by Barbara Ebel
“Is your patient still going for surgery today?” Pittman asked Dr. Mack.
“He is,” Marlin said.
“So what are the most common sites of the body for abscesses?” Pittman asked the students.
“This is Dr. Tilson’s patient,” Marlin said. “She should be reading up on this.”
“Dental abscesses are very common,” she said.
“But we’re dealing in medicine,” Marlin said.
“Yes,” Pittman said, “but that’s true. What else?”
“Skin or under the skin,” Annabel added.
“What organisms?”
“Bacteria,” she shot back. “Parasites, too.”
“That’s a good one,” Pittman said. Annabel grinned because she knew firsthand about it from one of her father’s cases … an intracerebral parasitic abscess.
Pittman stepped back, leaned up against the wall, and put his foot up. “Dr. Roth, tell us how an abscess is formed.”
“White cells infiltrate an area of infection,” Da’wan said, “accumulate with the causative agents and damaged tissue, and there’s a fluid buildup.”
Annabel looked at Bob and they both gave each other a bemused smile as the topic absorbed the team’s time. Across from her, Robby seemed preoccupied and not focused on teaching. His soft leather shoes dominated his attention and he occasionally rubbed the back of his neck. She feared his interview had blown up in his face, his weekend had been a waste, or that perhaps more legal papers had arrived regarding Mr. Simmons. But then, what difference did it make to her. She had her own set of problems and priorities. She did, however, miss his charismatic participation and managed to steal a glance now and then at his eyes which today were like a sad beagle being left in a kennel.
Robby looked at his watch. The discussion about an abscess had gone on long enough so he reminded Dr. Pittman that they needed to see Mr. Blair so staff could transport him to the OR. Their attending nodded and the rest of rounds proceeded quickly.
When Annabel and the students were dismissed, Bob said, “Pensive, isn’t he?”
“You must mean Dr. Burk,” Da’wan said, right behind Bob and Annabel.
“You noticed it, too?” Bob asked.
“Annabel must have noticed it the most,” Ginny said. “She watches him the most carefully.”
“Really?” Bob responded, his face crestfallen.
“Does it show that much?” Annabel said to Ginny.
“Duh.”
“I guess guys are the last to pick up on these things,” Bob said. “Here I was thinking Annabel and I could get hitched.”
“Bob, you’re so sweet,” Annabel said. “You are dear to me and everyone on this team. I even bought you something this morning.” She pulled out the espresso chocolate box and, after ripping the bag open, she dropped some into his hand.
“Thanks. This means you do think about me. There’s hope.”
“Thanks for your understanding. Don’t worry, this little girl’s crush I have on Dr. Burk will end up being a passing infatuation.” They sidestepped a patient and therapist and, as they slowed, she touched his sleeve. “Now you know one of my most intimate secrets. I hope you can keep it to yourself.”
“Mum’s the word. I can’t imagine what your other secrets are if I didn’t even pick up on this one.”
He wouldn’t even believe what she did in some of her spare time, she thought.
-----
After Wilbur Gill and his attending doctor put Gustavo Blair to sleep, everyone pitched in to help. Wilbur safeguarded the patient’s endotracheal tube, Robby and Marlin helped lift and gently flip him, Annabel helped hold his feet and the circulator moved the stretcher as soon as he was on the OR table. They positioned the patient to pad his pressure points and for best exposure of his buttock abscess. And the abscess was a doozy. At least the size of a baseball, Annabel could not even imagine how it had fit in Mr. Blair’s clothing or how he walked with it. Why hadn’t he seen a doctor sooner? But that was a common issue: the bizarre medical problems people allowed to get worse before seeking medical care.
As the surgical site was cleaned with isopropyl alcohol and povidine iodine, the team scrubbed and gowned. Robby then leaned against the drapes and tapped the huge mass to confirm its soft consistency. He looked across the table directly at Annabel. “This isn’t going to be pretty.”
