by Barbara Ebel
Annabel smoothed a handful of silky hair to both sides of her collar. She followed Stuart to the hallway, where Dr. Gillespie and Dr. Clark were both bent over charts.
“Good morning,” Heather said, acknowledging them. “Welcome back. Follow me, Dr. Schneider.”
“Miss Tilson,” Dr. Gillespie said, “come on.” He knocked and, inside, a little girl sat on her father’s lap. She turned to him and buried her head into his chest.
George introduced Annabel and handed her the record. While her attending made small talk to them, she read the notes. The patient, Stephanie Miller, was a three-year-old. Mr. Miller told the nurse he brought her in for a “lump below her belly button” and that “she wasn’t very hungry.”
Dr. Gillespie coaxed the girl to the examining table and continued gaining a history of the patient’s chief complaint. As Annabel now saw the girl in full, the area around her eyes stood out. It was as if the skin had been stained darker than the rest of her pale face.
“Tell me about the lump,” Dr. Gillespie said. “When did it start?”
“It may have been there before, but my wife and I noticed it about two weeks ago. We thought it would go away. Instead, the bump is getting bigger. We realized Stephie is also picking at her food, not even eating macaroni and cheese, which she usually loves.”
“Any fever, night sweats, or changes in her behavior like lack of energy?”
“Seems like she’s less peppy. Yeah, she’s been avoiding playing in the backyard. More or less, she has been sticking to lying on the couch in the afternoons. That’s what my wife notices the days she has off from work.”
Annabel scanned the office folder again to find Stephanie’s vital signs to be normal. When she checked her prior history, it was negative for surgeries or medical illnesses. She was even born a full-term, healthy infant.
Mr. Miller turned from the table and sat back in the corner. The attending looked in the girl’s ears and nose and checked her eyes. He lingered at the sight of her periorbital discoloration. Stephie flinched when he put his cold stethoscope to her chest and listened.
Annabel stepped to the bottom of the table. George pulled her pair of shorts down and her underwear. “Just going to see that bump your daddy is telling me about,” he said.
For sure, Annabel noticed, there was a distinct mass in Stephie’s left lower quadrant, which extended somewhat to the right; a bump like a big pebble underneath the skin of a small girl.
Dr. Gillespie didn’t touch it when he pointed and asked, “Does it hurt?”
Stephie remained stoic. George palpated her abdomen and her mass. He turned his head slightly to glimpse at Mr. Miller, who was watching intently. Stephie squirmed very little with his examination.
The pediatrician examined her lower abdomen so slowly that Annabel switched her weight from one foot to the other. The pace in a private office surely was slow compared to the wards, she thought, but then admonished herself for thinking such a thing. Good medicine takes place out of the hospital, she reminded herself, and is the backbone to the diagnoses of many cases that get admitted.
After another minute elapsed, George began pulling up Stephie’s underwear. Mr. Miller shot up and helped.
“Stephie, dear,” Dr. Gillespie said, “we need to take a few tests to find out why you don’t feel so well.” He looked at Mr. Miller. “We’ll need to take some blood. Also, for some of the testing, we’ll need a twenty-four-hour urine sample from her. My nurse will come back in to give you the supplies to use at home and explain it to you. Please bring the sample back in when you have it, and my office will schedule a return visit after the results are back.”
Mr. Miller raised his eyebrows. His thick arms picked up his daughter and he rocked her like an infant. “What are you thinking, doc?”
With a shake of his head, the pediatrician said, “Can’t say. It would be like giving a test score before you took the exam. Let’s wait and see, because we’re only talking a few days at the most.” He nodded and stepped out.
Annabel patted Stephanie on the back. “I hope you feel better, Stephie. Nice to meet you, sir. Lots of luck with her. She’s a sweetheart.”
Stephie shyly turned her head and returned a tiny smile.
CHAPTER 6
Annabel poured coffee into a cup in the kitchenette and then inched one over to Stuart. She dumped two flavored creamers into her own.
“You’re the one who needs these calories, not me,” she said.
