by Barbara Ebel
The smile lines around his eyes disappeared as he spoke. When he finished, he added one more thing as he grabbed an empty wheelchair to transport back to the ER. “Dr. Fleming is at the white board in there.” He leaned over. “She’s the real deal.”
Annabel thanked him. She sat inside at a round table while the anesthesia resident used an eraser to remove a name. The woman shot her a glance.
“You must be a new student. Welcome. I’m Kristin Fleming, a fourth-year resident; a third-year anesthesia resident.”
“I’m Annabel, a third-year student. A fourth year in residency is a long way off for me.”
“I hear you. You have a long haul, but you’ve done a lot already. The journey is what’s important, Annabel, not the end result.” She put the eraser down, and with a spring to her step, she pulled out a chair. Dark, wide-rimmed glasses sat on her broad nose and two sets of earrings made up for her otherwise lack of jewelry. She was flat-chested, tall, and extended her lanky upper limbs on the table.
“I missed the case that just came out of the OR,” Kristin said, “because I was in a patient’s room doing an epidural for a woman’s labor. Did you go in?”
“I followed and stayed out of the way. I always hate the beginning of a new service because I feel so helpless.”
“That’ll change. You’ll be doing scut work before you eat lunch. That, in and of itself, is useful to the team.” She contracted her lips in a pucker like some people furrow their forehead in thought, and then mumbled under her breath,“If you can call them a team.”
“So true about the scut work, but don’t get me wrong. I’m not complaining. I make the most of my rotations and end up having the most memorable, off-the-graph experiences. I love medical school and wouldn’t change what I’m doing for all the gold in Fort Knox.”
“Awesome. You interested in OB/GYN?”
“I don’t have a clue. My dad’s a neurosurgeon and I have an uncle who’s a paramedic, so I had little exposure to that type of specialty talk at home.”
Kristin nodded as Dr. Watson and Dr. Gash strutted in. They went straight to the couch and sat cozily next to each other. Ling unfolded a sheet of paper, flattened it down on the short table, and then noticed Annabel. “You might as well join us,” she said. “Are Barker’s lab results back yet?”
“I don’t know,” Annabel said, hesitating to sit across from them.
Ling rolled her eyes like Annabel was a fly on the wall. “It’s obvious you inherited her as a patient. All right then … sit down. Now is as good a time as any to explain the rotation to you despite what you might have heard. Every medical school doles out their OB/GYN rotation the way they want, but this is how we do it here. Ours is short compared to surgery or internal medicine. Four weeks is all you have unless you become totally impressed and enraptured like I am with the last remaining natural God-given act on the planet – childbirth. If you are, then I’ll see more of you in a few years when you do a residency.
“However, the four weeks are basically split up. Two weeks of obstetrics and two weeks of gynecology, except that clinic days will be a combination of both types of patients. There’s only one test at the end of the four weeks, which obviously covers the whole kit and caboodle. This week you’ll do OB during the day and next week, you’ll be on the twelve-hour night shift. The other student, Stuart Schneider, will be alternating the days and nights with you. We don’t care what twelve hours you’re doing when bi-monthly grand rounds are scheduled. You must attend that lecture no matter what. You’ll most often see our attending doctor in clinic.”
Ling tilted her head at Caleb. “Anything else you want to tell her?”
“Sure. We discuss patients once in the morning and late in the afternoon, but that is not set in cement because there may be active patient care going on … like what happened this morning. Our course of action around here depends on what’s going on with a parturient’s uterus and vagina.”
“Keep up with the status of the patients on the board and write a daily note on everyone,” Ling added. “It’s not uncommon to salvage some time to study during the day, so do it. Dr. Gash and I won’t be holding your hand. Don’t forget that around here we’re not only taking care of this predominantly young female population, but the safe delivery of their infants rests with us. That is a huge responsibility so, most of the time, we’re on auto-pilot and not paying attention to students.”
