by Barbara Ebel
“This is perfect,” Annabel said, “if the pollen blowing around doesn’t cause us to have an allergy attack.”
“A little walk will help tire me out before taking a nap when I get back home.” He looked at the dog. “If Oliver doesn’t demand any attention.”
Annabel let the dog sniff to his heart’s content and they walked. “I have off on Sunday. Why don’t I take him then? You can have more time to yourself before going back on Monday.”
“Sure. It will be your turn to enjoy him anyway.”
Two trim young men dressed in running gear slowed their pace. “What kind of dog is that?” one of them asked. “He’s gorgeous.”
“We’re not absolutely sure,” Annabel said. “We just adopted him from the shelter.”
“DNA will tell you. Have a nice day.”
The two men sprinted off and Annabel admired their pace. “We better spring for the kit so people stop telling us to do that. I’ll buy the kit and we’ll find out once and for all what Oliver’s ancestry is. That’s right, boy. Are you like Bamse, the famous Norwegian dog, or Balto, the famous Siberian husky?”
“Or the famous collie, Lassie?” Bob pitched in.
Annabel patted Oliver’s head. “He is walking like a charm. I bet he’s grateful that he is with us and lives in a place that he can call home; he’s being extra polite to please us.”
“I agree.” Bob glanced at Annabel. She wore a smile as she walked the dog. She needed for this to happen, he thought. He did too. Something from the natural world to focus on while away from their four-walled routine and stress … besides seeing each other like he planned.
“So what is the topic for your grand rounds?”
“Medical errors and physician burnout.”
“No way you can cover all of that.”
“Dr. Harvey expects me to only hit the highlights. There’s not enough time to do justice to both topics nor do I have the time to prepare so much.”
They neared the end of one whole loop and Annabel stopped. An elderly couple passed them single file and patted Oliver on the head. He wagged his tail and sat down. Annabel jimmied the zipper on her shoulder bag, reached in, and pulled out the chocolate-covered blueberries she previously bought for Bob.
“Here you go.”
His rich blue eyes sparkled as he took the box and tore it open. “Thanks, what a treat. I’m glad you didn’t buy the expresso beans since I should stay away from the extra caffeine.”
“You’re welcome.”
Bob shook some into his hand and rattled them towards her. He poured a few out for her as well. Oliver watched.
“Don’t give us that sad expression,” Annabel said. “These would be a double whammy for you. Chocolate and blueberries aren’t good for dogs.”
“I’m glad you know these things. I’m more of a novice than you.”
“I learned a lot from my dad inheriting Dakota. Come on; you should go relax and I need to go show up on the baby-birthing rotation.”
Bob curtsied in jest. “At your service, ma’am.”
He dropped her off at the front door of the hospital. It was a beautiful morning with her and Oliver’s company, he thought, even though he was second fiddle to what he was sure was a romp in the sack with Dustin the night before.
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Annabel took a gamble that it would be all right with Dr. Harvey, so she stopped in the cafeteria and bought lunch. Since she had eaten nothing at Dustin’s or her own apartment, her stomach growled.
She met Emmett pushing a wheelchair towards the elevator as she towed along her backpack, shoulder bag, and sandwich.
“Dr. Tilson, we missed you all morning. I’d help you carry something but, I’m headed downstairs with this. The place is jumping up here.”
“You’re thoughtful, Emmett. I suppose I’ll find out for myself.”
“That you will.” He clunked the wheelchair over the lip of the elevator and was gone.
At the nurses’ station, Annabel stopped to let her presence be known. Roosevelt did a double-take. “You’re here earlier than I anticipated.”
“Mission was accomplished, Dr. Harvey, and Mary Chandler’s parents appreciated the visit. I’m glad you recommended it and that I went. I did stop downstairs for a sandwich. Do you mind if I eat?”
“By all means. And since you’re dressed so nicely for the potentially messy business of being on the labor and delivery ward, change into scrubs.”
