WHEN Oliver checked the lists next morning, he switched a couple of patients from Caroline’s list to his own. Paula Russell, he knew, was one of Rachel’s favourites, and this was a case she’d definitely want to know about this evening.
‘How are you, Paula?’ he asked when the thirteen-year-old walked in with her mother.
‘All right, thank you, Dr Bedingfield,’ she said politely.
‘How’s the pain?’ he asked gently.
‘It’s bearable,’ Paula said.
‘Darling, I know you’re being brave, but tell the doctor the truth,’ Mrs Russell prompted. ‘She’s been pretty rough, Dr Bedingfield.’
‘We’ve had the results of your tests back.’
‘So you know what’s wrong?’
Oliver nodded. ‘And it’s treatable.’
‘Thank God,’ Mrs Russell said. ‘So it’s not...’ She closed her eyes and her voice trailed off.
‘It’s not leukaemia, no,’ Oliver said. It was one of the conditions Rachel had managed to exclude through testing. She’d also established that the swelling around Paula’s joints hadn’t been reactive arthritis, swelling caused as a reaction after a virus or an infection such as Lyme disease or Streptococcus. Paula had come in four months ago with a limp and swollen knuckles, and when the inflammation hadn’t gone down within six weeks Rachel had organised a variety of tests, including blood tests, to look at the numbers of Paula’s white blood cells, red blood cells and platelets, a blood culture to check for bacteria, ESR or erythrocyte sedimentation rate to test for inflammation, and finally a test for rheumatoid factors, an antibody found in adults with rheumatoid arthritis. That test had been positive.
He smiled at them. ‘It’s something called JIA or juvenile idiopathic arthritis—it’s called “juvenile” because it started before you were sixteen, “idiopathic” because we don’t really know what causes it, and “arthritis” because your joints are inflamed.’
‘I don’t understand. Why don’t you know what causes it?’ Paula asked.
‘Some doctors think it’s an autoimmune disease,’ Oliver said. ‘Your immune system normally protects you against invaders, such as bacteria and viruses. With an autoimmune disease, your white blood cells can’t tell the difference between harmful invaders and the body’s healthy cells, so your immune system releases chemicals that damage your healthy tissue and makes it painful and inflamed.’
Paula’s form of JIA was polyarticular, meaning that more than four joints were affected. JIA usually affected the small joints of the hands, plus weight-bearing joints such as the knees, hips, ankles, feet and neck.
‘So what does it mean for Paula?’ Mrs Russell asked.
‘Her joints might feel warm, swollen and stiff in the morning or after she’s been resting for a while, and she’ll need to take very good care of her teeth. You might find that you get flare-ups sometimes, Paula—often just after you’ve had a virus or if you’re very stressed. Flare-ups can make you feel tired and you might lose your appetite,’ Oliver explained. ‘You’ll also need to see an eye specialist every few months to check out your eyes for something called uveitis—that’s when your eye gets inflamed. Sometimes uveitis makes your eyes hurt and go red, but not always—that’s why you need to go for check-ups.’
‘Arthritis. It—well, it makes me sound like an old lady,’ Paula said.
‘Well, you’re not. And there are more people than you think with your condition,’ Oliver said. ‘The good news is that we can give you treatment to keep your symptoms under control and help you lead a normal, active life.’
Paula frowned. ‘Does it mean I’m going to need my hips or knees replaced—like my gran?’
‘Possibly, when you’re a lot older,’ Oliver admitted. ‘But many teenagers with JIA grow out of it—the chances are two in three that you won’t have any problems when you’re an adult, and you’re likely to be independent.’
‘So what do we do in the meantime?’ Mrs Russell asked. ‘Do I still keep giving her the painkillers?’