At least he said something, she thought, but his words were understated as the tech handed him a surgical blade and he made an incision in the burgeoning ball of pus. Marlin held a steel pan, ready for the jet of green, putrid fluid which shot out and continued as the size of the abscess began to shrink.
The smell not only filled Annabel’s nostrils but the coffee she had drunk earlier filled her mouth and she swallowed hard, determined not to upchuck into her mask.
Marlin handed the tech a sample in a container for identification of the bacteria in question and Annabel knew it would determine their selection of antibiotics.
Robby began cleaning out the drained cavity while the tech stacked gauze near the edge of her tray table for him to pack the space.
“Annabel,” Wilbur said, “do you have any more ideas after our discussion the other day?”
“I’ll tell you later,” she said. She looked at Robby who squinted his eyes at her; Marlin cleared his throat.
“Okay, this is a wrap,” Robby said after packing with iodinated gauze pieces. “Let’s get Mr. Blair turned and on a stretcher. Dr. Gill, I hope you can extubate him here. And let us cross our fingers that this patient has no crazy incidents postop. No more morbidity and mortality!” His voice turned sterner. “And Dr. Tilson, I want to see you immediately in my office.”
Annabel gulped. As she held Gustavo’s feet to help turn him, Marlin smiled under his mask and gave her a thumbs down when Robby wasn’t watching.
She wished she could pour some of the abscess drainage into a cup and serve it to Marlin as fruit juice.
-----
Annabel stopped in the rest room. Her bladder was full but, in addition, the fear of facing Robby made it feel like it was going to burst. She washed her hands and heard a faint ding on her cell phone. Hoping above all that it was her father who had sent her a message, she checked the incoming text. As busy as he was on a Monday morning, his name showed up at the top. If he had found out anything from the anesthesiologist on his tumultuous case, she would be grateful.
She read the message before swinging open the door: Good morning. Had a quick talk with anesthesiologist re: Saturday’s case. She used rocuronium bromide - an aminosteroid. Hope this helps. Keep me posted. Love, Dad
Yes, she thought, this helps. But how, she wasn’t yet sure. She tapped across her phone: Thanks, Dad. Love you back.
-----
In his office, Robby realized he had been duped. Marlin may sometimes be offensive, but he had not misled him about Annabel going into the anesthesia office. And that was after Robby had told her to concentrate on surgery. How many fictitious stories had she told him?
“Close the door,” Robby said when she arrived. She did what he asked as he folded his arms in front of him and continued, “I was willing to give you the benefit of the doubt after our last talk but it appears your interest still lies with the anesthesia department and not on this rotation. Your final exam needs to be passed but, other than that, are you deliberately trying to make your chief resident and attending give you a poor clinical score? Don’t you know that a student’s attitude and interest in his or her work and patients is part of what we look at?”
Annabel stood frozen. Clearly he was fed up with her.
“Dr. Burk, I realize that and I may not be able to dig myself out of a hole and pass. You must think so poorly of me and mistrust me that there is nothing I can do or say to make you understand. A doctor’s Hippocratic Oath mentions that the prevention of disease is preferable to a cure. That means the prevention of morbidity and mortality which goes along with understanding what might be causing it.
That’s what I was doing. Can’t I be a detective of the losses both departments have suffered and do it on my own time without getting into trouble?”
Robby sighed. “Why is it that you are a thorn in my side? Okay, sit down and explain to me what this is all about. And what do you mean by the losses of both departments?”
“That’s what started me thinking. By talking to Dr. Gill, we came to realize that the recent rash of deaths were both surgery and general anesthesia patients. Then there are differences which allowed us to rule out particular pharmacology which could have been involved and yet similarities in all the deaths like a certain class of neuromuscular blockers that they all received. Maybe all the patients had a respiratory arrest because of residual blockade within the first twenty-four hours. Yet, that doesn’t make sense,” she said, thinking aloud, “because in anesthesia’s opinion they were breathing fine enough to extubate.”
