Unnatural : Erica Rosen MD Trilogy: Book 1

By Deven Greene

In this medical thriller, Dr. Erica Rosen is perplexed when she sees a young Chinese girl with blue eyes in her San Francisco pediatrics clinic. The girl's mother, Ting, is secretive, and Erica suspects she has entered the country illegally. Later, Erica encounter

• Language: English
• Publisher: Panthera Publishing
• Release date: May 17, 2024
• ISBN: 9781964620015

Deven Greene

Deven Greene enjoys writing fiction, most of which involves science or medicine. She has degrees in biochemistry and medicine, and practiced pathology for over twenty years. Her website is https://www.devengreene.com

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Chapter 46

Note from the Author

Acknowledgments

Chapter 1

Exiting the restroom where I’d been unsuccessful in removing the vomit stain from the front of my white coat, I’d barely taken two steps before my physician’s assistant spotted me.

There you are, Dr. Rosen. You’re in room nine next. Here’s a clean coat.

Thank you, Martha, you read my mind. I shed my soiled coat, grabbed my stethoscope and other items from the pockets, and tossed the garment to my assistant. She handed me a clean white coat which I slipped on, all without missing a step as I strode toward room nine. We’d done this drill many times, synchronizing our moves for maximum efficiency. I often imagined my coat-switching exercise must be similar to refueling a jet in the sky. After I’d filled my pockets with the items in my hands, Martha removed my nametag from the dirty coat and handed it to me. I attached it to the upper pocket on my clean coat with the alligator clip. Who’s the patient?

Martha smiled and held out a clipboard for me. Evan Fields and his mom. Forearm laceration.

Continuing to walk, I grabbed the clipboard. Thanks. Martha started to speak, but I interrupted her. I know, I know. Room nine.

Martha, a stout woman in her late thirties with short brown hair and a pasty complexion, slowed down, letting me approach the waiting patient on my own. When I reached the door to room nine, I knocked twice to let Evan and his mom know I was about to enter, then stopped. Obvious waste of time, I reminded myself. I slowly opened the door to the small, cluttered exam room, the familiar Shrek poster the first thing that greeted me. Pushing the door farther, I saw Evan sitting on the firetruck exam table, his mother seated in one of the two adult-size chairs. The two children’s chairs were empty.

As usual, my jaw tightened a bit upon seeing the computer terminal, like the others found in every exam room. It sat innocently enough on a small table with a faux wood top near the sink. The best thing one might say about the computer is that it united all physicians practicing in the clinic and in clinics and hospitals across the country. Male, female, black, white, brown, tall, short, progressive, conservative, they all hated the computer, the bearer of the despised Electronic Health Record, or EHR. After two years in the clinic, you’d think I would be used to it, but I wasn’t. I still resented its intrusion into the time I spent with my patients and their parents. Instead of having a comfortable discussion with that now almost passé element known as eye contact, I needed to spend most of my appointment time sitting before the terminal, typing. Resigned to postponing my long-planned ax attack of the computer, I logged in and confirmed Martha had made sure all the necessary information, such as patient’s name and age, parents’ names, address, insurance, and reason for visit, was up to date.

Evan and his mom looked at me and smiled while I signed Hello. They each responded with a reciprocal sign. Both Evan and his mother are profoundly deaf. I was the only clinic doctor or staff of any sort proficient in American Sign Language, so it was always up to me to take care of the severely hearing-impaired patients, something I enjoyed.

Evan was holding a bloody washcloth over his left forearm. His mother was signing furiously, informing me that Evan had fallen while climbing a tree, and cut his arm on the sprinkler below. I signed to Evan, requesting to take a look. He peeled away the washcloth, revealing a ragged two-inch gash on the lateral aspect of his forearm. I conveyed that I needed to clean the area and put in a few stitches.

I left the room to get a suture kit, returning a few minutes later to find Evan sitting on his mother’s lap. He’s afraid, she signed.

I explained it only hurt a few seconds when I injected the numbing medicine, and when we were done, I’d give him a dollar bill he could use at the dollar store a few blocks away. That’s all the encouragement Evan needed. I anesthetized the area, cleaned it, and put in five stitches. When I was done, Evan’s mom signed that she was proud he was so brave. I spread antibiotic over the wound and handed the boy a crisp dollar bill—one of six I had in my pocket. Most days I needed at least three to coax my patients into submission for various procedures.

