by Barbara Ebel
“What were you doing when you were eighteen years old?”
Annabel swung around where she stood. Emmett, the orderly from upstairs, frowned.
“Not having babies, that’s for sure.”
He nodded. “I think these young girls were deprived of love as youngsters and are still longing for it. They think that by having a baby themselves, they will make up for that deprivation. They believe they’ll give and receive love to and from their offspring like it’s a winning gamble.” He sighed heavily, un-gripped the back end of a chair, and plopped himself down.
“It’s like this,” he added. “Going into their adulthood, they think they’re giving their future a value right off the bat. They ante up the pot with a newborn. Or so they think. In reality, they make themselves a donkey player.”
“A donkey player?”
“I forgot,” he said and shook his head. “You medical students don’t have time for anything else except medicine. I’m talking poker. These little girls deal themselves the worst hand. Like holding a 2 and 7 off suit.”
“I see. I’d better run along, though.”
She hadn’t expected the orderly to render such an opinion, but, then again, he could be a multi-faceted individual and this could be a side job for him. He could have a master’s degree in psychology and be a stellar card player for all that she knew. She grabbed a handful of the blue drape at Mary Chandler’s cubicle, ready to step inside. In four weeks, however, she was sure there would be no questions on her test about poker games.
-----
Ling took the clinic record from Annabel as soon as she entered. Mary Chandler swiped her hand along her belly like someone was ready to snatch her growing fetus away from her.
“You just did internal medicine,” Dr. Watson said to Annabel, “where you followed patients with high blood pressure mostly stemming from their lifestyle choices. Here lies a different ball of wax. There are hypertensive disorders of pregnancy. The state of pregnancy can instigate hypertension!”
“She said my blood pressure is way too high,” Mary said. She swiped at the side of her eye where moisture began accumulating, ready to slip down her cheek in the form of a tear.
Ling folded down the stretcher’s white sheet on Mary’s lower abdomen and applied gel to her skin. From the cart alongside the bed, she grabbed a hand-held electronic Doppler ultrasound device and smoothly glided it across her patient’s abdominal skin to evaluate the fetus’s heart rate. She took her time and finally nodded. Mary gripped the side of the stretcher in anticipation.
“You remember what they told you in clinic? What the normal baseline fetal heart rate is?”
“A little bit,” Mary said. “They told me that theirs is way higher than us grown-up people. Is my baby okay?”
“A normal fetal heart rate is between 110 and 160 beats per minute, which correlates with a good assessment of fetal status and well-being. Your baby is beating smack in the upper middle of normal.”
“Thank God! So I can go home?”
“No way,” Ling said. “Your blood pressure is 154/106.”
Dr. Watson pointed to the clinic chart, suggesting that Annabel take a look. Mary’s vital signs at each clinic appointment were jotted down on the inside flap of the folder. Annabel noticed the normal numbers around 110/70 for weeks … up until last week, when they registered a reading of 130/88.
“We need to check some labs, but it appears that you are preeclamptic,” Ling said to Mary.
“Pre what?”
“Preeclampsia … a hypertensive disorder of pregnancy. Right now, your diagnosis is very concerning. Good thing you came in, Ms. Chandler. Let’s get you upstairs. Stabilizing you and your baby is our highest priority at the moment.”
Ling pushed back the chart and eyed the woman’s cell phone nearby.
“Make your calls. You won’t be going home for dinner.”
CHAPTER 5
After several years of working the same job, Emmett considered himself an expert in the particular specialty of transporting obstetric patients. Little by little, he’d seen it all, or at least all that could be gleaned by escorting wailing mothers from one area of the hospital to another. On the other hand, the patients sometimes displayed an opposite expression – one of sheer joy if their baby had been delivered and mother and baby had healthy results.
