Chapter 9: See Chapter 1 disclaimer

Martin came back from the fish market with a few fillets for New Years Day supper when he noticed that a voicemail had been left on the surgery phone. He put the fish into the fridge then retrieved the message from the answerphone in his consulting room. It was Leonard Maitland. Martin gulped. "Oh my god, I should have followed up with him much sooner", he thought, but so much had been happening.

Leonard's voice came out of the speaker. "Hiya, Doc, I'm calling to follow up on those tests you wanted to run. You told me they didn't need to be done right away on Christmas Eve, but you did make them seem as if I shouldn't put it off, what with this See-Lee-something-or-other thing you think I have. Anyway, give me a ring to let me know if I should come in before the New Year."

Martin was still technically on holiday, but he did want to get Leonard started on a new diet if indeed he did have coeliac disease. Martin also planned to start him on a course of vitamin and mineral supplements for a few months to make up for the deficiencies that had already accrued from an untreated disease.

Martin copied down the caller ID from the incoming call and rang Leonard back. The ringing tones sounded four times, then the call was picked up by voicemail. Martin became concerned, because although Leonard's message on the surgery voicemail had sounded strong, he was in a weakened state from the blood loss he had suffered on Christmas Eve. Martin started berating himself for not following up sooner when Leonard picked up the line mid-outgoing-message, answering with a simple but breathless, "Hello."

"Ah, Leonard, this is Dr. Ellingham. You sound out of breath."

"I had to hurry up to get the phone, Doc. I was out in the kitchen. Thanks for calling back."

"Are you feeling strong enough to come to the surgery for me to conduct those additional tests I mentioned? Or do you need me to come to you?"

"I feel right as rain Doc, so I can come in. Now that Christmas is over, I've got all the time in the world. This afternoon would be fine with me if it's fine with you."

"Mm, yes, good. That would be very good. 15:00?"

"Alright, Doc, I'll see you at 15:00." Martin was relieved and stopped mentally beating himself up for failing to follow up earlier.

At the appointment time, Leonard Maitland presented himself at the surgery in canvas jeans and a flannel shirt under a field coat. He was almost unrecognizable to Martin without his Santa suit. Leonard greeted Martin with a Happy New Year.

Martin replied, "Right, ah, same to you. Come through."

The two proceeded into the consulting room, and Martin instructed Leonard to take a seat in the patient chair. "I'm going to take some blood and, if the result comes back showing the presence of antibodies like tissue transglutaminase, I'm likely to recommend a biopsy of the small intestine to check for characteristic damage caused by coeliac disease. In the meantime, you should continue your normal diet, including eating foods with gluten, for the test results to be accurate."

"Well, Doc, I'm not exactly a young man. Is it completely necessary to do an invasive test? What's the worst that could happen?"

"As I mentioned, you could have malabsorption and malnutrition and you are already severely anemic. However, if the bloodwork comes back as I expect, we could start an exclusion diet to see the effects. That is, we could assume that you do have coeliac disease and treat it as such. At that point, the treatment is straightforward - changes in diet and the addition of dietary supplements. You would need to eliminate gluten from your diet, which can be easier said than done. I would refer you to a dietician who would help you."

"What sorts of things would I need to exclude, Doc? You said anything with wheat, right?"

"Yes, but gluten is the main culprit. Unfortunately, gluten is a component of many grains and is in any number of things we normally eat and drink. I hope you already avoid Chinese food because, in addition to being loaded with sodium, MSG contains gluten."

"Chinese food was the opposite of the Christmas situation for me, Doc. I loved it and my wife hated it. But since she's gone, I don't have the hankering for it that I once did. Maybe because it's no longer the forbidden food. Of course, now it will be forbidden again." Leonard chuckled. "Well, that's not going to make me want to eat it again."

Martin continued, "If I recall, you drink alcoholic beverages. You will need to be careful to choose beer, lager, ale, whatever, that has no gluten. The dietician can also help you with this, and there are many resources on the internet that are reliable. There are also many more products made for gluten intolerant people nowadays. Now roll up your sleeve."

Leonard exposed his elbow, and Martin drew a blood sample, averting his eyes whilst the vial filled. Martin taped over the puncture wound and, once he was finished, Leonard rolled his sleeve back down.

Martin continued, "I should have these results back tomorrow or the day after, in case things are delayed because of the holidays. I'll give you a call with the results and then we will start next steps." Martin paused and remained silent but looked as if he had more to say. The moment stretched a little awkwardly.