‘There are two strands of therapy,’ Oliver said. ‘The first is physical therapy. I’m going to refer you to a physiotherapist, Paula. The physiotherapist can teach you some exercises that will make you feel a lot less stiff. Some days you won’t feel like doing anything other than sitting still, but your muscles have to be kept healthy so they can help support and protect your joints. The exercises will help you build up your strength, and you’ll need to make sure you warm up your muscles properly before you do any exercise.’ He smiled at her. ‘Do you like swimming?’
‘Yes.’
‘Good—that’s a great exercise. Walking’s good, too. So’s riding an exercise bike.’
Paula smiled back. ‘We’ve got an exercise bike. It’s Mum’s—and it’s covered in dust!’
Oliver chuckled. ‘If I had one, mine probably would be, too.’
‘You said there were two things,’ Paula said. ‘What’s the other one, Dr Bedingfield?’
‘Medication,’ Oliver said. ‘The anti-inflammatories Rachel prescribed for you obviously haven’t been quite enough to control the pain, so what I’m going to prescribe for you is called a DMARD—that stands for disease-modifying antirheumatic drug. The one the rheumatologist suggests using is called methotrexate, and we’ll try it by tablet first. You just need to take one once a week. Though there are some side-effects you need to know about. You might find you don’t grow as quickly as the other girls in your class—though you will catch up with them—and your periods might become a bit irregular.’
Paula flushed. ‘Oh.’
Oliver smiled. ‘Sorry, but I’m afraid I need to embarrass you a bit more now. If you’ve been taking the odd sip of your mum’s wine, you’ll need to stop—if you drink alcohol when you’re on methotrexate, you can feel quite rough and you might damage your liver. You’ll also need to be a lot more careful than the average teenager when you’re old enough to have sex—if you get pregnant while you’re taking methotrexate, it can affect the baby.’
‘I’m not having sex with anyone. I’m only thirteen,’ Paula muttered.
‘I know,’ Oliver said kindly. Damn, he’d handled this clumsily. Rachel would have done a much better job. ‘But I also know how teenage boys can put the pressure on. You’ve got a great excuse to say no.’
‘What happens if she doesn’t take them properly?’ Mrs Russell asked.
‘You’ll get a flare-up,’ Oliver said. ‘So you need to take your medication regularly, Paula. And make sure you eat properly and get enough sleep, too—the healthier you are, the less your arthritis is going to affect you.’
‘Right.’ Paula sighed. ‘Mum’s always going on about what I eat.’
‘Everything in moderation,’ Oliver said. ‘If you fancy the odd choc bar or ice cream, that’s fine. Just don’t stuff your face with junk food all the time—and, just as importantly, don’t go on any extreme diets.’
Paula looked worried. ‘Will I put on weight?’
‘You shouldn’t do, no,’ Oliver said reassuringly. ‘Oh, and one more thing—chickenpox is doing the rounds. Have you had it?’
Paula nodded. ‘When I was eight.’
It was rare to get chickenpox more than once. ‘That’s good.’
‘Why?’
‘On methotrexate, if you get chickenpox you might get it a bit more severely than normal. The medication affects certain viruses, so I can’t give you a TB or polio vaccination, but you’re fine to have the meningitis vaccination.’
‘Does this methotrexate work?’ Mrs Russell asked.
‘Tests show it’s safe for teenagers to use and it’s effective, though it doesn’t work for everyone.’
‘What if it doesn’t work for me?’ Paula asked.
‘Sometimes the tablet form doesn’t work and you need to take it by injecting it under the skin instead. We’ll keep a close eye on you to see how you’re doing. If you need to change from tablets to injections, I can teach you how to do the injections yourself—a bit like if you were a diabetic,’ Oliver said.
Paula pulled a face. ‘I don’t like needles very much. Is there anything else I can have instead?’
