by Barbara Ebel
The ache in Annabel’s head that she woke up with intensified. She drew a blank with common information about her patient’s probable diagnosis, but she also realized the abundance of knowledge the residents possessed. They could even rattle off medical studies and findings, which meant pouring over the latest journals. When would she have so much material absorbed in her brain that she could read “extra”?
Dr. Schott opened May’s chart, scribbled some order, and then marched in her room.
“I can’t believe you came up with ‘asbestos,’” Annabel said to Bob. “I had forgotten about that.”
“I am more aware because my uncle worked in a World War II shipyard and died from lung cancer.” He gave her arm a little squeeze, trying to make her feel better.
“Mrs. Oliver,” Donn said. “How are you doing this morning?”
“Please don’t call me Mrs. Oliver,” she said, turning around from the window. “It makes me think you’re talking to someone much older than I am. I’m only thirty-two, in case you forgot. Can you all call me ‘May’ instead?”
“Thirty-two is my cutoff.” He smiled. “May it is.”
“Thank you. Since I will live until I’m ninety, there is plenty of time later to stick a ‘Mrs.’ in front of my name.” She slumped into the chair and pulled a magazine from the sill with her. “Just like I planned on Misty being with me until I at least turned forty. The lawyer says I’ve got a straightforward convincing case against that doggie day care especially because, in this state, pets are considered part of the family and not property. But I don’t care about the money from a lawsuit. I would rather have my dog back.” She coughed and wiggled her hand for a tissue. Annabel leaned over to the nightstand and passed two of them over to her. “Bloody mess,” May said after spitting in one.
“The loss of your dog came at a bad time,” Dr. Schott said. “While you were here.”
“She would be alive if I had not shown up here.”
“Yes, I see your point,” Donn said, trying to get away from the conversation and on to pulmonary matters. “Did the lung doctor explain your procedure for tomorrow?”
“He is only going to insert a long gadget down my throat into my airway to look around. If he snags a tiny sample of the material he saw on x-ray, then the lab will take a look at it to make sure it’s normal.”
“Yes, it will be the pathologist that does that. He or she is skilled at different types of tissue under the microscope. They often deal with cells that are growing too fast and/or where they shouldn’t be. Perhaps cells that are abnormal and benign or abnormal and cancerous.”
“He said something to that effect,” she said. “Did I show you the picture of Misty yesterday?” She clutched the other tissue and rubbed her eyes.
CHAPTER 7
Wide-open curtains allowed the team to appreciate the fluffy cumulous clouds outside. The heat blew up from the floor heating system, but a chill could be felt from that section of the hall. Annabel rubbed her hands together as they waited for Dr. Burg to finish writing an order on May Oliver for the next day’s bronchoscopy.
“Dr. Palmer, you’re up next,” Donn said, “for a report.”
“Mr. Harty has been stable since yesterday without any further blood loss. His blood pressure is fine as well and his H&H has not dropped any further. Dr. Watts and I are in agreement for him to go home today. With your permission, sir.”
“Most likely,” Donn said. “What if you had a patient without the overt blood loss that Mr. Harty presented with? What if you have an outpatient who is suspected of having blood loss from the GI tract? What can you do to begin the workup to find out?”
“Give them one of those fecal occult blood tests,” Bob said.
“Yes. A stool guaiac test which they can take at home. However, that should never substitute for a skilled GI doc or one of us internal medicine doctors doing an endoscopic evaluation.”
“I guess my patient and Annabel’s patient are both examples of folks needing a scope down or up either end of the body for diagnostic purposes.”
“So true,” Dr. Schott said. “But, as we are aware, Mr. Harty is past that stage and the procedure was not proven useful the last time or two. We also have not talked about his iron deficiency anemia due to his chronic or acute blood loss. Your astute resident is going to send your patient home with a prescription for iron replacement. A better iron level will help with his exercise tolerance.”
Bob nodded while Annabel stole a glance outside. Donn turned, heading for the patient’s room.
