amphetamines.” She turned to Lincoln. “I want this boy moved to the hospital. Now.”
“Too much movement,” said Dr. Chapman, the radiologist. “We’re not going to get very clear definition here.”
Claire leaned forward, watching intently as the first cross-section of Taylor Darnell’s brain appeared on the computer screen. Each image Was a compilation of pixels formed by thousands of tiny X-ray beams. Aimed at different angles along one plane, the beams distinguished between fluid and solid and air, and the various densities were reproduced in the image on the screen.
“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
