'Can you tell me what happened?' Libby spoke softly, her eyes fixed on the child, assessing her breathing. 'When did she become ill?'
'She was a bit under the weather yesterday morning and then she just got worse and worse. By teatime she was just lying on the sofa.'
And she was just lying now. Totally unresponsive. It wasn't a good sign.
'Could you get her interested in anything-toys, books?' The mother shook her head. 'Nothing. She just lay there. Finally I panicked and took her to the GP and he sent us in here.'
'And when did she last have paracetamol syrup?'
'Two hours ago.' The mother looked at her anxiously. 'What's going to happen?'
'I'm going to check her temperature now and then ask one of the doctors to see her straight away.' Libby reached for the thermometer. 'Has she had all her immunisations, Mrs Miller?'
'Please, call me Alison and, yes, she's had everything.'
'Good.'
Libby checked the temperature and recorded it on the chart. 'It's very high, as you know. Has she been drinking much?'
'She's just not interested in anything.'
'When did she last have a wet nappy?'
The mother looked startled by the question. 'I don't know … '
'It's a way of judging her fluid output,' Libby explained, and the woman nodded.
'Oh, I see.' She frowned slightly. 'I suppose I changed it about three hours ago.'
Libby checked the child's blood pressure and then gave Alison Miller a brief smile.
'OK, well, the next thing to do is to ask one of our doctors to see her. We need to find out what's causing this temperature. I'll be back as soon as I can. If you're worried, press the buzzer.'
She gritted her teeth and went to find Andreas. She would have preferred to have avoided him completely but that wasn't an option. Bleeping one of the more junior members of his team would have taken time and she didn't have time.
And, anyway, she didn't really want one of the more junior members of his team.
She was worried about little Rachel. She needed someone experienced and he was the consultant after all.
She found him at the nurses' station, checking a set of X-rays, his shoulders impossibly wide as he stood with his back to her.
Libby swallowed and dragged her mind back to her work. She already knew he was a fantastic kisser. It was time to find out what he was like as a children's doctor.
'I need a doctor to see a new admission for me urgently.' Her tone was cool and ultra-dignified as she struggled to behave as though she hadn't kissed him senseless and then woken up half-naked in his spare bedroom. 'I don't like the look of her. Seeing that the rest of your team are elsewhere, I wondered whether you'd do it.'
Or was he the type of consultant who preferred to delegate to his staff? He turned and she backed away a few steps, watching him warily.
In work mode he suddenly seemed very imposing.
'I'll see her.' He flicked off the light-box and moved towards her. 'What's the history?'
Relaxing her guard slightly, Libby fell into step beside him as they walked back to the side ward. 'She was referred by her GP, but the letter just says that she's worried about the child's temperature. Not much else. The child is floppy, she's refusing fluids and I don't like the look of her.'
She'd been a children's nurse long enough to trust her instincts and her instincts were shrieking about Rachel.
'Great.' He shot her a wry smile. 'It's wonderful to be a GP, isn't it? If in doubt, refer to hospital and let someone else make the decision.'
'Before you insult GPs, you should probably know that my brother is doing a GP rotation-'
He lifted an eyebrow and his mouth twitched in humour. 'This is the same brother who forgot to buy you last night?'
Libby gave a wry smile at the reminder. 'I still have to speak to him about that. But despite his shortcomings as a brother, he's a very dedicated doctor. I expect he was caught up with a patient, which was why he didn't show up. Unluckily for me.'
'But luckily for me,' Andreas breathed softly, his eyes narrowing as he looked at her.
She blushed hotly. 'Stop it!'
'Stop what?' He dealt her a slow smile. 'Libby, I haven't even begun yet.'
Without giving her a chance to speak again, he walked into the side ward and introduced himself to Alison Miller before bending over the cot.
His swift shift from professional to personal and back again flustered her more than she cared to admit, and Libby struggled to concentrate as she followed him into the room.
Andreas didn't seem to be suffering from the same affliction. His eyes were on his tiny patient.
