by Barbara Ebel
“Speaking of really sick,” Annabel said, “how’s your little girl?”
“She’s on amoxicillin and went to sleep at the normal time. And my husband, well, he texted me a half dozen times for reassurance about whatever he was doing for her all evening. I guess they’re both okay.”
“What’s her name?” Annabel asked.
Ginny fluffed the flat pillow under her head and smiled. “Katie.”
A pager beeped and Annabel looked over at Bob. He plucked it up from the side of his pillow and stared at the screen.
“Guess you need to get ready for a challenging case,” Ginny said.
“Just call me bad luck,” Bob said.
“No,” Ginny responded. “Annabel has that distinction.”
“If that’s true,” he said, “she will soon shed it like a sleek feline molting her winter fur.”
“Yikes,” Annabel said. “I don’t know if that’s a compliment or an insult.”
With a quick maneuver, Bob was standing on the floor. “It’s a compliment but I’m not being sexist. I’m just tossing you a middle-of-the-night colorful remark.”
Annabel had to grin. She closed her eyes as he opened the door to leave. “By the way,” he said turning around, “you are sleek.”
When he was gone, Ginny spoke as she stared in the semi-dark at the upper bunk. “I think he likes you.”
“No shit,” Annabel mumbled.
-----
The more Annabel tried to go to sleep, the more she couldn’t. It would make more sense, she thought, if she could get some peaceful rest but even that didn’t occur. Two hours after Bob left, the door opened again and Da’wan sneaked in.
“Da’wan,” Annabel whispered when he was between the bunks, “what’s going on out there now?”
“I’m finished but Dr. Burk, Dr. Wallace, and Bob have gone to the OR with a nasty case.”’
“Glad you’re getting to go to bed for a while,” she said. “Do you know what the case is?”
“A ruptured appendix is all I know. This time, the real McCoy.”
“I’m not sleeping anyway,” she said. “Do you think they would mind if I watched?”
“I don’t think so. Seems to me that your clinical curiosity would bode well with the chief resident. And you deserve to see a real appendectomy patient after getting stuck with that faker today.”
Annabel planted her feet on the top step of the ladder and climbed down. She had beaten herself up enough tonight, she thought, so instead she would use her time more productively.
“No sense trying so hard to fall sleep,” she reiterated. “I’ll go watch the surgery.”
-----
Annabel stopped at the OR desk. “What room is Dr. Burk doing surgery in?” she asked.
“Two. You can’t miss it,” the charge nurse said. “They’re busier in there than an OB delivering triplets.”
“Thanks,” she said and slipped on shoe covers. Outside the surgical room, she donned a mask and stared inside the window while a nurse rushed past her and into the room. Dr. Burk was alongside the scrub tech and her instrument table, Dr. Wallace and Bob were across from him. The anesthesia resident and attending scrambled at the head of the table hanging bags, injecting syringe contents into IVs, and pushing buttons on monitors. There seemed to be extra operating room staff; delivering IV pumps to anesthesia and rushing back and forth from the counter to the head and foot of the table. As far as she knew, appendectomies weren’t supposed to be that difficult; a ruptured one must be a different story.
She walked in. Other than the anesthesia equipment, Annabel was surprised at the silence. She stood next to the screened drape between surgery and anesthesia. A short resident, Dr. Gill, reminded her of the Harry Potter character with dark-rimmed glasses. He connected suction to a tube inserted in the female patient’s nostril which then drained dark liquid from her stomach into a canister. An NGT or nasogastric tube, Annabel remembered.
Dr. Burk glanced over quickly, holding his instruments still for a second inside the patient’s lower abdomen while Dr. Wallace was bent over the area using her hands. For a moment, their eyes held.
“Dr. Tilson,” he said, “a ruptured appendix. The patient has peritonitis, is septic, and may not even make it. It’s a bed of infection in here.”
Annabel craved to look longer at his warm eyes above his mask but their gaze finally broke. She took consolation that he had told her, a measly medical student, the pertinents of the case. How could appendicitis ever have gotten this bad?
