by Barbara Ebel
Donn led them out the room and, with chart in hand, they soon stood inside May’s room. The bathroom door was open and she leaned over the sink.
“More coughing up blood,” she said out the door. “On top of this, you all disallowed me from eating breakfast.”
“You can’t have anything in your stomach for the procedure,” Dr. Schott said. “You will be sedated and we don’t want food passively coming up and accidentally going into your lungs or hindering the process. Is anyone here with you this morning?”
“No. My boyfriend, Jeff, is working.”
“Dr. Tilson is going along. She’ll show up in the procedure room.”
May walked out, her hospital gown hanging loosely off her shoulders; Annabel could swear she’d lost weight since her admission.
“I would appreciate that,” she said. “Besides the depression of losing Misty, I’m feeling lousier by the day. What’s wrong with me anyway?”
“We’re aiming to find out,” Dr. Schott said.
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Annabel volunteered to start May’s IV so she could practice that skill and slid a narrow-gauge catheter into May’s hand. The pulmonologist, Dr. Cantrell, ordered Versed immediately and the RN in the procedure room slipped one cc into the IV. Next, the doctor squirted local anesthetic into May’s nose and throat; she sneezed, coughed, and then settled her head again against the back of the stretcher. The doctor looked again at her chest x-ray while waiting for the numbness to take effect from the spray.
“My lawyer thinks the dog kennel with the day care isn’t going to want the publicity of my lawsuit,” May sputtered to Annabel. “He thinks they are going to settle out of court. Maybe they’ll pay me so much that it covers all my medical bills.” The sedation fully kicked in, she closed her eyes, and her hand relaxed on her abdomen.
“Don’t worry about a thing,” Annabel said softly. “It sounds like you have a dependable attorney and your lung doctor here is going to make your procedure seem effortless.”
Dr. Cantrell inserted the flexible fiber-optic scope through May’s nose. Adequately drowsy, they also had her hooked up to oxygen. At the tip of the scope was a light and as the doctor began threading the device down May’s throat, the view was seen on the camera at the upper end. Annabel stood against the stretcher and the nurse gave one more dose of Versed when May reacted to the passage of the tube through her vocal cords. They viewed the progress down the cartilaginous and membranous trachea or windpipe.
“Can you guess the age group I do the most frequent emergency bronchoscopies on?” Dr. Cantrell asked.
Not knowing the answer, Annabel shrugged her shoulders. She was not out that long from the first two years of medical school bookwork to know. “No,” she said. “I wouldn’t guess that many are done.”
“Pediatric patients,” Dr. Cantrell said. “Kids. They put the craziest things in their mouths, they choke, and then whatever it is gets aspirated into their lungs. The biggest thing I’ve retrieved so far was a bracelet.”
“Jeez,” Annabel said.
“Really. Aspiration of foreign objects surprises me half the time too.” She infused a warm saline solution down the scope to help clean May’s airway, allowing better visualization, and also to collect some of that fluid back through the scope to be used as pathology samples.
They watched as the scope came upon the carina where the trachea divides or bifurcates into two separate smaller airways called bronchi, one going into each lung.
“Based on the respiratory tract’s anatomy,” the pulmonologist said, “if someone aspirates a foreign object, which path would the object most likely take? The right or left bronchi?”
Annabel thought about her gross anatomy class. The bronchus going to the left lung was longer and the right bronchus was shorter. Maybe more important, she thought, was that the left bronchus took an abrupt angle, making it easier for food or an item to take the less resistant path along the right. “I suspect the right side,” she said.
“Correct. And here we are going off to the right, which, as you can tell, is a more effortless path for the scope. We’re heading this way because Oliver’s area of suspicion is in the right lung.”
Stemming from the bronchus were smaller bronchial tubes; Dr. Cantrell guided the scope with the necessary attachment down a main one and then snagged a tissue sample of the questionable area. After she finished examining May’s lungs and procuring the biopsies, Dr. Cantrell removed the bronchoscope.
