by Barbara Ebel
“Ha! My outlet was too small for a big girl!”
Harry placed a framed picture of his wife, his daughter, and himself on the nightstand. The family huddled close to each other in front of a Christmas tree.
“I tell it differently,” he interjected. “There was no way Amy was going to spill out our daughter, who was as plump as a honeydew melon.”
“You must have welcomed the C-section.”
“We did,” Amy said.
Annabel thought about follow-up questions about this pregnancy while Harry crouched down, slid off his wife’s hospital slipper socks, and put on the ones they’d taken from home.
“What did the obstetricians in the clinic tell you about this baby’s size?”
“He’s not as huge as our Susan was. They’ve monitored me by ultrasound. You know, years ago, they used to automatically do follow up C-sections on women who had their first baby by surgery. Nowadays, they decide on each case separately.”
“Yes, they have you down for a trial of labor after cesarean section or TOLAC,” Annabel said. “And why did they admit you now?”
“I’m overdue, so no sense in letting little Wagner grow any more!”
“What about the last nine months? Any problems we need to know about or any medical history?”
“Not at all. I’m pretty healthy too.”
“She’s a skier,” Harry said.
“What kind?”
“Both,” Amy said. “Snow and water.”
“She’s being modest,” Harry said. “Snow includes downhill and cross country and water depends on how many feet she wants to put in skis … or not … and get pulled by a boat at a hundred miles an hour.”
“I bet you have that short blonde haircut to fit it snugly under a winter ski cap,” Annabel said. “Much of what you’re talking about sounds exciting. Has little Susan stood on skis yet?”
“Amy is going to see to it,” Harry said, beaming.
Caleb made an appearance at the door and came straight in wheeling an ultrasound and a fetal monitoring machine on a cart.
“Mrs. Wagner, I presume,” he said. “I’m Dr. Gash. I saw you in clinic once or twice.”
Harry shook his hand and introduced himself.
“Dr. Tilson,” Caleb said, “are you almost finished with your H&P?”
“We’re making progress, but I still need to examine Mrs. Wagner.”
“You can close the door and watch while I do an ultrasound. Since Mrs. Wagner underwent a previous C-section, we’ll assess her lower uterine segment one more time to determine whether sufficient thickness is present to support labor.”
Amy took the clue and wiggled up on the bed. Caleb prepared the patient’s lower belly and was soon rolling the ultrasound around. He nodded and pointed out the black and white picture to Annabel as he went along.
“That’s my son in there,” Harry beamed. “He’ll be on this side of that incubator by tomorrow.”
“Since when is my uterus an incubator?” Amy commented.
“It counts as a controlled environment; it most certainly is an incubator.” He took her hand and kissed it.
Caleb stopped and wiped off the gel on Amy’s abdomen with a hand towel. “You’re set to go with our original plan.”
“Easy for you to say. I guess the next item on the agenda is an IV.”
“Precisely.”
“May I start it?” Annabel asked.
“Caleb raised his eyebrows. “If Mrs. Wagner allows it …”
“I’ll give you one chance,” she said. “Two tops.”
“With the few that I have inserted, I’m not too bad. I’ll ask the expert anesthesiologist to help me out if I fail, so as to avoid the tech as the middleman. I do need to wrap up my H&P, however, and listen to your heart and lungs.”
-----
Annabel still needed to write up the H&P on Mrs. Wagner, but the IV was the first priority to start her patient on oxytocin to begin inducing labor. She grinned; she was finally learning some obstetrics.
She familiarized herself with the supply room and grabbed what she needed. A large-bore IV was not needed, but she didn’t want something too small either. She chose an 18-gauge IV catheter knowing that a 20-gauge was a backup plan for a smaller vein. After shoving more supplies in her pocket, she headed back to Amy’s room.
Harry ambled from one side of the bed to the other, forcing his wife to smile as he clicked cell phone pictures of her.
“You are the proudest father I’ve come across so far,” Annabel said, “and your baby isn’t here yet.”
