by Barbara Ebel
She slipped into the bathroom on the ground floor. If Dr. Burg could spruce herself up during the day, then so could she. Looking in the mirror, she admired her straight, white teeth, the product of wearing braces in high school. That time had also corresponded with her tomboy years but, when college rolled around, as well as her first true boyfriend, the boyish manners and interests had disappeared.
That boyfriend, David, ended up being a patient of her neurosurgeon father after a concussion on the basketball court. She was so grateful they were still good friends and that, in all respects, it had been a mature relationship. Would they still be together if his medical course had not interfered with their dating? Maybe his sudden tragic event and the outcome between them was the reason why she become gun shy about serious male connections since then and why she had jumped into quick flings through social apps. However, the situation should change, she thought, and Robby Burk was just the one to put her back on track. There would be so much in common with him. They could share medical stories and always be on the same wave length as far as “career” pursuits. But she was getting ahead of herself. They had yet to go out on their first date!
Annabel rearranged some of the clutter in her two lower pockets and looked in the mirror again. Her slender build was becoming on her 5’8” frame and her medium blonde hair was peppered here and there with darker highlights like her mother’s. It hung to her neck and, depending on the weather, it sometimes formed graceful curls. She stroked her fingers through it while appreciating the shiny luster. Fingers worked better than a comb or brush; her lab coat had no room to carry such things. Pockets were meant for med student items related to patients and learning. Except, of course, for the treats that she and Bob secretly harbored to share. She’d have to look into replenishing their supply since doing psychiatry, especially since he influenced the schedule doctor to put them on the same team. She smiled thinking about him; he always treated her with kindness and concern and was full of positive qualities. No wonder he had a blooming relationship with the med student, Karla.
She stepped back out into the hallway and her phone pinged with a text notification.
You getting some shut-eye yet? Bob wrote.
Ha, no, she replied, surprised at his message. Going to see another admission!
They rarely used to text each other on the wards and their chief made it clear not to use social technology to communicate. But, she figured, it was work related.
Waiting on another H and H. Pt may need another transfusion again! Annabel frowned. At least she was not the only student still walking the hallways. She knew the ‘H and H’ stood for a hemoglobin and hematocrit, allowing Bob to check the patient’s blood count to guide him and Dr. Watt about giving more transfusions. And “pt” stood for patient … who was having a rocky course.
Sorry, she countered. Hope pts and docs get some rest!
He sent her back a smiley face while she pushed open the silver doors to enter the ER.
-----
“I was getting ready to call you,” Chineka said as Annabel approached her. “Another interesting patient for you, but this time, you’ll work with me instead of Dr. Burg.”
Donn was planted in a chair with a bag of microwave popcorn in his lap. “A seventy year old with Parkinson’s disease,” he said. “The subject can take up an entire textbook all by itself, but before you go in there, what do you presently know? We can give you a short bio of the essentials.”
Chineka leaned over and grabbed a few pieces of popcorn. “He can also use some help with this midnight snack.”
Thinking about his question, Annabel nodded.
“The patient comes in for medical reasons,” Donn added before she could speak, “but too bad Parkinson’s is already her established diagnosis. It would be splendid and memorable if you wove through a patient’s symptoms and history to make the original diagnosis of Parkinson’s disease.”
“She’s still going to appreciate it, though,” Chineka said.
“What’s more, there are always exam questions about it,” Donn said, and popped a cluster of popcorn into his mouth.
They kept talking like she wasn’t there until Annabel cleared her throat.
“Okay, then,” Donn said. “We’ll shut up. Enlighten us at this point.”
“I’m fortunate because the little I learned in my first year neurosciences, I retained. Although those patients rarely presented to my dad as surgical cases, he used to talk about Parkinson’s disease since it’s a disorder of the central nervous system.
“It is a neurodegenerative disease markedly characterized by motor symptoms. The term came from the doctor who first described it and was nicknamed ‘the shaking palsy.’” Knowing that historical fact, she beamed.
“As you’ll find out,” Donn said,” the non-motor symptoms can be severely disabling as well. But here’s the thirty-thousand-dollar question. What’s the key, most important reason or etiology why patients exhibit Parkinsonism or Parkinson’s disease?”
“From the loss of brain neurons which produce the neurotransmitter dopamine,” she said and reached over to snatch some popcorn.
“Here’s some butter flavoring.” He pushed a small plastic bottle towards her.
“He’s not that prepared,” Chineka said after seeing Annabel’s look of surprise. “He stole it from the ER break room.”
“Thanks. Knowing where the essentials are around here is a priority.”
Donn raised an unpopped kernel up to the light. “Think of this tidbit as a brain neuron. It’s supposed to pop with activity, releasing the sizzling neurotransmitter, dopamine, which plays a role in proper motor movement. When it doesn’t, you find patients with rigidity, resting tremors, and bradykinesia. What does that fancy word – bradykinesia - mean, however, Dr. Tilson?”
Annabel shrugged. “Slow movement.”
