by Barbara Ebel
“Stuart, thanks for the synopsis on symptoms,” Donn said. “Now let’s go round on our patients.”
He pulled ahead of all of them and spoke over his shoulder. “Annabel, hunt down Dr. Enno and tell her what you heard.”
CHAPTER 25
Annabel wrote updates in her patients’ charts after rounds and kept her eyes peeled for Dr. Enno. When she went back to the unit, she found a note from the infectious disease specialist on Jae’s chart. She had missed bumping into her, so the next likely places in the hospital were the doctor’s lounge or the cafeteria. More attendings and residents filtered in and out of the doctors’ lounge during the day than medical students.
Annabel never visited there very long, but she wished she could. Conversations often focused on the care of doctors’ current patients. Listening was an educational experience; she yearned to be in their shoes.
Even though Shania Enno sat facing the other way, Annabel knew it was her from the bun in her hair and Alejandro slanted alongside her chair.
“Dr. Enno, do you have a moment?”
“For a medical student? Always.”
“I noticed you went by to see Jae Nixon. I have information from his co-worker which, I believe, none of us knew.”
Shania’s slow hand picked up her cup, but her smile faded when she peeked in the bottom.
“Serve yourself from the counter over there and, if you don’t mind, fix me an herbal tea. Come back and we’ll discuss our patient.”
“Sure thing,” Annabel said warmly. The spread of bagels and fruit proved perfect since her stomach was running on empty except for coffee. She dropped a cinnamon spice tea bag and hot water into two different cups, made herself a small plate, and bused them over to Shania’s table.
“The young ranger’s brain swelling is under control,” Dr. Enno said, “and your crackerjack medical team is managing his respiratory support and IV fluids like a champ.”
“Dr. Enno, I worry every morning I step into the ICU that he’s taken a turn for the worse. I’ve heard of patients spending months on a ventilator in an ICU. How do medical care providers and families maintain their optimism under such conditions?”
“People in our modern society have lost the ability to be docile and tolerant of situations they cannot control. Under the scenario you speak of, they must unwillingly adapt and practice enormous patience.”
Annabel nodded as the older doctor steeped the tea bag and pulled a single packet of honey from her pocket.
“Now, what did you hear about your patient?”
“Before Jae Nixon initially came down with flu-like symptoms, he was bitten by a tick during a deer-hunting expedition.”
Shania stirred the honey around in the cup while processing the missing part of Jae’s history. “In some cases, ticks are the size of a pinhead or a watermelon seed. It depends on whether it’s in the larva, nymph, or adult life cycle.
“Certainly, one of them could have injected Mr. Nixon with an infectious agent. This is an important piece of information.
“And most cases of meningitis are caused by viruses. Which is so critical, because meningitis accounts for one of the more important causes of hospital admissions.”
“My dad’s a neurosurgeon, so I’m always interested in the brain; from the neurology and medical aspect as well as the surgical standpoint.” Annabel opened a pat of butter and began spreading it on a bagel. “You went straight to talking about ticks transmitting viruses. Yet our absent medical student has Ehrlichiosis caused by a tick transmitting a bacteria, not a virus, and this morning, our medical team also talked about Lyme disease, a tick-transmitted bacterial disease.”
Shania gave her a half-smile. “Then your group is keeping up with the times. This gives me an idea. Are you aware of who the department asked to give grand rounds in the near future?”
Annabel paused, took a bite, and shook her head.
“I will be the speaker. Although I had a topic in mind, now it will be something entirely different.” She wrapped her hand around Alejandro and clicked it once on the floor. “I don’t know if ticks are our tiniest threat, but for the purposes of my discussion, they will be.”
Annabel raised her eyebrows. She wished she could sit with the woman the rest of the day.
“My talk will be called ‘Our Infinitesimal yet Colossal Danger.’”
“I won’t miss it, Dr. Enno.”
“So, back to Jae Nixon. Fortunately, the CDC does not put me on hold when I call, so I will talk to them soon, as well as our state health department.”