Emmett glanced around the cubicle to make sure all of Mary Chandler’s personal possessions were stashed under the stretcher. He had all of her paperwork at the foot of the bed; not a problem since she was slightly elevated and she’d propped her knees up. He didn’t want to dillydally. When he heard Ling Watson use the term “preeclampsia” at the ER desk, he knew the obstetric floor would be expecting the patient and one of the first things someone would do upstairs was to put oxygen back on her via a nasal cannula.
“I’m taking you on a short journey,” Emmett said. “Out of the ER and on your way. You will like the obstetric rooms. Nice and comfy.”
“When I get to feeling better,” she said, “all I’ll want is food. Forget about later … right now I could eat a horse. Dr. Watson made it clear I was barricaded from going home for dinner, but that doesn’t mean I’m not eating here. With a lady doctor, she’ll get this preeclamptic disease under control right away. Then someone can smuggle me in some kind of a Big Mac.”
Emmett pushed the stretcher along and grinned. “Will anyone be coming by to keep you company?”
“I told my mom and dad. They live north of Columbus. My mom is taking off tomorrow and driving down.”
They reached the staff elevators and he pushed his load inside. A few floors up, they bounced over the lip of the door and headed down the main corridor.
“No one’s given me a bumpy ride in a long time,” she said. “Not even in a car.”
Emmett grew concerned and she smiled at him. “I’m just yanking your chain.”
“I see. You know what they say about rides. If you plant your feet on the ground and stay put, life will be predictable. But if you take a ride, life will be a lot more interesting and nothing is guaranteed. Including the bumps.”
“For sure,” she said as an aide from the desk approached and waved them to an empty labor and delivery room. Emmett turned in.
“What’s your name?” Mary decided to ask him.
“Emmett.”
“Hmm. Your mother blessed you with an uncommon name.”
“It’s been around. Apparently, Emmett is the masculine form of the female name Emma and I believe both origins are German.”
“I’m still wondering about baby names. Isn’t that crazy?”
Emmett slid the stretcher next to the bed and locked the pedals. Mary began to creep over.
“Nope. Happens here more often that you would think. Every week, anywhere from one to a handful of mothers will pick out their baby’s name at the last minute.”
She stopped for a moment to gather her breath. “Emma or Emmett. Those names have a ring to them. I’m going to consider them.”
“Be my guest,” he said and helped her scoot over. The nurse’s aide stood on the other side and spread the sheet up to Mary’s chest.
“I’ll be right back,” Emmett said. “I’m going to first take the chart work to the desk. The nurse assigned to Ms. Chandler will be expecting it.” He moved the stretcher to the side; he still needed to move Mary’s belongings somewhere else but figured he would do that when he came back. First things first, he thought.
At the counter, an obstetric nurse stretched out her hands for the paperwork as soon as Emmett arrived. Ling scribbled their new patient’s name on the OB board and came out of the room with Annabel trailing behind her.
“She’s preeclamptic,” Dr. Watson said, “bordering on having severe features. All of us need to start moving and put out this fire.”
The RN, chief resident, and Annabel headed to the room. Emmett turned and followed the three of them. After going through the doorway, Ling continued her hectic pace, her eyes s
traight ahead at Mary Chandler. She mis-stepped and plunged straight into the stretcher.
Ling righted herself, grimaced, and massaged her hip. She spun around and glared at Emmett. “Why the hell did you leave this here? No … actually, there is no excuse for leaving an obstacle in a hospital where it shouldn’t be.” Her hands landed on her hips. “Idiot!”
Mary Chandler shrank further into her bed and massaged her belly. Emmett swallowed hard and held his tongue. The RN looked away. Annabel kept her mouth shut too. Despite what happened and despite whose fault it was, she thought Ling Watson should have spared the outburst in front of their patient.
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Mary looked to the side while tampering with the pulse oximeter on her finger. The nasal cannula oxygen prongs were in her nostrils and the reading from the oximeter showed 96%. Annabel felt a wave of relief for the young woman. At least mother and baby were getting enough oxygen; if there was any further worsening of the situation, she knew her residents would move fast towards delivering the patient’s fetus.
