaning. Madeleine took care of child care, meals, and the daily tasks.

“Well, Sparky will need you more. Can you call them tonight?”

“I called them when I heard about the operation,” she said. That’s what he liked, initiative. “Is it all right to pay them if they don’t work?”

“I would think. We contracted for their time; they are willing to supply it. Can they stretch a week before they get the check?”

“They didn’t raise that question. Laundry and stuff like that won’t get done, and I can’t take up the slack.”

“Prioritize,” he told her. “Sparky is hurting, and she wants you there. The house doesn’t matter in comparison.” Indeed, if he could trade the house to stop Sparky’s pain he would do it in an instant.

“I don’t even think I made your bed.”

“I should hope not. I’ve slept on floors and on a pair of desks shoved together. An unmade bed won’t kill me ... Can one, in fact, sleep in a made bed? Doesn’t the act of getting in it unmake it?” That wasn’t his priority, but Madeleine didn’t know any more about Sparky’s condition than he did. Any other subject was welcome.

“Well, you’ve slept on top of a made bed once or twice,” she said. That was once or twice since she had come to work for him and Laura. In his younger days, when he did real programming, he’d been that tired more often. He had never made the bed the next day. Madeleine always did.

He had read once that inside every fat man is a thin man trying to get out. Well inside the CEO of Dendarii Software with a house of his own and a housekeeper to keep it shipshape, there was a young programmer who had lived in single rooms without owning a vacuum cleaner. Sometimes, the young programmer wanted to get out. Then, he remembered that Sparky depended on the CEO. She certainly depended on the housekeeper. Then, too, the young programmer had Laura in his future then. If he couldn’t have Laura in his future, he would keep her in his memory.

Diane was aching in every bone by the time she got off the floor. She left the hospital immediately, and stopped in a Thai restaurant. She wanted to go home and drop into bed, and she needed to buy Christmas presents for her brothers and sisters-in-law soon. This was laundry night, however. She went back to the apartment, got the dirty clothes into two bundles and took them to the coin laundry. She did get a nap sitting down while the washer was going. She went back to the apartment and made her bed with another set of sheets while the dryer was going. As soon as she got the laundry back to the apartment, she went to bed.

In the morning, she showered, dressed, and dumped the laundry bag out on her bed. She would sort it out when she came back in two days. She got breakfast at her usual diner and got to the hospital at quarter ‘til. That gave her plenty of time to drop off her coat and reach the floor by six.

Tracy Reynolds, who had been getting better for days, now had a raging fever again. Diane added an order for sed rate on the -- otherwise routine -- blood test on her own initiative.

Valerie Barnes was scheduled for her appendectomy at 10:00. Which meant that the operation would be any time after that that the operating room was free and the team available? When she stopped at her room, Valerie was understandably nervous. Mrs. Grant was trying to soothe her, but Barnes was on pins and needles. That might be understandable, too, but it was not helping his daughter. She gave him full disclosure for what he was permitting. Barnes wanted to sign it without hearing it, but that wasn’t permitted.

“Look,” Barnes said after he had signed the forms, “they say I can’t be with Sparky during the operation.”

“Yeah. Those are the rules. Could you step outside?” He followed her out of the room. Diane closed the door and walked a few feet further down, leaving Mrs. Grant with Valerie. “Look. There will be a team in there with sharp knives slicing your daughters belly open.” He blinked at that statement. “Then they are going to remove one little bit of her intestines without, they hope, slicing into any other part of them. Now, do you want all their attention on what they are doing?”

“Well, yes.”

“So do I,” she said. “So do they. So does the hospital. That’s why we don’t want anybody but the patient and the surgical team in there. We don’t want the tiniest distraction. Now as soon as she goes in, you can wait outside in the area for family. When she comes out, they will take her to a recovery room, and you’ll be in there with her before she wakes up. We think this is medically best for her.”

“Okay. You think I’m being selfish?”

“I think you’re being a concerned parent. I wouldn’t fault your motivation for one second. On the other hand, her nervousness is going to complicate the anesthesiologist’s work. And the more nervousness you show the more nervousness she will develop.”

“So it’s better for her if I sit on it?” he asked.

“I really think so.”

“Then I had better sit on it,” he said. “Thanks.” He went back in the room, leaving the door open. She went to the sanitizer dispenser and washed her hands before seeing the next patient.

Diane told Dr. Chan about ordering the sed rate for Tracy Reynolds when he came on the floor.

“Very well,” Chan said. He saw residents as his students not as threatening usurpers. “You think that the temperature spike may be a resurgence of the infection?”

“I think it might be. It might be something relating to the insult her system has received this past few days. It might be something totally unrelated. Still...”

“Still, since we don’t know, more information will make my decisions better informed guesses. Don’t tell the parents I said that. If she were your patient, what would you do?” That was always Chan’s question.

“I’d order a culture of her next stool.”

“You think that this might be another infection?”

“Well,” she said. “The previously identified bacillus may have staged a come-back, and that might be a newly-developed resistance to the antibiotic.”