“What should I tell Dr. Schott and Dr. Burg?”
“Supportive care is of utmost importance. Dr. Schott understands that. I will get us a diagnosis if it kills me, zone in on any other possible curative treatment, and you fine doctors will keep him alive.
“And the next time Mr. Nixon’s co-worker is here, let me know. I’d like to talk to her.”
-----
At the end of the day, Annabel veered home to her apartment instead of straight to Bob’s. She repacked but, more than that, she wanted to stop at the corner café.
“Hey, Pete,” she said at the counter. “I want to surprise my friend Bob with something light yet nutritional.”
“What about a ‘take two?’ Half a sandwich and a cup of soup?”
“How about two grilled cheese sandwiches and tomato-basil soup that we can share?”
“Are you finally dating that young man?” Pete turned and handed the order through the door to the cook.
“Bob? No, but I’m dating the policeman again that I dated a few months ago.” She picked up a box of chocolate espresso beans as well as a box of chocolate-covered blueberries from the bin in front of her. “I’ll share these with Bob as well.”
“Seems like you share a lot with him. Bob, that is.”
“Yeah, well, right now, we don’t share our medicine rotation. He’s hung up with a disease from a tick. Thank God he’s been diagnosed and on his way to recovery. The lives of medical students are fragile; one wrong turn and our education blows up in our face.”
“College students can suffer the same fate.”
“So true. My college boyfriend in our last year suffered a concussion, his schooling was terminated, and it took him a long time to get back on track. We split up too, because our lives went in different directions. At least we’re still friends. As a matter of fact, I could count on him in a pinch just like I can with Bob.”
Pete stirred a long spoon in a paper cup and handed the drink over the counter.
“What’s this?”
“On the house.”
“A mocha cappuccino. Thank you.”
Pete soon packed up Annabel’s order and said, “Tell Bob I said hello.”
Annabel held the cup carefully and the bag in her other hand. She wanted to sit on a bench against the wall and sip on the hot drink but, more than that, she wanted to hang out with Bob.
-----
At Bob’s apartment, Annabel showed up first with the food. “I’m hoping your appetite has improved today,” she said while checking him out. His hair was less messed up than yesterday and a small pile of folded clothes was on a chair behind him.
“I’ll take these while you go back to your car.”
When Annabel entered again with her bags and books, he was pouring orange juice into a juice glass.
“What a day,” she said. “But, first, how are you?”
“I’m still very tired, but it was the first afternoon I didn’t feel like I was hit by a train and left for dead. I washed a small load of laundry.”
“Wow. You’ve made progress … like going from an ICU ‘critical’ condition to ‘stable.’”
“I won’t be joining you for any marathons, however.”
“Don’t worry. I’m not up to speed either.” She smiled at him and pointed to a chair.
“I did hear from Dr. Raymond’s office today,” Bob said as he sat. “They were called about the Ehrlichia IFA results e
arlier than they anticipated. Sure enough, I tested positive. Leave it to me, I passed the disease’s gold standard laboratory test.”
“Bob Palmer, that’s not a surprise. Hallelujah that you are already being treated for the correct diagnosis.”
“Then we should celebrate,” he said, “with a grilled cheese.”
“And our flavored champagne tonight is tomato basil.” She pulled the Styrofoam container out, warmed the soup, and then ladled it into two bowls.
“So what happened today?” he asked.
“There’s more to tell you today. I didn’t want to overload you yesterday.”
“I’m listening. Any juicy gossip?”
“Dr. Schott is anxious and Jordan is his usual self. I’m glad he’s obsessed with iPhones.”
“If he lived in New York City, he’d be like one of those people you see in videos. Walking along and not seeing where they’re going. Bumping into taxis and pedestrians rushing along on the sidewalks.”
“He’d never make it in that city. He’s just a small fry with a big attitude. I wish he was the one who took the run with me. A tick needs to take a bite out of him.”