I broke away to sit on the stool facing the dreaded computer so I could enter information about the visit. I usually spoke to my patients as I typed, often just small talk. My inability to sign while I typed made me hate the EHR even more. After I finished typing, I instructed Evan and his mom how to care for his injury. Mother and son motioned their thanks, I handed Mom a printed set of wound care instructions, gestured goodbye, and backed out of the room.

Martha wasted no time in finding me. Five-year-old girl and her mom in room four for kindergarten physical. New patient. Good luck with that one. Mom has heavy accent. Chinese, I think.

The UC San Francisco pediatric clinic was always busy. In addition to the myriad clerks, physician’s assistants, nurses, and doctors rushing through the halls, there were the patients and their entourages. Each small visitor was accompanied by a parent, sometimes two, often with one or more siblings or a grandparent. Between the ages of two and eight, patients and siblings frequently ran through the hallway, not mindful of anyone or anything in the way.

Making my way to room four, I dodged three-foot-high twins running in front of their mother, the colorful LEDs on the soles of their shoes flashing erratically while they laughed and bumped into the legs of strangers. According to the clock above the clerk’s station, it was 11:30 a.m. Two patients behind already, I picked up my pace, brushed back the stray hairs that had escaped my low ponytail, noticed the name tag on my coat that read Erica Rosen, MD, Pediatrics, was crooked, and knocked on the door of room four.

From within, I heard the muffled voice of a young woman. I barely heard, Come in.

I straightened my name tag before opening the door, glancing up in time to see the clinic director, Dr. Gabe Lewis, turn the corner and walk in my direction. As usual, his white coat was clean and pressed, his hair looked ready for a photo shoot, and he looked more like a TV doctor than a real one.

Avoiding eye contact, I pushed hard on the door and entered. The door slammed behind me.

Hello, Ms. Chen, I said, consulting the clipboard. I’m Dr. Rosen.

I gazed around the familiar room with torn posters of SpongeBob SquarePants, The Little Mermaid, and Minions. The two adult-size chairs were empty. An attractive, thin young Asian woman with short hair sat in one of the little chairs, a small child on her lap with its face buried in her chest. The child had straight shoulder length shiny black hair.

Damn. Martha didn’t get the kid stripped down to her underwear. Only took her shoes and socks off.

The woman seemed nervous, unable to speak for a few seconds. When she finally spoke, it was with a heavy Chinese accent. This Wang Shu, Doctor. I Ting. His mother.

Pleased to meet you, I said, happy my roommate, Daisy, had exposed me to her parents and their heavy Mandarin accents countless times. Over the years, I had developed an ear for understanding their speech.

Hello, Wang Shu, I said in my winning pediatrician’s voice, smiling. How are you today?

The child didn’t move. He shy, Ting said.

Knowing Asians pronounce he and she the same in their native tongue, the inappropriate gender reference didn’t surprise me.

I understand you’re here today to have Wang Shu’s kindergarten physical form filled out.

"Shi. Yes." Ting reached into her purse and handed me a two-page form, folded in thirds.

I took a moment to examine the form. It looked familiar, resembling many I had filled out previously. I sat facing the computer and checked the EHR. Other than the patient’s name, age, address, and mother’s name, her chart was blank. It wasn’t unusual to have patients with no medical insurance. Has Wang Shu had her vaccinations? I asked.

Shi, yes. Everything. He have very good medical care. The best.

I’m glad to hear that. Do you have some documentation?

Ting looked at me blankly.

Papers that list her vaccinations.

We come from China. He get them there. I not have papers, but I know he get everything. Very excellent medical care.

Wang Shu doesn’t start school for over a month. Can you have the information sent to you?

No. Not possible.

You must have shown documentation when you moved here. How long have you been in this country?

Two month.

You speak English very well for someone who’s been here such a short time.

I study hard.

Since it was only two months ago, you should still have the documentation of vaccination you showed to pass the health inspection when you came here.

I not find it.

If you don’t get the documentation, we’ll need to revaccinate her. Without proof of vaccines, she can’t go to school.

Oh. He no like more vaccine. But no choice.

This woman seemed intelligent, clearly educated enough to speak English and know about vaccines. But something didn’t seem right. I have to ask you this, I said in a gentle tone so as not to alarm her. Did you enter the US illegally?

Ting burst into tears.

I grabbed a tissue and handed it to her. It’s okay. You can tell me. I won’t report you. But if you came here illegally, I’m going to insist that Wang Shu also have a TB test.