Robby looked grimly back at his work and asked the OR tech for an instrument. “Give me what I want, not what I ask for,” he said after she placed an instrument in his glove. He handed it back to her.
Bob turned his head, noticing Annabel. He took a half step back. “I can give you a little space up here to see,” he said quietly.
“That’s okay,” she said, “I’m not gowned like you, so I’ll hang here.”
Annabel couldn’t see into the incision but Dr. Burk’s and Dr. Wallace’s gloves were soiled with pus and the lap sponges were tinged with the same. She took a step up from where she stood alongside the rising bellows of the anesthesia machine and watched more carefully what they were doing.
“We’re fighting septic shock up here,” the anesthesia attending said to her.
Dr. Gill saw her eyes squint and, knowing she was a student, leaned over to explain. “The patient has severely low blood pressure. We’re giving drugs and fluids to try and correct that but we’re not being very successful.”
She nodded and watched him hit buttons on the infusion pump. The attending took down an empty Lactated Ringer’s fluid bag and replaced it with a full one. The resident made notes on a clipboard and then injected more medication into an IV port. Besides the anesthesia machine, a rolling cart was behind them. The top was covered with labeled syringes and equipment. She wondered about anesthesia; they must be pharmacology experts besides being doctors, she thought.
“Dr. Burk,” Bob said, “can I ask you a stupid question?”
“Sure. I’m watching Dr. Wallace’s every move and I expect you students to be asking questions, especially during calmer surgeries than this.”
“What causes an appendix to rupture?”
“That’s not a stupid question. If this otherwise insignificant piece of large intestine becomes obstructed or infected, normal bacteria inside proliferate. Inflammation occurs and pus accumulates.” He pointed at a piece of bowel for Dr. Wallace to evaluate and glanced at Annabel.
“Then,” he said, “as the pressure inside increases, it exerts pressure on the wall causing blood flow to be choked off. That causes some tissue to thin out and slowly die due to ischemia. The appendix wall is vulnerable and then it breaks open, spilling all that pus into the rest of the abdomen. You’re seeing the result of that right now.”
Dr. Wallace put the foul appendix they’d removed in a small metal tray and Robby placed it to the side. “How are we doing up there?” he asked anesthesia.
“We’re holding steady only because of vasoconstrictors,” the senior doctor said. “BP is 96 over 56.”
“And antibiotics are in?”
“Absolutely.”
Annabel was rooted to the spot, watching the best of both worlds: her chief resident and the procedure on the right and the sleep doctors on the left. She cringed when Robby or Brandy used the suction catheter in the young woman’s belly and a stream of pus got sucked into the canister.
“Dr. Burk,” Annabel said, “how long does it usually take for an appendix to rupture once it has appendicitis?”
“It varies, but usually in one to three days. That’s why it’s imperative for a patient to seek medical help up front. But what’s worse is, if it does rupture, a patient may feel better for a short time because the original appendix pain may diminish. Meanwhile, an abscess or peritonitis may be developing.”
Annabel shook her head. She still had her appendix and now she knew the pitfalls.
Dr. Gill hooked a blue-labeled syringe onto a stock cock of the IV and pushed in only one cc.
“What’s that?” she asked.
“Fentanyl,” he said.
“What’s that?”
“It’s a narcotic.”
“And what are you doing there?” she asked, watching him dial some kind of round cylinder mounted on the machine.
“Come on around here,” he suggested.
She looked over at Robby, his eyes glued on their work. This was not a case she had needed to scrub for so she didn’t see the harm in going to the head of the table. She walked around the machine, the red anesthesia cart, and over the plugs lying all over the floor.
“This is a vaporizer,” the attending said, showing her the round cylinder labeled ‘sevoflurane.’ This inhalational anesthetic gas is traveling into the patient via her endotracheal tube. But we have it very low right now because of the patient’s low blood pressure.”
“So the higher you go with it, the lower it causes the blood pressure to drop?”