“Feisty today, are we?”
“Maybe so. Anyway, getting back to what’s important. My patient, May Carter, came into the clinic the other day. Remember her?”
“Absolutely.”
“She followed through with everything modern medicine had to offer to no avail. The metastases from her lung cancer are choking the quality of her remaining days to being intolerable. She refuses admission to the hospital again and I’m sure that was the last time I’m going to see her.”
“I’m sorry. For her and for us too.”
Annabel took the last sip of the cold cappuccino.
“And the female ranger friend of my ICU patient came by this morning and told me that he was bitten by a tick.” Her eyes shot over to him. “Yeah, just like you. But he was hunting deer.”
Bob’s mouth fell open. “I’m glad I’m not as sick as he is, but I don’t have venison to show for it either.”
“Spare the hunting, please. Don’t get me started on my opinion about killing beautiful animals like them.”
“Uh, oh. I won’t. What does Dr. Enno think?”
“Your Dr. Raymond said that your case was a reportable tick disease. Dr. Enno is also going to talk to the CDC about Jae Nixon. Since we’ve narrowed it down to a virus, which one, transmitted by a tick, can put a previously healthy, non-immunocompromised person on death’s door?”
A shudder ran through Bob as he held half the sandwich.
“Before I forget,” Annabel added, “she’s going to present the next grand rounds. Your energy needs to ramp up so that you can attend. Can you imagine a doctor in her seventies teaching young medical students the latest on CDC-reportable vector diseases?”
“I’ll probably be dead when I’m seventy.”
She squinted her eyes. “We’ll make a deal. Neither one of us should die before eighty.”
“Will we still know each other?”
“With Facebook and other social media, it’s difficult to lose touch. Plus, there will be medical school reunions to attend as well.”
“So true. Plus, we may work in the same town.”
They both made progress on the food Annabel brought and she rummaged through the bag for the boxes of chocolate-covered treats. “Dessert,” she said.
“What about your sister, Nancy? Still no word?”
Annabel shook her head.
“How about if I text her?”
“She liked you when you came home with me … when Dakota died. I didn’t tell you that before. Her interest then became diverted to Jordan and we both know how that ended.” She rolled her eyes and popped a chocolate in her mouth.
“She had a crush on me?” he asked mischievously.
“You scamp. You’re not supposed to return to your normal behavior this quickly.”
He shrugged his shoulders and inched his hand forward for her iPhone. “Do you mind?”
“Go ahead.”
Bob found Nancy’s number and texted.
Yo, Nancy. It’s Bob, Annabel’s friend. We’re wondering when you’re coming up again to visit. There’s much more to see and do in Cincinnati!
Bob read Anabel what he wrote. “All right with you?”
“Sure. If you can’t elicit a response, then nobody can.”
He pressed send and glanced at her questioningly. “So when are you going out again with the cop?”
“Dustin? Soon.” Annabel looked at her watch. “No more wasting time. Let’s start studying. And, by the way, have you gulped down all your antibiotics today?”
“Yes, Mom. What’s the topic for tonight since we only have time for one?”
“Anaphylaxis. It shows up on tests and we’ve had no exposure to it on the wards.”
Bob nodded, enticing her to go on as she opened up a small textbook to a bookmark and began reading.
“Consider anaphylaxis an acute and life-threatening response … a type I hypersensitivity reaction. IgE mediates the activation of mast cells. When those cells degranulate, they release inflammatory mediators, interleukins, and the biggie … histamine.
“And here’s another definition we must know – angioedema.”
“Swelling of the face?”
“Yes, but the body area can be less than that. Technically, it’s swelling of the lips, periorbital region, face, feet, or hands. And this is super important. What’s the most common cause of drug-related anaphylaxis?”
“Penicillin.”
“Good. And overall - beta-lactam antibiotics.
“What about the most common cause of food-related anaphylaxis? I would not have guessed this, although I hear discussions about food that mistakenly carry it as an ingredient.”
