by Barbara Ebel
Donn nodded. “So what do you two have to say for yourselves?” he asked Bob and Annabel.
“I can’t hide my excitement,” Annabel said, “to finally learn general medicine, but I hope it’s not fraught with monstrous problems like the last two rotations.”
“I second that,” Bob said. “Dr. Schott, what’s our testing schedule and when do we meet our attending doctor?”
“Study routinely because over the next sixteen weeks, you’ll only have two exams. Your clinical evaluations are super important and will come from me and your attending. He, however, is not as visible on rounds as some. He’s Dr. Sebastian Mejia, a cardiologist. He’s side-tracked with acute cases all the time because of his reputation. Much like an obstetrician being called away for deliveries.”
Donn raised his cup of coffee and after taking a sip, he put it down and then picked up his tray. “I’m going back over to select a lousy dessert, and when I come back, we’re talking about patients, not about ourselves.” He stepped out from the table and waddled away.
After the two residents began talking to each other, Bob turned to Annabel. “I’m going to burst a blood vessel if you don’t tell me.”
“Tell you what?” she grinned.
“About your heartthrob, Robby Burk.”
CHAPTER 2
The two female residents, Melody and Chineka, rose from the table and followed Donn to also select a dessert. Annabel swung one leg over the bench and faced Bob.
“I went to the important meeting the Friday before our break,” she said, “between psychiatry and this rotation. You know, the conference that was pending with the anesthesia and surgery departments and the Drug Company and FDA … all about that OR drug that was called into question. Anyway, Dr. Burk attended, and at the end of the meeting, he came over and walked with me to the elevator. He said since he wasn’t my chief resident anymore and I was no longer his student, would it be possible to go out to dinner with him sometime before he heads to Africa on his medical trip.” She replayed in her mind what happened and how the elevator doors had snapped shut and she rode to the ground floor with a pounding pulse.
Bob’s heart skipped a beat, but he forced a smile. “That’s a major development in your personal life. Congratulations. Have you gone out with him yet?”
“No. I only got back from Tennessee last night. If tonight is a decent call and I’m able to sneak in some rest tomorrow afternoon, we’re going to meet for dinner tomorrow.”
“You must be excited. You alluded to other dating this year, but I guess nobody was important enough to mention. Have a great time; I hope he lives up to your expectations.”
Annabel nodded. His speculation about her dating all along was correct but finding people on her dating app, Findar, had not been for finding relationship material at all. Something he had no clue about. It had been more for an occasional romp in the sack. Her thinking was that if men could do it, she could do it, too; it had also served multiple functions.
However, Annabel’s use of the app, or another one like it, now took a back seat to her starting medicine and making time for Robby Burk.
_____
Donn walked back to the table and placed down a piece of pie with a dollop of whipped cream. Dr. Burg and Dr. Watt shared two cookies from a baggie that they bought at the cash register.
“Now we’re ready to roll,” Donn said. “Each of you students had an admission since this afternoon and, unbeknownst to you, I staged a little trick on you. I use a teaching method on the first day to emphasize a point. Dr. Palmer, it’s customary as a student to write up your H&P, or history and physical, after you’ve seen you patient. Correct?”
“There’s no other way,” Bob said.
“However, your supervising resident and your chief resident saw the patient before you. How much of your written H&P is then plagiarized from your resident’s H&P already placed in the chart?”
“Uhh…” Bob stammered. “If I haven’t talked to them yet about the patient and I’m stumped on the possible diagnosis or plan, I do reword what they’ve written.”
“You’re an honest young man.”
“Mostly,” he chuckled. “However, I do sometimes stretch the truth when I’m complimenting people.”
“That only goes for women,” Annabel said.
Bob rolled his eyes. “She’s knows me better than I think.”
Donn swallowed and pushed around a few crumbs with his fork. “So each of you must have noted that either Dr. Burg or Dr. Watt’s H&P was missing from the charts of your patients today. That’s because they are in your resident’s pockets, ready to be put in the patient’s record.” He looked squarely at each student. “Unfortunately, on rounds, students are subconsciously taught to regurgitate the same information that their superior wrote about their patient.”
He put a forkful of pie in his mouth, letting them digest what he said. In a few moments, he continued. “My point in doing this today is for each of you to learn the skill of thinking for yourself like a seasoned physician, make educated guesses before you see what your resident has written, and be willing to have a constructive discussion about possible diagnoses and be open to positive feedback.”
He focused on Annabel. “Let’s start with your admission, Dr. Tilson. Why don’t you begin with a short version of your H&P? Remember always that there is no substitute for being at the bedside and no replacement for a careful history and physical examination.”
Annabel dug her hand into her jacket and pulled out her cards. Each of her three patients had their own index card where she wrote down their most pertinent information. She held May Oliver’s.
“Like I’ve mentioned,” Donn added. “I’m a pretty mellow guy, so right now, this will be informal. Go ahead, Annabel. Tell us what you know.”
“May Oliver is a thirty-two-year-old white female who came in with a four-month history of coughing up blood. She reported an unintentional weight loss of thirty pounds and increased fatigability, but she’s devoid of a temperature and lacks fever, chills, or night sweats.”
