The Dr Annabel Tilson Novels Box Set

by Barbara Ebel

  She hurried getting dressed and took him downstairs. The street and sidewalk showed an aftermath of the night’s weather, with twigs, sticks, and leaves littering the wet ground. Oliver had more to sniff and was back to his normal self.

  After the walk, she put on a single serving cup of coffee and began packing up for the day, when her phone dinged. Her heart rapidly beat. It must be Dustin.

  No such luck. She quelled her disappointment, because at least it was Bob. Since he was on the hospital rotation, he started earlier than her, both for his own rounds on his patients and team rounds as well.

  “I told Dr. Mares what we both found regarding eosinophilic meningitis. Would Dr. Gillespie excuse you for a few hours to come enlighten him/us with your input?”

  “I would love to, but I’d have to ask him. I’ll get back to you.”

  What fun, she thought and called the office. At least Becky should be in the office this early. She did Annabel a favor and called George at home.

  Annabel texted Bob after receiving her attending’s okay. “I’ll be there.”

  He stuck in a “thumbs-up” emoji and wrote, “Find us in the team’s office.”

  She gave Oliver a big kiss on his head. “Mind the house, boy.”

  With the notes she wrote in the middle of the night, her normal backpack material, and a reused fast-food coffee cup with her brew, she rushed out the door and took her own car, knowing there was no time to call a car service.

  Inside the lobby of the hospital, she chucked her empty coffee cup and went upstairs. With purpose to her steps, she came around the pediatric nurses’ station and heard the team conversing inside.

  “Annabel Tilson,” Dr. Mares said, “welcome again. Thank Dr. Gillespie for me. It was thoughtful of him to share you with us.”

  Annabel pulled out a chair. Bob smiled at her. Three other students were there, including Linnell. The team’s white board on the wall was crammed with names of their patients. At the bottom was Toby’s name listed as “orthopedic consult.”

  “I’m happy to be here.” She put down her dependable notebook.

  “Toby Owens, your original patient, is still worthy of our attention. I hunkered down with the subject of meningitis caused by parasites last night as well, but was deviated by calls from the hospital. Share with us what you found in the literature. Bob highlighted his end of it, but you can start from the beginning.”

  The team all had coffee cups. Donuts dusted with white powdered sugar sat in the middle of the table.

  “They are small enough to eat by the handful,” Rick said. “Help yourself.”

  Bob popped up and poured her a coffee. She thanked him and, with two bites, ate one donut.

  “From what I’ve heard,” Rick said, “you’re a damn smart medical student. If you don’t mind, in the essence of time, I’ll ask you in stages what we need to know. If you know it, that is.

  “Such as … what are the risk factors and epidemiology for an angiostrongylus infection?”

  “Bob and I learned yesterday that Toby ate a raw slug in Florida on a dare. That’s a red flag, since the actual reported risks are the ingestion of undercooked or raw snails or slugs infected with the parasite. It can even be pieces of those that accidentally end up in vegetables or salads, or foods contaminated by their slime.

  “The epidemiology is creepy because this parasite is a worm, a rat lung worm, that is transmitted between rats and mollusks in its natural life cycle. Humans can’t transmit the disease; they are unfortunate accidental hosts. Reports indicate that Angiostrongylus cantonensis has been spread to around thirty countries, mostly because of rats transported on ships.”

  Annabel took a sip of coffee. She was tired from lack of sleep, but the coffee, subject matter, and audience helped boost her eyes open.

  “Bob told us about rats with the parasite from the early nineteen hundreds,” Rick said, “first discovered in China. It’s making its way around the globe.”

  “But very few cases have been discovered in the U.S., and only in the south. Terrible cases have ended up in children’s hospitals near the Gulf Coast of Louisiana and Mississippi. Perhaps this is the first case more east, but I’m not sure. The CDC does recommend that these patients get reported, but it is not a mandatory reportable disease.”

  Rick nodded. “Absolutely. If Toby has it, we will call it in. And his case would be a clear example of how a person’s travel history is important and how a traveler could pick this up when outside the country.”

