by Barbara Ebel
Donn nodded with his hand rubbing one side of his mustache. “How do we classify heart failure, Dr. Palmer, and what did you and Dr. Watts decide about his classification?”
“Since CHF or congestive heart failure is a chronic and progressive disease, the New York Heart Association designed criteria to assess it.” He made eye contact with everyone on the team. “The method used is to determine the patient’s exercise tolerance. Dr. Watts and I believe he is now a Class III because he has marked limitation of physical activity. He is symptomatic with light activity. However, with this pleural effusion, his symptoms this morning are at rest, which makes me wonder if he is now a Class IV.”
“Nice job,” Dr. Schott said. “What are more symptoms of CHF, Dr. Tilson?”
“His low cardiac output produces fatigue and lethargy as well as the dyspnea, peripheral edema on physical exam like what Bob mentioned, and ascites.”
“The dyspnea or difficulty breathing makes it hard for him to even tie his shoelaces,” Bob said.
“Dr. Watts, tell us about Mr. Hogan’s ascites. Inform the students again what that is and what are we going to do about it?”
Chineka smiled. Dr. Schott made sure the students learned on their feet. “Ascites is the abnormal accumulation of serous fluid,” she said, “in the spaces between the tissues and organs in the cavity of the abdomen. It accounts for the increasing abdominal girth as well as much of the increased weight you see in patients like Mr. Hogan. We have treated him with diuretics and slashed his dietary salt, but the time has come for a paracentesis.”
“A para what?” their chief resident asked, goading them on and turning back to Bob.
“A surgical procedure that internal medicine doctors get to do!”
Dr. Schott lightly smiled. “Yes, we do play surgeon once in a while.”
“Anyway,” Bob added, “it is a procedure to draw off the abnormal fluid or effusion from the abdominal cavity.”
“What for?” Donn prompted him.
“To make him less symptomatic. He’ll breathe much better when his abdominal girth is gone.”
“Dr. Watts,” Donn said, “fine tune what student Palmer just said.”
“I will perform it for both diagnostic and therapeutic purposes,” she said.
“That’s correct. This will be the first paracentesis for this group. Dr. Palmer, be sure you’re there when Dr. Watts performs it.”
Dr. Schott and Dr. Watts disappeared into Manuel Hogan’s room first. Annabel gleamed at Bob. “You’re sharp today,” she said softly.
“Only today?”
Inside, Mr. Hogan’s thick white head of hair matched his furry eyebrows which practically fell down obscuring his eyes. His legs rested on the foot rest of the recliner and the swelling and redness in them made Annabel squirm. Mr. Hogan adjusted two prongs in his nose which delivered supplemental oxygen, making it slightly easier for him to breathe and help reduce the workload of his heart.
“Mr. Hogan,” Dr. Schott said, “good morning. Dr. Watts will be back to talk to you about draining some of that fluid off of your belly. How does that sound?”
“I bet it can’t hurt any more than how I’m suffering with it.” He patted his belly over the hospital gown like a pregnant woman in her ninth month.
“I’ll go out on a limb and assure you … you’ll be glad we do it.”
“How about a new heart while you’re at it?”
“You’d never survive a heart transplant, Mr. Hogan. Your age is a big factor. We’ll keep treating you with the proper standard of care.”
“My wife took off for heaven without me; she beat me to the pearly gates. Saint Peter is tapping his feet waiting on me to join her, so all’s I want is another six months here, doc, to clean up my affairs. Just give me that, will you?” He pleaded with his eyes and Donn furrowed his brow with sympathy.
“We’ll try our best.”
-----
After rounds, Annabel wrote her morning progress note on May Oliver at the nurses’ station and jumped up when she saw a man in a white coat enter her room. It must be the thoracic surgeon, she thought, who they were waiting for.
Annabel followed him in as he introduced himself as Dr. Barrett. “I’m here at the request of the Internal Medicine doctors,” he said, “to evaluate you for lung surgery.”
Annabel was surprised to see May’s boyfriend, Jeff, by the window as Dr. Barrett glanced at her.