To the uninitiated it might have seemed as though he was just looking at the baby, but Libby knew that he was accumulating vital pieces of information. She saw his eyes rest on the child's chest, assessing her breathing, saw the way that he noted her skin colour and the way she lay limp and unresponsive in the cot.
He lifted his head and looked at Libby, the humour gone from his eyes. 'Temperature?'
'Forty point seven,' Libby said immediately, and his mouth tightened.
'How did you take it?'
'With a tympanic membrane thermometer. I find it the best method in a child of this age.'
It gave an accurate reading of a child's core body temperature and didn't cause undue distress.
Andreas nodded his approval and looked at the chart Libby handed him, his eyes scanning the detail. Then he lifted his head and talked to the mother about the illness, questioning her about immunisations and family history.
As he finished scribbling on the notes, the baby started to cry fretfully.
Alison looked at them. 'Is it OK to pick her up?'
'Of course.' Andreas answered her with a reassuring smile before slipping his pen back into his pocket. 'Cuddle her. Then I will examine her. Libby, can I take a look at the letter from the GP?'
Libby handed it over. 'She did speak to Jonathon, your SHO.'
Alison scooped the baby out of the cot and looked at them anxiously. 'She said that it was probably just a virus but that it was best to be safe as her temperature was so high.'
It didn't sound as though the GP had even examined the child.
Libby glanced briefly at Andreas but his expression didn't flicker.
'Right.' He checked in the notes and frowned. As Libby had commented, there was virtually nothing in the referral letter. 'I'd like to examine her again, please. I'll go and fetch my things while you get her ready.'
Libby nodded and spoke quietly to Alison, explaining what was going on.
'Just hold her on your lap,' she suggested, fetching a chair to make it easier. 'Dr Christakos needs to examine her ears, and it's easier if you hold her like this, and like this … ' Libby demonstrated and Alison did as she'd requested.
Andreas examined one of Rachel's eardrums and then waited while Libby helped turn the child round so that he could examine the other ear.
He was very, very skilled with the child. Gentle and swift, with no fumbling.
'Her ears are fine, and so is her throat,' he said finally, unwinding the stethoscope from around his neck. 'I'll just listen to her chest.'
Finally he rocked back on his heels. 'Her chest is clear so we need to start thinking about the less obvious.' He frowned thoughtfully and rubbed long fingers over his darkened jaw. 'Has she ever had a urinary tract infection?'
Alison's eyes widened and she shook her head. 'No. Well, not to my knowledge. Isn't that something that adults get?'
'And some children,' Andreas told her. 'It can be a cause of unexplained fever and I'm wondering if that could be the case with Rachel. There are some tests I want to do. I need to take some bloods and I want a urine sample.'
Libby pulled a face. 'That's never easy in a child of this age, as you well know, but I'll certainly try. She hasn't had a wet nappy for a few hours so we might be lucky.'
'Please.' Andreas gave her a nod. 'UTI is one of the commonest bacterial infections of childhood. It accounts for about five per cent of febrile illness. Rachel is very unwell and her temperature is very high. We need a specimen of urine urgently, and in the meantime we'll give her some ibuprofen to try and bring that temperature down.'
He scribbled on the drug chart and Libby went off to fetch the medicine and the equipment she'd need to take the urine sample.
Andreas caught up with her in the corridor. 'Your instincts are good. That child is very sick,' he said quietly. 'I'll give you an hour to get that sample and if you don't have any luck I'll have to do a supra-pubic aspiration.'
'An SPA?' Libby pulled a face. A supra-pubic aspiration meant inserting a needle into the bladder to draw off the sample of urine. It was sometimes used in very small babies when a sample was needed urgently and other methods had failed. 'Do we have to? That's invasive.'
'I'm aware of that.' Andreas ran a hand over his jaw, his expression serious. 'I'm also aware that the risk of renal scarring in infants and young children with undiagnosed and untreated UTI is high. I want to start antibiotics as soon as possible and I can't do that until I've taken a specimen. Call me if there's any change.'