“I’ll follow Mrs. Oliver after the procedure,” she said, “but you will also be taking care of her. What were the risks of the procedure and what should you monitor her for?”
“Bleeding and infection,” Annabel said, “which seems to be a common risk for many procedures. Also, breathing difficulties and hypoxemia, even though May tolerated the procedure well with the oxygen that you delivered. Now, I’ll watch her for a fever which could signify an infection, monitor if her hemoptysis becomes worse; and, also, if her lung was accidentally punctured, we could be dealing with a collapsed lung. I mean a pneumothorax.”
Dr. Cantrell listened and gave Annabel a thumbs-up.
“Thanks for letting me be a part of the procedure,” Annabel said.
“It’s part of your journey,” Dr. Cantrell commented. She studied May’s vital signs on the monitors and patted her shoulder. “Mrs. Oliver, the procedure went fine and we are finished.”
May’s eyes opened and closed and she nodded as best she could
“You’ll still be groggy, but you can rest for a few hours,” Dr. Cantrell said. “You can’t eat or drink for a while anyway because your throat is numb. Then for a day or two it may be hoarse.”
May grunted an “okay” and squeezed Annabel’s hand.
“I’m going to go peer over the pathologist’s work,” Dr. Cantrell said, “and let you all know as soon as we have Mrs. Oliver’s tissue diagnosis.”
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Mr. Harty dozed in his recliner, but he startled from a noise outside his window. A maintenance man stood on a ladder in his winter work clothes clipping a tree limb which had caught on the gutter. The place used him for just about anything and he wondered how much longer the man would continue to work at the facility.
A woman appeared outside the doorway with a therapy dog named Rusty. She visited once a week with her trusted companion, who caused many residents to smile when they saw and petted the dog. Kevin was particularly fond of animals and looked forward to and appreciated the visit more than most. He pushed out of his chair and made his way out to the hallway.
The young woman smiled and waited with the furry American Eskimo dog for Mr. Harty. The dog’s tail whipped around and it pranced in its place with anticipation of greeting the old man and being petted. When Kevin stood at the doorway, another resident named Mrs. Potter reached them with her walker leading the way. She wore a loose-fitting top and flared-out knit pants, which sometimes doubled as pajamas. Her skinny fingers un-gripped the top brace pipe and her index finger waved at the woman with the dog.
“Get that dog out of here,” she said.
“Mrs. Potter,” the woman said, “Rusty is a certified therapy dog and is allowed to visit the residents here.”
“Get that dirty dog out of here.”
“She’s not dirty, Ma’am.”
“All dogs are dirty. I know what they do.”
The therapy dog woman hesitated and stole a glance at Kevin.
Mrs. Potter waited a second; she tensed her lips in anger because her complaint was not being heeded. “I’m allergic to dogs,” she added. “Get the damn thing out of my way.”
The therapy dog woman frowned. “Sorry, Mr. Harty,” she said and turned. With the dog taking backward glances, she trotted him back to the entrance and headed over towards the nursing section.
Mrs. Potter put her hand back on her walker, huffed, and slowly resumed her way. A satisfied grin spread over her face.
Kevin walked back into his room, his shoulders sagging. If
only he had run his fingers through the dog’s soft fur and received a wet, sloppy kiss on his hand. Mrs. Potter was a bitter old lady, he thought, knowing the place was half-full of them.
He nestled into his chair again, too tired to poke around on his computer before dinner. He knew it would take weeks to regain his strength after his GI bleed; however, this time, he doubted it would happen. He sensed he was facing one big bleed after the other.
In a half hour, a woman came in with a tiny cup of meds and tapped her foot while Kevin slid them down his throat with some water. “Time to go for dinner,” she said when she left.
Mr. Harty took off his non-skid slippers, slipped into presentable shoes, and went up the hallway to the dining area. Totally hungry, he sat at his usual table; he had balked at the lunch or main meal in the middle of the day and had gotten up and left. Now he absolutely needed the nutrition and calories. What they served would be vitally important.