“Ah, ha. But it’s so much more than that. Yes, a patient may turn into a slow, mundane walker and eater, but that slowness redefines his or her personality and who they are. The idiosyncrasies of swinging or gesturing with our hands and arms, or even our seemingly insignificant facial expressions, are erased.”
“Plus,” Chineka, added, “you may also realize that dopamine is more than a neurotransmitter for movement. It enhances our memory, sleep, mood, learning, behavior, and, right now, the pleasure we’re experiencing from eating this snack.”
“We’ll quit lecturing and I’m going to bed for as long as I can,” Donn said. “March in there now to see your patient and the family caretaker who’s with her. To save you the suspense, the reason the Parkinson’s patient is here is for systemic symptoms of a UTI.”
He crumpled the bag, tossed it in the garbage, and patted Annabel’s shoulder as he passed. She took a big breath with tiredness and excitement. Since it was now the next day, she tried not to think about seeing Robby Burk in the evening. She slipped into a back cubicle to catch up on her new patient’s paperwork.
-----
Annabel read all the doctors’ entries on her patient and also noted that some lab work was outstanding. Of course, that would be her job to round them up if they were still missing by morning rounds. Time for overnight sleep was slowing ebbing away.
She memorized her new patient’s name and age of seventy, wrote them on an index card, and plunged ahead through the blue drapes. Two women were inside; separated only by age and the passage of time, they were clearly mother and daughter. The older woman’s hair was drastically short but otherwise they shared similar nasal anatomy, narrow eyes, and golden honey-colored hair. That’s who Dr. Schott meant was the caretaker, she surmised - a loving daughter.
“I was waiting for a med student to appear,” the younger one said.
“Did my residents prepare you that I’d show up?”
“One of them mentioned it, but I interviewed at this hospital yesterday since I’m trying to change jobs. They explained to me that this place is also a teaching hospital affiliated with the university.” T
he woman stood and shook Annabel’s hand and then rubbed her palm on her cotton pants. “I’m Gloria Pratt and this is my mother, Darlene.”
“I’m Annabel Tilson. Nice to meet you both.” She shifted her position to Darlene, who was bolstered forward on the stretcher with several pillows. “Mrs. Pratt, what brought you in here today?”
Gloria sat back down. “She’s not a good historian because of some dementia; some days worse than others. You’ll have to get most of that stuff from me. Around eighty percent of patients with Parkinson’s disease develop dementia within twenty years of diagnosis and it’s been twenty years for my mom.”
Annabel scrutinized Gloria, who swung her leg over her knee and bobbed it back and forth. She wore heavy black laced shoes which Annabel thought would be worn by someone much older.
“That must be difficult for both of you,” Annabel said. “I understand you take care of her.”
“You bet I do. I spend most of my time doing it too. I live in my mom’s house where I converted the living room into a nursing home floor. There’s a hospital bed there for her where she spends a substantial segment of each day. I work three ten-hour shifts a week when I have a home health nurse cover for me. I need to make the income and it helps me get out of the house.”
“Your dedication to her is commendable. You’re obviously doing a remarkable job.” Annabel figured that Gloria was approaching forty; not a fun way to be spending her middle-aged years.
“Thanks. Although she told me years ago she never wanted to get to this stage.”
Annabel nodded absentmindedly while noting Darlene’s tremor. It was as if her hand was having a convulsion trying to rest on the mattress.
“Getting back to your original question,” Gloria said, “Mom is often incontinent, but the last two days have been worse and I detected a hint of blood in her urine. After I got home today, the nurse who left said Mom had a fever. So here we are.”
“Any other symptoms?”
“When I do manage to situate her on the portable toilet, she grimaces. I think she’s in pain, it burns, and it smells bad.”
“Has this happened before?”
“Sure. We go through the UTI, or urinary tract infection thing, at least once or twice a year, but this time I can tell that maybe the infection spread further.”
“I think you’re right,” Annabel said. “The ER record has her temp at a hundred- nd one.”
Annabel continued with a thorough history and had to remind herself to focus on the immediate medical problem. Asking about Mrs. Pratt’s Parkinson’s disease was a separate issue that could take her the whole night. That disease and its course could be dealt with on rounds and after she spent some time with her patient after her admission.
She started Darlene’s physical exam and found her lungs and heart to sound normal and Mrs. Pratt didn’t flinch when Annabel palpated over each kidney. The increased muscle tone in her arms from Parkinson’s impressed her and there was marked resistance to passive stretch when Annabel tried to move her limb. Rigidity was a hallmark of the disease.
As she continued her exam, Mrs. Pratt stumbled through a slow progression of words that at least made sense.
“What … is your name?” Darlene asked.
“I’m a medical student. Dr. Tilson.”
“Shit,” she said.
“Be prepared,” Gloria said. “She hasn’t forgotten bad words.”
“It won’t offend me. She must have been feisty in her time.”
“No kidding,” Grace mumbled.
The woman became quiet again while Annabel studied her rhythmic tremor. She noted it increased while she asked Annabel her name, it only occurred on the right side, and she rubbed her thumb and index finger against each other over and over again.
Annabel stepped back when she finished. “Do you mind if I call you Gloria since you both have the same last name?” she asked the daughter.