Robby listened and by the time she stopped, he had unfolded his arms and slid to the side of his chair. With an elbow on the armrest, he put his head on his hand.
“I know it sounds crazy, but my father and my paramedic uncle have had strange patient deaths in Nashville, too. Deaths after surgery, like the patients went dead still later on,” she added with steel determination. “I asked my dad to make an inquiry and I just heard from him. The anesthesiologist used an aminosteroid like the cases here.”
Robby raised his eyebrows. “When you string this all together, it does seem like more than circumstance. And you found out that anesthesia’s M&M is up like ours?”
“Yes, sir. And their department was presenting Dolores Vega like you were for their M&M conference.”
“So where do we go from here?” Robby got up and paced the floor.
“I’m sorry I’ve been a problem on top of a problem, especially since you are at crossroads in your own life with trying to land that foreign job. I hope your weekend was successful.”
“I meant, where do we go with these ideas and the information you have pieced together?” He stopped and sunk back into his chair. “Anyway, the weekend had a bad outcome and perhaps a good outcome.”
Annabel tilted her head and held her tongue as it sounded like his philanthropic goal was not to be.
Robby gave a small smile. “They welcomed me on board for the assignment in Africa.”
“Congratulations! That’s fantastic.”
He rubbed the back of his head and replied, “But I’m worried that the pending lawsuit with Mr. Simmons may somehow interfere with my departure next summer.”
“Depositions can proceed quickly, and maybe the suit can settle or a judge will give allowances because of the nature of the position you’re undertaking.”
“That’s what I’m hoping. I have to run that by the attorney.”
“Dr. Burk, if it were me, I wouldn’t be thinking that the weekend had any bad outcome.”
Robby’s face soured and he cleared his throat. “I wish that were true; however, it took a toll on my personal life. It appears my fiancée has broken our engagement because of my ‘selfish decision.’” He did an air-quote as he spoke the last two words of his sentence.
“Like I said, in my opinion, I don’t think your weekend had any negative outcomes. It worked out in your best interest.” Regardless of her own feelings for him, she was happy for his next job and gave him a warm, sincere smile.
“Hmm,” he mumbled, thinking over what she said.
The atmosphere in the room became uneasy and unsettling. He didn’t know what to do about this student, especially since Dr. Mack kept hurling complaints about her to him. And the grievances were like glitter; they wouldn’t go away … four days later, he was still trying to make them disappear.
He looked at her and Annabel returned his gaze. A big mistake because those brown puppy-dog eyes melted her senses and Robby quickly got out of his chair.
“Now, back to the other …,” he said. “You have given some deep thought into the deaths we’ve had on this service. I can’t fault you for that, Annabel.”
It was the first time she had heard him use her first name, not something he would do around the team and it warmed her heart. Maybe his attitude toward her was changing and he’d go easier on her.
Robby noticed a stack of mail on his desk and realized it was about time he heard back from the doctor working on Mr. Simmons’ autopsy results; there were also reports still pending for rarer laboratory blood work. He took a deep breath, then exhaled loudly.
“We don’t know yet about the rest of the blood they were going to analyze,” Robby said, for any uncustomary compounds, legal or illegal drugs, or other anomalous substances like organisms.”
He reached for the phone and dialed. “This is Dr. Burk. Is Doc Martin there?”
Annabel wished she could hear the entire conversation. As if reading her mind, Robby hit the conference call button.
After a few moments, a creaky voice came on the line. “Dr. Burk, did you get Mr. Simmons’ report that I sent you? Interdepartmental as of yesterday.”
With a start, Robby spread out the mail pile and clutched at an envelope. “It’s here but I didn’t know,” he said. “What can you tell me, if anything?”
“Very odd finding. A first for me, that is, for any patients I’ve ever had on my death table.”
