by Barbara Ebel
Jordan stopped texting, slipped his cell into his pocket, and wrapped his fingers around the donut and napkin he had put on his lap. “You should be glad I’m around too.”
Annabel waited for Jordan’s explanation as to why, but none came.
“Dr. Tilson,” Donn said, “you’re as brainy as the best of them. You have proven that to all of us.”
“I wouldn’t go that far.”
Donn finished, eyed the remaining five donuts left in the box, and noted his students’ and residents’ cheery expressions. “Let’s go see patients like we’re supposed to.” He walked out the door with lazy steps, giving them all plenty of time to gulp down their last bites.
Annabel paired with Bob in the hallway as she tried to sort through her index cards. “Are your legs sore from our run yesterday?”
“I’m not sure. I’m a little lackluster as far as energy goes, but the run and Pete’s was worth it.”
“Guess who I was just texting with back there?” Jordan asked, butting in from behind.
“I guess you’re referring to my little sister. Otherwise, you wouldn’t mention it.”
“She’s not little to me. She has no classes on Friday and she’s playing hookey on Monday, so she’s coming up for the weekend.”
Annabel gulped. As long as Nancy and Jordan didn’t get in her way. Studying and silence in her apartment came first. Although she was guilty of scheduling a date with Dustin on Friday night, she could rationalize that; she was more and more looking forward to seeing him and, besides, it would give her an excuse to break away from her own social app search for reasonable flings.
“She must see something in you,” Annabel said and exchanged glances with Bob. She rolled her eyes without Jordan noticing.
Donn stopped short and the students scrambled to gather all their patients’ charts and stack them. After they rolled the cart down the hallway, they saw Bob’s COPD patient, whose difficulty in breathing had improved. Next, they stopped outside Meagan Helm’s room.
“Annabel, would you like to give us an update on Mrs. Helm?” Chineka asked.
Annabel nodded. “Dr. Watts helped me to understand mitral stenosis like it was a plumbing project.”
“The circulatory system is about plumbing,” Donn said. “The blood has to travel to where it’s supposed to be to supply oxygen. If there’s a leak or a blockage, then the cells suffer from hypoxia.”
“Her echocardiogram yesterday verified mitral stenosis and an enlarged atrium,” Annabel said, “but labelled as ‘mild.’ Her ejection fraction, or the amount of blood pumped out of the ventricles with each contraction, is basically normal.”
“Explain the plumbing to me, Dr. Tilson.”
“Like an obstruction in a pipe, pressure mounts in the area before it, and if it were malleable, it would dilate with the pressure and the volume. So if the valve between the left atrium and ventricle is clogged or stenotic, then the pressure in the left atrium will increase, leading to left atrial dilation … which could lead to pulmonary hypertension, which you alluded to the other day.”
“You enlightened us with a commendable presentation,” Dr. Schott said. “So we are all faced with thought-provoking questions. What is a big risk for a patient with mitral stenosis and atrial fibrillation? Should Mrs. Helm be treated with anticoagulants? What would be the risks and benefits?”
Donn’s glance veered to Chineka, so she spoke up. “Patients with atrial fibrillation run the risk of developing an atrial thrombus, which is a blood clot that remains attached to its place of origin. However, if it dislodges and travels, it’s called an embolus. An embolus can then get stuck in a dangerous place, such as in an artery to the brain, pinching off blood flow to needed tissue. That would result in the patient suffering an ischemic stroke.”
Chineka held the students’ attention as an orderly passed with a stretcher, so she continued. “Anticoagulation reduces the risk of ischemic stroke because it decreases the ability of the thrombus to form in the first place. However, treating a patient with an antithrombotic anticoagulant such as warfarin increases their risk of bleeding.”
“Well put for the students to understand,” Dr. Schott said. “I’ll take it from here. There are tools we can use to assess risk scores to help us determine whether or not to anti-coagulate a patient, but they are not highly predictive. It comes down to us as physicians to assess each patient individually and use our clinical judgment.