  Bob shook his head. “Like on a Caribbean vacation.”

  Annabel nodded. “Yes, the parasite has been found there.”

  “Ugh. Maybe I should reconsider my medical school graduation trip.”

  “If you can get it in Florida,” Rick said, “I wouldn’t change my plans.”

  Bob laughed “Just kidding; a trip there is wishful thinking.”

  Nell pulled her braid forward and stroked the end. “Does this parasite have anything to do with a rat’s lungs or do they just call it that?”

  Annabel thought about another donut but waited to pick one up. “The adult worms live in their pulmonary arteries.”

  “Too gross,” one of the other students said.

  “I agree. The females lay eggs, they hatch into larvae, which travel to the pharynx. There, they are swallowed and eventually pass into feces. Next, they either penetrate or are ingested by the intermediate host … our snails or snugs.” She opened her notebook and checked the second page. “In a definitive host, a third-stage larvae migrate to the brain, eventually to become young adults.”

  She shook her head. “Long story short, Nell, the life cycle is way complicated.”

  “Not to worry,” Rick said. “I doubt if anything about Angiostrongyliasis is going to be on your rotation final exam. Unless, of course, some chief resident asks the test writer to throw in an extra credit question.” He winked at Annabel. “Let’s get back to humans. How do Toby’s symptoms compare to what is reported?”

  Annabel turned her head towards Bob.

  “Patients present just like they have a bacterial meningitis,” he said. “Which is what we thought initially. He’s had the correct symptoms of nausea, vomiting, a stiff neck, and headaches. After his trip to Florida, the incubation period fit into the timeline too. Anywhere from a day to six weeks.”

  “He complained about muscle aches,” Rick said.

  “Which are included as well.”

  “We’re down to what is most important for our young patient. We have the high eosinophilic count from his spinal tap, but are there any tests to make a definitive diagnosis? And how are we going to treat him? The beginning of school is looming any day for this lad.”

  “Sixth grade,” Bob said. “I can’t remember that far back.”

  “You old man,” Annabel said with a laugh.

  Rick reached for a donut and Annabel swigged down more coffee.

  “I only saw mention of this in one scientific paper,” she said. “In the case in Louisiana in the 1990s, they did a serologic test. A. cantonensis was diagnosed, proved positive by enzyme immunoassay.”

  “Hmm. I will have to look into that. In any case, I will report our suspicions to the CDC and they can help us out with testing if the hospital’s lab can’t.”

  “Dr. Mares,” Bob said. “You probably guessed already. The only treatment for this parasitic meningitis is supportive care.”

  “Why won’t antibiotics work in this case?” Rick asked Nell.

  “Because it’s not a bacterial disease,” she answered.

  “Also,” Annabel added, “other countries have tried anti-helminthic drugs without any success.”

  “I read if those drugs do kill worms,” Bob said, “those dying worms could exacerbate a patient’s neurologic symptoms.”

  “Yuck,” Nell chimed in.

  Rick pointed to the box. “Finish the donuts. We’re going to go see Toby Owens.”

  -----

  Rick Mares rubbed his u
ndersized chin as he forced the students to keep up with his lengthy stride down the pediatric ward. He looked over his shoulder. “Anne Owens spent another night with her son. I hope she’s still here.”

  Annabel and the team geared up outside Toby’s room and Rick went in first after he finished tying on a mask. Both parents were with their son.

  “I stopped by on the way to work,” Jack Owens said, standing alongside the bed. He rubbed his hands together like he wanted to play ball with his son. “I’m glad I’m here. Maybe you can give us an update on Toby’s condition.”

  Anne moved an afghan and got up from the cot placed beside the other side of the bed. She held a small travel pillow.

  “I really am awake,” Toby said from the bed. “Headache and all.”

  “I swear his red hair looks like it’s being tossed around from that headache,” Anne said.

  “No, Ma. It hasn’t been combed in days.” He let out a big sigh and turned his attention back to Rick. “Dr. Mares, I’m so tired of this.”

