Claude started his rapid but thorough examination by feeling Becky’s pulse and checking the turgor of her skin. He looked into her mouth and ears. He used an ophthalmoscope to peer into her eyes. He listened to her chest and checked her skin for rashes. He gently poked into her abdomen, which was tender. He searched for enlarged lymph nodes.
“You seem okay to me, except for that slightly sore belly,” he said at last. “Now, I’m going to step outside and talk to your parents. Okay?”
Becky nodded.
Tracy leaned over and gave her daughter a kiss on the forehead before following Claude and Kim out through the curtain. The corridor was busy, so the group drew to the side to avoid the bustle. David happened to see them and walked over. He introduced himself to Claude.
“I was just about to give a summary to the parents,” Claude said to David.
“Mind if I listen in?” David asked.
Claude looked at Kim and Tracy.
“That’s fine,” Tracy said.
“All in all, she looks good to me,” Claude began. “She’s a little pale, of course, and a bit dehydrated. There’s also some generalized abdominal tenderness. Otherwise, on physical exam she’s quite normal.”
“But the hemorrhage?” Tracy questioned. She was afraid Claude was about to dismiss the case.
“Let me finish,” Claude said. “I also went over her laboratory work. Compared to last night, there is a slight drop in her hemoglobin. It’s not statistically significant, but in view of the mild dehydration, it might be important, considering the history of the hemorrhage. There’s also a slight drop in her platelets. Otherwise, everything is within normal limits.”
“What’s your presumptive diagnosis?” Kim asked.
“I’d have to say food-borne bacterial illness,” Claude said.
“Not viral?” Kim asked.
“No, I think it’s bacterial,” Claude said. He looked at David. “I believe that was your feeling last night as well, wasn’t it?”
“Yes it was,” David said.
“But why no fever?” Kim asked.
“The fact that there has been no fever makes me think this has been more a toxemia than an infection,” Claude said. “Which also goes along with the normal white count.”
“What about last night’s culture?” Kim asked. “Is there a preliminary twenty-four-hour reading?”
“I didn’t see a culture,” Claude said. He looked at David.
“We didn’t do a culture last night,” David said.
Kim shook his head in disbelief. “What the hell are you talking about?” he demanded. “I even gave you the sample.”
“We don’t do routine stool cultures for simple diarrhea here in the ER,” David said.
Kim slapped his hand to his forehead. “Wait a sec! You just said you’d made a presumptive diagnosis of a bacterial infection. Why wouldn’t you do a culture? It just stands to reason, much less being good medicine. How else could you treat rationally?”
“AmeriCare utilization rules proscribe routine cultures in this kind of case,” David said. “It’s not cost-effective.”
Kim’s face reddened. Tracy was the only one who noticed. She reached out and gripped Kim’s arm. He pulled it free. “Cost-effective! What kind of screwball excuse is that? What the hell kind of emergency room are you running here? You’re telling me that to save a few measly dollars you failed to do a culture?”
“Listen, you prima donna,” David snapped. “I just told you, it’s standard operating procedure not to do them. Not for you, not for anybody.”
Losing control as he’d done the night before, Kim grabbed David by the lapels of his white jacket. “Prima donna, am I? Well, your goddamn screwed-up operating procedure has lost us a whole damn day!”
Tracy grabbed Kim’s arm. “No, Kim!” she cried. “Not again!”
“Take your hands off me, you arrogant son-of-a-bitch,” David growled.
“Calm down!” Claude said as he insinuated himself between the two much larger men. “It’s okay. We’ll run some cultures stat. We haven’t lost that much, because I doubt we’d treat anyway.”
Kim let go of David. David smoothed his jacket. Each man glared at the other.
“What would you expect to see in the culture?” Tracy asked, hoping to defuse the situation and get the conversation back on track. “What kind of bacteria do you think is involved’?”