“It’s more complicated than that, but that’s a general statement,” he replied. “Try to spend some time with our department sometime.”
“I think I will,” Annabel said, as she watched.
A board extended from the table where the patient’s arm was appropriately strapped; there were two round sticky pads on her forearm and wires looped between them and the device.
“A nerve stimulator,” Dr. Gill said as he saw Annabel’s curious look.
“What for?”
“In a nutshell, the patient is paralyzed. Using this allows me to monitor that paralysis.”
Who would have thought? But then Annabel remembered learning a bit about muscle relaxants in physiology. She realized how amazing it was being a spectator in the OR. All the dry book material was coming to life not only by being at the head of the table but especially because of her awesome teacher and chief resident, Robby Burk.
Chapter 7
As quietly as she could, Annabel dragged her overnight bag off the top bunk and went into the bathroom. She decided to take a shower; it would make her more alert for rounds. In any case, they would be the first surgery team to leave today because they were post-call and to check out their patients to the next call doctors. She could go home to her cozy little place and crash.
The tepid water soothed her tired muscles and injured pride. The shower stall was an add-on to the bathroom, like a plastic appendage shoved in the corner. But the accommodations were tolerable and she knew she’d be spending time in a vast number of call rooms and bathrooms the rest of her career … provided she got through the two clinical years of medical school and then residency. So far, she hadn’t had a good start.
When she stepped out, she dried herself with a lumpy towel and finished getting ready. She put on a fresh pair of scrubs instead of the change of clothes from home. They were so comfortable, like affording herself the luxury of walking around in camouflaged pajamas.
Annabel took her things over to the office; she had extra time to leisurely see her patients and even have breakfast before rounds. She stepped through the doorway to find Brandy Wallace and Marlin Mack. Brandy slouched in the corner of the couch, her lab coat on as if wearing a buffer from the air conditioning. Marlin sat at the desk wearing an attitude as if he were president of the hospital wing. They continued their conversation when Annabel came in and stowed her bag.
“I’m glad I retook the MCAT a second time the year I applied,” Brandy said. “The first time I tested, I did it for the practice. Anyway, I was accepted with the first application.”
“With me it was a different story,” Marlin said. “I graduated from college, took the MCAT, and tested absolutely fine. Subject scores varied but the average was good enough … maybe the top fifty-percent. But no, I didn’t get in. So I started working. Even took the MCAT again and again.”
“That’s no fun,” Brandy replied. “How many years did it take you to get in?”
“Three. And all that time I had to find jobs and make employers think I was interested in a banking career with my sights set on becoming an officer. Yet all the while I tried to do a little medical volunteer work and maintain my MCAT scores with studying in my spare time.” He swiveled in the chair and glowered at Annabel.
“You got into medical school the first time around, right?” he asked sarcastically.
“What if I did?” she countered softly, sitting next to Brandy.
“Because without a doubt, you did. You prove what I despise about favoritism and it’s outright unjust to people like me. Somebody like you who can’t even derive a plausible assessment of a patient after doing their history and physical gets into medical school immediately.”
Feeling cornered and under attack, Annabel slinked back further, her eyes wider than they’d been all night in the OR.
Marlin leaned forward, his elbows on his knees and began again with a feverish pace. “I know about your father and his reputation. The admission committee of this medical school must have been like, ‘Look who has graced us with an application. It’s the famous Dr. Danny Tilson’s daughter. We better snatch her up before another medical school does.’”
He stopped a moment while hurling her an icy stare. Annabel considered leaving at once but she was too dumbfounded and frozen in her spot.
“You, you spoiled brat, are only here because of nepotism.”
Annabel clutched her fingers into her palm while her heart raced and the skin on her arms tingled from nerves. She felt like the physiology teacher’s description of the ‘flight or fight’ response. Defending her position would be useless with the likes of him; leaving immediately was still an option, but she didn’t have to budge as Marlin got up and stormed out.