  “You have every right to be, Toby. Since yesterday, we’ve dug up some information that we believe pertains to your case.”

  Anne and Jack sidled closer to each side of the bed, waiting for Rick’s explanation. Toby cocked his head.

  “We think you may have what’s called Angiostrongylus cantonensis, the parasite responsible for your eosinophilic meningitis.”

  “What on earth is that?” Jack Owens blurted out.

  Rick gritted his teeth. He was trying to brush over giving them some of the sordid details, such as being a lung worm of rats.

  “That bad, huh?” Jack asked, not getting a response.

  “We are going to inquire about a special test to confirm the diagnosis, to be certain.”

  “Come on, doc,” Anne said. “How did our son get this angio parasite?”

  “Probably that slug he ate.”

  Anne’s motherly fury showed on her taut lips and she popped the pillow on Toby’s head.

  “Ma, would you quit hitting me on the head!”

  “You deserve it. Jonathon wasn’t crazy enough to eat a slime ball. What were you thinking?”

  CHAPTER 23

  Dr. Mares corralled his team outside Toby’s room, where he addressed Annabel first. “Thank you for your input. Now go have a productive day in Dr. Gillespie’s office.”

  “You’re welcome. I’ll never forget this meningitis. My dad’s a neurosurgeon and deals with ‘head’ cases all the time, so I’ll be sure to tell him about it.”

  Rick nodded, and with a hand wave, guided his team to finish rounds.

  Lastly, Bob turned. “Talk to you later.”

  “For sure.” Annabel put a mask back on and poked her head back into Toby’s room.

  “Come on in,” Mrs. Owens said.

  “I’m leaving,” Jack Owens said. “My hardware store doesn’t function without me.” He patted his son on the shoulder and gave Annabel a smile as he left.

  At least he didn’t clunk his son on the head, she thought. “Toby, when you eventually leave the hospital, I’m sure they’ll give you a follow-up appointment with your pediatrician. I won’t see you again at Dr. Gillespie’s office because I will only be there a few more days. Then I’ll be here in the hospital. I’m sure you’ll be discharged by then. I want to wish you luck and a smooth recovery.”

  “Thanks a lot. Can you be my doctor later, when I grow up?”

  “How sweet. I wish, but I’ll probably be leaving Ohio.”

  “Oh,” he said sadly and looked down at his leg. “I hope when I change to a grown-up’s doctor, he or she quits checking my private parts.”

  Anne Owens scowled over at him. “Doctors know what they’re doing, Toby, and some exams are tailored for the individual. When men get older, they need what’s called a prostate exam, which are done for cancer screening. Exams are for your own good.”

  “There are many doctors around in every specialty,” Annabel said. “Sometimes the trick is finding one who is an excellent at his or her field of medicine, but you also like them as a person; you feel comfortable with their bedside manner. Sometimes it’s difficult to find both.”

  Toby scrutinized his leg. “You haven’t signed my cast.”

  “It would be an honor.”

  “There’s a black magic marker over there.”

  Annabel fumbled through the items on the nightstand and picked it up. She hovered over his leg about what to write.

  “Mom, I’m serious about this.” Toby’s red freckles seemed to grow larger on his cheeks as he continued with authority in his voice. “Please change my doctor to Dr. Clark. I like her so much better. Jonathon goes to her too.”

  For a few moments, Mrs. Owens stared at him. “That will make for an uncomfortable situation with Dr. Gillespie, but I’ll talk to Becky. Yes, if that is what you prefer, I’ll make it happen.”

  Annabel smiled at him. “Your office records are all in the same place, so that makes it easy. If you would like, I can subtly ask Becky to make the transfer when I go back.”

  “Thanks, Dr. Annabel,” Toby said as his mom nodded.

  She glanced down and wrote in cursive: “GET BETTER and best of luck in 6th grade. Maybe someday you can be that exemplary pediatrician that you seek!”

  Toby beamed. He had never thought about that. His eyes sparkled as he looked at Annabel.

  “If you can get through this, even medical school will be a snap.” She winked, nodded at Anne Owens, and left. It was time to show up at Dr. Gillespie’s office.