“The absence of those latter symptoms makes you believe what?” Donn asked.
“There is no suggestion of an infection.”
“Exactly. Already you told us so much. In the back of your minds, you should all be churning out a differential diagnosis for hemoptysis. If you can’t do it now, then you’ll be snapping it out it in a few weeks. Did you ask her if she had any recent surgeries or chest pain?”
“Not directly,” Annabel said.
Donn turned to the resident assigned to Mrs. Oliver. “Melody, why is that piece of information critical?”
“Because you want to evaluate for a pulmonary embolism, which can be life threatening. That would be suggestive with a history of recent immobilization such as a hospitalization for a surgery. She could have developed a deep venous thrombosis in a leg which broke off and got trapped in her lungs, causing her chest pain and shortness of breath.”
Donn gave her a thumbs up. “So back to the differential diagnosis. Our attending doctor, Dr. Mejia, has been practicing medicine for a long time, so he could tell you that years ago the most common causes of hemoptysis was tuberculosis or a lung abscess. But these days, it boils down to bronchitis or lung cancer.”
Annabel worried about what he’d say next. Surely lung cancer couldn’t be a strong consideration. Her patient was too young.
Donn ate another piece of pie and chased it down with a gulp of coffee. “In your short history, however,” he said, “you neglected telling us an important point. Your patient’s smoking history or lack thereof.”
“She never smoked,” Annabel said.
“We boiled it down to bronchitis and lung cancer, but the most common cause of bronchitis stems from smoking. See how far we’ve come?”
He turned his fork over and tapped the tines on the plate. “We’re left with a primary working diagnosis of lung cancer. The only type not usually associated with smoking.”
_____
Their team office was way too small. The hospital was undergoing a facelift and until some areas were spread out into the new wing, the physical space of some departments was tight. When they got back, Donn tucked himself into the end of the sofa and opened up his USA Today.
“This is my intermittent diversion all day long,” Donn said to no one in particular. “An old-fashioned newspaper which I bring in whether there’s rain or shine.”
Annabel grinned at Bob. Their chief was hidden behind the colorful front page of the “Life” section with a satirical picture of a movie celebrity.
Donn folded back a corner. “It’s nice to see the media ridiculing someone in Hollywood for a change, since all they do is make fun of certain politicians. I’d like to see some of those privileged folks taking on the responsibility of an area of government. They can’t act their way through that.”
Annabel knew better than to get into that discussion. “Dr. Schott, we don’t know where our call rooms are. Perhaps we can unclutter this room and remove our overnight bags.”
“Come on with me,” Dr. Burg said. “I’ll bring you all over. The rooms are finished in the new wing and you won’t believe it. Each student and resident has their own call room.”
All four students shot a glance at each other with disbelief. Hastily, they gathered their things like the offer may be rescinded and followed Dr. Burg and Dr. Watt out the door.
“Annabel,” Dr. Burg said, “my H&P is on Mrs. Oliver’s chart now and she’s off in radiology getting x-rays.”’
“Should we tell her of our suspicions tonight?”
“No use in telling her our thoughts so late. Sleeping in a hospital is bad enough without wrestling with the idea that you may have cancer.” They reached an abrupt transformation into the new wing with shiny new floors and lighter walls. “Here you go, everyone. Pick a room and don’t forget the key, which should be right inside on the shelf. Now is my opportunity to change my shoes.” She pointed to her duffel bag and disappeared into the first room.
Annabel entered the first door across from her. It was small but appreciated. All four students didn’t have to pile into the same room and disturb each other by coming in and out all night for new patients or problems on the ward. She changed into scrubs for the overnight haul, grabbed the key, and headed back out. Bob was waiting for her a few feet away.
“We have a problem,” he said as they began the trek back over.
“There’s always some kind of dilemma,” she said, grinning. “What is it this time?”
“I did not find a separate, upscale coffee shop in the hospital lobby. Not only will we be out of rich brew, but we won’t be able to buy our chocolate espresso beans or blueberries.”
“You’d think a government hospital would rent out space to make some extra money, being that they’re always short of funds. At least I hear from the reports about doctor shortages and overflowing clinics and long patient wait times. I guess the new part of the building is to factor in some of these changes to help expand and hire.”
“Maybe so. But none of that is going to solve our immediate dilemma. Especially when it comes to tomorrow morning or rounding without our secret treats.”
“I agree. We must come up with a plan. Either buy a stash for the rotation somewhere else or change our addiction to something from the cafeteria.”
“Heaven forbid,” Bob said. “Do you want to get us poisoned? Did you notice those lousy cookies our residents were eating before?”
“Yeah, I guess you’re right.”
“So where are you going right now?”
“I have to check if Mrs. Oliver’s chest imaging is done yet as well as her other labs.”
“And I suspect Dr. Watt ordered a transfusion for our bleeding colon cancer patient.”
They parted ways and Annabel went to the ground floor x-ray department. In a stack of new films, she pulled out May’s chest radiograph. Even as a novice reader of films, when she put it up on the viewer box, there was no denying the lung mass on the right side.