‘There are other drugs, yes—but they’re still being trialled at the moment. There’s something called etanercept, a TNF-alpha receptor fusion protein, which looks pretty promising.’ He smiled. ‘And now I’m talking jargon at you. We might also need to give you something called corticosteroids—these aren’t the same as bodybuilders take, so don’t worry about that. What they do is reduce the inflammation and help you control the pain. Though they can have other side-effects. You might bruise more easily and your bones can become brittle, so if we give you corticosteroids you’ll need to make sure you get plenty of calcium—dairy foods and sardines.’
‘What about these bumps on her elbows?’ Mrs Russell asked. ‘Show them to Dr Bedingfield, Paula.’
Paula rolled up her sleeve to show him. ‘They don’t hurt or anything.’
‘And they’re nothing to worry about,’ Oliver said when he’d examined the small nodes. ‘It’s part of JIA—you sometimes get small bumps and lumps on areas where there’s pressure from you sitting or leaning. You might get the odd temperature every now and then, too, Paula.’
‘There’s an awful lot to take in,’ Mrs Russell said.
Oliver nodded. ‘I know, and you’re bound to have a lot of questions. I’ve got some leaflets that might help—you can’t be expected to remember everything I’ve said when you get home. You might find it useful to join a support group. There are a couple of national groups which have meetings locally in Maidenhead—Rachel found the local contact numbers for you.’ He took the leaflets from his desk and the note Rachel had written with the telephone numbers. ‘If you’d like to come and see me or Rachel in a couple of weeks, we’ll see how you’re getting on. You should get an appointment through the hospital to see the rheumatologist again, and also the eye specialist.’ He printed the prescription, signed it and handed it to Paula. ‘And if either of you are worried about anything in the meantime, or you have any questions, just give me a call.’
‘Thank you, Dr Bedingfield,’ Paula said. ‘At least I know what’s wrong with me now, so they’ll shut up at school and stop saying I’m being lazy or a skiver.’
‘There are some good long words in those leaflets,’ Oliver said with a grin. ‘Go and blind ’em with science.’
‘I will,’ she said, lifting her chin. ‘Definitely!’
* * *
Oliver managed to get home that evening on time—purely because Caroline walked into his consulting room before he could call his next patient.
‘What are you doing?’ he asked in horror as she calmly logged him off the system and switched off his computer. ‘I’ve got patients to see!’
‘I’ll see them. Go home,’ she said.
‘But—’
‘But, nothing. You’re supposed to be going out to dinner with your wife. So you are not going to work late tonight, Oliver Bedingfield. And before you fuss about who’s going to lock up the surgery, I will. I’ll drop the surgery keys off at your place on my way home.’
It was one of the most transparent excuses he’d ever heard. And he had a good answer for it, to make quite sure she didn’t get to see Rachel. ‘I’ll lend you my spare set for tonight.’
She gave him a knowing look. ‘Right. Have a nice time.’
‘Yeah.’
Her voice softened. ‘Oliver. Just tell her what we talked about.’
‘I...’ How could he? Rachel would be furious that he’d discussed her with another woman, that he’d laid bare all the private things between them. Including the fact that their sex life was less lively than a damp squib.
‘Just talk to her. It’ll all be fine.’
He wasn’t quite so sure.
‘Go.’ She took his hand, pulled him out of his chair and virtually pushed him out of the room. Oliver, deciding it would be pointless to protest—particularly as he knew she was right—simply did what she suggested and went home.
Rachel was getting ready when he arrived.
‘You’re home early!’
Why did she look so shocked? He wasn’t always late...was he? ‘Cally pushed me out of the door.’
‘Oh.’
His wife’s face clouded. Oliver frowned. What was the matter? Surely Caroline had just done her a favour? Or was she worried that he’d been listening to his mother’s usual rant about how a mother’s place was in the home, not at work, and was planning to use Sophie’s illness as an excuse to replace Rachel in the surgery and make her stay at home? ‘Rachel, she’s your locum. She’s only staying as long as we need her there.’
‘Right.’ But Rachel didn’t look any happier. Sometimes, Oliver thought, he really didn’t understand his wife.
