by Barbara Ebel
Dustin shifted his eyes toward her. “I heard somewhere that sex can be satiating.”
“We just proved it. You wore me out. I don’t know if my legs are going to work tomorrow.”
He inhaled a deep breath. “Me too. I better be stuck in the patrol car most of the day.”
“I won’t be so lucky. I’m on my feet most of the time.” She tapped his lower lip. “Should we eat our dinner? Then I better go to sleep.”
“Sure.” He gave her a kiss and walked straight to the bathroom while she enjoyed the view. She rolled off the bed, threw on a T-shirt, and scooped Cajun food on two plates. Dustin dressed and came out while the microwave beeped.
“Just enough to quench our appetite,” she said, taking out the second plate. “I’m going to appreciate the leftovers too.” She put the Styrofoam containers in the fridge and soon they polished off their food.
Annabel grabbed her cell phone. “I’m arranging an Uber drive for the morning.”
“I hope you’re not cursing me out tomorrow for sabotaging your needed sleep tonight.”
“On the contrary, I’m going to be smiling all day thinking about both aspects of tonight.”
He carried their dishes over to the sink. “One of these days, I’ll make dinner for you. I’m not too bad of a cook.”
She used the app while watching him clean the dishes. He wiped his hands on a towel and motioned her up off the stool. “Get to bed. Save more lives tomorrow.”
They kissed tenderly and he was out the door. She scrambled into bed. As she turned to get comfortable, she realized she had never invited a man to her own bed before. There was a first time for everything and it had definitely been worth the wait.
-----
Hours later, after her trip to the hospital, Annabel hunted around the cabinets in the ICU for the tallest cup she could find. She found a small stash of sixteen-ounce cups in a drawer and pulled one out. Although feeling guilty for taking so much of the unit’s hot coffee, she poured as much as she could and left a little room for cream. It went down smooth and velvety, and she told herself the caffeine would succeed in making her alert for morning rounds.
She also tried to wipe the silly grin off her face – the “morning-after glow” or the “I just got laid look.” She was glad that Bob was currently absent because she bet he would sense her elation and question the hell out of her.
Annabel put the half-finished cup and Jae Nixon’s chart next to each other on the main desk and went into his room. Even though she was only in her first year of clinical rotations, a pattern was beginning to develop. Jae wasn’t her first ICU patient; the ability to anticipate a patient’s needs and problems was beginning to form. His baseline blood pressures trended lower than before and his heart rate a little higher. Urine output was also less robust. Like usual, she admired his tattoo, and then examined the rest of his arm. His IV probably needed changing, and if that were the case, a larger one should replace it.
After listening to Jae’s heart and lungs, she walked back to the desk where Dr. Enno flipped through his chart. The infectious disease consultant was seeing her consults earlier than her own attending and chief resident made rounds.
How could the senescent woman be that dedicated, interested, and attuned to her patients and the world of medicine and manage such long hours? She shook her head. Shouldn’t the woman be retired and lounging on a cruise deck overlooking the mighty blue ocean where she could watch dolphins cascading further out from the perimeter of a ship’s hull?
Annabel wrapped her hand around Alejandro to move it out of the way and sat down. The cane felt comfortable and polished, so she lingered her fingers on the bend of the handle.
“Good morning, Dr. Tilson. One of our results is back on Mr. Nixon.”
Annabel wondered if it was the HIV test. Medical students were the ones who scooted around the hospital and found results faster than anyone else, but not so with Shania Enno.
“He is HIV negative,” Dr. Enno said. She patted the shaft of Alejandro like she was petting a dog. “If Nixon’s HIV status was positive, I would be sitting here telling you my next teaching points.”
“Will you tell me anyway?”
“Of course. What would be essential is that we estimate our patient’s level of immunodeficiency with a CD4 or T4 cell count. Normal adult levels range from 600 to 1500 cells per cubic millimeter. When levels decline to less than 500, the immune function of patients is compromised, and they become more and more susceptible to obscure and rare infections.