“As far as a bleeding risk from anticoagulation, Mrs. Helm’s age of forty-seven makes her a significantly lower risk than, for example, a seventy-year-old. And her history makes me lean towards not initiating anticoagulation. She does not have hypertension, diabetes, or congestive heart failure. She does not have chronic atrial fibrillation and has no prior history of a stroke. Also, she’s not older than seventy-five. We can iron this all out for her with a layperson’s understanding of risks and benefits, but I’m going to suggest no oral medication. We’ll follow her in clinic and check her heart rhythm when she comes in for her appointments.”
Donn waited for any input from Chineka, since she was the resident on Mrs. Helm’s case. Dr. Watt nodded in agreement.
“Let’s go in and explain the situation to her,” he said.
Mrs. Helms greeted the team with a bright smile when they paraded in and gathered around her bed. “Dr. Watt explained the test results to me,” she said. “My understanding of my heart problem is that it could have been worse.”
Donn fiddled with his mustache. “Yes, your mitral stenosis is mild and we’ll watch you like a hawk in clinic.” He sat down on the edge of her bed. “Anticoagulation is always a possible treatment for patients with atrial fibrillation, so I’m going to explain to you why we’re not recommending it in your situation. And if you agree, Dr. Watt can write out your discharge orders so you can get out of here and spend time with those three grown kids of yours.”
CHAPTER 8
Jae left a voicemail for his partner, caving in to the fact that he shouldn’t be working.
“Don’t worry about a thing,” the petite ranger said later as she stood in his cabin doorway.
“You should have taken off a few days ago,” she barked as he leaned over the counter.
“I’m going to call a part-time ranger in for the day as well as another volunteer. This park was functioning well before we arrived here and will continue to do so with or without us. Regardless of any sick days we need to take.”
Patty frowned at him like she was scolding an elementary schoolkid. She held her hat and her uniform looked like it had been pressed twice.
Jae managed a small smile and shook his head. “You’re right, as usual. Don’t mind if I say this because I’m not being sexist. You’re my first woman partner and I’m the first to admit that you, or possibly any woman, is more devoted about looking after the health and well-being of a partner than any man would be. A male counterpart would now be wondering why I’m not sucking up to my job no matter how lousy I feel.”
Patty nodded. “Women earn the top trophy when it comes down to common sense and practicality.”
He popped a slice of wheat bread in the toaster. “I better eat something. Perhaps tea and toast.” After turning around, he dumped his coffee down the drain.
Patty stepped over and placed down her hat. She grabbed a tea bag from the cupboard.
“One more thing,” Jae said. “Twist isn’t feeling well. He vomited this morning and looks like a cat dragged him in.”
“I should say.” She pushed her bangs off her forehead as Twist’s lethargic gaze peered up at them with the mention of his name. Not far from his paws, a full bowl of dog food lay untouched.
The sound of nails on the wooden floor came from behind them as Curley trotted in from the porch. He pranced over to his best friend, but he plopped on the floor when he found Twist not his spunky self.
“I haven’t fed Curley yet,” Patty said, “so he might as well have a go at Twist’s breakfast.”
&
nbsp; Curley didn’t wait for Jae or Patty to give him an “okay.” He spotted the kibbles, began chomping them up, and, with little chewing, swallowed one mouthful after the other.
“You are busy enough,” Jae said, “but maybe one of us should bring Twist to the vet.”
“Not you.” She gave him a firm stare. “The animal hospital has a vet stay late every day to 8 p.m. and then he or she stays on call. I’ll take him after work.”
Jae sighed with relief. “Thanks.”
“No problem. The dogs are part of the operation around here. We can’t ignore their needs.” She crouched down and rubbed her fingers into Twist’s coat. The dog opened his eyes and stared at her until she stood back up.
The microwave with a mug of hot water beeped as Jae buttered the toast.