“Can’t help it. The background I told you about … orphanages aren’t known for their food. Not eating much those early years simply stuck with me, even after I was adopted.”
“A gust of wind will sweep you away one of these days. I, on the other hand, wish we were back with Dr. Schott on internal medicine, when boxes of donuts would materialize in the office.”
“I heard that,” Dr. Clark said, stepping behind them. “We do indulge once in a while, but with all the women in this office, we make a point to not tempt ourselves very often.”
The office manager stood in the doorway. “Dr. Clark, these poor medical students are famished. I’ll do something about that tomorrow.”
“If you stop on the way in, I’ll reimburse you. If the neon sign is blaring ‘hot donuts’ or ‘just made,’ I’ll even pay you double to veer in and pick up a dozen.” She laughed at her own plea.
“Sounds like a generous bribe. Also, the University department just called to remind us to spring the students this afternoon for pediatric grand rounds downtown.”
“Thanks, Becky,” Heather said. “You two leave later for lunch today and then go straight to the department lecture at 3 p.m.”
“And then we’re done for the day?” Annabel asked.
“Sure. By the time you would drive back to the office, we’ll be closing up. And, Stuart, our next patient is here, but his mom went back to the car for insurance information. He’s by himself in the waiting room. Feel free to make him comfortable and find out why he’s here.”
Heather left and Stuart placed his unfinished coffee on the counter. He walked past the front desk and out the door to the waiting area, so Annabel followed with her coffee.
Stuart crouched down to the only child in the room. “What’s your name?”
A little boy with big ears grinned up from a building block set. “My name is Thomas. I am a whole six years old.”
“Wow. You are big enough to make a skyscraper with those blocks.”
“What’s a skyscraper?”
“A tall building.” Stuart inched his arms up over the boy’s head and Thomas put his hand over his mouth in surprise.
“I’m going to try and fix the blocks up high. Just watch me.”
“Why did your mom bring you to see the doctor today?”
“My throat hurts. Last time, the doctor gave me a shot.” He contorted his face with displeasure and went on. “I’m afraid of shots and I don’t want one.”
Stuart eased himself onto a child-sized plastic stool and handed Thomas several blocks of different shapes. Slowly, the boy stacked them up on his growing creation.
Annabel found several Legos under her chair and handed them over for their project. She had never seen Stuart before with a child and his easy-going interaction was a surprise. Now the two males bent their heads over and the building was gaining width as well as height.
Stuart tilted his head and admired their work. “I think a boy who can build a magnificent skyscraper like this isn’t too afraid of a shot of medicine to make him better. If the doctor thinks he needs it, of course.”
Thomas tugged on the cartoon character T-shirt he was wearing and eyed the two medical students like he’d been awarded a trophy. “I should make buildings when I grow up … or be a doctor!”
“Maybe. There is plenty of time to think about that.”
Thomas’s mother came in the main door waving her insurance cards at the front desk. “Has Thomas behaved himself?”
“Most certainly,” Stuart s
aid. “I’m one of the medical students and we’ll see Thomas in the back in a little while.”
-----
Annabel warmed her coffee in the microwave while Stuart and Dr. Clark went in to see their patient. She was on her own because Dr. Gillespie had left for a lunch meeting.
“Dr. Clark invited you in back there,” Becky said, popping her head in. Her short, prematurely gray hair was stunning enough for an AARP magazine cover and she patted the bun at the back of her head.
Annabel nodded. “Sure thing. Don’t want to miss little Thomas’s sore throat.”
“The rooms get crowded,” Becky added. “Med students rarely can double up.”
Annabel opened the door quietly. Thomas was on the table fully dressed and Dr. Clark held some kind of kit. “This is our other medical student, Dr. Tilson. I also want to show her Thomas’s throat.”
On cue, Thomas opened his mouth wide and Annabel took a look.
“We’ll do a rapid antigen test,” Heather informed them, “but this appears to be classic strep throat with red tonsils and white patches in the back. Thomas’s lymph nodes are swollen in his neck too.” She opened the package and rubbed a swab in the back of his throat. “Please bring this to the lab, Annabel.”