“I’m the medical student taking care of Mrs. Oliver,” Annabel said. “May I listen in?”
“Certainly,” Dr. Barrett said. He wore a studious look but a carefree pair of sneakers.
“I was just leaving,” Jeff said.
“You don’t have to,” May said.
“No, I came for a quick visit. You have important matters to discuss with the doctors.” He passed May and slid between Dr. Barrett and Annabel and rushed to the door. A look of abandonment crossed May’s face, but she managed to peel her eyes away from the back end of her boyfriend in flight and settle on the surgeon.
“Mrs. Oliver,” Dr. Barrett said, “you are aware of the adenocarcinoma that has been discovered in your lung. I am here to offer you one solution - to operate on your lung to remove it as best as we can. Hopefully, the entire mass.” A comfortable silence ensued as he let her think about it. “Lung surgery is risky because we must deflate the lung we’re working on so it won’t be breathing for you at that time. Fortunately, with some organs, we have an extra one - like your lungs and your kidneys - so your other lung will do all the work while we work on the first one. Skilled anesthesiologists do this, allowing surgeons like me to root out the tumor in question.”
May glanced at Annabel and she nodded.
“Like with many surgeries, there is a risk of infection, bleeding, stroke, or death; also technical problems whereby I can’t deliver what I promised. An anesthesiologist will also talk to you if you decide to proceed.”
Dr. Barrett stood over six-feet-tall and finally sat on the bed and leaned forward. “Having a thoracotomy is a reasonable and expected procedure in this situation especially since some of the objectionable cells are seeding themselves elsewhere. But, the decision rests entirely with you.”
“My mind was made up before you arrived,” May said. “Please don’t think I wasted your time because I needed to hear what you had to say. I would like to proceed.”
“Never would I consider my explanation to you pointless or unnecessary. We shall go ahead, then. Expect to be on tomorrow’s schedule.”
“Thank you. Dr. Tilson, will you be there?”
“I am on a medicine rotation, not surgery, but I’ll ask Dr. Schott if I can.”
“He’s a reasonable chief resident,” Dr. Barrett said. “If it serves educational purposes and you can help with the care of your patient, I’m sure he won’t mind.”
Dr. Barrett stood and focused again on May. “Someone in the anesthesia department will be by today to talk to you and both services will be writing orders … such as nothing to eat or drink after midnight.”
Annabel lingered after he left.
“He stayed but five or ten minutes,” May said, her eyes clearly glued on Annabel. “My boyfriend, that is. When I told him I might be having lung surgery and then the surgeon walked in, he fled out of here like he was on fire. That’s the last I’m going to see of him.” She bit her lip and her face crumbled with despair.
“May,” Annabel said, “please don’t lament over him. If I may say so, the relationship wasn’t meant to be.”
May’s head gave a little bob. “Perhaps it was an imaginary relationship that I had with him all along. It was one-sided and I kept trying to make it work but, luckily, it wouldn’t cooperate that way. Sometimes circumstances make it easy on you because they are telling you something. It’s about time I listen.” She rubbed her hands back and forth like she was brushing off crumbs.
-----
Annabel ate lunch by herself figuring she had missed everyone in her group. When
she got back to the office, only Stuart was quietly hunched over the desk, reading. With relief, she realized she was caught up with medical “errands” and had time to study like Stuart. She wanted to know more about Mr. Hogan’s procedure that afternoon and opened a text from the shelf to “thoracentesis.”
A text message made a ding on a cell phone; maybe her own because Jordan wasn’t in the room. She weeded it out of her pocket and found an update from her sister.
I’m on campus but Mary and Casey just brought Dakota’s ashes home.
Annabel slipped out the door and leaned against the wall. She dialed Nancy instead of texting back. “Hey, thanks for the message. I wanted to talk.”
“That’s fine,” Nancy said. “I’m in a lounge where students are goofing off. Mom and Dad are working but Casey came off a midnight shift and wouldn’t have it any other way but to go with Mary to the vet’s and pick him up.”
“It figures,” she said. “I’m so glad Dad did that. You know, he also said he wants Dakota’s ashes to be buried with him.”
