Glossary:
Failure to thrive: most commonly refers to children who don't gain weight or grow as expected. Can also refer to weight loss and malnutrition in adults, usually the elderly or chronically ill.
Parenteral nutrition: giving someone nutrients through an IV line.
Nasogastric tube: a tube that goes up the nose, down the throat, and into the stomach, and can be used to administer medication such as activated charcoal, provide nutrition to someone unable to take food by mouth, or to empty the stomach.
Note: while it does not deal directly with the topic, this chapter may be triggering to those who've had eating disorders.
"How is she?"
It was Alice, my youngest daughter. Her faelike face was creased with worry.
"The same," I reported. It had been twelve hours since Esme had moved from her position lying on the couch. "Where are the boys?"
"Still hunting," she reported. "And Rose is shopping in Tacoma. They won't be back until tomorrow. But they know something's wrong. Emmett was there when she missed that deer."
I nodded gravely, and looked down at my wife's pale, sunken eyes, her lips stained with dried blood from my earlier attempt to feed her. She breathed a few times an hour, a shaky inhalation through the nose. It was a ghoulish spectacle. Alice looked too, with big sad eyes.
"We need to make her drink." My daughter said it before I could.
"Yes. She said your moose blood tasted off, but I couldn't taste anything wrong with it."
"It could be the refrigeration. Maybe if I brought her a small animal or something, live, she could drink it fresh. Maybe she'd like that."
I shook my head; even if she were healthy, she wouldn't like that. Esme was a merciful huntress; she did not taunt her prey, or fight it like the boys sometimes did. She went for the clean kill, and the animal was dead before it even had time to be afraid. She wouldn't approve of us holding some poor raccoon or muskrat captive for hours before we killed it. She would probably just take the poor creature outside and let it go with an apology.
"You're right," Alice said with a sigh. "Maybe give the moose blood another try?"
"We could try."
While Alice fetched the blood from the fridge, I helped Esme sit up. Alice brought a cup with a straw this time, and she offered it with a hopeful smile.
"It's very sweet of you, but I'm not thirsty right now," Esme murmured. "Please, I don't want any blood."
"Momma, no, you need to drink," Alice begged. "You're just going to get sicker and sicker—how is your throat not on fire?"
"Alice," I whispered, placing a hand on my daughter's shoulder. She moved back and set the cup down on the desk. There were tears of worry in her eyes. I understood her frustration. Over the years, I'd watched patients grow worse, all the while refusing the treatment that would make them better, whether it was a blood transfusion, a drug, or simply to quit smoking. But now my patient was someone I loved.
How did one treat failure to thrive in a vampire? Well, how did one treat it in a human? If Esme were a human patient, I would have set up some kind of force-feeding method already. Parenteral nutrition wouldn't work on a vampire; we had no bloodstream. But a nasogastric tube might, as the nasopharynx and esophagus of a vampire were much the same as a human's.
"Stay with her for a few minutes," I instructed Alice. "I'm going to get some supplies from my office."
She checked the future to see what I was planning, and nodded in solemn understanding. I left her perched on the back of the couch, keeping a watchful eye on Esme while I ran down to my office.
For reasons best left unknown, medical professionals have a compulsion to hoard medical supplies, and I am no exception. I found what I needed in the colored chest of drawers in my office, and filled a couple of the big 50ml syringes with moose blood. Supplies in hand, I went back upstairs. Alice hadn't moved an inch, and neither had Esme.
"You need my help?" she asked.
I nodded gravely. "You think you can?"
"It's going to help her."
"You can't …see what this is, can you?" I asked, already knowing the answer. If she'd known, she would say something.
She shook her head and said, "It's blurry, unresolved. I guess the future depends on us this time."
"A sober thought."
"Yeah. Hey, Esme?" Alice tapped her mother's arm. "Esme, you with us?"
"I need you to sit up," I instructed her, taking her more firmly by the shoulders. This seemed to rouse her from whatever stupor seemed to have taken her. She stirred and, with my and Alice's help, sat up. Alice sat on the back of the couch behind her and pulled her dull hair back from her face. Esme looked down and saw my medical tray, the tubes, the syringes, and grimaced.
"Are you going to …?" she started to ask.
"You need nutrients," I explained. "I'm going to put a tube down your esophagus into your stomach so that you won't have to taste the blood."
She sighed and didn't say anything. I hated the resigned, beaten look on her face more than anything. And I knew that feeding her would only treat a symptom.
I put on gloves, out of habit more than anything, and unwrapped the nasogastric tube, a long yellow silicone snake. I dabbed lubricant on the tip to make it go down easier. There was a numbing gel you could use, but I doubted it would work on vampires.
"It's not going to be comfortable," I continued. "You're going to feel like you're gagging. Try to swallow. I'll do it as gently as I can."
She nodded. "Okay."
I tried to feed the tip of the tube into her nasal cavity, but Esme leaned her head backwards, whimpering at the sensation.
"Alice, hold her head," I instructed. Sometimes you have to be cruel to be kind.