"Right, um, okay then, Doc. I'll be going. Please wish Louisa a Happy New Year for me." Leonard put his coat back on and walked out of the consulting room. Martin was about to call after him with a question about their Christmas Eve conversation, when the door to the surgery opened, and Roger Fenn walked in carrying a child accompanied by a worried woman.

Frustrated, Martin started to say, "The surgery is open for emergencies only" when he noticed the child was too old to be napping in Roger's arms. Roger had never seemed like an alarmist to Martin, and the look he had on his face indicated a great deal of concern. Instead, Martin told Roger, "Follow me," and led Roger and the woman into the consulting room. Leonard followed them with his eyes, then slowly exited the surgery.

Roger laid the child onto the examination couch and Martin put the light on. He listened to the child's heart and breathing; he also took a pulse and checked her pupils with a torch. "Who is the girl? When did this start?'

The woman spoke up. "That's my Ellie. She started vomiting yesterday and I thought it was just something she ate, but she wouldn't stop, and I didn't know what to do, so I called our GP in Camelford and they referred us up to Bude. I couldn't get there, so I called Roger for the name of the closest doctor."

Roger interrupted, "This is Ann Sanders, Doc. The Sanders family moved to Port Gaverne a couple of months ago and I've been giving Ann piano lessons."

Martin told Roger to stop talking, then asked, "What was Ann doing prior to becoming unconscious?"

Ann replied, "It's Ellie, Doc. I'm Ann. Ellie seemed to be walking crooked, like she was dizzy or something. Then she just sank down to the floor, like her legs couldn't hold her up." She stifled a sob. Roger took over, "Ann called me up because Rich, her husband, had taken their car and she had no way to get anywhere. We live right around the corner from them."

Martin pinched the child's skin on the back of her hand, and it was slow to return to normal. "She's severely dehydrated, probably from the vomiting. I'm going to start a drip to get some fluids into her, but she needs to go to hospital. Roger, call an ambulance. Was there anything that she ate that was different from the rest of the family? Or is there anyone else in the family who seems to be sick?"

"Richie said he felt a bit queasy yesterday and doesn't feel great today, but he's not been barfing, and it didn't stop him from working. And, yes, everyone had the same meals in front of them, but I can't say if everybody ate some of everything. I mean, there's five of us and I'm not really watching that close." Roger had warned Ann that Doc Martin could be a bit abrasive when questioning patients, and that it might sound as if he were scolding, but that he didn't mean anything by it. Still, it didn't stop Ann from feeling a bit defensive that she might not be on top of what her family ate.

Roger reported, "Ambulance can be here in 20 minutes, Doc."

"All right, I'll set up the drip and see if I can get her to wake up. Emma, can you hold her arm still. I'll need access to her hand and the prick of the needle may cause her to wake and try to jerk her hand away."

Ann looked around to find this Emma person, and Roger said, "Ann, Martin, it's Ann, not Emma. Ann, can you hold Ellie's hand." Ann did what was asked, and the Doc expertly inserted the cannula into a vein on the back of Ellie's hand, taped things down carefully, and started the fluids.

In the meantime, Louisa had been coming back from the village with bundled-up James and Mary when she saw Leonard coming out of the surgery. "Hello there, Leonard! Did you have a lovely Christmas Day after the excitement of Christmas Eve? James, say hello to Mr. Maitland." James dutifully said hello to the stranger.

"Oh, hello, Louisa, how nice to see you again. Just finished up with the Doc, and Roger Fenn came in with a woman and little girl who didn't look that great. I hope all is well there." James didn't remember ever seeing this man before, but he did sound a little familiar.

"Oh dear," exclaimed Louisa, "It's possible I might know them, if their children attend Portwenn Primary School. I haven't been gone that long. I'm off, Leonard. I want to get inside to see if there's any way I can help." At that, Louisa hustled up to the surgery with the children, got James settled with a quick glass of milk and the instructions to play quietly, and tucked a sleepy Mary into her playpen. She then tapped on the door to the consulting room.

"I'm with a patient!" Martin shouted, out of habit. Louisa replied, "Yes, Martin, I heard. I might know them and thought I could possibly help."

Ann, hearing a familiar and friendly voice, replied, "Oh Louisa, yes, please come in."

Louisa entered the consulting room and saw that it was Ann Sanders and Ellie, who she knew from Portwenn Tots, as Ellie and James overlapped there for a year. Ann looked stressed and upset, her hair askew. Martin gave an exasperated look as the room was getting crowded but said nothing. Roger noticed and said, "I'll wait in the waiting room, Doc. Shout if you need something." Martin appreciated Roger's interpretation of the situation and nodded once, quickly, in gratitude.

