by Barbara Ebel
He turned to her with a gleam of moisture in his eyes. “A kid named after me. Like being handed a gift. I would have had something to brag about after all these years.”
-----
It dawned on Annabel that she shouldn’t just be standing there. She had never gotten any farther than Mary Chandler’s room. There were other patients to see on the floor.
The door to the lounge jerked open and Ling tapped the secretary on her shoulder. “I need to start filling out the death certificate and other paperwork.”
The seated woman anticipated her question and handed her a stack of papers bound together with a pink paperclip.
“Thanks,” Ling said and noticed Annabel. “You might as well come in.”
Annabel trotted in after Ling, and her senior resident closed the door again. Dr. Watson sat at the round table and spread the papers beside Mary Chandler’s chart. Caleb left the couch and joined her.
“You must be the new student,” the attending doctor said. “I’m Doctor Harvey.”
“I’m Annabel Tilson.”
“I heard a good word about you from your internal medicine attending. I also got wind that your father is an esteemed neurosurgeon in Nashville.”
His introductory remarks were unexpected; she was at a loss for words. He poured a cup of coffee from a pot shoved on the far end of the counter. “Would you like some?”
“No thank you,” she said, finding her tongue again.
Dr. Harvey stirred in a packet of sugar and motioned her to the couch. He appeared to be a solid sixty years old and wore a toupee that looked like it would blow off with a sneeze. His shoulders sagged off his light build and he wasn’t wearing a white coat. She figured he had rushed there after being summoned to the emergency and wasn’t quite prepared to be on the delivery ward.
“The residents will fill out the paperwork, the young Mary Chandler will be picked up for the morgue, and I suppose her mother is going to be glued to the waiting room until her husband arrives. Maybe as we sort things out, we’ll have some answers for them.
“You oversaw your first patient with preeclampsia. In our field, it is a pregnancy complication that we treat with utmost respect and diligence. Hence, did we do something to fail in the care of our patient?”
CHAPTER 10
Ling and Caleb continued with their official paperwork while Dr. Harvey gave Annabel more of his attention. He dreamed up questions for her slowly and methodically like the way he sipped on his coffee.
“The diagnostic criteria for preeclampsia is hypertension, edema, and protein in urine or proteinuria, but do you know what they used to call it?”
“No, sir.”
“Toxemia of pregnancy. Don’t use that term, however, because toxemia is a misnomer. There is no toxin circulating around these women’s blood and causing preeclampsia.
“Overall, what is the incidence of hypertensive disorders in pregnancy in the US?”
As she blinked, Annabel drew a blank. “I’m not sure.”
“Estimates are between three and ten percent. What causes most patients to die from eclampsia?”
Annabel wanted to make a stab at guessing, but she figured it would be worse to come up with a ludicrous answer. She shrugged her shoulders.
“Pulmonary edema. With no evidence of that on Ms. Chandler’s chest X-ray or by auscultation, this is a unique case and off the bell-shaped curve of normalcy.
“Okay, here’s an easy one. What is the last of the three major signs of preeclampsia to appear?”
“Edema?”
A muscle twitched near Dr. Harvey’s eye. “No. It was the third criteria we talked about. Proteinuria, primarily albumin.
“Since you don’t seem to know much about your previous patient’s illness, maybe you are aware of what to look for, say, in clinic visits, before a patient develops the hypertension?”
Annabel crunched up her face and wanted to crawl under the table. Ling glanced at her, her lips twisted in a wry smile.
“I’m not sure what you’re looking for,” she answered.
“Dr. Tilson, when your patients are seated before you, it will have nothing to do with what I am looking for. It is all about reading about your patients while you are managing them; watching and learning every single day of your medical school journey.”
He crunched the empty cup in his hands. “Before hypertension sets in with these patients, there is a first sign that is quite dependable. A weight gain of more than two point two pounds in a week or six point six pounds in a month is often regarded as significant. An astute clinician following patients along prenatal clinic appointments will pick up on this sudden excessive weight gain.”