Okay, we not legal, but I know he not have TB, Ting said, her tears now a slow trickle. He very healthy, never around people with TB.

She still needs the test. I can’t put other children at risk.

No, no, Ting said, still sniffling. He have BCG vaccine.

The BCG vaccine is given to protect people from TB in countries like China that have a high incidence of the disease. When a TB skin test is given to people who have had a BCG vaccine, the test is often falsely positive. I turned to the child.

Now, Wang Shu, I have to examine you, I said, wondering if the child understood a word I was saying. Don’t worry, it won’t hurt.

I got up from my seat at the computer, picked up Wang Shu and placed her on the exam table. For the first time, her tiny face was exposed as she looked straight at me. Black hair cut into short, straight bangs across her forehead. Light olive skin. Typical Asian features, with a small nose and epicanthal folds in upper eyelids. I almost gasped. Light blue eyes. What I was seeing was not possible.

Chapter 2

A blue-eyed Chinese person? Genetically impossible. And yet, there she was. She looked one hundred percent Asian like her mom. Was it possible she had Scandinavians in her family tree, with eye color being all that was left of those foreign genes?

My, what beautiful eyes you have, I remarked. Wang Shu looked at me blankly.

He no speak English, her mother said.

Where’d she get her blue eyes? Is her father Caucasian?

No. He Chinese. And he dead.

I’m sorry to hear that. Ting looked nervous and started to tear up again. Wanting to avoid more waterworks, I changed the subject.

I’m sure it’s stressful moving to a new country. Both for you and your child.

Ting nodded.

I’ll need to examine her. Could you help her take off her shirt and pants? You can leave her underpants on.

Please, Ting begged. Keep his clothes on. Nurse try to take off clothes, but Wang Shu get very upset. He no like doctors. Or nurses.

With Ting starting to tear up again and Wang Shu staring at me, her body almost frozen in fear, I acquiesced against my better judgment. Okay, I can examine her under her clothes.

Thank you.

I offered Wang Shu one of the dollars from my pocket, but she ignored it.

She no understand, Ting said. No use money in China. Pay for everything with phone.

Unable to bribe her, I steeled myself for some resistance as I listened to Wang Shu’s heart, lungs, and bowel sounds through her clothes, palpated her thyroid, liver, and spleen, and checked her reflexes. I quickly lifted her shirt to inspect her skin, front and back, then examined both feet, looking for signs of poorly fitted shoes or other problems. Wang Shu seemed tense the whole time. I anticipated a problem with the next part of the exam, intentionally leaving it for the end. I laid her down and quickly pulled her pants down to examine her external genitals. Wang Shu became hysterical. I saw what I needed in less than two seconds and pulled her pants back up, but the damage had been done. Wang Shu was inconsolable as Ting grabbed her, held her in her arms, and spoke to her quietly in their native tongue.

I felt like shit. All I could do was look on helplessly. The crying finally stopped, and Ting sat with her child on her lap, Wang Shu’s face again buried in her chest.

I’m sorry I upset your daughter so much, but I needed to do a full exam.

I understand. Ting said a few words to her daughter in Chinese, then turned to me. I tell him I buy him treat when we leave. He be okay.

I’m happy to say that your daughter appears to be very healthy. I want to order a blood test for thalassemia, if you don’t mind, because it’s so common in the Chinese population. We routinely test Asian children for thalassemia, a genetic disease resulting in decreased hemoglobin production, with varying degrees of anemia.

No thalassemia. Blood fine. Test in China. He get excellent care there. Maybe too much care. Make him very upset.

I’m not sure how good the testing is there, I said.

Very good thalassemia test in China.

I’d feel better if you could show me some documentation.

Cannot get papers from China.

I was struck by the story unfolding. This child had excellent medical care in China, according to Mom. Yet she couldn’t get any documentation. She was here illegally. The child’s father was dead. Maybe he was a political figure in China. It wouldn’t be a stretch to imagine he was executed, and she fled with her child, fearing governmental reprisals.

Have you applied for political asylum? I asked.

I cannot. I not a political.

But if your husband, or Wang Shu’s father was, and you came here because you were afraid of your government, you could apply.

Ting’s eyes started to fill with tears. Wang Shu father no enemy of government. The government love him. He no dead. He dead to me.

As the conversation grew stranger by the moment, I was intrigued, curious about this woman’s story. But I was already behind. Other patients were waiting.