“Besides iron,” Bob said to Annabel as they stepped away, “I want to give Mr. Harty a gym pass for a personal trainer who makes his clients bench press 135 pounds in one week.”
“I don’t think Dr. Schott was referring to that kind of exercise tolerance,” she said. “He meant like just getting up to go to the refrigerator or out to the mailbox.”
Bob smiled. “I was checking if you were listening on rounds or out there in the clouds.”
“Sometimes you’re a pain, you know it?”
“I hope so.”
Donn glanced back once making sure his group fell in line.
“We’re springing you out of here tomorrow,” Dr. Schott said, entering Mr. Harty’s room. “Are you up for that?”
“I suppose,” the elderly man said. “If I had to vote on it, the old people’s home is slightly more preferable to the hospital. Say your good-byes because I refuse to come back.”
“Maybe you won’t have to. Dr. Watts and Dr. Palmer are going to fix you up with some iron and we’ll follow you in clinic. Why don’t you go back and beat everyone at bingo, card games, and chess?”
“Chess?! I’d be lucky to witness any of them play a decent game of checkers.” He glanced at one student after the other. “But you young saplings probably don’t have a clue what that is. You all grew up with video games. However, I don’t mean to belittle other seniors. We’re all in the same boat; we’re just paddling with different oars.”
“Life is short,” Dr. Schott said. “We may make it to your age someday too, and we’ll have full empathy and understanding for what you’re going through. I often tell my students ‘Don’t die young and don’t get old.’”
“Wouldn’t that be nice? Living that way would be a miracle.”
-----
The team rounded on Stuart and Jordan’s patients. Annabel and Bob exchanged glances; it was getting late in the morning and the students still had notes to write and busy work to do. They were on their way to see Darlene Pratt and Annabel figured her daughter had long since finished feeding her breakfast.
Dr. Schott stopped abruptly. “Here comes our attending doctor in charge,” he said.
A man about sixty years old wearing a crisp sports jacket came their way. With his last few steps, his comb over became more obvious and his otherwise serious expression became less intense.
“I’m Dr. Mejia, Sebastian Mejia,” he said to the group. He nodded at Donn. “Dr. Schott, am I in time for a few patients?”
“One interesting patient left,” Donn said, “although they’re all fascinating.”
“Then we’ll do a thorough study of one aspect of their disease. And by the way, I’m a cardiologist,” he told the students. “I keep hearts ticking.”
“I plan on cardiothoracic surgery,” Jordan said.
Dr. Mejia directed his attention solely at Jordan. “Are you aware that, more and more, heart problems needing anatomic intervention are being taken care of without the knife? Consider gallbladder removal surgery because of gallstones – a cholecystectomy. Years ago, that small organ used to be taken out with a big open incision. Now they primarily remove it with a couple of instruments through a few holes. These days, cardiothoracic surgeons with less business wish they were poking holes and running catheters and small instruments into the heart like me.”
Dr. Mejia turned away from Jordan and made eye contact with Bob, and after all introductions, he asked, “Which student and res
ident has the last patient to see?”
Annabel and Dr. Watts spoke up.
“Dr. Watts, why is your patient here?”
“She’s a seventy-year-old with Parkinson’s disease admitted for a UTI.”
The attending fiddled with his tie. “Unfortunate but fascinating disease, Parkinson’s.” He went from shaking his head to nodding. “Dr. Schott, how much have you discussed its equally engrossing treatment?”
“Not too much except that the students understand that patients lack the brain neurotransmitter dopamine and need replacement therapy.”
“Dr. Schott even brought popcorn into the analogy,” Bob said with a smile.
“Perfectly understandable for Dr. Schott to bring food into the picture. The interesting pharmacology is that we can’t just hand out dopamine pills for patients to swallow. Resident Watts, tell them why.”
“Exogenous dopamine cannot cross the blood-brain barrier,” she said, “so it is an ineffective treatment.”
“The blood-brain barrier sounds like some kind of wall built inside the brain,” he said. “Talk to these students like they’re premed and assume they know nothing. Describe to us what you mean by the infamous blood-brain barrier.”