Two other usual residents came over and sat at his table; the three of them resigned to little chit-chat at meal times. The only huge news ever to befall any of them was if a family member was due to visit, especially grandkids. Their visit would practically give a resident a stroke, such was his or her excitement. Kevin nodded at both of them but was in no mood for small talk about his hospitalization. It was done and over with and discussing blood per rectum was not a fit discussion during their meal.
Two women with aprons on came out of the adjoining kitchen wheeling two aluminum carts. They placed dinner plates down for each resident. Mr. Harty stared in front of him: a round mound of macaroni and cheese, a couple of French fries, and a slice of dried meat loaf. The bread basket was filled with dense rolls and butter packets. Amazing, he thought, no hockey-puck chicken tenders, but the meat loaf and the rest of the crap was no better. He pushed away from the table and ambled over to the kitchen door.
“Helen,” he said to the older woman inside. “Can you serve me something else to eat? Honestly, I cannot and better not eat anything on that plate.”
“Why?” the woman asked with a shake of her head.
“There is no fiber, vegetables, or greens to make my intestines work the way they are supposed to. Why bother with the three items, anyway? Just serve us bread and potatoes and be done with it. That plate is filled with starch, loaded with calories, and it gives me severe constipation, which makes me have to strain when I go to the bathroom. My doctor calls it a Valsalva movement. Some of my GI bleeds have erupted after I needed to do that.” He tried not to glare at her. “We’ve been through this before, but you asked me ‘why,’ and forced me to give you the real, unadulterated answer.”
The woman squirmed.
“Again,” he said, adding more to make his point, “you asked me, which made me spell it out for you. I will end up in the hospital again soon if I keep eating this institutionalized food not even fit for Rusty.”
“I don’t have control over the menu or the purchase of food like you think I do,” Helen said. “But, in any case, aren’t most of you on handfuls of laxatives?”
“Yes, precisely, and a variety of them. Which tells you how bad the situation really is. Even they can’t make proper waste of the poison you feed us.”
“All I can tell you is that I will relay your concern at the next meeting between kitchen services and administration.” She stood over the sink with an unused plate of food for a resident who didn’t show for dinner and scraped it down the garbage disposal.
“That’s exactly where it belongs,” Mr. Harty said. “And you can add mine to it.” He turned and walked by the residents at the tables with ceramic ornaments in the center and kept his focus on the floor.
Back in his room, he took out a slim album of photographs and thumbed through them until the sun was long set and the facility’s outdoor lights came on outside his window. So many memories in one single book, he thought. Snapshots of being a youngster with bony knees and a fishing pole, photos with his wife while they toured New York City, color snaps of a him giving a presentation to business people in a conference room. He had been successful and esteemed and had forged some loving relationships. What a pity that many of those people were gone. It was better not to hang on like a spent fish at the end of a line when all the odds were against him. If he couldn’t stand it now, what made him optimistic that things would be better in six months or a year? By then, the severity of his problems would escalate to such depths that they would be total hell-on-earth.
Kevin placed the album with loving respect on his bureau and closed the blinds of his window. There was not a peep now coming from the hallway, only one loud television blaring from some resident’s room. He went to the doorway and looked up and down the hall and noted doors either open or closed. The bulk of the old timers were either fast asleep in bed or half-passed out in chairs. The few staff working the overnight shift had barricaded themselves somewhere where they weren’t seen; being out of sight was a ploy so residents didn’t ask them for assistance.
He closed the door and padded back into the room in his trusty slippers; he wouldn’t worry anymore about storing two pairs of them. In essence, he wouldn’t have to worry about or put up with anything anymore. Especially his GI bleeds and consequences.
Kevin opened the double doors to his closet. Shirts and trousers lined the hanging bar from left to right. The regularly used clothes, bathrobe, and jacket he kept on the right hand side; less used and good clothes were to the left, although since moving there, he had only used the finer clothes for funeral services. At the very end of the left side, he took down a hanger with a pair of clean, pressed trousers that he’d never worn. He undid the button on the back right pocket and pulled out a plastic baggie meant for sandwiches.