“Your white jacket is different from those other two,” Mary said to Annabel.
“I’m sorry. I thought I blended into the background. I’m a medical student; the rotation just began for me, so I am naive yet useful. I learn fast, and believe it or not, many, many patients become imprinted into my memory bank. Almost every patient can demonstrate a lot to someone in training.”
“I’m a guinea pig, aren’t I?”
“More like a celebrity. For the rest of my career, I’ll remember you as much or more than a favorite actor in a good movie scene.”
“Wow. Then I came to the right place.”
“Did they give you the antihypertensive medication yet through your IV?”
“Yes, and Dr. Watson and Dr. Gash said they were … ‘cautiously optimistic’ that they wouldn’t have to get my baby out soon.”
Annabel checked the pulse oximeter reading again and then glanced at the continuous electronic fetal heart monitoring. Mary did the same. The ultrasound transducer placed on her abdomen conducted the sounds of her fetus’s heart; the rate and pattern of the fetal heartbeat were displayed on a computer screen and printed onto a special graph paper.
“It looks like Greek to me,” Mary said.
Annabel leaned closer to the bed. “Don’t tell anybody, but right now, it looks that way to me too.”
Mary’s tense shoulders relaxed. “You ever get pregnant and give birth?”
“No. Not yet. I would be anxious just like you. Try to keep calm and brave for your unborn child.”
“I’ll try. I’ll feel better when my mom gets here tomorrow. My parents were furious with me when I got pregnant, but they’ve accepted it. My mother more than my father. My mother finally told me … everyone makes mistakes and they must learn to live with whatever it is. Mine was bigger than most and it will leave a footprint on the rest of my life, but I must make it a huge growing experience. I will be thrust into the immediate demands of taking care of another human being and adult priorities will take root.”
“Sounds to me like you’re maturing already.”
Mary smiled and patted her belly like her unborn fetus had taken his or her first step.
Caleb Gash poked his head in the door while calling Annabel by name. “Better hunt down Ms. Chandler’s chest X-ray and bring it up here … the one they did before she left the ER. There’s a lot riding on that.”
“I’m on my way.” She passed Caleb while realizing she still needed to write up her H&P on Mary. It would have to wait.
In the radiology department, Annabel did what she often did. Many students would just pick up the films from the slot box and leave, but radiologists, she found, always seemed willing to teach a medical student. Their days did not bristle with human interaction like the teams on the floor, so she figured they enjoyed it when she asked them questions. Plus, she should learn everything she could and not discount the field as a future specialty.
The door was open to the doctor’s dimly lit reading room. “Can you give me any pointers about our obstetric patient’s chest film?” she asked the man.
He squinted his eyes. “Sure, come on in.”
Annabel handed him the envelope and, after reading the note from the referring doctors, he slipped it in the viewing box. “Aha. Says here the presumptive diagnosis is preeclampsia. So the status of her lungs is very important. Did you do a physical on her?”
“Yes, sir. Her lungs sounded clear to me.”
“Isn’t today the change-over for medical school rotations on your service?”
Annabel nodded. “I’m as green as a frog.”
The doctor laughed. “Have a seat, young lady.” He read the name tag on her jacket. “Dr. Tilson, that is.”
The man took off his glasses and rolled his chair back a few inches. “Do you know the three features that make a case of preeclampsia ‘severe?’”
“For sure, a high blood pressure. Over 160/110 mm Hg fits the category.”
“A patient can have chronic hypertension with a superimposed high blood pressure from preeclampsia. Does she have a preexisting chronic condition?”
No one had mentioned that possibility, but then she remembered reading the pressures from the clinic notes. “No, her early visits in the prenatal clinic gave no history of chronic hypertension and her vital signs were all registered as normal except for the last pressure, which crept up.”
“Excellent.”