Caleb stood behind Roosevelt’s shoulder. She scrambled to the table inside and dug into her hot barbecue sandwich. Roosevelt and Caleb followed and discussed the information on the board.
“We have admissions,” Roosevelt said. “Annabel, when you’re finished, ask Dr. Fleming if you can tag along while she puts in an epidural on Laverna Santana.” He tapped on her name listed for Room 2. “She’s a twenty-nine-year-old obese G2P1 woman. And Dr. Gash, we better go get a bite to eat too.”
Caleb glanced down where Annabel struggled to keep from making a mess, especially with good clothes on. “Does that bun hold more barbecue sauce or brisket?”
“Whichever it is,” Annabel said, “this barbecue is competitive enough against the downtown joints on Broadway in Nashville. For the hospital cafeteria, a miracle must have happened.” She shook her head, wondering about her fortunate cake last night and now her sandwich. Or maybe it was the men in her life spicing everything up.
“I’m headed that way. Annabel, mind the shop.” Caleb raced to catch up to Roosevelt, who beat him out the door.
Annabel scrunched up the trash, washed her hands, and changed in the female locker room. She hunted for Kristin Fleming and found her already in Room 2. Inside, she approached the patient first. “I’m Annabel Tilson, a medical student doing obstetrics. I’ll be asking you questions for a history and physical when Dr. Fleming is finished.”
Laverna Santana had a sizeable pregnancy protruding in front of her, but the rest of her was pretty big too. Dr. Harvey was correct with his “obese” terminology and Annabel wondered how much weight gain she had amassed during the last nine months or if she started out with a husky size. She had heard that some women go nuts and “eat for two” and wondered how much their doctors advise them not to do that.
The woman shrugged her shoulders. “I’ll be comfortable by then and won’t mind your questions because Dr. Fleming will be giving me drugs.”
“An epidural,” Kristin said to clarify.
Laverna grimaced and looked toward Jed, the man sitting on the windowsill. He wore a baseball cap and a five o’clock shadow.
“Yeah.” Laverna said. “The sooner you get that epidural in, the happier I’ll be.”
“Is it okay if I watch?” Annabel asked.
“Absolutely.”
Jed jumped off the sill. “I’m outta here. I can’t stand needles.” He rubbed his hand on Laverna’s shoulder and went out while a nurse came in.
“Adios.” Laverna shook her head. “Afraid of needles!”
“I’m Pam,” the RN said. “I’m going to help Dr. Fleming. Let’s move you to the side of the bed with your feet dangling and, when the time comes, we’ll ask you to bow your back out.”
Laverna scooted as she was told and faced the door while Kristin stepped to the window side and rolled her cart close by. The red cart held everything she needed.
From what Annabel had previously observed watching anesthesiologists, she already liked the field, so she paid strict attention to Dr. Fleming. Kristin settled her wide-rimmed glasses firmly on her nose and prepared an epidural kit on the side table, making sure to not touch anything inside. The blue drape it came in hung over the sides and she peered at the contents of the container as if she was running a checklist off in her head.
“I’m going to wash your back off,” Kristin said, “with an antiseptic.”
“This will feel cold,” Pam said with a husky voice as she stood in front of her large patient. She adjusted the open back of Laverna’s gown to the side.
“Arch your back like you’re in the fetal position,” Kristin instructed her. Pam gave Laverna a demonstration and the doctor and nurse glanced at each other and frowned. Due to Laverna’s large size and compounded by her big belly, her ability to push out her back was limited … which would make it more difficult for Kristin to access between her intervertebral spaces with the large epidural needle.
After palpating some more, Kristin selected the skin spot between the second and third lumbar space and injected a bee sting of local anesthetic. She hooked a glass epidural syringe on the large-bore needle and inserted it to no avail because all she hit was bone. Her aim was to ever so slowly advance the needle to the epidural space, the area between the dura, which was a membrane, and the vertebral wall. The dural sac would be filled with cerebrospinal fluid and the nerve roots. The real trick was not to go too far and puncture the dural membrane. Otherwise, spinal fluid would drain into her needle and would be a “wet” tap, most likely causing a headache … possibly a severe one.