‘You, um, look lovely tonight,’ he said. Not that she needed make-up. He’d always thought her beautiful enough without it. Always would.
She didn’t seem flattered by his comment. Suspicious, if anything. He gave up. ‘I’ll have a shower and see you downstairs in about fifteen minutes, OK?’
* * *
When was the last time they’d been out together without the children? Rachel wondered as they drove to the restaurant. They usually went out as a family. On the few weekends when Oliver hadn’t been working—which meant any Sunday before he got called out—they’d gone to the beach or a castle somewhere, then eaten at a family restaurant. They always celebrated birthdays as a family, rather than as a couple.
Maybe they should make more of an effort. But when would they get the time? Between work, the children, Oliver’s course and her PTA commitments, there wasn’t much left. And she didn’t like to keep asking Ginny to babysit all the time, even though she kept an eye on Ginny’s son Jack sometimes in return.
It would be different if they lived in Newcastle—her mother or sister would suggest it before she could even ask them. But Oliver’s family wasn’t like that. Rachel had the strong impression that Isabel didn’t like children very much. She tolerated the children’s visits, but only just. Rob usually had his nose in a book so he was too quiet to irritate his grandmother, but Sophie was loud and would get an A+ for being demanding, attention-wise. Which was why Rachel didn’t ask Isabel to babysit.
‘Sophie’s definitely on the mend,’ Oliver said when they’d sat down and given their order to the waiter.
‘She’ll be back at nursery on Monday. Mum’s going home on Friday afternoon,’ Rachel told him.
‘Right.’
For the first time she could remember, she actually felt awkward with Oliver. As if he were a stranger. Weird. They’d always been able to talk.
Until Caroline Prentiss had come back on the scene.
‘I saw one of your patients today.’
She frowned. ‘I thought my locum was seeing my patients?’
‘She is. But I noticed that Paula Russell was on the list, and I thought you’d want to know how things were going, so I switched her over to me.’ He raised an eyebrow. ‘I’m not sure if she was more relieved to get a diagnosis at last or shocked to realise it’s JIA. I think I embarrassed the poor kid, though—telling her about the drawbacks of methotrexate, especially when it comes to alcohol and sex.’ He smiled ruefully. ‘I think you’d have handled it better.’
‘So I’ll be the one doing the birds-and-bees talk with Rob, then?’ she asked, smiling back.
‘I think so. Anyway, I’ve told her to ring us at any time if she has questions, and I gave her the number of the local support group you found for her.’
‘Thanks.’ Rachel wished Oliver would show the same care to his family as he did to his patients. She thought about telling him—but something stopped her. If she told him how she felt, it might push him too hard. Worse, it might push him to Caroline. Or ‘Cally’, as he called her. The kind of pet name people gave to the people they loved: it was a dead give-away.
Maybe it was time she met Caroline for herself. Not a direct confrontation: she wasn’t stupid enough to give Oliver an ultimatum. But maybe if they invited Caroline to dinner, it would give the other woman a chance to see Oliver at home with his wife and children. Then maybe Caroline would realise what she was asking him to give up—and maybe she’d do the right thing and leave him alone.
‘We ought to have her over for dinner, you know.’
‘Who?’
‘Caroline.’ Cally. The name almost stuck in her throat.
Oliver looked uncomfortable. ‘Why?’
‘You said yourself that you’d known her for years and she’s just come back to the area. Sometimes it’s difficult to fit back in again.’ Though she certainly wasn’t going to fit right back into her old relationship with Oliver. Not if she had anything to do with it. ‘If she comes to dinner, it might help her feel that she’s still got friends around here. Plus, it’s a way of saying thank you—for stepping in for me temporarily at short notice.’
Oliver shifted in his seat. ‘Mmm.’
‘So why don’t we?’
She could see him trying to think up an excuse. When he clearly couldn’t come up with one, he sighed. ‘When?’
‘Saturday night.’
‘She might be busy.’