Before he moved into the facility, he had saved unused narcotic prescription drugs. If ever the need arose that life was not worth living or he needed Kevorkian action to be taken, he would have a plan and a method in place. He had plotted adequately for most things in his life; it made sense to do the same for the terminal end of living as well. His current situation deserved and demanded the enactment of his strategy.
He carried the baggie with him, poured a glass of water, and sat back down in his only chair. The bag contained mostly oxycodone pills and he poured all of them into his hand. One by one, he put them in his mouth and took a sip of water. They went down smoothly and he continued the process, making sure he didn’t drink too much liquid that he became full. With all of the contents of the bag gone, he stepped over to his bed, slid under the covers, and rested his head on the pillow.
For the first time ever, he gloated over the fact that the place was theoretically unattended and no one would find him until the morning when perhaps a CNA poked her head in to remind him of breakfast. He closed his eyes and thought back through his life, picking out the beautiful scenery he’d witnessed, the people he’d loved, and the one and only dog that had meant the world to him. He had been caring and supportive to people and causes, as well as an intelligent and successful man. His euthanasia also reflected his unselfish ability to not hinder any more people with his management; he would not tolerate the continuance of the absurd medical problems and living condition he was presently imprisoned in.
Simply, he was desperate to die, and his death proceeded with ease and serenity.
CHAPTER 10
On the next day’s morning rounds, Dr. Mejia showed up unannounced. Jordan Maldonado finished presenting his newest patient to the group and wrapped up his student H&P.
“This young female patient has persistent nosebleeds, so our job is to differentiate if it is from a systemic disease or just an isolated epistaxis.” Jordan took a subtle step to the side, his shoulder impolitely putting Donn behind him as he tried to impress the attending. “The plan is to work her up and consider all bleeding disorders.”
“When and if you go into cardiothoracic surgery,” Dr. Mejia said, “bleeding problems will be your nemesis. Even I get into trouble threading stents up pe
ople’s major blood vessels into the heart when they have undiagnosed abnormal bleeding. In your first two years of med school, you learned that platelets circulate in the blood stream and assist in blood clotting. They do that by adhering to each other and damaged epithelium in blood vessels.” He opened the patient’s chart in his hands, looking for Jordan’s H&P, and continued, “Since you read up on your patient, you may tell your fellow students the name of, and the official number of, a low platelet count.”
Jordan faced Annabel, Bob, and Stuart. “Thrombocytopenia is the term for a platelet count that’s below normal; a count of less than 150,000, but some definitions use a count of 100,000.” He glanced from one to the other and spoke slowly as if teaching children.
“But,” the student said emphatically and gloated, “the most serious risk for life-threatening bleeding comes with a count less than 10,000.”
Annabel wished Dr. Schott was in front and could see the smirk on Jordan’s face.
“A count that wimpy has dire consequences,” Dr. Mejia said. “Knowing your patient’s sex and age already gives us a high suspicion that she has ITP, or idiopathic thrombocytopenia. Which means we won’t find the cause; it’s spontaneous and the etiology is obscure. But, of course, we will do a full work up because it’s possible the problem is due to something else.” He smiled at Jordan and expected a perfect answer to his next question.
“Pertinent to this day and age, what would be a strong possibility of a secondary cause to your patient’s low platelet count?”
“Hepatitis C or autoimmune hemolytic anemia,” Jordan said.
“Good, and …” Dr. Mejia furrowed his forehead and waited. Without an answer, he focused on more possibilities from the other students.
“We heard a convincing patient case history at grand rounds this week,” Bob said. “It made an impression on all the students who attended about the effects of thrombocytopenia.”
“I remember seeing the topic posted on the internal medicine bulletin board.” Dr. Mejia stared back at Jordan while Bob stole a glance at Annabel. She parted her lips and held back a full smile.