  -----

  Annabel hummed to the music in her car on the way out of the parking lot. The sunshine was bold and bright and the Cincinnati sky was blue and free of even a wisp of a cloud. She wished she could look into a crystal ball and find out what young Toby Owens would do with his future. Now experienced with his own surgical and medical problems, perhaps it would make an impression on him to grow up and be on the other side of patient care.

  She changed channels once, sampling both country music and top pop. Parking in the back of the lot when she arrived, she left spaces out front for parents and kids.

  With her lab jacket draped over her arm and carrying the rest of her gear, Annabel entered the waiting room of Gillespie and Clark’s pediatric office. Notably, there was a lack of babies in mothers’ arms, which made for a quieter area than normal. Three young children were grouped around the square rug sharing toys and a toddler played against the wall with a tall doll.

  She slipped into the front office and approached Becky.

  “How did it go? Was your morning as mentally stimulating as this place?” Becky slipped a file into the vertical folders on a tall shelf. Her bun was tighter than normal and swirled to hide much of her premature gray.

  “Kind of. Dr. Gillespie’s patient, Toby Owens, is in the hospital with an interesting meningitis from a parasite. He also has a leg fracture. When it rains, it pours.”

  “My goodness. I’ve known that family for some time. Poor Toby. Nice kid. Are they taking good care of him?”

  “Yes, and Toby and his mom have a request for after his discharge, that you switch over his records and future care to Dr. Clark. Toby would prefer not using Dr. Gillespie anymore; you may confirm that with them. I’m only the messenger, the middle-man.”

  “Hmm. These days, I’m thinking of switching the order of their names on the sign outside to ‘Heather Clark, M.D. and George Gillespie, M.D.’”

  Annabel narrowed her eyes.

  “Every once in a while, a mother or older pediatric patient finds his behavior unpalatable,” Becky whispered. “The Owens are not the first family to switch care.”

  Becky sat and Annabel wanted to ask her more, but it was not her place. She repeated her recent mantra to herself. “Only a few more days.”

  “Is Stuart in a room with a patient?” she asked.

  Becky craned her neck to the hallway. “I believe so. Dr. Clark is sharp as a tack this morning. We’ve phoned several prescriptions
into pharmacies, admitted a girl to the hospital, and Xeroxed a bucket load of back-to-school paperwork for her patients.”

  “I’m sharing Toby’s case with him because we students are learning pediatrics together. I’ll tell Stuart later.”

  The fax machine on the desk came alive and a report started streaming out. The paper landed face down and Becky took a peek. “George is waiting for this one. He’ll be out of his office soon to check if it’s here.”

  Becky stood and glimpsed over the counter. A four-year-old was dwarfed in the seat of a chair, grasping an iPad. The volume was up and game music roared across the waiting room. The child’s mother sat next to him, but she isolated herself from the problem. She was plugged in with earbuds to her iPhone hung on her waist.

  Other parents rolled their eyes and a stir of remarks filtered through the room. “How rude that we must listen to this,” a woman said to her husband. “Some people don’t care what their kids do,” he replied.

  “As long as it doesn’t affect her,” she said. She stuffed the magazine she tried to read back in the rack and picked up her toddler.

  Becky sighed as she lowered herself back in the chair. “During my twelve years working here, I have watched first-hand the decline of public social manners. But the descent is everywhere. Have you taken a flight recently? Waiting for a plane is an exercise in futility. Some guy will get on his cell phone a half an aisle away from you and will talk so loud that his private conversation is broadcast publicly. You can’t read a book or a magazine, or think straight to use your own phone for a quiet call or a text message.”

  She cleared her throat and went to the door. “Sweetheart, would you mind turning that down a bit?”

  The little boy looked confused and continued on just the same. Becky shook her head, turned, and looked down the hallway. “Annabel, on second thought, please go back to Dr. Gillespie’s office, let him know you’re here, and hand this fax to him. Wait and see … then he’ll be up here in a jiffy to tell me what to do about this.” She waved the paper once and handed it over.