If you need the name of a good immigration attorney, Lisa at the reception desk can make some recommendations. I started typing as I spoke. In the meantime, I’m ordering vaccines, a test for thalassemia, and a chest X-ray, instead of the TB skin test we usually do, since she had a BCG vaccine. Once those are done, you’ll be notified, and you can come back to pick up your school form.

Typing into the computer, I swore under my breath—the EHR was hung up, preventing me from proceeding. Finally, when the damn thing had regained its composure, it gave me a hard time for ordering an X-ray to rule out TB instead of the more economical skin test. Despite it being common to rule out TB with an imaging study rather than a skin test in people from countries where the BCG vaccine is often administered, I was going around in circles trying to explain this to the computer. One more bad experience with the EHR to add to my list of hundreds. I eventually managed a workaround, requesting the X-ray to look for a lung mass, with a freehand comment to rule out TB. I hit send and prepared to say my goodbyes before hightailing it to my next patient.

It was a pleasure to meet you, Ms. Chen, I said, standing. I look forward to seeing you on your next visit. Martha will be in to assist—

Another question, Doctor. Another question, Ting interrupted.

Her insistence surprised me, although it wasn’t uncommon for patients, or their parents in the case of pediatrics, to wait until a visit is almost over to bring up an issue of grave concern.

I worry about Wang Shu.

The waterworks started again. Was I ever going to get out of there? Now, now, Ms. Chen. Tell me your concern. Like I said, your daughter seems healthy, so there’s probably nothing to worry about.

I handed her the box of tissues from which she removed several to blow her nose. I worry about Wang Shu because he suppose to be boy. Once she blurted out the last words, she cried uncontrollably, her whole body shaking.

Doing my best to hide my disapproval of what I assumed was a negative attitude towards having a girl, I said, Why do you say that? You should be happy with your beautiful, healthy daughter. I expected her to describe a ritual she had performed, or an herbal concoction she had taken, to assure the birth of a boy.

It took minutes before Ting could speak. They do genetic test before he born. He a boy. Then he born, and he a girl.

I sank back onto the stool opposite the computer. What had been a strange visit was entering Twilight Zone territory. If what she just told me was true, the adorable little girl sitting in front of me had the genetic makeup of a male. I knew of a rare condition, complete androgen insensitivity syndrome, in which genetically male individuals are born with a complete lack of testosterone receptors on tissue, rendering them unable to respond to the male hormone, testosterone. Because of this, affected people look and develop like females in every way, except they are infertile, lacking a uterus and ovaries. This is not usually diagnosed until the person reaches late puberty with no sign of a normal menstrual cycle.

How old are you, Ms. Chen? I asked. To me, she looked to be in her late twenties. An age so young genetic testing is not typically done without a family history of an inherited disorder.

Thirty.

You were only around twenty-five when you were pregnant. Why did you have genetic testing? Is there a heritable disease in your family? Or the father’s? Did you have a problem with another pregnancy?

No. The test done to be safe.

Did it show any abnormalities?

I no think so. They not tell me everything. But they tell me is boy.

I couldn’t have been more confused, but from my exam, this was definitely a girl. At least from the outside. There was no way I was going to do a pelvic exam on this child. I started typing on the computer. I’m referring Wang Shu to the genetics department. She may have a rare condition that causes genetically male people to appear female. Unfortunately, they are unable to have children, but can otherwise live normal lives as females.

I swore under my breath some more when the EHR rejected my referral multiple times until I finally logged out and back in again. Success, at last. I didn’t look forward to the argument I knew I would have about this with Gabe. The tightwad clinic director kept a close eye on the budget and also happened to be the man I was romantically involved with until two days ago when I’d decided to call it quits. I hadn’t told him about the calling it quits part yet.

Chapter 3

It was 8:00 p.m. when I opened the door to my apartment, a fifth-floor, two-bedroom, two-bath unit in a modern high-rise South of Market. I’d known my roommate, Daisy Wong, since we were in the sixth grade. After a year of fierce competition to be the best at everything in our class academically, we pretty much tied for that honor—she being slightly better at math and grammar, I slightly better at science and social studies—and became BFFs.

I thought you were going to start getting home earlier, Daisy chided me.

I meant tomorrow.

You’re going to kill yourself with the work hours you keep. One day, you’ll keel over and—

Not all of us can be part of the chosen few who get paid big bucks to write code from home.

You’re lucky I have some leftover lasagna you can heat up if you’re hungry.