She realized her first and second patients were not so lucky; one with an uninvolved father who only donated his sperm, and the second with a father who wanted to be involved, but the woman was not letting him.
“I’m sure Amy will have this one on skis early too. I am active in sports, too, and I’m a health fanatic. Little Bobby is going to be a chip off the old block.”
“You hope so,” Annabel said. “Sometimes kids don’t follow their patents’ agenda. I bet you two are stellar examples, however.”
Annabel set her supplies on the tray table and tightened a tourniquet around Amy’s arm. A straight, plump vein popped up on her hand. She leaned in, wiped it with alcohol, and opened the IV packaging.
“We also have a dog at home,” Amy said. “His name is Blue. He’s a German Sheperd and is baby number one. He plays with Susan and he also is the protector of all of us like he’s the house sentry.”
“He sounds marvelous. It turns out that I may be getting my own dog later today. Your enthusiasm over Blue makes me all the more excited.”
Over the dog discussion, Annabel had pricked the area with local anesthetic and had slipped in the IV to make its mark with a quick blood return. She heplocked it and secured it with tape to Amy’s hand. It wasn’t going anywhere when she finished.
Harry’s big tall frame peered over her shoulder. “Way to go for a medical student.”
“Thumbs up,” Amy said. “And you’re really getting a dog today?”
“Yes, with a friend. We’re going to take care of the dog together, even though we don’t live together. As students, our schedules fluctuate.”
“Good luck with that. Dogs shouldn’t be experimented with, but you’ll probably do fine. As long as you and your friend are cooperative with each other.”
Annabel trudged to the door, where she dumped the needles into the sharps container. “He may be my best friend ever. We’ll never know unless we try.”
“Dr. Tilson,” Harry said, “you must tell us tomorrow what happened.”
“Sure thing.”
Annabel took one step into the hallway. Emmett came zooming out of the next room and grabbed Annabel by the arm.
CHAPTER 14
Emmett’s bushy eyebrows stood out over his wide-open eyes. He grasped Annabel’s white coat by the sleeve and yanked her from the hallway straight into Bonnie Barker’s room.
For just two days of being on the rotation, Annabel trusted Emmett even more than some of the other medical people working in obstetrics. He seemed trustworthy, did his job without fanfare, and treated the patients and staff with respect. With curiosity and concern, she let him pull her next door.
“You’re the closest one,” he said as they turned at the doorway. “I walked into her room and … look.”
As Annabel approached the bed, she thought Bonnie was dead. Her own heart jumped like a car’s ignition had just been turned on. Her heartbeat raced as she simultaneously docked her fingers on Bonnie’s carotid to feel for a pulse. Please, not again, she thought.
“Emmett, get help.”
The orderly took off and she zeroed her attention on her patient. She felt it. A faint pulse under her fingertips. She exhaled, allowing herself the small relief of that discovery. But there was still a crisis as she watched the woman’s chest and tried to discern her respiratory rate. There wasn’t much of a rise to her chest, so she grabbed the nasal cannula off the wall oxygen de
vice and stuck the prongs in her nostrils. It was a band-aid only because her patient had little in the way of respiratory effort. She needed help; otherwise, surely in a minute or two, she would need to do chest compressions.
She heard them barrel in before she saw them. Kristin Fleming appeared to her side and then Dr. Gash. Emmett followed with the crash cart.
Dr. Fleming’s actions were quick as thought as she unlocked the bed and moved it away from the wall. “Emmett, see if any nurses are around or get me respiratory stat.”
Kristin waved at the cart. Annabel pushed it closer and, reading the anesthesiologist’s thought process, she opened the drawers for airway equipment. She handed her a laryngoscope blade, one she knew was of an appropriate size for an adult, and then laid three sizes of endotracheal tubes at the top of the bed. Caleb listened with his stethoscope to Bonnie’s heart.