“Text or call me if you need me,” Patty said. “If I don’t’ see Twist this evening, I’ll come by and get him.”
-----
Patty was the last one out of the visitor’s center at the end of the day, so she locked up behind her. She had not heard a peep from Jae, nor had she seen the dogs.
She lightly rapped on Jae’s door and inched the wooden door open when there was no answer. Lying on his side on the couch, Jae looked the picture of tranquility with his mouth semi-open; he wore comfortable cotton pants and a T-shirt.
She surveyed the room for Twist and found him beside the wall near the front door. As she walked over, she had to step over another pile of his vomit. She debated whether to clean it up and possibly disturb Jae, but she realized that the priority was Twist’s visit to the vet. After wrapping her fingers around the dog’s collar, she urged him up and out the door and then lifted him into her truck.
The female ranger and the mixed Shepherd soon visited the local veterinarian’s office where a young doctor filled two vials with Twist’s blood and recommended that the dog stay over for hydration and for test results, which should be ready by the morning.
-----
Inside the clinic, the students and residents huddled around Dr. Schott, who sat on a plastic chair peeling Saran Wrap off a homemade peanut butter and jelly sandwich. He grinned up at them. “Unlike the six of you, I had a department meeting at lunchtime and missed lunch.”
“I heard they sometimes serve food at those meetings,” Dr. Burg said, suppressing a smile and admiring her soft leather heels.
“You’re not to supposed to know that. But in my defense, the two platters in the middle of the conference table had more donuts. Can you believe it? Just the day that Bob treated us to the same thing. I think I’m going to roll out of here tonight full of bread flour and yeast.”
Most of them laughed and Stuart added, “You’re going to need milk of magnesia tonight.”
“Stuart!” Melody exclaimed. “That’s more than we needed to hear.”
“I don’t mind,” Donn said. “He’s correct. My GI tract may be devoid of any wavelike movements the rest of the week and the contents of artificial flavors and bread flour may end up sticking to the muscles of my intestines.”
“Yes,” Jordan said. “This is more information than we need.”
Bob grabbed a nearby chair and sat next to their chief resident. Annabel wondered why he wasn’t smiling. Normally, he’d also be adding to the humor of their conversation.
“Yes. Let’s drop talking about my eating habits. No more donuts for me for the rest of the rotation … except for once. I’ll bring them in the last day. Maybe.”
A medical assistant peeked her head out from the front desk. “Uh, are you all going to start seeing patients? All the rooms are full and the waiting area is soon going to become standing room only.”
Donn sprang up, reattached the plastic wrap around half his sandwich, and placed it on the counter. “Dr. Watt and Dr. Burg will each accompany a student into a room and the other two students can go see a patient and then come report them to me.”
Everyone grabbed a folder from outside an examining room. Annabel opened hers next to Bob. “Is something bothering you today?” she asked.
Bob shook his head and glanced at her. “Except for being tired, nothing is wrong.”
“Okay, but if you need to vent about something, I’m a good listener.”
Since they weren’t on call last night, Annabel wondered about him being tired. A busy night, perhaps? A new girlfriend and overnight bed partner? She chanced asking him, as timidly as she could.
“Is there a new girlfriend who wreaked havoc on your sleep last night?”
“I wish. No. I’d be smiling if that were the case.”
Bob opened the chart in front of him and Annabel flipped hers open as well. She had picked up her favorite inpatient’s chart. May Oliver had been discharged recently; an appointment so soon didn’t make any sense.
With a solid knowledge of her patient’s personal and medical history, Annabel only glanced at the reason for her visit. She adjusted her stethoscope around her neck, smoothed the waves of hair hanging alongside her white collar, and went into May’s room.
“I’m glad to see you,” Annabel said after opening the door. “The morning hospital rounds are not the same without you, but I’m happy you went home.”