Jammed into a spot that she couldn’t dig out of, Annabel swallowed hard. He was supposed to be asking her about the physiologic changes of a neonate, but how was he supposed to know that? Ling offered no mention of tying her up with a different reading assignment the night before and Annabel felt cornered to not mention it to her attending.
“Since you exhibit a hole in your knowledge starting out on this rotation, please be aware that during pregnancy, a gradual increase in weight is normal … a half a pound to a pound per week.”
Dr. Harvey rose and went over to make more fresh coffee. He shook his head, wondering how Annabel was given such complimentary accolades from other medical professionals.
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The residents peeled away from Mary Chandler’s medical and legal documentation of death and Dr. Harvey signed a few of their sheets. “Let’s make quick rounds together,” he said, stretching his arms out to the side, “and then I’m leaving for the office.”
They visited three patients and, each time, Dr. Gash properly summarized the patient as they cluttered up the hallway. Annabel hung on every word, now feeling more ready than the previous day on how to present obstetric patients. These patients were different than recapitulating surgery, psychiatry, or internal medicine patients.
They went outside Bonnie Barker’s room. “Perhaps Dr. Tilson can tell you about Ms. Barker,” Ling said, “although I don’t think she’s seen her patient yet today.”
Dr. Harvey held the patient’s chart and peeked at Annabel’s note from yesterday. He eyed Ling suspiciously. “Under this morning’s circumstances, did you stop in on your patients yet?”
Ling shook her head.
“Makes you all even,” he said. “Let’s hear it, Annabel. I realize the patient came in before you started the rotation, but you had the opportunity to familiarize yourself with her case and write a progress note on her.”
Annabel’s confidence finally inched up with the new attending and she plunged into her presentation. “Ms. Barker is an eighteen-year-old white female who was gravida one para zero on admission, at full term, with a negative prenatal course and history. Yesterday, she delivered vaginally, and after the placenta was delivered, she experienced significant vaginal bleeding, estimated to be at least one thousand ccs.
“The residents did a bedside uterine massage, but with continued bleeding, they took her to the OR. She was resuscitated with IV fluids and doses of oxytocin. Her diagnosis was uterine atony.”
She thought ahead but was unsure as to how much detail Dr. Harvey wanted. After all, she was not presenting a whole initial history and physical. Then she thought about the woman’s newborn, so she decided to include the baby too.
“The pediatrician was called; the baby’s initial evaluation or Apgar scores were something like seven and eight. I believe the pediatricians are monitoring her and doing some testing.”
Dr. Harvey attempted to shove some of his shirt’s loose fabric, which hung around his belly, into his pants, but it didn’t work.
“Much better,” Dr. Harvey said.
Better than what? Annabel wondered. Better than the wrong impression he formulated about her?
“So what are the risk factors for uterine atony?”
Annabel didn’t have a clue.
“Working with me, it’s bet
ter to be straight, such as ‘I don’t know.’”
Annabel cringed. However, she liked a straight-forward doctor. “I don’t know.”
“Uterine atony is always on obstetric exams. There are two opposite risk factors: a rapid labor and/or delivery … or a prolonged labor. The rest of them are overdistention of the uterus, an intraamniotic infection, high parity, which we don’t see often anymore, oxytocin use during labor, and magnesium sulfate.”
Annabel wished she could rattle off information like that. At the least, she better understand it all by the time she took her second official board exam or USMLE - United States Medical Licensing Examination. That test, Step 2, would be a two-day exam in the fourth year of medical school. The three Step exams were weed eaters … they pulled the lower tier of student or resident test takers and gobbled them up with cordless weed trimmers.
Roosevelt Harvey nervously glanced at his watch and practically galloped into Bonnie Barker’s room. “Congratulations on the birth of your baby,” he said, shoving the bedside clipboard into Annabel’s hands. He looked between Bonnie walking out of the bathroom and Tony, who sat on the windowsill. “I’m Dr. Harvey, the senior doctor in charge.”