Robby and Annabel waited for clarification as they shot each other a glance. “I can’t even proceed to guess,” Robby finally said.
“Ah, yes, and how could you? You are the doc with the skilled hands working on the living. I may make a mess with my sloppy wretched hands and no one will fault me for that. Do you know that I carry no malpractice insurance?”
Annabel rolled her eyes and Robby chuckled.
“No, I didn’t know that. Will you tell me or shall I open your report?” Reassuring him as to his importance, he said, “I have another doctor here and we take utmost interest in whatever you may have found.”
“Wonderful. Ahh, yes. Your patient had a non-depolarizing neuromuscular blocker in his system. The compound was intact. There had been no metabolism of it.”
“Oh my God,” Annabel blurted out. Robby simply stared at her, his mouth agape.
“Yes, whoever you are there,” Dr. Martin said. “A horrible way to die being paralyzed while awake, which is what I’m assuming happened.”
“Dr. Martin,” she said, “I am Annabel Tilson, one of the medical students. Can you delineate what class of neuromuscular blocker it was?”
“Of course, young doctor. It was an aminosteroid.”
Annabel leaned over the desk with relief; at least maybe now they were getting somewhere. Robby put his hand on her shoulder as if congratulating her for her investigative persistence.
“Aren’t you going to ask me which one?” Dr. Martin asked.
She nodded at Robby and spoke again. “That was my next question.”
“It was rocuronium bromide.”
Chapter 22
Annabel and Robby finished the call with Dr. Martin and stared at each other.
“What do we do now?” Annabel asked.
“Good question. I’m no more knowledgeable about drugs and their possible serious consequences and what to do about them than you are. But you’ve figured things out so far pretty well on your own.”
“I just thought of something. Our patient, Mr. Blair. Do you mind if I go check up on him? Knowing what we know, he may be at that vulnerable time in PACU for a bad outcome.”
“Let’s go,” Robby said. They both went out the door and hurried to the PACU. “And let’s put our heads together, too. I’ll make some calls today and arrange for a meeting tomorrow with the chairman of the surgery and anesthesia departments. We’ll be here all day on call; maybe we can brainstorm this problem.”
They pushed through the double doors and headed straight for Gustavo Blair who looked concerned when they both stood on either side of his stretcher.
“Hi, docs. How’d it go? I’d be lying to say that my butt
doesn’t hurt.”
Robby scanned the monitor at his vital signs and Annabel sighed with relief.
“You surgery went fine,” Robby said. “We’re just checking on you.”
“Bet it wasn’t a pretty sight,” Mr. Blair said.
“That was for us to deal with. Now it’s up to those IV antibiotics to start kicking in while we wait for confirmation of the bacteria and what antibiotic it responds to. Most likely, we’re covering it with what we’re giving you in the interim.”
“Fine by me.”
Robby motioned with his head for Annabel to follow him. At the nurse’s desk, he summoned the three PACU nurses. “I have a request,” he said, “and it doesn’t mean you all aren’t doing a fine job. There is a little issue we are going to be looking into so, in the interim, please watch all PACU patients extra carefully. No leaving them unmonitored at all and be alert if anyone is struggling for air. Call anesthesia first and then me.”
“Even if it’s not your surgical patient?” one of them asked.
“Yes, even then.”
He glanced over at Gustavo one more time and they left.
“I have another idea,” Annabel said. “What if … what if the drug manufacturer conjured up bad lots of neuromuscular blockers that went out en masse to multiple facilities or geographic regions? Maybe that’s the problem. They’d probably all have the same lot numbers on them and/or expiration dates. Drug companies have to keep track of that stuff.”
They walked to the elevator and Robby hit the down button, then looked at her. “That didn’t even enter my mind. It seems you’re smarter in practice than when you take your tests.”
“No, maybe not. I just see that quite often on the social apps I follow. Like docs on Twitter who tweet about food and drug recalls.”