Dr. Watson’s pager buzzed. She got up and disappeared out the door. Caleb leaned forward, ready to follow the chief resident. “Find out any updates on Bonnie Barker and her baby,” he said.
“How unusual was that this morning?” Annabel asked quickly.
“Here’s your fact for the day. Information to commit to memory. For a normal birth of a single baby in a vaginal delivery, Mom loses, on average, five-hundred milliliters. That equates to two full cups of blood. Our patient lost well over double that amount. As a matter of fact, she lost more than a fifth of her prepregnant entire blood volume.”
Annabel shuddered. Caleb rose and stuffed a notepad in his pocket.
“What about a cesarean section? What’s the normal blood loss for that?”
“An entire one-thousand milliliters and, it goes without saying, you better learn everything there is to learn about Pitocin.”
Annabel pulled out her pocket-size handbook on obstetrics and gynecology, and when she glanced back up, Caleb was gone. She thumbed through the index, ready to get her facts straight. In the first two years of medical school, she’d heard more about oxytocin because it was a protein produced by the pituitary gland; a naturally occurring hormone of male and female mammals that increases the concentration of calcium inside muscle cells which, in turn, controls the contraction of the uterus. She read that the synthetic, man-made version of oxytocin, is Pitocin and, apparently, used in obstetrics all the time for stimulating uterine contraction.
A “pop” sounded from the round table where Kristin Fleming opened a soda can and began pouring. Annabel broke from her reading. It was time to do her patient’s follow up.
“Pitocin comes in handy,” Kristin said, peering over her glasses. “It can induce abortion and be life-saving to control bleeding after childbirth. And labor? They don’t call it that for nothing. Damn hard on a woman. Exhausting and painful as hell.”
“You must be the guardian angel in all of this … providing their pain management.”
“So true. However, labor, plain and simple, can wear a body out. No matter how much a woman tries, her body just can’t or won’t push that baby out. Pitocin can induce labor or strengthen the contractions of labor. Often, that synthetic drug is as valuable to them as an epidural. They just don’t realize it.”
Annabel nodded. It was the same old thing. Patients often didn’t realize the intricacies of the medical care they were receiving. No different from customers understanding the minute details of a tax accountant working on their tax return or an architect trying to make a particular geographic landscape work with a certain house plan.
“Thanks, Dr. Fleming.”
Kristin gestured with her glass. “You’re welcome.”
-----
The newborn nursery and neonatal intensive care unit, or NICU, was on the same floor as obstetrics and gynecology, but straight forward off the central elevators.
The faces peering into the main nursery on the right were mostly lit up with smiles. Other individuals and family members giggled, pointed, and made funny faces at the swaddled infants in their bassinets. The scenario on the left, however, painted a different picture. The NICU housed the premature infants having difficulty or ones with congenital abnormalities needing specialized care, or pre or postop premies that were in dire straits … their battle to live begun way too prematurely without so much as taking their first steps on Mother Earth.
Standing to the side of visitors, Annabel scoured the names of the babies in the main nursery and saw a card for “Baby Girl Barker.” She wondered how a mother cou
ld carry a baby for months and not have a name picked out. Even if the mother didn’t know the sex by ultrasound, she figured a woman would at least have a name for a boy and a girl. But then again, maybe she was waiting to see what the baby would look like and a name would spring into mind. She wasn’t that familiar with newborns, but her impression was that they weren’t that distinctive. They had to grow into their facial and bodily features as well as their personalities. She shrugged her shoulders and stared at the female newborn who appeared scrawnier than the two babies on either side of her.
Annabel recognized the physician hurrying past her as the pediatrician who had showed up in Bonnie Barker’s delivery room. He seemed to be giving another doctor information as they walked together and opened the door to the nursery. “Another thing,” the pediatrician said. “The Barker baby’s position at birth? Breech.”
The two men clutched the rim of the basket. They talked with a seriousness that could only be construed as concerning. The pediatrician gently loosened the baby’s blanket and allowed the other physician to perform a physical exam.