‘If she’s only just moved back here, she probably isn’t. Ask her. Or maybe I can pop in to the surgery tomorrow and have a word with her.’
There were definite signs of alarm in his face now. Was he worried that his wife and mistress were going to meet at last? Or was she just being paranoid?
‘No, it’s all right. I’ll ask her tomorrow,’ he said hastily.
‘OK.’
‘You do know I love you, don’t you?’ he asked suddenly.
‘Yes.’ Though she had a nasty feeling that there was a ‘but’ attached. What?
I love you, but I should have married Caroline?
I love you, but our marriage isn’t working out?
I love you, but goodbye?
‘I love you, too,’ she said.
‘Good.’ He muttered something she didn’t catch, though she suspected it was something like ‘so that’s all right, then’. Except it wasn’t, was it?
The silence between them stretched out, punctuated only by the sound of cutlery against china. Although the chicken parmigiana was perfectly cooked, and Rachel adored Italian food, she found it more and more difficult to force down each mouthful. This was crazy. They were meant to be closing the gap between them, but the distance just seemed to yawn more and more as the minutes ticked by.
‘So how’s your course going?’ she asked eventually.
‘Very well.’ Oliver gave her an enthusiastic run-down of what they’d done the previous evening. ‘When we’ve finished the course, the tutor was talking about setting up a pilot scheme, using GPs trained in trauma medicine to help support the rapid response units. We’re often nearer to the patients than the hospitals are, so we can get there quicker.’
She could see by his face that he wanted to do it. She wasn’t surprised. Oliver had originally planned to work in emergency medicine. When Nigel had dropped out of his course in medicine, and it had become clear that it had been permanent rather than a temporary break, Oliver had felt duty-bound to switch his specialist training to general practice, for his father’s sake. Rachel had wholeheartedly supported his decision to take the GP course in trauma medicine—to do something for himself for once. And doing support work for the rapid response units would be the nearest he’d ever come to working in the area he’d wanted to specialise in. ‘Oliver, if you want to be on the pilot, you know I’ll back you.’
He blinked in astonishment. ‘Really?’
‘Really.’ Now it was her turn for the ‘but’. ‘But you already work ridiculous hours. If you want to do rapid response work, you’re going to have to delegate some of your other workload to make room for it. And the obvious thing is to start using a night and weekend call-out service.’
He sighed. ‘We’ve already been through that.’
‘I know. And I understand you want to keep the high levels of service that your father set. That’s only natural.’ She toyed with her chicken. ‘But the world’s not the same place it was when your father joined the practice. Our estate didn’t even exist. There were half the amount of people in Hollybridge that there are now, and there wasn’t the huge amount of paperwork per patient either.’
‘We’re a family practice.’
‘And we still will be. We’re just moving with the times. How do you think we’d cope if we still had to use a manual system for patient notes—where would we have the space to store everything? Or if you had to drive a pony and trap to house calls, instead of taking the car?’
‘That’s different.’
‘No, it isn’t.’ She reached across the table and took his hand. ‘Computers and cars have made our lives as doctors easier, and helped us give a better service to our patients. You’re working such crazy hours that you’re wearing yourself out—and you’ll get to the point where you’re not going to be able to give patients what they need. What’s it going to take to make you realise—missing a diagnosis? Giving someone the wrong dosage? A patient dying?’
‘You’re being over-dramatic, Rachel.’ He shook her hand off.
How to push your husband into his mistress’s arms—at breakneck speed, Rachel thought. She backed off fast. ‘I’m sorry. I don’t want to fight, Oliver.’
‘Me neither.’
‘I just want things to be...’ How they used to be. Before Caroline. Well, before that even. She didn’t regret having the children, not for a moment, but she did regret the pressures that were forcing her apart from Oliver.
‘Me, too. Look, everything will sort itself out.’
Maybe. She just hoped it would work out the way she wanted it to be—so they didn’t become a statistic.