“I was going to say some kind of shellfish.”
“Nope. Peanuts.”
“Goes to show. You never know what’s in your granola bar that could kill you.”
-----
Bob tired before Annabel had read for an hour; she had to coax him to go to bed. She tidied up his apartment and then readied for sleep. There was no answer from her sister regarding Bob’s text. She settled on the couch and put her medicine pocket manual on her abdomen.
Before she closed her eyes, she thought about the evening. Even when Bob was sick, she enjoyed his company. When she arrived a few hours ago, her speech had been pressured to catch him up on recent developments.
Was that what married life was like?
In a way, yes. That was what she had seen in her own home with her parents. She sighed. Marriage can’t be too bad, she thought. But, of course, when it came to Bob, there was a big difference. There was no sex between them. That would be a whole different thing.
Actually, she wondered …
CHAPTER 26
Annabel slept restlessly. The alarm clock was about to ring, so she stepped to the nightstand just inside Bob’s bedroom and snapped it off. He remained fast asleep on his side and she ducked back out.
This morning, she made one of his single-cup coffees. It was a nifty machine and she could get used to the variety of flavors. She drank it as she dressed, gathered her things as quietly as possible, and slipped out the door to a light rain. By the time she arrived at the hospital, the clouds had opened up more, and she ran from her car to the entrance.
She shrugged off the dreary weather. She was more concerned that the rotation was nearing to an end and there were dozens of diseases and patient problems that she had not seen. But, she figured, seasoned physicians, even Dr. Enno, might not see everything during their short or long careers.
After stopping at the office, she went straight into Jae’s room in the ICU where his nurse slipped a sheet up on his chest.
“Dr. Tilson, Patty Caye is here again this morning, but she went to the lounge because Jae was being sponge bathed. She’ll be back.”
“Perfect. I must grab Dr. Enno so we can both
talk to her. How did he do last night?”
“We went down on the dopamine a little.” She gave an encouraging smile.
Annabel glanced at his vital signs, listened to his lungs, and then went down to the doctors’ lounge where Dr. Enno sat in a plump leather chair. The wise old woman could double for a regal Tolkien character, Annabel thought as she approached her.
“Dr. Enno, you asked me to tell you when Jae Nixon’s co-worker shows up again. She’s here in the hospital. She probably went for coffee because they were sponge bathing our patient in the ICU.”
“Let’s go.” She wiggled her hand for Annabel to hand her Alejandro and they walked out. When they showed up in the cafeteria, Patty stuck out like Dr. Enno did walking down a hallway. Beyond the window, the rain outside had picked up.
“It reminds me of a summer gully washer,” Shania said to the women, “but it should be a late snowstorm.”
“May we join you?” Dr. Enno asked.
Patty nodded as they sat, the rain outside growing stronger in the parking lot.
“For a hospital admission,” Shania said, “a doctor performs a history and physical on a patient. Notice that a ‘history’ comes first. I would like to know more about your partner’s lifestyle. We’ve been looking for a white glove in an imaginary snowfall and you told us an important element of Mr. Nixon’s recent past.”
Patty listened with her hand wrapped around a cup of coffee. “Please go on.”
“Recent travel, and exposure to unusual places and things, is particularly consequential to an infectious disease physician like me. To give you an example, I recently consulted on a college professor with flu-like symptoms and a red, spotty rash. Her fatigue and joint pain became so bad, she couldn’t go into work. I found out that about three weeks before all of that began, she had travelled to New Mexico where she spent time in the desert soil studying ancestral Pueblo Indian villages and cave dwellings.”
Annabel’s eyes grew wide and she understood the enthusiasm the woman had for her field. “What did she have?”
“Valley fever. In medical terms … coccidioidomycosis. It’s caused by a fungus with a complex life cycle. Since the spores are so small, they are carried by the wind and inhaled into the lungs where nodules of residual infection can later show up on chest X-rays.”