CHAPTER 4
The cafeteria of the University Hospital bustled with activity as Annabel slipped through the aisles and found an empty table. How disappointing to eat lunch alone, she thought. She didn’t even see any medical students around from other rotations. Maybe she missed them all because she peeled away from the labor and delivery floor later than her growling stomach wanted to. She had spent time in the ER with a pregnant patient who ended up not being admitted, but they had not informed her of that. Time may fly, heal, or steal, but to a medical student, wasted time was worse than being on a ship lost at sea.
Annabel reached for the salt as long fingers gripped it before she could and handed it to her. Tony stood over the table looking as forlorn as an abandoned puppy. He pulled out a chair across from her and sat without a word.
She jiggled salt on her side dish of steamed vegetables, hoping he wouldn’t be too chatty, especially if he wanted to discuss his girlfriend’s condition. At this point, he would be better off scrolling through Safari on his iPhone rather than asking her any obstetric questions to do with Bonnie.
He broke out in a smile. “My little girl is tiny, but I can hardly wait. Although I only wiggled my way through high school, she’s gonna go to college. And I swear, she’s gonna be a super soccer player.”
“You play?”
“Play?” He straightened his shoulders and beamed even more. “I’m a soccer coach.”
“Nice. You must enjoy the kids.”
“Yeah. That’s me. I have five siblings, so I grew up with people around me. I am more excited about this new baby than I ever imagined. Damn. Bonnie needs to marry me. But no mind; I won’t let the young one grow up without a father. As a matter of fact, this is so cool - I plan on giving her brothers and sisters too, like me … even if they’re half-brothers and sisters.”
Annabel thought he was getting ahead of himself, but at least he didn’t seem to be the type to shirk his responsibilities. She also wondered if there was a problem with the baby. Why had the pediatrician called in another apparent pediatrician? She stirred the straw in her iced tea. “Did you hold your new baby yet?”
He set his wide jawline in a stern scowl. “No. Not yet. They’re busy tending to her. I didn’t know that nowadays births are complicated by all this modern scientific mumbo jumbo. I mean, I bet my sneakers that nobody did genetic testing on me when I was born.”
“Genetic testing?”
“Some doctor upstairs told me they are going to test Baby Barker.”
After he left, Annabel finished her meal in silent contemplation. Her first OB patient had not only encountered a problem, but apparently her baby had too. Bonnie and Baby Barker were mired in bad luck today. To their better fortune, which Bonnie was ignoring, Tony was a young man on the sidelines who really seemed to care about their well-being.
-----
Upstairs, after scrolling for the information on the computer, Annabel made a note of Bonnie’s hemoglobin and hematocrit on the index card she wrote up for her patient. As with other rotations, she logged each of the patients she followed in such a manner and always had their pertinent information in her white jacket pocket. In her opinion, the young mother’s red blood cell counts were now acceptable. Of course, Bonnie had been transfused … the purpose of which was to bring the levels up so she would not continue to demonstrate the effects of an acute anemia, like what had happened in the OR.
Based on the scant reading she did before the rotation, she already knew that anemia is a common complication in a pregnant woman – if there are not enough erythrocytes or red blood cells that can carry hemoglobin, the functional iron-carrying protein. That critical protein transports oxygen molecules to the body’s tissues and organs. Too few blood cells and a body will be oxygen deprived … causing symptoms of fatigue, shortness of breath, dizziness, rapid heart rate, and impaired cognition.
She opened up her handbook and looked under the “physiology of pregnancy” and scanned several paragraphs. In the pregnant woman, it said, anemia was most often due to iron deficiency due to two reasons. The first reason may be due to decreased iron stores prior to pregnancy. Or, secondly, it may be due to increased demands for iron because of an increased need from the growing fetus and an expanded maternal blood volume.