A stout young man from respiratory therapy sidled next to Dr. Fleming and hooked up a suction catheter. Kristin yanked on nylon gloves, opened Bonnie’s mouth, and in two moves with the blade and the tube, had Ms. Barker’s trachea intubated. The therapist hooked it up to an Ambu bag and squeezed oxygen into Bonnie while Kristin verified breath sounds.
Dr. Fleming nodded. The tube was in the right place, not the esophagus, and both lungs rose with bilateral breath sounds. Another therapist wheeled in a ventilator and the team finalized everything they had done.
“Her heart likes that much better,” Caleb commented. “But I’m not crazy about it. She’s slow … in the fifties. Now she needs to be in the unit.”
“Yes, get her transferred to the ICU right away,” Kristin said. “What on earth happened?”
“I intend to find out.”
Annabel thought back through the afternoon’s events. “Bonnie Barker complained about pain when we rounded on her early today. I think Dr. Harvey and Dr. Watson came to a treatment decision and the nurse dispensed her medication this afternoon. The RN wondered what was written.”
“That’s a start,” Caleb said as the therapists and Emmett unhooked connections and began wheeling Bonnie Barker to the ICU.
Caleb ran to find her chart. He needed to document the occurrence as well as write orders for the transfer. He also needed to alert Ling, wherever the hell she was, and put in for a medical consult with internal medicine for management in the ICU. The electronic medical record was another thing, but he also needed to investigate what Annabel had spoken about.
Annabel tailed after him. She could almost see the wheels in his brain churning. They both heard the running of shoes on the shiny corridor until Ling stopped short next to them. She tried to catch her breath. “Our patient passed me on her way to the ICU with a breathing tube jutting out of her mouth. What the hell?”
Caleb and Annabel glanced at each other first.
“Annabel showed up first.”
“She was nonresponsive and barely breathing.”
“And I have my hands full at the moment,” Caleb said. “We honestly don’t know what happened yet. Maybe you can follow Ms. Barker over to the unit, give them ventilator settings, and request help from internal medicine or a hospitalist.”
Ling’s ponytail swayed as she turned on her heels and left.
Annabel and Caleb looked at each other again.
“That was a surprise,” Annabel blurted out.
“Easier than I thought,” he said. “Perhaps she figures she’ll follow the path of least resistance.”
Annabel nodded. “We better take a look at Bonnie Barker’s previous orders and then the medicine cart to check what was or was not given.”
“I hope Emmett didn’t grab her chart when they went over.”
“If he didn’t, they’ll be calling for it any minute.”
They hustled to the stack of charts at the nurses’ station and Caleb found it under the lip of the counter.
Dr. Gash flipped to the end of the “Orders” tab to look for recent activity. There were a set of orders from earlier in the day. They both angled so close to each other their sleeves touched. He pointed.
“I’m having difficulty reading this order,” he said.
“Dr. Watson’s handwriting is …” Annabel started.
“Illegible. The 200 mgs looks fine. What’s in front of it, with normal scrutiny, looks like morphine because the “m” and the “o” are clear.” He averted his gaze to Annabel and his eyes popped wider.
“Shit,” Annabel whispered. “Bonnie Barker received 200 mgs of morphine. Dr. Watson should’ve written the real pain medicine of Motrin really clear. The nurse, her last name is Fox, said something to me about it in the hallway and I sort of questioned her thought process.”
“Let’s check the medicine cart.”
They ripped across the aisle and into the supply room. Annabel opened the record lying on top. “Sure enough, it’s what we thought.”
Their eyes met.
“We should reverse the actions of the opioid,” Annabel said.
At the same time, they both quipped, “Narcan.”
“Come on.” Caleb waved past the doorway.
Before they made it to the staircase to run up to the unit, Dr. Harvey stepped out of the family consultation room near the waiting room. They almost banged into him. He wore a forlorn expression. His toupee lacked buoyancy and sat atop his head like someone had sat on it.
“Are you two going to a fire?” he asked. His attention focused on Annabel; sometimes students divulged more than their higher-ups.