Kristin hated when an accidental wet tap occurred. Laboring patients were already in pain, but that headache was a real burden in the postpartum period when a mother should instead be enjoying her newborn baby.
Kristin was also slick at the paravertebral technique, so she numbed off to the side of where she’d been and went in at an angle. She advanced the needle gingerly and also pressed her finger on the end of the syringe, which was filled with air. Since Kristin was lanky and trim, she had to work at her maneuver to get through Laverna’s back. After a few moments, she encountered the correct epidural space and her syringe encountered a loss of resistance and she tapped a few cc’s of air into the space. No wet tap occurred and Kristin sighed with relief.
The anesthesiologist took off the syringe from the end of the needle and uncurled the thin, long catheter from the plastic kit. She threaded it into the needle and advanced it correctly and then removed the needle over it.
“You can relax just a bit,” Kristin said as she adjusted the end of the catheter to the pieces where she could deliver drugs. She secured the epidural catheter on Laverna’s back with a see-through bandage and gave Laverna a test dose of local anesthetic which contained epinephrine. Since her patient was hooked up to monitors, her heart rate would increase if the catheter was incorrectly placed and the epinephrine raced into a blood vessel.
Everything so far checked out perfectly and Kristin’s job was now to dose the epidural. She began opening the drawers of her cart. “You can settle back on the bed. Worst part is over.”
Annabel pitched in to help while Laverna wiggled on the mattress to the top of the bed. Kristin opened and shut drawers again and frowned. She tinkered with the two sets of earrings on her right ear lobe.
“The anesthesia tech restocked those drawers this morning,” Pam said, noting Kristin’s displeasure. “Is there something missing?”
“I heard the drug shortage of local anesthetics is getting worse. Do me a favor and call the tech. Only thing in here is the stronger concentrations of bupivacaine. Ask her if she has any 0.125% bupivacaine.”
Pam called the front desk to send in the tech and the woman soon poked in her head.
“What’s going on with an eighth of a percent of bupivacaine?” Kristin emphasized her discontent and threw her arms in the air.
“Sorry, Dr. Fleming. I double checked with the FDA website this morning, so I know that Ohio is not being singled out. There is a national shortage of what you want and not much of the .25% bupivacaine left in our carts either.”
“Thanks. It’s not your fault.”
Kristin shook her head. This was a situation she had no control over. “These shortages of drugs, which has been going on recently, affects more than anesthesia. Outpatient caregivers and patients have to seek out other methods of pain relief, which, I believe, worsens the opioid crisis. And in the hospital, surgeons can’t use the numbing drugs at surgical sites, which again ramps up the need for injectable opioids like fentanyl and morphine.”
She tapped her foot. Laverna squirmed and pleaded with her eyes for some pain relief.
“Usually I give a bolus dose of ten cc’s,” Dr. Fleming added, “but I’ll give less and do my usual short increments. We don’t want Mrs. Santana to get a heavy motor blockage with the higher dosage. What we normally want is a sensory blockade with little motor deprivation.”
Kristin aspirated from the catheter to make sure there was no blood on return and then injected three cc’s of the .25% concentration. After four minutes, she injected another three. She wrote an order for the pharmacy to make up a bag of a bupivacaine solution with very low dose fentanyl so they could put it on a pump and infuse it into the catheter.
“My pain has eased. Thank you,” Laverna said after a while. “Anesthesiologists are angels that fly down from heaven when a woman goes into labor.”
“Hmm. I’ve never been called that before.” She cleaned up her mess and looked at Annabel. “Are you staying to do Mrs. Santana’s H&P?”
“Yes, and thanks for letting me watch.”
Kristin glanced at the fetal heart rate monitor and cycled Laverna’s blood pressure cuff one more time. Satisfied, and with a spring to her step, she headed out.