“Or,” Chan added, “for some reason, the antibiotic, which is administered orally, might not have reached the site. The pill could have passed through. She might have vomited it up.” A nurse, could, of course, have failed to give Tracy the pill, although there were elaborate checks to prevent that. Neither of them would mention that possibility.

“Or,” she said, “It just might be that there was another bug hiding in her intestines. When we killed the first one, the second one had a clear field. If so, the second one has to be immune to the antibiotic we’re using.”

“You’re starting to see the possibilities. I’ll order that culture. We won’t have to wait long for a stool sample.” Tracy was suffering from diarrhea among other symptoms. “The likelihood that it will show anything new is small, and the likelihood that the insurance company will bitch is huge. You know, the practice of medicine would be so much simpler if we weren’t doing it on humans.”

She smiled. That was Chan’s favorite joke. However often he repeated it, it was still true.

Eric saw that the waiting room outside the operating theaters was already occupied when he got there with Madeleine. The seats interfered with any pacing opportunities. Once Eric saw the faces of the other people waiting, he decided to restrain himself. Sparky wasn’t the only kid going under the knife, and he wasn’t the only worried parent.

When they told them that Sparky was in the recovery room, they suggested that only one person be with her at one time. Madeleine yielded to him. He stopped the woman -- nurse? -- who was leaving.

“How did it go,” he asked.

“Go? It was a routine appendectomy. Nothing went wrong, if that’s what you mean. Anyway, she’s starting to come out from under already, but she isn’t awake yet. She’ll be logy for a while. Call me if anything looks wrong.”

“Can I hold her hand?”

“Sure,” the nurse answered. “She’s all sewed up. Asepsis is over.” So he held Sparky’s hand. Staring at her face didn’t reveal anything. He decided to watch the wall as long as he could and only then look at her face. Her hand would occasionally twitch in his hand. When it did, he would look at her hand, look at her face, and decide that twitching was a normal part of coming out of anesthesia. After all, he didn’t think that those motions would be noticeable if he weren’t holding her hand. At one twitch, her eyes seemed open when he looked at her face.

“Daddy’s here, sweetheart,” he said. “The operation is over. We have to wait until you’re more awake. Then we’ll go up back up where you were before, and you can hug the monkey that Mrs. Darling bought for you.” She didn’t respond, but he kept talking so she would know that she was with her family.

She woke up further. She got to the point that she didn’t want her hand in his and took it out. Then the nurse came back in and decided that she had recovered enough to send her back upstairs. They were almost a parade: the big bed with the little girl, the guy pushing it, Madeleine, and him.

Diane saw Valerie coming back. She didn’t have to ask if everything had gone okay. Barnes’s smile could have lit the hall. She visited Valerie some time later.

“Happy?” she asked. Barnes smiled and started to say he was. Valerie interrupted him.

“Hurts.”

“Yes,” she said, “but that pain will be less tomorrow, and you can have another shot in...” She consulted the chart and the clock on the wall. “another hour.” It was less than that, but Valerie wouldn’t complain if it were early. Barnes winced at that promise. When she left, he followed her out.

“Look,” he said as she was sanitizing her hands, “I certainly don’t enjoy Sparky’s -- Valerie’s -- pain. Are these shots safe? I keep imagining addiction.” Well, at least this was one overconcerned parent who wouldn’t be nagging them for more pain medication than was safe.

“Well, addiction is one reason that she doesn’t get enough shots to keep her totally out of pain. She’ll get pain pills later, but pills are contraindicated right after abdominal surgery. They have to be absorbed in the intestines, and we just messed around with her intestines. Then, too, the pain pills that are effective can be addictive, too.”

“At this age,” she continued, “injections have two advantages over oral administration. The dose can be adjusted for weight. We could give her half the pill we would give you, but she weighs less than half as much. Then, too, when she goes home, you will take pain pills with you. Having them in the household is a poisoning risk. No six-year-old is going to give herself an injection.”

“You keep saying that you’re doing dangerous things.” He laid his hand on her arm as he said it. It wasn’t an inappropriate gesture, but her response was totally inappropriate. She felt a rush. The radius isn’t an erogenous zone, she told herself, and this is a concerned parent, not a lover. Well the forearm felt like an erogenous zone when he touched it. Luckily, he took his hand away and she could answer coolly.

“Yeah. Nothing that we do in medicine is safe. The problem is that the alternatives are worse. Now, if you’ll excuse me...” She hurried away. She did have other patients to see, but she was really running away from that touch.

“Yeah,” he said. “You have a building full of patients to care for, and I only worry about one of them.” He gave her a sort of salute.

Eric was dazed. He was ogling her hips as she walked away, and that was wrong. Dr. Thibault was Sparky’s doctor, and she came into his orbit because she was caring for his daughter. Coming on to her was even worse than making a pass at a DSI employee. That touch had definitely turned him on, and she must have noticed it. She had stiffened. If he shouldn’t even be in the room when the operation was going on lest he distract the surgeons, he sure shouldn’t let his lust interfere with the doctor’s treatment.