Martin stated, "I'm going to wake her up with smelling salts. Continue holding her still so she doesn't pull out the cannula." He snapped the smelling salts in front of the little girl's nose, and Ellie startled and tried to move. Her mother had her well secured and whispered quickly to her, "Ellie, it's okay. Mummy is here and you're going to be fine. Just lay still there, honey. You're at the doctor's."

Ellie was still but looked a bit panicked, as she did not recognize this doctor nor the room. She did see Mrs. Ellingham, James' mum, though. Louisa gave her a bright smile and said, in a tone friendly but unexcited, so as not to add energy to the situation, "Hello, Ellie, it's nice to see you. I'm sorry you've been poorly. My husband is a very good doctor and he's going to see about making you better, okay?" Ellie's face relaxed a bit.

Martin asked Ann, "I don't have Ellie's records. How old is she? Does she have any chronic illnesses? Any recent medical issues?"

Ann replied, "Ellie is six years old, and, let's see, she gets ear infections a lot and it seems like every cold she gets turns into bronchitis. She just got over a bout right before Christmas."

Martin was surprised to hear that Ellie was six. Her size was more in line with a four-year-old. Add to that the frequent ear infection and bronchitis history, the evidence suggested the child might have an immune system issue that was not yet diagnosed.

"Does she have incidents of stomach upset or vomiting frequently? Have you introduced any new foods?"

Ann replied, "She has the occasional tummy ache, maybe a little more than the other kids did at her age, but nothing like this vomiting. And we don't have any new foods. Of course, we eat a little differently at Christmas compared to other times of the year, but it's the normal traditional Christmas treats that Ellie has had in prior years."

"Ok, then, I'm going to recommend she have bloodwork and a urine sample at the hospital. I'm going to ask them to look for any markers of immunodeficiency. That would explain the frequent earaches and complications from colds." In the back of his mind, he was thinking of Mark's idea of a depressed immune system and Janice's similar vomiting issues. He asked Ann, "Has Ellie complained of foods or drinks smelling any differently to her? Has her appetite been good?"

"No, Doc. Nothing like that. And her appetite has been fine up until now." To Ellie, she said softly, with a smile, "You didn't have any trouble downing all those lovely cookies, now, did you?" Ellie had been relaxing a bit more, but the mention of food triggered a dry heave. Ann said, alarmed, "Do you think it was the cookies, then, Doc? I mean, look at that?!"

"No, if anything it's the mention of any, ah, consumable, but I think it was just part of her gastrointestinal upset, and the timing was a coincidence."

At this point, there was a clatter at the surgery door and Roger guided the ambulance crew in to assess the patient. Martin filled them in on the situation and gave them a script of the tests he wanted run, as well as the inclusion of additional IV fluids should the first bag run out on the way. The team brought in a wheelchair and lifted Ellie into it, then wheeled her out the door of the surgery, where they put her on the stretcher and then put the stretcher into the ambulance.

Martin told Ann to go with them, informing the crew that Ann was the child's mother. Roger volunteered, "I'll call Rich and have him meet you at the hospital. If he's not able to get there quickly, I'll drive down myself and keep you company until he gets there." With that, the ambulance drove off.

Louisa asked Roger suddenly, "Who is with the older two?" Roger replied, "Maureen is there now." Louisa turned to Martin and asked, "Martin, do you think they'll hold Ellie overnight?" Martin looked distinctly uncomfortable, not only about sharing medical details but also about speculating. Louisa gave him an impatient look, and said, "Martin, we need to understand whether someone will be needed to help out with the other two Sanders children if both Ann and Rich have to say with Ellie."

Martin surrendered, and said, "Yes, I think it's likely they'll keep her. They will administer fluids, and they'll want to wait until test results are in, and they may be lightly staffed given the holidays. The parents won't need to be there, although I can understand they may want to." Martin was aware how he would feel if James or Mary were in hospital, and he knew Louisa would not leave under any condition.

Louisa looked appreciative. "Thank you, Martin. I'll start organizing the villagers. Roger, if you can keep in touch with Ann or Rich and let us know their plans, that would be great. If Rich comes home, we need less of a backup plan." Roger agreed, said his goodbyes, and left.

Crisis over, Martin looked at Louisa and said, "I'll write up my notes and then cook dinner. I bought us some fish."