She extended her legs under the desk of the computer station and thought back to her surgery rotation where she had observed trauma patients. That was where she witnessed more than ever the color coding of blood. Arterial blood filled with oxygen-laden hemoglobin was bright red, but after it returned to the lung without its oxygen, it would lose its brightness. That blood would become bluish and was more synonymous with venous blood.
Thinking back to Miss Barker’s postpartum hemorrhage, she couldn’t imagine a few hundred years ago when there was no such thing as large-bore intravenous catheters and packed red blood cells for transfusion. No wonder women quite often died during or after childbirth in those days. And that was without taking into account the other horrendous problems and complications of pregnancy and delivery.
In essence, she didn’t have to mimic what the anesthesia resident or the orderly had said. She already made up her own mind that women, even if they didn’t know it, took on a lot by becoming pregnant!
-----
“Are you going to sit there all day?”
Ling Watson paused as she delivered her comment while Annabel glanced up at her senior resident, who wore all the right curves in all the right places. Her nails were manicured perfectly and her fingers looked exquisite. She wore a solid blue gemstone on her right ring finger. The time she must spend on her hands, Annabel thought, was short changed when it came to her hair. She was blessed with smooth, shiny, jet-black hair, which she easily wore in a pulled-back, tight ponytail.
Dr. Watson tore down the hallway and Annabel caught up.
“Bonnie Barker’s H and H is 11 and 33,” Annabel said.
“Those are decent numbers, considering.”
“Yes, I read that anemia in a pregnant woman is considered to be a hemoglobin below 10. But did you know the pediatricians are doing some kind of a work-up on her baby?”
“I’m hard core about the fetuses of my pregnant patients, but I’m all too happy to turn the newborns over to pediatricians once they take that first breath of air, which, by the way, should be within the first ten seconds of delivery.” She stopped short. “You can come downstairs and watch if you want. A new patient. You can write up an H&P afterwards. Also, it’s a huge subject. Tomorrow, regurgitate to me the adaptations a newborn must make to extrauterine life.”
Annabel fidgeted with her hair as she trailed Ling into the elevator. At least that topic had been brushed over in courses such as physiology and embryology, but it was a complex subject. Now, for today and tonight, specific reading awaited her. It was doubtful she would have the time to address the personal items on her agenda.
In the ER, Ling barely glanced at the board as she swiped a stack of papers from the counter and brought them with her. She knew exactly where she was going as she shoved curtains back and entered a cubicle. Other than her protruding belly, a woman before them in a hospital gown appeared to be more like a medical patient than an obstetric patient. She struggled with difficulty breathing. Her hand rested on her abdomen as her quick breaths and unfamiliar situation caused her big brown saucer eyes to glance at them with fear.
“I’m not galloping, but I feel like a race horse gulping for air,” she said in a high-pitched voice. Annabel guessed her age to be nearly twenty, but her voice made her sound like a prepubertal teenager.
“How long has this been going on?” Ling asked.
“A few hours.”
“How far along is your pregnancy?”
“Last week I was 28 weeks.”
“You been coming to prenatal clinic?”
“Yeah.”
“First pregnancy?”
“Yeah.”
“Any medical problems?”
“No.”
“Any problems during the pregnancy so far?”
“No,” she whimpered.
“Annabel, go check if the clinic chart notes have been sent over or if the secretary has printed out those notes from the computer.”
Annabel hated to miss out on watching her first full history and physical of a pregnant lady, but she did as she was told. She scurried out and put a name to a face by glancing at the ER board: Mary Chandler, eighteen years old. She was boldly designated on the board and chart as G1P0. The “G” stood for gravidity … the patient’s number of total pregnancies, including the current one. Had Ms. Chandler had any before, that number could have also included miscarriages and stillbirths. The “P” stood for parity, which was the number of pregnancies ending in a gestational age greater than twenty weeks. Miss Chandler’s G1P0 correlated with her confirmation that the current pregnancy was her first one.