“The clinically sneaky part of HIV is that seventy percent of patients remain asymptomatic, the disease undergoing up to a ten-year latent period before they are clinically immunocompromised.”
“What about the other thirty percent?” Annabel asked.
“They present with a sudden, acute HIV syndrome, which is one consideration I had for Jae Nixon.”
Annabel nodded, trying to commit the information to memory.
“I’ll leave a note for your team, but tell your chief on rounds that our patient is HIV negative.” She grabbed a progress note sheet and began writing with her slow hand as Annabel held Alejandro.
The cane had been with the old woman to diverse medical settings over the years and Annabel wondered if it was a physical substitute for a meditation mantra. She eyed the woman’s pulled back gray and black peppered bun. She didn’t have a doubt that the woman practiced meditation – most likely the reason for the tranquility which spilled out of Dr. Enno like crystal clear water flowing through a mountain pass.
-----
Donn leaned against the desk, his unused newspaper folded behind him, as he waited for the last of the team to trickle into the office. Since finding out about the Meagan Helm lawsuit, he had not read to the team from his paper. Annabel missed that aspect of their morning routine. She never had time to read like that and she only saw highlights about current events when they popped up on her iPhone. The state-by-state information that Donn usually relayed to them on a daily basis was news she never heard of anywhere else.
Annabel sat between Melody and Chineka on the couch. She was still on a high, or a drunken stupor, from being with Dustin only ten hours ago. The entire evening’s tryst with him was difficult to forget. She took a deep sigh and Melody gave her a questioning glance.
Jordan arrived, oblivious that Dr. Schott was waiting for him.
“I thought you’d be here first,” Donn said. “Without a cell phone, you have no distraction inhibiting you from performing your clinical duties. Unless, of course, you already bought a new one.”
Jordan twisted his mouth. “I’m picking one out tomorrow after call.”
“Great. I hope they sell you a lemon.” Donn shifted his gaze to Annabel. “What did you and Bob find out at Dr. Raymond’s office?”
“He is sicker than either of us imagined. His platelet count is 40!”
Donn’s eyebrows shot up. “How in tarnation? What does he have?”
Feeling giddy and mischievous, Annabel looked at Jordan.
“What are you looking at him for?” Donn asked.
“I thought since he diagnosed Jae Nixon with Leptospirosis, he still thinks of himself as a genius and is ready to diagnose Bob.”
“But he was dead wrong.”
“Exactly. Maybe he can redeem himself.”
Jordan’s eyes narrowed in anger as he backed up against the book shelf. “I don’t know his symptoms like you do.”
“Annabel,” Dr. Schott said, “even if he did, I would no longer give Jordan the benefit of the doubt. What did Dr. Raymond say?”
“He has Ehrlichiosis.”
Donn scratched his beard. “I read about that months ago from an article in an internal medicine journal.” He looked at the residents. “What about you two?”
Chineka and Melody shook their heads.
“Dr. Tilson,” Donn went on, “I must make other announcements, but sometime on rounds, you are going to teach us a thing or two about Bob’
s diagnosis. We’re on call today, so let’s look sharp and ready. We also have clinic hours this afternoon. You students will take all guidance from the residents and Dr. Mejia, if he shows up. I’ll be gone early this afternoon for a deposition. Time consuming legal matters have begun.” He lowered his eyes to the floor.
-----
Before they trotted into the unit, Dr. Schott gathered the team next to the panoramic window of the empty ICU waiting area.
“Tell us everything you know, Dr. Tilson, about Bob’s illness. I take it he’s grounded for the rest of the rotation?”
“Yes,” Annabel scowled. “But he plans on sitting for the final exam.”
“I will let the department know. Now, tell me about Ehrlichiosis as if you are writing a succinct, one- or two-paragraph description. Cover all the basics like a pro.”
Even though Donn’s attitude was in a wad, Annabel thought, he still knew how to get them to think on their feet. She planned her description carefully.