Annabel left with the sample, appreciative of being called into the case. After waiting in the lab, she relayed the result to Dr. Clark.
Heather scanned the sheet. “Sure enough, Thomas has strep bacteria like he had one other time. I’m going to prescribe an oral antibiotic and, to relieve throat pain and reduce his slight fever, please give him Tylenol at home.”
Thomas’s mother nodded. “No shot?”
“No shot.”
The little boy looked past Heather and grinned at Stuart, who gave him a thumbs-up.
Heather approached the door. “We’re finished. You get better and bounce back to your normal health, Thomas, and drink lots of fluids like your mom tells you.”
“Bye,” Thomas responded. “And, Dr. Stuart, I wouldn’t of cried if Dr. Clark gave me a shot.”
“I figured that. After all, you’re a master Lego builder.”
Along with a broad smile, Thomas’s eyes twinkled, and Annabel was sure that Stuart had made a friend.
-----
“Since we’re not coming back here,” Annabel said, “I can’t forget my stuff.”
Stuart didn’t respond and both students stuffed their paperbacks into their backpacks. The heat hit them heavy when they stepped outside. The sun was in full force and not a leaf stirred.
"I'll give you a ride downtown,” Stuart waved, “but first let’s eat. Same place as yesterday?”
Annabel bobbed her head. “You ever have strep throat as a kid?”
“Never. How about you?”
“Never.” They walked a medium pace to avoid working up a sweat, yet fast enough to soon pop into the restaurant’s air conditioning. This time, they were led to the area with a yellow-painted wall, which seemed to correlate with the sunshine outside.
“Any interesting patients this morning?” Stuart asked.
“A three-year old with an abdominal mass. Who knows what the heck that will be?”
“Hmm. I bet the differential covers a whole list of possibilities, yet I wouldn’t have a clue.”
“I don’t believe that.”
A waitress with long nails and a wrap-around wrist tattoo poured ice water into their glasses. “What’ll it be?”
Annabel wasted no time. “Any specials of the day?”
“BLT on Texas toast and fries.”
Annabel nodded. “Make that two,” Stuart said.
“Substitute a small salad for the fries,” Annabel said.
The waitress reached into her pocket and dumped ketchup packets and two straws. “Coming right up. I bet you two are the new recruits in Dr. Gillespie’s office. I’m Donna.”
“Thanks, Donna, we are,” Annabel said.
Donna slapped an order slip at the kitchen window and Stuart leaned across the table. “Regarding the kid with an abdominal mass, I guess the patient’s age has a huge bearing on the possibilities. However, I would segregate categories in my mind. Such as flank masses … whether they are renal or nonrenal. Then whether I suspect a GI mass or a hepatobiliary mass, related to only the liver or biliary system. And heck, there are always pelvic masses to think about. If it’s a girl, it could stem from an ovarian problem. Could it be an abscess related to the appendix?”
“This was more to the left and midline, but it was lower abdominal. I would think the patient would have been sicker if she had appendicitis with an abscess.”
“What about labs?”
“Dr. Gillespie ordered the bloodwork and electrolytes and more than the usual. He even ordered a twenty-four-hour urine.”
“What amazes me is that these doctors we work with are like detectives. Most of the time, within a few minutes of hearing the patient’s history, they have a strong suspicion of the medical possibilities and order what they need to know. Do you think we’ll ever get there?”
“Stuart, we’re on our way. You need to acknowledge that to yourself. Especially you.”
The waitress came with the food and now slipped packets of salad dressing on the table. “Bon appetite.”
Annabel took a bite of the toasted sandwich. “This is tasty, but dinner tonight will surely be better.”
“You’re not going out on a Tuesday night, are you?”
“I’m going to meet Dustin’s mother.”
Stuart looked up from his hunched position over his food. “I’m not saying a word.”
“Come on, Stuart, spill it out. I have my own ideas whirling around inside my head. If it were you, would you be conjuring up ideas about a more serious turn in a relationship?”