“I hate to think of that day.”
“But would you ask him something? I would like a small urn with some of Dakota’s ashes with me up here.”
“I can ask. If he says yes, I’ll bring them up. I’m coming to visit. Would next weekend or the following weekend work for you?”
“I don’t know if I can stand you that long but I’ll let you know.”
“I have something else you may like.”
“What’s that?” Annabel asked.
“I brushed Dakota regularly. Two or three times before he passed, I saved samples of his hair in baggies. I can bring one to you.”
“I’d appreciate that. I carry a plethora of stupendous memories but that would be one more thing to cherish.”
“Consider it done. And I bet Dad won’t mind sharing a bit of ashes. If you don’t hear from me, he has granted your request.”
When they ended the call, Annabel closed her eyes, thankful for mutual family support.
CHAPTER 19
“Annabel, Dr. Watts and I are going to do Mr. Hogan’s paracentesis,” Bob said as he passed her in the hallway going the opposite direction.
Annabel stopped short. “Can I come along?”
“Sure,” Dr. Watts said. She kept moving and, inside the supply room, she barked orders at them. They stacked the necessary supplies in Mr. Hogan’s room.
“Mr. Hogan signed his consent form already,” Chineka said. “For procedures like this one, you would never do it on a patient with a bleeding disorder or thrombocytopenia.”
“Thrombo what?” Mr. Hogan asked.
“A low platelet count,” Chineka said. “Mr. Hogan, you may lie on your back and we’ll adjust the bed so your head is raised a little.”
Bob rolled over the blood pressure machine and wrapped the cuff on Mr. Hogan’s arm while his patient wiggled on the bed to get comfortable.
“I’ll get a baseline blood pressure and pulse,” Bob said. He cycled the machine and listened with his stethoscope.
Chineka began cleaning Mr. Hogan’s abdomen, gowned and gloved, and draped sterile towels around the site. “I’m going to make a little bee sting on your skin while I inject some numbing medicine,” she said, drawing up lidocaine.
“I always use the lower left quadrant,” she said to the students and gave the local anesthetic a minute to take effect. “An ultrasound can also be used for guidance, especially if there isn’t too much fluid.” She slowly put the larger paracentesis needle into Mr. Hogan’s belly.
“Ouch,” Mr. Hogan said.
Chineka tilted her head. “You should feel pressure, not really pain.”
“Pressure,” he said. “You shoulda knocked me out for this.”
“This is much safer for you,” Bob said. “The needle in the abdomen is similar to what awake pregnant women go through for an amniocentesis.”
“That’s why men don’t have babies.”
Annabel suppressed a chuckle as Bob glanced at her.
Carefully, Dr. Watts began to aspirate fluid into a large syringe. “Be sure to lie completely still,” she said.
“What else am I going to do? Do you know what I’m gonna do when I am sprung out of here?”
“You are going to get your affairs in order,” Bob said while Chineka continued focusing on the procedure.
“Right,” Mr. Hogan said. “I told you young folks that. Specifically, I’m going to go pick out a headstone. Of course, I want to be buried, but why shouldn’t I be the one to select what will be resting above me for God knows how long? Maybe just a century because the world’s population is burgeoning and my plot will someday be needed for land area under a high-rise apartment building. And I want to write a creative inscription ahead of time, something which will make people stand there and ponder over the nut case underneath. Something like ‘Stayed still for a Paracentesis.’
“I see you students half-grinning,” he said. “You two have such baby faces, you’re young enough to be my great-grandchildren.” He glanced down and, for the first time, studied what Chineka was doing as the heat from the baseboard kicked on and made a steady drone.
“More than a liter drained already,” Dr. Watts said.
“I don’t feel so great,” Mr. Hogan said. “I mean, I haven’t felt fantabulous since getting CHF, but now I’m going to droop.”
Annabel and Bob exchanged glances and nodded. Bob cycled the blood pressure cuff while Annabel positioned her stethoscope on his forearm. “110/76,” she said when it finished. “I’ll run and fetch fluids.”