Chineka shifted her weight to the other foot. “It is a semipermeable membrane, highly selective, formed by tightly-connected endothelial cells which separate circulating blood from the brain’s fluid outside of cells in the entire central nervous system.”
“In other words,” Dr. Mejia said, “it is a real membrane barrier with an intense purpose. Your point is that if we give someone a dopamine pill, it can’t travel into the brain through the barrier. How do we get around that?”
“Scientists came up with a drug years ago. A ‘prodrug.’ In other words,” she said focusing on the med students, “a different chemical form of dopamine which can pass through the barrier into the brain. The name of it is levodopa and the brain actually converts that drug into dopamine.”
“So if human beings are determined enough, they find a way to achieve what they want,” Dr. Mejia said. “In medicine and life.
“But the pharmacology story does not end there,” he said. “The prodrug, levodopa, undergoes too much metabolism in the gut, so little would be left for availability, so another drug called carbidopa must be added to it. That reduces the body’s conversion, outside the brain, of levodopa to dopamine. Therefore, more levodopa is available to pass into the brain. We end up with a domino effect and we can’t have one without the other two!”
Annabel appreciated their attending’s enthusiasm for pharmacology, especially since he clearly enjoyed using his hands for the procedures in the cath lab. It made her think of the little she knew of anesthesia. They also needed technical skills and an abundance of pharmacology knowledge.
“Part of the responsibility with our Parkinson’s disease patient is making sure their dose of carbidopa with levodopa tablets is therapeutic and to watch for potential adverse side effects.”
Dr. Mejia looked at Annabel this time. “What are the harmful effects?”
“If too much of a dose or a high level occurs, I suppose central nervous system effects,” Annabel said, “since it works in the brain.”
“Understandable guess, but you don’t know the specifics,” he said.
She hoped Bob wouldn’t rattle off the answer to this one, too, or she’d surely feel left behind. Dr. Watts spoke up.
“Central nervous system, CNS, effects for sure,” Chineka said. “Confusion, hallucinations, sedation; and GI effects may include nausea and vomiting, or other things that happen with Parkinson’s itself, making it difficult to separate symptoms from over-treatment or from the disease itself.”
“Yes, confusing, isn’t it?” Dr. Mejia said. “Actually, Parkinson’s is such a large subject that some doctors become experts because they deal with it as a substantial part of their practice or in a center. It’s no wonder why, since it is the second most frequent neurodegenerative disorder after Alzheimer’s disease and more common in the elderly. Not to say that either sex can’t develop Parkinson’s in their thirties and forties. However, there is a ratio of men to women of about two-to-one.”
Dr. Mejia patted his forward-facing fluffed hair. “What’s your patient’s name?” he asked Annabel.
“Mrs. Pratt.”
“This way,” Donn said. They walked around a nurse with a medicine cart as she dropped pills into little plastic cups and then they entered Darlene’s room.
“We’re being invaded,” Gloria said, seeing the whole team. The bedsheet half covered Darlene’s bare chest as Gloria held her mother’s right arm, trying to wiggle it into a blouse sleeve.
“I’m changing her top because she soiled it,” Gloria said. “Come on, Dr. Tilson, take the other sleeve from behind her and pull it on her on that side. Be careful of the hep-lock for her IV antibiotics.”
Annabel chipped in to help as the assistant from outside also came in with a pill cup.
“We must get her pills down with something soft,” Gloria said.
“Let’s try this,” the nurse said. She mixed the pills in applesauce and handed the cup over.
Gloria pulled over Annabel’s side of the blouse in front, buttoned it up, and then tied on a bib. She spoon fed the contents of the pill container while everyone waited. Mrs. Pratt barely opened her lips, so Gloria clenched her mouth with one hand and slid the applesauce in with the other.
“Mission accomplished,” she told the nurse, knowing it was part of the woman’s job to make sure the patient took their meds.