From her perch on the back of the sofa, Alice held Esme's head still as I slid the tube into the nasal cavity, past the nasopharynx, the pharynx, down the esophagus, and into the stomach. Esme coughed weakly a few times as it went down, her eyes shiny with tears, but didn't say anything. When I was done, I checked the placement and taped the tube to her pallid cheek. She reached up and touched it, feeling this invader with the tips of her fingers.
"Does it hurt?" I asked. "It shouldn't hurt if it's in properly."
Slowly, she shook her head. "No pain."
"I'm going to push some blood," I told her, picking up the first syringe I'd prepared. "Let me know if anything starts to hurt or feel wrong." I connected the syringe to the tube and pushed about a milliliter every five seconds. Alice sat next to Esme and cradled her mother's head against her shoulder while I finished the first syringe. I started on the second, watching carefully for signs of improvement. By the middle of the third syringe of blood, the purple spots under her eyes had faded just a little, and her waxy pallor was slowly lifting.
"How's it feel, Momma?" Alice asked.
"Better," Esme whispered. She rubbed at her forehead. "Now, if I could only ease this migraine…"
Alice cast me a worried glance as I disposed of the packaging and used syringes.
"She's had migraine-like symptoms for the past few days," I said. "I'm going to need to do more research to find out why, but we can try some of the usual human remedies in the mean time."
"Cold cloth, dark room, stuff like that? I can handle it if you want to go hit the books."
"Very well. I'll be in my office if you need me."
Three hours later, I had read every single word Beatrice Sutcliffe sent me, and I was no closer to diagnosing Esme. There were three known diseases that affected vampires, all mutant strains of candida, all very rare, and none of them matched her symptoms or the progression. So either this was something new—entirely possible, given the rate at which bacteria evolve—or it was the result of exposure to something toxic.
Something toxic. The thought triggered a memory, and an idea. Typing furiously, I penned another electronic missive, this one to a young man that I wouldn't exactly call a friend. He was human, unlike most of my acquaintances, and sometimes I found myself mourning that he only had another forty or fifty years left, while I had hundreds. But I knew that he wouldn't have it any other way.
Martin Hunter came from a long line of, for lack of a better word, vampire slayers. According to family lore, his ancestors had narrowly survived an encounter with the Voluturi, and been inspired to learn every weakness that the vampire species possesses, and how to exploit them. Their descendants had continued the tradition, and by the time Martin and his siblings came along, the Hunter clan had several rather high-profile kills under their belt. I'd known a few of their victims by reputation, and I could safely say that the world was better off without those particular vampires.
Martin himself was an expert in the various chemicals that vampires were susceptible to, and he designed chemical and biological weapons for his family to use on the hunt. We'd met once, years ago, when his sister brought him to my emergency department with acid burns on his hands and forearms from a "work accident." His sister had come perilously close to killing me, until she noticed the color of my eyes and allowed me to explain that my family was different. Martin had thanked me for my medical treatment, and my discretion, and since then he emailed sporadically, mainly because it irritated his family that he was friends with a vampire.
He wasn't exactly a scientist; his highest level of education was a GED. But he was the closest thing to a paranormal toxicologist that I knew, and right now he was probably my best hope.
To my relief, he got back to me less than an hour later. I clicked on the email.
Carlisle,
Lovely to hear from you. Sorry about the missus. Well, a few thoughts:
First of all, you're right; it's not a disease. If it's causing appetite loss, my money's on one of the neurotoxins. Almost all the neurotoxins that affect humans also affect vampires, but the effects aren't as dramatic, just dulled reflexes, fatigue, head pain, appetite loss, stupor, feeling lousy, and it takes a pretty large dose to get to that point.
So, the usual suspects—any snakebites lately? I doubt they can pierce your skin, though, and it would take about fifty snakebites to reach a toxic dose. Botulism, but you guys don't eat, so I can't imagine where you'd pick that up. The stuff produced by tetanus bacteria would do it, but again, you'd need a ton of it. Shellfish toxins, and the stuff produced by algae blooms—so maybe going swimming in red tide? Lead, mercury, and most heavy metals would do it too. My advice would be to try and figure out where she's been and where she might have been exposed. I asked sis and she says treatment is mostly to stop exposure and provide supportive care.
Oh, and sis also says to tell you hi.
Much love and formic acid,
MH
As hastily written as that email was, it had given me as much insight as Dr. Sutcliffe's and Anna Camp's work. And speaking of Anna…I slowly shut my laptop and stood up, remembering the note she'd scrawled at the bottom of her neurology paper, about targeting the hypothalamus to control appetite in newborns.
I flashed back to Esme as a newborn, her bloodred eyes, her lightning reflexes, her hair streaming out behind her as we ran through the woods, hunting for her first meal. The sound of the bear we pursued together. The smell of blood, fresh and sharp and enticing, from a duck hunter's scraped forearm.
Esme, standing over his body, blood dripping down her chin. It had happened so fast that she didn't even remember doing it. Her first blood had been human, and I'd never completely let go of the guilt. Neither had Esme.
Thank you all, for the reviews, follows, and favorites. I am humbled by the response that this little exercise in medical writing has gotten.
The next and final chapter will be the reveal, but I think some of you will be able to guess the answer.