She hurried out to the supply area again knowing that, for Mr. Hogan, he was hypotensive. His pressure had been a lot higher when they first started, so it was not unusual for him to be lightheaded, especially after spying on the needle and the procedure. She grabbed only an IV bag and tubing.
Annabel came back into the room and Bob wheeled over a pole from the corner. Between the two of them, they hooked the fluids into Mr. Hogan’s hep-lock, took his pulse, and recycled his blood pressure. He rested with his head back and his eyes closed. Bob patted his forearm, which was speckled with previous bruises from attempts at starting IVs and bumping into things.
“I’ll be okay,” Mr. Hogan said softly.
“This will do,” Chineka said. “Over two liters. We’ll let Mr. Hogan readjust to the loss of volume and not drain anymore.” She took the needle out of his abdomen and applied a bandage over the site. “I’m sending some of the fluid for testing, but we don’t expect any surprises. The white cell count and culture will probably not show signs of an infection.
“How are you doing, Mr. Hogan?” Dr. Watts asked.
“Hanging on. I haven’t had this much attention since my wife rubbed horse liniment into my aching muscles.”
“Glad we can be of service,” she said and turned to the students. “Mr. Hogan needs his blood pressure, pulse, and temperature monitored over the next hour. I’ll write the orders. Staff should call me if his vital signs deteriorate from what they are now.”
“If we stay free to do so,” Annabel said, “Bob or I will pop back in too.”
With Mr. Hogan looking peaceful and feeling better, they stepped out.
“You two worked like a team in there,” she said, “without my even telling you what to do. I’m impressed.”
“Thanks,” Bob said. “Those words would shine if they were written on our clinical evaluations,” he added with a pleading smile.
“Dr. Palmer,” she said, “sometimes you’re priceless.”
-----
The next morning, Mr. Hogan appeared more comfortable as the team congregated around him. Every light was on in the room with the gray sky a contrast through the window. His fork dabbled with the scrambled eggs on his breakfast tray.
“These would taste like a filet mignon if I could sprinkle salt on them,” he said.
“No salt,” Dr. Schott said. “Not under my care.”
“I figured you’d say that
.”
“You look no worse for wear after your paracentesis yesterday.”
“That motley crew of yours drained my belly yesterday like they tapped open a beer keg.”
“It’s a heck of a way to lose weight,” Dr. Schott said. “How did you fare with the procedure?”
“Besides getting all dizzy and your medical students rescuing me, I hung in there.”
“They come in handy once in a while,” Donn said.
“Mr. Hogan’s weight is down two pounds today,” Bob said to Dr. Schott, “and the lab values from his ascitic fluid so far show no sign of infection.”
“A little more tuning up, Mr. Hogan,” Donn said, “and we’ll try and discharge you to home.”
Dr. Schott led the team outside. “I am not optimistic about Mr. Hogan. I believe his ejection fraction is much worse than the last time he was evaluated. Dr. Watts, please order an echocardiogram on him and give the students a small primer on the topic.”
“This is a subject I have pored over in my own life,” Chineka said, “since my mom has CHF. When an illness or disease is personal in nature, then I use it to my advantage to learn every last morsel about it.”
“You students have heard this before,” Donn interrupted, “and you’ll hear it a thousand times. Standing on your feet on rounds, hearing a subject over and over, is what makes it sink in so that it is second nature. Go ahead, Dr. Watts.”
“The heart’s ejection fraction,” she said, “is a number that is a percentage. It is the percentage of oxygenated blood that is pumped out of the left ventricle, the main pumping chamber of your heart, with each heartbeat. Fifty-five or higher is considered normal, but below forty may be evidence of heart failure or cardiomyopathy. The last percentage assessed for Mr. Hogan was below 40 percent.
“Since Dr. Schott wants us to reevaluate Mr. Hogan, the best, most common method to assess ejection fraction is by doing an echocardiogram. That test uses sound waves to produce images of the heart and the blood pumping through the heart. The result can guide us with our patient’s treatment plan and tell us if he is going down a slippery path.”