_____
Annabel approached the quiet nurses’ station down the hallway from May’s room and found Melody Burg dancing her fingers across her iPhone.
“It’s not personal,” Melody said as Annabel leaned against the counter. “I’m looking something up in the PDR.” The PDR, or Physician’s Desk Reference, was a heavy-weight textbook of pharmaceutical knowledge. Technology couldn’t have done a better job than getting the monster on a mobile device for clinicians to carry in their pockets. “I’m checking the dosage of a drug for Mrs. Oliver,” she added. “I’m ordering her a cough suppressant and rest to help minimize her hemoptysis.”
Annabel nodded at the two simple strategies which would help. “I just pulled her chest x-ray from downstairs, which is waiting to be read by the radiologist; you all were right. She has a lung mass.”
Melody slipped her phone back into her pocket. “What do you think is the next step in her work up?”
Annabel thought through the steps: making the diagnosis, staging a disease, treating it by knowing what stage it’s in, and then following the course and disease’s response. They were still in the infancy step of making the diagnosis and the only way to cinch that was to make a tissue diagnosis.
“I suspect a biopsy procedure is in order,” Annabel said.
“Precisely.” Melody closed the chart and stood up. “And tomorrow morning, we’ll discuss all of this with her.” She nodded towards the hallway. “Her boyfriend came and they’re inside her room with the door closed. If you look in on her, you can at least tell her that her lab work looks okay.”
“I’ll tell her and at least meet her friend. She may have him listed as a contact person.”
“As for me, I have a break since Chineka, Dr. Watt, is in the ER with Dr. Schott seeing the next patient. I use every minute I can to squeeze in other items that can’t be avoided. With that, I’m going to the call room to file my nails.”
Annabel smiled. “No wonder you look so meticulously groomed.”
“I may be a doctor, but I’m not overlooking my femininity. Women with successful careers anymore think they need to blend in with the guys. I look at it opposite. If they are free to be ‘guys,’ then I’m free to be myself too.” She took a step. “And by the way, downstairs is our team’s fifth admission for today, and you’re up again next.”
Annabel frowned. She needed to speed read through a chapter on lung cancer and now there may be another medical topic to absorb. More importantly, the sleep she desired before her big date tomorrow might not be possible.
_____
Outside May’s door, Annabel paused before knocking. She was glad she did because it sounded like someone was crying inside. Strange, she thought, since her boyfriend may still be with her. She tapped on the door, poked her head in, and received a neutral glance from both of them. She proceeded inside where a thirty-plus-year-old man rested his head in his hands next to the bed and May fought to hold back her sobbing.
Annabel thought twice about disturbing them but couldn’t back out now. “I’m one of the medical students,” she said. “Can I help out with something?”
“I’m Jeff,” the man said. “May and I are close friends.” He looked at his girlfriend, who didn’t respond and he shrugged his shoulders at Annabel.
“I came by to check Mrs. Oliver’s vital signs from the bedside chart and to tell her most of her lab work fell into the ‘normal’ category.”
May wiped her right eye and stared at the tissue in her hand.
“Dr. Burg ordered you a cough suppressant, which may help you sleep better tonight and if your dinner didn’t appeal to you, perhaps we can smuggle in a soft snack from the kitchen.”
“I’m not hungry,” she said. “I don’t think I’ll ever be hungry again.”
Jeff ran his fingers through straight black hair and then shook his head.
“How could this have happened?” May sobbed.
Perplexed,
Annabel asked, “What are you referring to?”
“I do it when the need arises and it’s never been a problem. Tell her what happened, Jeff.”
“May left her labradoodle at the doggie day care this morning before going to work. She knew she was going to seek medical advice after work about the darn bloody cough she’s had, so didn’t want Riley left so long. Anyway, I swung by there to pick him up.”
Annabel shifted her weight. She didn’t want to hear that the poor woman’s dog was sick.
“Jeff picked him up all right,” May interjected, angry and sad at the same time. “Picked up a dead dog.”
A silence lapsed while May wiped her eyes again.
“I’m so sorry. I’m a dog lover, so I can understand your shock and despair.”
“Riley was in a large room and most of the other dogs had left. One of the girls who works there came back through with her own dog because she forgot something. Her pet picked a fight with May’s dog. The pit bull managed to snap Riley’s neck.”
Annabel’s muscles tensed up and she couldn’t finish the breath she’d been taking. She wished she didn’t just hear that or picture the tragic event in her mind. Being a dedicated dog lover, she couldn’t handle the emotional strain when she heard of pets being hurt.
But by tomorrow, May would be facing her own personal, physical news besides what happened to her four-legged best friend. If anything, Annabel hoped the loss of her dog would circumvent her dwelling on the significance of her own diagnosis, but it was too bad the woman had to deal with both.
CHAPTER 3
At 11 p.m., Annabel longed to stretch out in the call room. Any minute, however, she expected to be flagged down by Chineka Watts or Donn Schott to see her next patient in the ER. Lying down would only taunt her into wanting to stay in that position longer. She might as well go head off the call, show up in the emergency department, and behave like a student thirsty for another admission.