“Aw. That is sweet of you to say so.” May sat on the exam table; her hair was still mostly shaven off. It had looked terrible and sparse from chemotherapy for her lung cancer and metastases, so May went ahead and shaved most of it off to make it more sculpted and neater. The end result defined her attractive yet thinned-out face, and large emotional eyes.
May reached out to Annabel’s hand and squeezed it. “I am not much use anymore to anyone. But I do tell people how I am helping a young medical student learn all about lung cancer.”
“Don’t say that. You are more useful than you think and I have learned more medicine because of you, but I would trade it all in if we could eliminate your cancer and suffering.”
May gave Annabel’s hand another squeeze, let go, and then rested her listless hand on her tan trousers. “Another hundred or two hundred years from now, human cancer may only be in medical history books. Anyway, I’m here now with the diagnosis and there’s nothing we’ve tried that makes it go away. I thought your team could help me, however, with the new cough and runny nose I seem to have acquired.”
Annabel glanced at her recorded vital signs. They were fine except for a low grade fever. “Are you still coughing up blood?”
“No. Some of what I’m coughing up is greenish as well as what I blow from my nose. It started the day after discharge.”
“Sounds like an infection, but we’ll check with Dr. Schott. Your immune system is not up to par with all the chemo and radiation you’ve had thrown at you, so I wouldn’t be surprised. You were also in the hospital, which is not a good place for an immunocompromised patient to be as far as picking up germs.”
Annabel examined May: her lungs and heart with her stethoscope, her abdomen by palpation, and her eardrums with an otoscope. She opened the door and peered up the hallway. She signaled to Dr. Schott when he saw her.
“May Oliver is here,” she said.
Donn came in, and after listening to Annabel’s synopsis of May’s visit and her physical exam, he agreed with her tentative assumption. He sent May for an X-ray and confirmed an infection.
They walked back into May’s room. “Here,” Dr. Schott said, handing her a prescription. “You have an infection, so we’re putting you on an antibiotic for ten days.”
As May dressed, Donn and Annabel left the chart at the front desk. Donn grabbed the other half of his sandwich. “You handled her visit like a pro,” he said.
“I am worried that one of these visits will be her last.”
Donn’s expression soured. “I agree.”
“I said a prayer for her a month ago. I’m going to do it again. I’m not the religious type, but if anyone deserves a blessing, it’s her.”
-----
Although late-day rounds back at the hospital proceeded like clockwork, Annab
el had too much scut work to do. By the time she called for a ride home on her cell phone app, she was impatient to be home. She spotted the scheduled driver outside the revolving doors of the hospital within five minutes and jumped in the back seat.
The GPS started immediately as the driver headed out of the parking lot and glanced in the rearview mirror. “Busy day?” he asked after Annabel let out a big sigh.
“With little exception, every day is hectic.”
“Ain’t that the truth. I just got off my day job, will drive you, and then attend to pressing matters at home.” He wore a leather jacket and a dangling, unilateral earring. Soft, soothing classical music streamed from his iPhone.
“You sound like a hard worker.”
“I usually take on a few rides after work for supplemental income. I have a twin brother who lives with me. He’s unemployed at the moment, not by choice.” He became silent and Annabel became curious.
“Is he an identical twin?”
“Like a mirror image.”
“Wow. I bet you both play pranks on people.”
“We pull some winners.”
“I have young twin cousins – a girl and a boy.”
“Unlike my brother and I who are monozygotic twins, your cousins are fraternal twins from two separate eggs fertilized by two separate sperm.” He smiled into the rearview mirror.
“Few people know that kind of embryology,” Annabel said, surprised. “I guess folks who do are twins themselves.”
He nodded. “I was premed for a while and studied my ass off. Had to give up the idea and go to work after college.”
“Maybe that was a blessing in disguise. I’m in my junior year and the years still to come are daunting.”
He stopped at a light and glanced back at her. “Are you going to become a family doctor like a lot of females or an orthopedic surgeon like most guys?”
“That does sound stereotypic, but I haven’t a clue. So far, I’m liking all my rotations.”