CHAPTER 24
Annabel finished asking Laverna about her past history, surgeries, and previous pregnancy. The twenty-nine-year-old had no problems from the past that should pose a problem for this delivery. So far, that was what she liked about obstetrics. The patients were young and mostly healthy, unlike internal medicine, where cardiovascular disease, COPD, and diabetes was rampant in most patients who walked through the door.
But for the last few minutes, Laverna grew paler. “I don’t feel so well,” she mumbled.
Annabel cycled her patient’s blood pressure cuff and at the same time noticed the fetal heart rate monitor, where she detected evidence of fetal distress. The baby’s heart rate did not seem to change in response to Laverna’s contractions and the rate was slowing down from the brisk hundred and forty beats per minute that he’d been exhibiting.
The pressure registered on the bedside monitor as 96/68. Annabel stepped to the doorway and glanced up and down the hallway for Dr. Fleming. The room was close to the nurses’ station, so she called out for the anesthesiologist.
Kristin stopped what she was doing in the supply room and came running. “I learned that a hollering medical student is to be taken seriously!” she exclaimed as she surmised the entire situation with one scan of the room.
She took Laverna’s blood pressure again, with the same result as when she came in the room. She popped out a vial and a syringe from her anesthesia cart and drew up a concoction. She injected it into Laverna’s IV.
Kristin moved her patient’s gown off her belly and took a dull needle and poked it on her skin at various spots above and below her umbilicus. “Do you feel this?” she asked each time and asked her to differentiate how much numbness she felt from the epidural block she had placed.
Jed burst into the room. Some soda splashed out of the paper cup he held, so he slowed his pace. “I was in the cafeteria and overheard a conversation about recent life-threatening situations happening to unsuspecting patients on the OB ward. And then I get to the floor, and a nurse tells me to hurry in here!”
Kristin eyed the monitor. The baby’s heart rate had picked up; otherwise she was two seconds away from calling the obstetricians stat. Laverna’s pressure was also better. She took in a deep breath.
“She had a spell of hypotension, low blood pressure,” Dr. Fleming told them. “How do you feel now, Mrs. Santana?”
“Not like I’m going to faint anymore.” She glanced at her husband’s paper cup. “Don’t drink that in front of me. I’m dying for something to eat or drink and you�
�re making the temptation too great.”
“I think she’s feeling better,” Jed said. He turned around and sipped the rest of his cola and tossed the cup. “There, that should make you happy.”
“Really? The only thing that would make me happy right now is for you to be having this baby and me standing there watching you.”
He rolled his eyes. “You’ve turned into someone I never knew existed.”
-----
Annabel followed Kristin back to the supply room, where Annabel chuckled. “Some of these couples are hilarious. Seems like a lot of women get testy during labor and take it out on the guy.”
“Sometimes keeping a straight face in the rooms is quite difficult.”
“So what went on in there?”
“It can happen … a more intense sympathetic nervous system block than anticipated. In this case, it may or may not have been due to the concentration of the bupivacaine that I used. In any case, medical drug shortages are another problem to deal with. During my training, it appears like they are increasing in frequency, but imagine being a patient waiting nine months and then being told she can’t have an epidural because the anesthesiologist doesn’t have the correct drug?”
“I guess I wouldn’t want to be on the receiving end of that statement.”
“Me neither.”
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Besides doing scut work and seeing two other patients, Annabel managed to study for an hour. She was out of view from the nurses’ station because she huddled at the end of the couch. Traffic increased into the lounge as some nurses changed shifts and reassigned their names on the board and Caleb came in twice to change the status of patients’ stages of labor.
She managed to read a synopsis of gestational diabetes, which was a different affair than what happens with a non-pregnant person. An extra consideration was how it impacted the fetus. She slipped the open book down to her thighs and stretched out her arms as Dr. Harvey walked in.
“Annabel, I know the answer to my question because I read over Mrs. Santana’s clinic record. I’m wondering how astute you were with her history? Did you ask any questions about her weight?”