As Annabel’s pulse returned to normal, Brandy turned sideways. She raised her eyebrows. But not wanting to get involved, she didn’t say a word.
-----
Much to Annabel’s dissatisfaction, Dr. Pittman attended their early rounds. She learned that he would usually be there for the morning after call because he had to know about the patients they had admitted overnight. He must have a poor opinion of her after her botched-up presentation the day before, she thought. The scariest part was whether his impression would translate into a bad written review of her at the end of the rotation. That could have dire consequences.
All she wanted to do was to go home and bury herself in her apartment. She kept thinking about an expression her grandfather used to say when she was growing up. When he thought she needed to be more emotionally mature, he’d tell her to be “strong like the Rock of Gibraltar.” She had actually done a pretty good job with that, especially after her sister Melissa had died. She had even turned into a bit of a tomboy and had later stood up to her father when it came to her previous boyfriend’s medical care. It must be that medical school is wearing her down, she thought; being the ‘low man on the totem pole’ in the hierarchy of becoming a physician was degrading. She was a scut monkey and had no experience whatsoever in caring for patients. It was far worse, she imagined, than being a first-day intern in a Washington political campaign.
As she trailed behind everyone else in her clogs, she realized no one had prepared her for the ramifications of being a clinical medical student. Was being ridiculed and demeaned by peers normally part of it? It added insult to injury like adding chili powder to hot seasoned food.
They came to the end of the hallway outside of Mr. Newman’s room. As they turned in, Annabel thought again about the Rock of Gibraltar. Better yet, she half smiled thinking about her grandfather. Her father’s father and mother had been beloved by them all, and she’d been fortunate to have them around and as strong influences in her life. She stepped past the other students to the foot of her patient’s bed to muster up the courage to give the team a morning update.
“Good morning, Mr. Newman,” Robby said. “The whole team is here to check up on you.”
Annabel wished she had Robby’s
enthusiasm. Who would have thought he’d been up all night? Where did he get that passion for what he did?
Mr. Newman beamed back. “Good morning to you all, too.” His tray table with breakfast extended over his belly and he kept stirring his coffee.
“Finish your coffee,” Robby said, “and don’t mind us for a moment. Dr. Tilson is going to give us an update on your condition.”
Mr. Newman smiled and dumped another sugar into his cup.
Annabel turned slightly to face Robby and Dr. Pittman. “Mr. Newman has remained afebrile and his last dose of antibiotics went in this morning. He tolerated the soft diet and he’s now on regular food. Labs yesterday were all normal. The GI service was by late yesterday and they suggest a discharge today with a follow-up in clinic within a week.”
“And that means you can take that IV out, too,” Mr. Newman interjected. “I like you and everything but, next time I’m admitted, I’ll have the seasoned doc do the IV.”
“Mr. Newman,” Robby said, “hopefully there isn’t a next time. But if so, Dr. Tilson will be a crackerjack IV-starter by then and you won’t want anyone else to do it.”
“Maybe so,” he said. “In any case, I have to thank her and Dr. Wallace for getting me oatmeal this morning.” He waved his spoon over the brown sugar clumped on top of the oats.
“Enjoy it,” Dr. Pittman said, “because we’ll be following GI’s recommendation to send you home. Dr. Wallace will be getting your discharge orders in this morning. Any questions?”
“No,” he said. “Thanks, doc.”
Dr. Pittman pointed to the door and they went past his roommate watching TV. When they arrived near Sharon Douglas’s room, Dr. Pittman stopped short and grimaced at Annabel.
“Dr. Mack,” the attending said, “why don’t you tell us what transpired since yesterday with our next patient.”
“I’d be happy to, sir. Psychiatry came by and did a full evaluation. They left a short note on the chart but their full report is with dictation and should be available shortly. However, I tracked down the psychiatry resident in charge and we had a long discussion about Mrs. Douglas. His impression, collaborated with his attending, is that she is a full-fledged patient suffering from Munchausen’s syndrome. In the interim, our workup for appendicitis came up negative.”