The nurse dropped the empty cup into the waste bag hanging on her cart. “Thanks, ma’am,” she said and disappeared out the door.
“Like we were saying outside,” Dr. Mejia said, “Mrs. Pratt’s meds are essential. No different than many other patients. At least in the hospital there is accountability for them being taken in the right dose, the right time, and the correct route.”
“I’m Mrs. Pratt’s daughter,” Gloria said and gave her name.
“I’m Dr. Mejia, the attending doctor on your mother’s case. Do you have any questions for me?”
“No,” she said. She turned to the sink faucet and poured a few ounces of water into a cup and then added a bit of the protein drink from the tray table. She mixed it with a straw as Dr. Mejia watched and then encouraged her mother to take a sip. “I expect Mom will be out of here soon.”
“Yes,” Sebastian said. “The team believes so. She is making progress with the IV antibiotic.”
Darlene took a sip and then pursed her lips to keep away the straw. Gloria shrugged. “Thanks,” she said. “Dr. Tilson, I’m sure, will keep me updated. She’s been very helpful.”
Listening to Melody’s heels on the polished floor, the group trudged out and pulled shut the door behind them. Few patients, Annabel thought, end up with the loving one-on-one care that Gloria showers on her mom.
-----
Donn strolled into the office and waved Bob off the desk chair. “Almost three thirty,” he said. “Time for you students to get over to the University for your weekly lecture at 4 p.m. No coming back here either. The days you have your lecture, the residents and I will take care of the patients before we leave.” He pulled a baggie forward from the back of the desk, opened it, and slid out a half peanut butter and jelly sandwich.
“That looks good,” Jordan said. “Wish I had brought one of those.”
“Peanut butter is a great picker-upper. But I go light on the jelly after several times of wearing red strawberry goop on my white coat.” He took a bite and closed his eyes for a second, savoring the taste. “Any idea who’s lecturing today or what the topic is?”
“One of the staff from downtown,” Annabel said. “I guess we’ll find out the topic when we go over there.”
“Pay attention. A few exam questions always come from lectures.”
Annabel bundled up and made sure she gathered her books. All four students went down the staircase, and
as they headed for the front door, Jordan peeled off taking a different way.
“He must have parked around back,” Annabel said.
Bob shook his head. “Nah, he’s playing hooky.”
“I don’t profess to know as much as Jordan to do that,” she said.
“Neither do I,” Bob said. “See you there.” They braced themselves against the cold and drove separately. By the start of the lecture, they were scouting around at the back of the conference room looking for each other. Bob sat next to her; the first lecture slide was up on the main screen announcing the speaker and the topic of “Human Immunodeficiency Virus (HIV).”
“I’m going to take notes,” Bob said and weeded through his bag for a notebook.
Annabel checked her phone, made sure it was silenced, and placed it on the empty seat next to her.
“You’re keeping tabs if Robby Burk texts you, aren’t you?” Bob asked quietly as the speaker fiddled with the computer setup for the presentation.
She frowned and nodded as they both settled back and listened to information about the clinical approach to a patient with HIV. The MD talked about opportunistic infections because of patients with increased levels of immunodeficiency.
Annabel wanted to close her eyes. A cat nap would be wonderful. She wished she had one of Dr. Schott’s pb & j sandwiches to give her a boost, or better yet, a stiff cup of coffee. A caffeine blast. Caffeine, she thought, remembering what she had forgotten about the entire day - the chocolate espresso beans and blueberries. She had bought them for both Bob and her and they were shoved in the outer pocket of her backpack.
Her mouth watered with anticipation and she leaned over to the bag on the floor and discreetly opened the zipper. She grasped both boxes and slinked them into her lap. With a pat on Bob’s knee, she got his attention. He also looked like he was about to fall asleep.
Bob’s smile grew wider upon seeing both items. He wiggled his fingers, ready to try either one. Annabel gave him the blueberries to open while she pried the box top off the espresso beans.
“Other patients can have a latent period,” the speaker said, “when there are no clinical manifestations of immunocompromise. That can last up to ten years.”