“Ehrlichiosis is caused by bacteria. That bacteria is transmitted to a human by the bite of an infected tick and flu-like symptoms occur within one or two weeks of being biten. In our country, there are about three different Ehrlichial species, but Bob’s disease most likely came from the lonestar tick.” She stopped to think about how to continue while all her team members stood stunned on hearing how he acquired it.
“Symptoms can include a fever, headache, fatigue, and muscle pain.”
“Perhaps this disease is ‘going around,’” Jordan boldly interrupted. “It could be the one affecting your ranger since he doesn’t have Leptospirosis.”
“Leptospirosis and Ehrlichiosis are both caused by bacteria,” Annabel said, “but we already determined that bacteria are not the cause of Jae Nixon’s illness or meningitis.”
Donn nodded, pleased with Annabel’s report and reasoning. “Give us a quickie on diagnosis and tell me what Dr. Raymond ordered for Bob’s treatment.”
“It seemed to me that a high index of suspicion for thinking outside the box was necessary for Dr. Raymond to consider this disease. Blood tests were necessary; thrombocytopenia, leukopenia, and high LFTs are usually present, which was the case with Bob. Further, special testing is used to detect the presence of antibodies against the disease and if it isn’t correctly diagnosed, it can be fatal.
“We stopped on the way back to Bob’s apartment yesterday and picked up Dr. Raymond’s prescription for doxycycline and the serologic testing, the indirect immunofluorescence assay, is pending.”
“Thank you,” Donn said. “How Bob acquired this gem must be a mystery.”
“We have an idea about that, sir.”
“Rare diseases are often unexplainable.” Donn said. “Which brings us to Mr. Nixon. Let’s go into the unit.”
Melody Burg stepped forward outside Jae Nixon’s ICU room and gave the update on his medical condition, sparing Annabel being on the hook again.
“And his HIV result came back negative,” Annabel added to Melody’s summary. “Dr. Enno happened by earlier when I was here.”
“What do you two think needs to be done with your patient today?” Donn asked.
“Continued and more supportive care,” Dr. Burg said, “including a mild dopamine drip for his renal perfusion.”
“Does he need a central line?” Annabel asked.
“Your peripheral IV skills have improved,” Melody said and looked at Donn. “How about I guide Annabel through her first central line? I’ll gown, glove, and step in to take over if needed.”
Annabel’s heart raced a couple of beats. She couldn’t believe what Melody said. If Donn agreed, it would be her biggest procedure yet; something she didn’t expect to do until she was a resident. She held her breath, waiting for Donn to make a decision.
“I’m not personally in a good mood to say ‘yes,’ but I can’t take my attitude out on Annabel. Her skills and conscientiousness are noteworthy enough. The two of you put in a right subclavian line. However, do it before lunch and clinic so that if you have any doubts or need help, you can call me. I’m leaving around twelve. Plus, admissions will probably start rolling in later.”
Annabel felt like yelling from a rooftop. Remarkable fortune was following her; maybe she needed to go out with the police officer and grasp Alejandro more often. “Thank you. I’ll be careful and successful.”
“Good luck,” Stuart said. “I’m envious.”
Donn motioned for the team to move on and Jordan and Annabel brought up the rear of the pack.
Jordan’s mouth narrowed and his eyes glared at Annabel with resentment.
“Don’t forget,” Jordan said softly. “When you stick the needle in under his clavicle, the apex of his lung will be right there. That’s a minor detail you slept through during gross anatomy. Don’t puncture his lung and cause a pneumothorax.”
Annabel wanted to smack him, but no way was she going to let him downgrade her elated mood.
“Jordan, you have your entire life to be a jerk. Why not take today off?”
CHAPTER 21
After rounds, Annabel and Dr. Burg grabbed a central line kit and other materials from the supply room.
“You’re on,” Melody said as she hastily began opening the kit on the tray table next to Jae’s bed. Annabel took a deep breath but watched every move her resident made while the nurse turned Jae’s head and breathing tube to the left.
“What are the two biggest contraindications to placing the central line?” Melody asked as she prepped Jae’s upper chest area.