Annabel held her tongue for an extra moment, hating to saddle her attending with another team medical emergency. “Ms. Barker is in the ICU on a ventilator. She mistakenly received morphine instead of Motrin.”
Roosevelt Harvey gasped while Annabel peered into the room he had exited from. The Chandlers had fortunately not been close enough to hear their conversation about another patient. Mike tried to control his sobbing wife while he wiped tears away from his own eyes.
-----
Dr. Harvey, Caleb, and Annabel swiftly left the corridor and caught the attention of visitors in the waiting room as they walked shoulder-to-shoulder with their heads down.
“Are you sure about this?” Roosevelt asked.
“The entry is in the record,” Caleb said, shaking his head. “I can understand why the mistake was made.”
Roosevelt stopped short. “There is no excuse for errors!”
Caleb and Annabel flinched.
“What? Tell me your interpretation of the mistake.”
“The nurse may have misinterpreted Dr. Watson’s handwriting,” Caleb said.
Dr. Harvey sagged his shoulders more than usual. “God forbid,” he mumbled as he opened the door to take the stairs instead of the elevator. He took one step at a time like it was a chore and he was out of steam. “We all have patients to take care of, there are women in labor, and I’m due back over in my office. You all are making a mess and all I’m doing is putting out fires!”
Caleb reached for the doorknob and they exited next to the ICU. The automatic doors opened and the first person they saw was Ling.
“Dr. Watson … Dr. Gash and Dr. Tilson just informed me that Ms. Barker received high-dose morphine.”
“Based on her pinpoint pupils, I guessed that. What stupid idiot did that?”
“Your handwriting may have been misconstrued based on what your teammates are telling me.”
Ling took a second to process that and then gave Caleb a heavy glare. “What you are implying is preposterous. There must be more to it than that.”
“Let’s put this to rest right now and check with the RN.” He tilted his head towards Annabel.
“Melba Fox,” she said.
“We’ll talk to her,” Ling said, “but we need to give Bonnie Barker an opioid antagonist.”
The group went into her ICU room and Dr. Harvey examined her. Bonnie was covered with a sheet to her shoulders and the tubing to her endotracheal tube pulsed with the respirations from the machine.
�
�Here’s what you’re going to do, Dr. Gash. While Dr. Watson and I go talk to the nurse, you’re going to methodically treat her overdose. You can start off by titrating slowly and staying right here for a few doses. Since she is on the ventilator, we don’t have to worry about her oxygenation. Start with an initial dose of 0.4 mg of naloxone IV and you can use repeated doses if necessary.
“Dr. Tilson, you will stay with Dr. Gash to learn an important point. Even though you both may think she begins to come around and breathe adequately, the duration of action of the morphine will probably exceed that of the Narcan, so she needs to be kept under continued surveillance. No extubating her prematurely. No taking her off the ventilator just because she may open her eyes.
“Meanwhile, Dr. Watson and I will go talk to the RN who was responsible.”
-----
“This will be a slow, easy process,” Caleb said after he gave Bonnie her second dose of naloxone. “As a matter of fact, it’s best if we reverse at least half of the overdose and let her rest tonight on the ventilator.”
“That makes sense.”
“I’ll give her a third dose in a little while. In the meantime, grab a chair.”
Annabel perched herself at the end of the nurses’ station and took out her cell phone. The volume was turned down all day, so she checked immediately if Bob had contacted her, hoping that today was yet another improvement in his energy level. Especially since he was the appointed task master for setting up for their pet. The dog might end up memorable in more ways than one and more pleasant than the events that took place on the ward.
Her index finger plugged in her opening password and she went to text messages where his message popped up. Even if he had not made progress with their agenda, she was glad to see it.
Hey, workaholic medical student. Don’t deliver too many babies today. Save some for your residents!
What a doofus, she thought with a smile.
‘Shopping’ for dog ‘basics’ is done. And you won’t believe it. I scouted out dogs at the kennel … where some dog, I think, stole my heart. I’ll be curious to see what you think about the furry beast.