How about if I’m famished? I was already looking through the refrigerator for said lasagna and found it in the vegetable crisper. I placed the comfort food in the microwave for three minutes and turned, noticing a vase of red roses on the kitchen table. Who are those from? I asked.

I was wondering how long it would take you to spot them. You don’t really have to ask, do you?

I called it, didn’t I? A dozen roses two days after our last blowout fight.

Well? Are the roses going to work again, or are you going to tell that misogynist asshole, gorgeous on the outside while rotten to the core on the inside, to go fuck himself?

This time he really did go too far. I’m going to tell him to go fuck himself.

It’s about time. This time, I hope you mean it, girl.

Say, why don’t you take these flowers and put them in your room?

No problem. They’re beautiful, even if they’re a gift from the devil himself.

C’mon, now. He’s not that bad.

Are you going to wimp out on me again? If you don’t dump him this time—

Don’t worry, I’m going to do it.

When? You have to tell me when.

After I finish all the lasagna.

How much after? Five minutes? Five months?

You won’t leave me alone till I do it, will you?

You see right through me.

How about I send him a text?

How ’bout you call him on the phone, thank him for the flowers, and then tell him to go fuck himself?

Don’t forget, he’s still my boss.

Oh, that.

.  .  .

The lasagna was good. Or maybe it wasn’t. I ate it so fast there wasn’t enough time for the taste to register. I sat at the desk in my bedroom, a half-empty glass of Cabernet in front of me, and stared at my cell phone. I needed to do this. Sure, it would be awkward at work. He could try to fire me, but he would know I’d have his ass in a sling, our hospital having strict rules against retaliatory firings. San Francisco is nothing if not a bastion of liberal values, including #MeToo support. I loved my job, but if it got too awkward, I could always find work elsewhere. Jobs for physicians can be hard to fill in the city, because of the high cost of living. At the time, paying over two thousand a month for my share of the rent didn’t bother me. I’d finished my residency and fellowship two years earlier, was single, with no kids or financial obligations except repayment of school loans. I was planning to seriously consider saving for a house at some future date. At least nine hundred thousand for a dump here in SF. But at the time I was young, carefree, and living the life.

I pressed Gabe on my phone and waited.

Did you like the flowers?

It was just like Gabe to act as if nothing had happened after sending me a bouquet following a major argument. They’re very pretty.

Say, what’s all this shit you ordered on one of your patients? Including a genetics referral for complete androgen insensitivity syndrome? Do you have any idea how rare that is and how much money you’ve wasted by ordering that work-up? You should thank me for approving the testing so you wouldn’t be embarrassed. But really—

So, I should thank you for not publicly humiliating me, merely berating me privately.

Now that you mention it, yeah. I’m doing you a favor, but don’t think that because you’re fucking the boss, you can do whatever you want.

Listen, you condescending jerk, I ordered that referral based on my sound medical judgment, not a judgment based on the bottom line. I plan on continuing to depend on my medical acumen at work. I don’t care if I’m no longer in the boss’s favor. We are history. I’ve had it with you.

Wow! I did not see that coming. I’ve never seen you so pissed off. Take a few more days to cool off.

A few days won’t change my mind. I shouldn’t have let things go on for so long, with your yelling and bullying. But you crossed the line the other day when it got physical, and you twisted my arm. I still have a red mark from your grip. You’ve got a serious anger management issue. I’d suggest you see a therapist. I pressed End, took a large gulp of the Cabernet, and felt much better.

I walked back to the living room where Daisy was sitting on the overstuffed beige couch, studying brochures offering tours of China.

Thinking of taking one of those organized tours with a bus and everything? I asked. Where they tell you what time to get up, what to have for dinner, you walk around with a large group of rowdy Americans, and everyone stares at you?

Well, since Brian can’t go with me on account of a conflict with his best friend’s wedding, and you won’t take time off from your fucking job to go with me, this seems like a reasonable second choice.

Brian was the latest of Daisy’s revolving door of men. I figured she’d be dumping him soon because they’d been seeing each other for over three months. He was near his expiration date.

Don’t try to make me feel bad, I said.

Why shouldn’t I?

Because you should be proud of me. I paused for effect. I did it, I said, smiling.

Daisy stood and gave me a high five.

Chapter 4

The next weeks at the clinic were awkward. I did my best to avoid Gabe, averting my eyes when we passed in the hall. I caught snippets of conversations when