“An infection at or around the site,” Annabel said, “and, for sure, a coagulopathy.”
“That goes for many invasive procedures.”
After they gowned, gloved, and masked, Melody showed Annabel how to prepare the contents of the kit. They did a more thorough prep, and applied a sterile drape.
“We’re going to use a triple lumen catheter instead of one big bore line,” Melody said. She ran her finger along Jae’s clavicle, stopped, and demonstrated. “This is the best insertion point to try and hit the subclavian vein.”
Annabel noted the landmarks, and with a finder needle, aspirated venous blood. After another needle and placement of the guidewire, she slipped in the triple lumen catheter and sutured it in place with Melody’s constant supervision. Her sense of accomplishment soared. Jae Nixon needed the line for important medications and fluids and she had needed the experience. She could cross off another “first” in her training, she thought, and made sure, that the dressing went on properly and the needles went into the sharps container.
“What comes next?” Melody asked. “Super important after a central line.”
“A chest X-ray. To make sure I didn’t drop Mr. Nixon’s right lung.” Annabel thought about Jordan’s snarky remark. It was apparent he wanted her to fail with her first ICU procedure.
“For sure,” Melody said. “Especially for Mr. Nixon. An awake patient may exhibit symptoms and difficulty breathing, but Jae is on a ventilator and signs and symptoms of a pneumothorax could be camouflaged.”
“After the film is taken, I’ll follow up with it myself in the radiology department.”
“If his lung looks fine, then we start him on dopamine for his renal perfusion.” Dr. Burg walked away from the beeping monitors while slipping on her resident’s jacket. “By the way,” she said, “nice job.”
“I had a good teacher.”
After Melody left, Annabel grabbed her white coat and listened to Jae’s lungs, which still sounded clear. She thought about her first encounter with the ranger at the sandwich shop. He was too young, healthy, and robust to be lying in an intensive care unit with a breathing tube jutting out of his mouth.
At least Dr. Enno had eliminated HIV as a cause, but was HSV out of the question as well? The acyclovir was doing nothing for him. Without any clinical improvement for Jae, the infectious disease specialist would probably stop it.
As she stood sadly looking at Jae’s tattoo, she realized the
team’s efforts with supportive care were currently the basis of getting Jae through whatever had invaded his body. Even though they had no idea about the etiology of Mr. Nixon’s sickness, their medical treatment was keeping him alive.
-----
Annabel waited in the radiology department for Jae’s chest X-ray and then stole it out of the “to be read” box. She rapped on the radiologist’s door, hoping he wouldn’t turn her away. She was becoming a pest.
The door to his long reading room opened. “It’s you again.”
“Sorry. I have a chest film on the same patient who had the CT a few days ago. I just did my first central line on him.”
The radiologist stepped back to his chair while holding a sandwich.
“Sorry to disturb your lunch.”
“No problem, young lady. I’ll help out an exuberant medical student any time.” He took the film out of her hands and slipped it into the viewing box. “No pneumothorax and you’ve done a fine job with placement.” He pointed to the tip of the catheter down the subclavian vein.
Annabel looked carefully; there was no evidence of even a subtle pneumothorax. She broke out in a smile.
“This patient of yours, he’s becoming more complicated, isn’t he?”
“Yes. My rotation ends soon. I fear that he’ll still be in the unit when I leave. I hope not.”
The radiologist pulled down the film. “Throughout your training, patients will come and go like lightning. There is something to learn from every one of them. Since there are residents and an attending dealing with patients, it is the rare student that leaves a positive impression on a patient. Be that student.”
Annabel gulped. “Thank you. I’ll try.” She softly closed the door behind her when she left and had a warm feeling of achievement.
-----
Like the radiologist, Annabel grabbed lunch from the cafeteria. She hoped to eat it in clinic before or between seeing patients. First, she told Dr. Burg that Jae’s chest X-ray was clear. Melody called the nurses to approve the use of the triple lumen catheter while Annabel unwrapped a chicken sandwich. She glanced at the first patient’s chart and cringed.