“Are you going to her house for dinner?”
“No. She lives far away, so she’s visiting her son. We’re going to a restaurant.”
“Much better. My advice? Don’t work yourself up with anticipation. It won’t be as scary as you think and she will probably like you immediately. Just don’t spill your wine on the tablecloth or take out your cell phone.”
Annabel mulled over the first things he said as they finished eating. “I’m grabbing the tab today, Stuart. I’m being a freeloader as far as hopping car rides from you.”
“Not a problem.”
Stuart and Annabel went back to the office parking lot and slid into his Jaguar. “Another thing,” he said. “It might be a nice gesture if you bring your future mother-in-law a tiny, tiny gift or something for her and her son to share later that night. She’ll be left with a last impression … one that is positive, no matter how much she likes or dislikes you.”
“Stuart?”
“What?”
“Future mother-in-law?!”
Stuart cocked his head with a bemused smile and started the ignition.
-----
The high-wattage bulbs of the pediatric conference room blared down into the room as Annabel and Stuart stood in the back on the top step. A frantic chief resident prepared his Power Point slides on the stage with the help of a technician. The one screen behind them lit up with the topic of the talk: “Lead Poisoning.”
“Interesting topic. I’m heading down front,” Stuart said and peeled away. Just like him, Annabel thought, and admired his tenacity to learn.
“You can’t sit here.” Annabel turned to the side as Bob swiped the chair next to him, imitating the bus scene from Forrest Gump.
Annabel laughed and scooted in, brushing his hand away. To the left of him sat the other three students on his pediatric hospital team. Two female students with crossed legs and skirts sat next to him.
“Hey, Annabel.” The girl next to him bobbed her head and then fumbled in a bag on the floor. She had long hair like Annabel, but it was pulled back and smartly braided. She pulled out a notebook and tapped it on Bob’s knee. “This is a rare topic. I bet our chief resident will be throwing us some questions this week abo
ut his talk. Why don’t I take notes for us? We may not find this information in a textbook.”
Bob nodded. “Smart thinking, Nell. We might not ever see a case of lead poisoning, but we won’t forget the topic.”
She shrugged her side into him. “Let me borrow your pen.”
Bob grabbed a pen off his top pocket and then Nell wrote the topic in fine cursive. Annabel noted her thick bracelet and dangling ivory earrings and wondered, Linnell may be studying to become a doctor, but where is her sensitivity to other species? Buying that type of jewelry may help out poachers, and they slaughter elephants.
“Annabel,” Nell said, “our chief resident is up there on stage. We have the best chief of all three hospital teams, don’t we, Bob?”
Bob nodded. “We lucked out. Sorry you’re not with us, Annabel.”
Annabel knew Linnell was an in-state student, born and raised in Ohio, and the fact that her goal was to become a general surgeon. They were both around the same age, and although Annabel had a healthy complexion, Nell’s shined like she massaged her face with pure cocoa butter.
The resident up front tapped the microphone a few times. “I’m going to begin, so everyone please take a seat.”
“So how’s it going?” Bob whispered.
“My relationship with Dustin must be ramping up. He wants me to meet his mother tonight.”
Bob bobbed his head. “I meant in Dr. Gillespie’s office.”
Annabel swallowed hard, realizing she’d inserted a personal, off-topic remark. “Oh, fine, I suppose.”
“As you know, our team is on call tonight. Nell already picked up a patient on life support in the ICU because a deer came through the front car window at her and I gained a young boy as an admission for newly diagnosed Type 1 Diabetes. These poor children. Can you imagine?”
Annabel shook her head. “There should be a law against children getting medical problems.”
“Wishful thinking,” Nell inserted, extending herself in front of Bob.
The microphone volume ramped up and the chief resident began. “Regulatory interventions have helped to decrease the incidence of lead poisoning in children, but this talk will make you aware of this still existent clinical problem. One takeaway point is where the major source of it now comes from … older buildings that still contain lead paint.”