“Sure,” she said, glancing at the clock. “Like me, I bet you’re dying to go to bed.”
“I can’t count on it,” Annabel said. “As far as your mom, do you have any questions? She is being admitted and they’ve ordered IV antibiotics for her, but we’ll know more from the lab in a day or two about the specific organism responsible for the UTI. At that point, we can change antibiotics to something more specific. The other docs may have mentioned it, but her bladder is probably involved with the infection and not her kidneys. She didn’t squirm when I examined the area around her kidneys, which was a promising sign.”
“I hear you. She probably has just an old fashioned E. coli infection.”
Annabel raised her eyebrows.
“I know a little,” Gloria said. “I’m a medical assistant and work in an outpatient ambulatory center where I do a combination of administrative and clinical duties. Mundane stuff like updating medical records, doing coding, and other clerical tasks. I like the clinical aspect better like collecting lab specimens, preparing and administering medications, removing sutures, blah, blah, blah. I even get to run the electrocardiograms sometimes.”
Annabel laughed. “That explains it. You’re qualified to take care of you mother too.”
“Surely you are aware that women are the real caretakers. The guys just pretend to be.”
Annabel half smiled and also noted the time. She still needed an H&P on the chart, which usually took longer to write than she thought.
“We’ll see your mom on rounds in the morning. They’ll be moving her soon.”
Gloria pulled a plastic bottle of hand sanitizer out of her purse, squirted a glob in her palm, and began massaging it into her hands as Annabel stepped away.
Outside, Annabel found a spot at a desk away from the busy ER staff and began writing.
Chief complaint: Daughter states her mother, the patient, has more incontinence than normal, blood in her urine, and a fever.
She paused, yearning to find out if she was the only medical student still working, and leaned back with her cell phone.
She texted Bob. Still on the ward?
I’m leaving now! Patient’s red blood count is stable. U?
Starting to write my H&P!
Bummer. You can always delay your date tonight with Burk to another time.
That’s a possibility but I’ll go if it kills me!
Then please don’t go. He finished with a smiley face.
She shook her head. As usual, he made her smile.
CHAPTER 4
Annabel hated the walk to the call room. Away from the wards, the quiet, desolate corridors with their strong white lighting gave her the creeps. Daytime was bad enough, but nighttime seemed much worse. She appreciated their separate rooms, but that compounded the desolation of the new area. Everyone else was tucked in bed and she would be lucky if her eyes closed by 3 a.m.
She threw her white coat on the chair inside, tightened the drawstring on her scrubs, and pulled back the blanket and nestled in. The pillow, mattress, and linen smelled and felt so fresh, she realized she must be the first person to use them.
Her mind jumped ahead to the evening. She needed to plan what to wear; even so far as two outfits, depending on where Robby and her would eat. Most days on the rotation with him, she had worn pants. Tonight called for showing off her legs. She formulated a skirt and blouse in her mind and decided on her emerald green dress if the evening called for a dressier look.
Annabel realized the importance of their meeting. A couple will always remember their first date, she thought; where they went, how it went. That successful first encounter seemed to be an iconic event which launched couples into the years that followed.
But how far physically would they go tonight? It might not be a wise idea to go all the way if she didn’t get enough sleep. Passionate sex takes vitality, she thought, and by tonight, she may be lacking sleep and vigor. And should she invite him back to her place or would he suggest his? Both scenarios posed a problem because if they spent the night, she had to get up and out early for clinic
al duties the next day. But what was she thinking? He had the same early schedule for surgeries.
She tossed on her side. Forget about all these stupid details, she thought. Only imagine Robby Burk … sitting across from him, looking into his eyes, taking in his karma. Sleep swiftly swept over her and when she woke back up, she had to scramble to see patients and be on time for rounds.
-----
Dr. Schott, the two residents, and four students piled into the office where Donn signaled to clear off the couch, desk, and two chairs.
“The floor and any space you can find on shelves is fair game for your gear,” Donn said as they moved items around. “If you make the clutter organized, so much the better.”
Annabel grinned at Bob. The two coat hooks were not enough for all the bulky winter jackets and Bob threw half of them on boxes in the corner. Annabel stashed three insulated food cooler bags past a book end and moved the desk printer as far back as possible so she could sit in its place.
“Are patients seen?” Donn asked.
Heads bobbed up and down.
“Annabel, did you make it to bed?”
“Eventually,” she said.
“Everybody get coffee?” He gestured with his plastic cup.
All heads shook no.
“Eww,” he said. “We’ll swing by the ICU after we visit all our patients. I’ll vouch for us to steal theirs.” Blank expressions stared back at him and he rubbed his beard. “We’ll plow through rounds. The attending can’t make this morning, so you’re off the hook with him. I’m briefing him on our admissions later and I’ll also check all our patients out to today’s call team.” Melody and Chineka smiled because they didn’t have to do it. They couldn’t ask for a bigger break.
Donn took a baby step and flicked his finger on the wall board with their patients’ names. “We’ll see Dr. Burg and Tilson’s patient, May Oliver, first.” His finger went to the door. “Onward and outward.”