“There are many other abnormalities for severe preeclampsia, but I’m not sure exactly which ones qualify as the worst.”
“And that’s a hell of a blood pressure for a pregnant lady who is usually acceptable and low. At 160/110 … can you imagine? A woman could suffer a stroke!”
A no-brainer, she thought, but he was enthusiastic about teaching and so willing to talk to her.
“The second most important severe feature,” he said, “is pulmonary edema. So your patient’s chest X-ray is clear.”
The certainty of no fluid in Mary Chandler’s lungs made Annabel feel more comfortable. “Makes her situation a bit safer.”
“Regular preeclampsia is still an alarming case. The third severe feature is elevated liver function tests.”
“I believe those results are still pending.”
He scooted his chair back in. “Of course, your residents must be focusing on stabilizing the mother’s status over and above the fetal status. Seizures are a complication.”
Annabel now remembered that; she was glad he reinforced that bit of knowledge.
He scooted back up to his table and scrutinized her. “Have your residents started her on seizure prophylaxis yet?”
“I don’t know. I am behind with her case; haven’t written up her H&P yet or reread the residents’ notes since the patient arrived in her room. What is the drug of choice?”
“Magnesium. Magnesium sulfate. A blessing for seizure prophylaxis and delivery.” He flipped the film down and handed it to her.
“Thank you so much for the discussion.” She rose and slipped the result in the envelope.
“Any time.”
In the main doctor’s lounge on the first floor, Annabel slid up to a computer and plugged in her patient’s name. She added the newer lab results to her index card; there were now a host of laboratory values: CBC with a platelet count, renal function tests, and the liver function tests or LFTs. Sure enough, the LFTs were higher than normal values. That now categorized Mary Chandler with one of the three severe criteria of preeclampsia. Although … she was close enough to having all three. Annabel glanced at the wall clock. The day was zooming by and her appetite to learn more about obstetrics was ramping up.
-----
Gone astray or hidden from action, Annabel didn’t see the residents when she made it back to the nurses’ station, so she stole Mary Chandler’s chart from the rack and settled into the lounge to write her H&P. With all the lab results and the senior doctors’ notes already written, her chore would be
a lot easier, so she began:
Mary Chandler is an 18-year-old G1P0 woman at 29 weeks’ gestation who presented to the ER because of a several hour history of dyspnea. She denied any previous medical problems and also stated her prenatal course has been unremarkable. Prenatal blood pressures in the clinic were normal except for a slight increase last week of 130/88.
Her presenting blood pressure was, however, 154/106, and respiratory rate was 30 breaths per minute. Oxygen saturation was 96%. Fetal heart tones stayed in the normal range of 110 to 160 bpm.
Annabel continued on, finishing with the “Diagnosis” and “Plan.” Pleased with herself, she looked up to find Emmett over at the nearby table reading a newspaper headline.
“You sure are quiet,” Annabel remarked. “That newspaper in here reminds me of a chief resident I had on internal medicine. He read us interesting tidbits from the paper every day.”
He glanced over at the door. “Doubt if you’ll experience that on this rotation.”
“I suppose not. I’ll go back to being clueless about what’s going on in the world besides my rotation.” She closed the chart while he put down the paper. “I bet you moved the stretcher out of Mary Chandler’s room pretty darn quick after what happened.”
“For sure … after I moved her belongings.”
“Hmm. Stretchers are substantial pieces of medical equipment to miss seeing. At least that’s what I’ve always thought.”
“Really? Like you’ve thought about that?” His thick eyebrows raised. A smile crossed his lips.
“Yeah. Just this morning, I woke up and figured there was no way I was going to stumble over a large object left a few minutes near a patient’s doorway. And even if I did, it would be my own stupid damn fault.”
“You thought all that, huh?”
Annabel shrugged. Emmett winked.
“Dr. Tilson, I’m so glad you’re on board for the next two weeks.”