Bonnie bounced her head up and down and lowered herself into the recliner like she had hemorrhoids. “It hurts to have a baby,” she squealed. “Since you’re in charge, remind me not to do it again any time soon.”
“You are a sturdy young woman; it took a lot to get through such a complicated delivery.” He shook her hand, which surprised her, and she began to smile.
“Dr. Tilson, what are Ms. Barker’s vital signs since yesterday?”
Annabel grabbed the bedside clipboard. “Her blood pressures have been less than 130 or 120 and diastolics are all normal. No problems with her respiratory rate or pulse, and she’s afebrile.”
“I can go home today, can’t I?” Bonnie asked.
Roosevelt peeked in the chart. He sat on the edge of the bed and read the latest notes in each section. “Hemoglobin and hematocrit have stabilized. Other labs are fine. No signs of infection. Let’s plan on releasing you tomorrow if you continue on this path.”
Tony sprang up from the ledge, more excited than Bonnie.
“I can’t wait,” she said. “But I hate to go without my baby, Sam. Maybe they’ll tell me more today.”
Dr. Harvey looked straight at Tony. “Are you a visitor or a significant other?”
Tony winced. “Half and half.”
Roosevelt didn’t want to touch that one. “Be sure and holler if you think of any questions today. Dr. Watson and her team will be here if you need them.”
“Yes, but can I have something more for pain?” Bonnie asked. “I still hurt down there.”
He glanced at the pain order she already had in place. An extra pill on top of what she was receiving was reasonable.
Ling Watson sighed and shifted her weight from one foot to the other. It was time to move on.
“Yes, that’s not a problem,” he said. He leaned into Ling’s left ear and softly told her, “Another 200 mg Motrin.”
Ling stepped close to Tony and perched herself on the windowsill. She opened up the chart to an order page, took a pen, and scribbled. She ended by rolling her eyes.
“One more thing,” Dr. Harvey said, looking at Annabel. “Mrs. Barker is breastfeeding, so we must take that into account. Motrin is the preferred pain medication for nursing women. Unlike narcotic pain pills, ibuprofen-like meds will not make her or her baby sleepy.”
Annabel nodded, grateful that despite his hurried schedule, he was taking time to teach.
Outside the door, Dr. Harvey absentmindedly patted the top of his head, making sure his toupee was still in place. “When Kathleen Chandler’s husband arrives, and if he would like to speak to the senior doctor, then give me a call.”
He disappeared off the labor and delivery ward to his own office where the waiting room was full of waddling pregnant women and women anxious to put their pap smears, exams, and requests for birth control behind them for the day.
-----
Ling dropped the brown binders on the round table in the lounge. “There are no orders in these charts that can’t wait,” she said to the unit secretary, who poked her head in and then went back to the desk.
“I sense a break in the action,” Caleb said. “Who’s joining me for a late breakfast or early lunch or whatever you want to call it?”
“Isn’t the earlier drive-through breakfast biscuit holding you for a while?” Ling asked.
“Up until this minute.”
Dr. Watson threw him a glare and fumbled in her locker.
“You coming, Annabel?” He started for the door.
Wondering, Annabel followed his springy and energetic gait to the cafeteria. When he arrived earlier, she didn’t notice him with a take-out breakfast and he didn’t sit down to eat. How did Ling know he stopped at McDonalds? Were they together before they arrived on the wards?
Annabel picked her lunch out a lot quicker than Caleb, so she already was seated at a table by the time he arrived.
“It’s nice to get away,” he said, placing his tray across from hers. “We had a hell of a morning. I don’t want to see any more OB deaths during residency. And after residency, I don’t want to think about it. CPR and resuscitation skills for obstetricians out of training end up being rusty; between you and me, I think they depend on anesthesiologists being around and backing them up.”
“You all pulled your weight this morning as residents, though,” Annabel said, complimenting him.
Nearby, there were four people sitting at a table and a female wearing a college sweatshirt diverted her gaze to Dr. Gash. He kept a beard, short on the sides and fuller on his chin, which took advantage of his square jawline. Annabel wasn’t surprised when he stole a sideways glance at her in return.
Annabel lowered her voice. “You’ve seen other OB fatalities?”
“Oh yeah, and they aren’t pretty. In this specialty, you’ll overhear docs talk about cleaning up after midwives. Don’t get me wrong … they are not one-hundred-percent bad, but there are those that don’t meet the minimum state licensing requirements and standards as well as those that are flat-out negligent. Midwives are more common and more needed in areas where there’s a shortage of OB/GYNs. Unfortunately, those are regions where hospitals are often a hell of a ways away in an emergency.”
He shook salt and pepper on a bowl of chili as Annabel hung on every word. So far, she had never heard anything good or bad about midwives.
“There are pregnant women,” Caleb continued, “that view hospitals, modern technology, medications, and having their babies in sterile-like environments as anti-natural. Like a mother not vaccinating their children against diseases. I mean, vaccines work and they are the biggest success story of modern medicine. Anyway, these pregnant women think that childbirth should be totally natural. If you ask me … subconsciously they want to give birth like women did in the Stone Ages.”
Annabel grimaced and speared a cherry tomato from her salad.
“Well, not that bad,” Caleb admitted. “Anyway, for the last ten years or so, home births are on the rise. Women choose to give birth in their own home. But in the event of an emergency, do these midwives have a backup plan?” Caleb paused. “No,” he said with emphasis.
“Then how did you happen to stumble upon a fatality where a midwife was involved?”
“EMS rushed in a dead baby after a botched at-home breech delivery by a midwife. The ER and OB docs then tried their damnedest to save the mother, who was also ambulanced in. That case was doubly negligent because, apparently, the midwife never talked to the parental couple about the dangers of vaginal birth after cesarean section or VBAC, which the mother had a history of.”
“Jeez,” Annabel said.
“That father or husband? In a couple of years, he won’t need to work another day in his life … if that’s what he wants. A jury will find it inhumane to not award him a mul
ti-million-dollar lawsuit against the midwife.”
Annabel shook her head. “I bet he’d trade back that windfall if he could have his wife and newborn back.”
“No doubt. I later stumbled upon him downtown after one of his attorney appointments. He told me something I’ll never forget. He said that if he ever bought a Lamborghini later on, he was going to put an infant car seat in the passenger side … to remind him how he came to acquire the vehicle and to always remember his wife and child.”
“I’ll peek in the next, or only, parked Lamborghini I spot to see if there is an infant seat.”
Caleb gave her a quick nod. “Since there aren’t too many of them cruising around, one of us will discover it.”
CHAPTER 11
As the elevator door began snapping shut, Caleb thrust his hand in and paused it. He sprang in and held the door for Annabel.
“Thanks for suggesting lunch,” Annabel said. “I don’t rank as high as you with Dr. Watson. I wouldn’t have suggested it in front of her.”
They stood on one side of the elevator. A neatly dressed man stood against the other back wall, his hand gripping a shiny aluminum cane. He tapped its rubber gripper on the floor several times. When they didn’t ride up immediately, he pushed the button for the OB/GYN floor several times.
“It worked out,” Caleb said softly. “Grabbing meals while monitoring and taking care of obstetric patients can be a luxury. Like today. You never know what’s going to happen. And with Ling, sometimes you have to ignore her shortcomings. Between me and you, I think she’s getting worse lately. She needs a vacation or something.”
The man between them took one step when they resumed moving, ready to spring out as soon as the door opened. When they arrived, he pulled ahead with a tilted gait.
“He’s three-legged and burning rubber,” Caleb said as they walked past the waiting room.
“He’s anxious, here to see a family member in labor, or he’s mad-as-hell about something.”