by Barbara Ebel
“As we suspected,” Dr. Pittman said.
“How does psychiatry want to proceed with her?” Robby asked. “We know these patients become defensive and angry when they’re told they don’t have real medical problems.” He looked at each student which made Annabel feel better that he included her.
“They suggest psychotherapy,” Marlin said. “He said they don’t outright accuse the patient of not having an illness, but suggest to them that they have a psychological cause for it. It’s practically impossible to cure so they focus on managing it instead.”
“Good work on getting this information before rounds,” Dr. Pittman said.
Annabel looked down at her shoes. It didn’t seem fair; she’d been shoved to the background of her own patient’s care.
“What about drugs?” Robby asked. “Did he order any prescription medications to start her on?”
“No,” Marlin said. “When they evaluate her further, they’ll determine if anything else is going on, such as depression or anxiety which can be treated pharmacologically.”
“Excellent,” Dr. Pittman said. “Now let’s go see the patient.”
Inside, Sharon Douglas was bent over on the bed filing her orange nails. She hastily looked up when she heard the shuffle of clogs, sneakers, and dress shoes come into the room.
“I’m trying to maintain my fingertips,” she said, “but it’s not easy with this excruciating appendix pain.”
“We actually have good news this morning,” Dr. Burk said. “You don’t have appendicitis.”
Her crestfallen facial expression recovered in a few seconds. “Then can you give me something for this awful back pain?”
“I thought you said it was your appendix,” Robby said.
“Then that explains it. The pain from my back must have been what you doctors call ‘referred’ pain to the front here.” She gestured to her right lower abdomen, uncrossed her legs, and leaned back.
“Perhaps an ibuprofen will help when you get home,” Robby said. “The good news is that we can discharge you today. That young doctor who saw you yesterday wants to see you in a day or two at their clinic.”
She nodded. “Alright. I guess I can go. A cousin was coming to support me while in surgery, but now I can just bum a ride home from her.”
“Dr. Mack will get your discharge orders written,” Robby said.
A few ‘good-byes’ and ‘take cares’ ensued as the team left. Outside the door, Robby turned to Marlin. “After rounds,” he said, “sit down with Dr. Tilson and explain to her what’s needed to discharge a patient.”
Annabel’s shoulders sagged. After the dreadful incident in the office, she’d probably have to sit close to him, enough to even smell his failed deodorant.
-----
There was no one behind the desk in the ICU when the team arrived. Each of the three nurses was in a room attending to a patient and the unit secretary stood in a nearby tiny kitchen making coffee. Dr. Pittman wanted their two ICU patients’ charts to be handy so Brandy Wallace scouted around the desk for Dolores Vega’s chart – the appendectomy patient they had operated on during the night.
“It’s here somewhere,” she mentioned. “I was in here earlier for quite a long time and wrote a note.” Her midsection leaned across the desk as she viewed everything standing in the chart rack. “Here it is.” She pulled out the thin brown chart and handed it to Dr. Pittman. He stood it next to him and rested his hand on it, making her realize he was ready to hear her history and physical.
“This is a complex patient whom Dr. Burk told me a little about,” he said. “So let’s have you give the presentation, Dr. Wallace, rather than the medical student.”
Brandy stopped fiddling with her fingertips and stepped forward. “Dolores Vega is a 25-year-old female who was brought to the ER by a friend. Although the history was hurried because of her symptoms of abdominal pain and low blood pressure with need for quick testing and transport to the OR, there was apparently no significant past medical or surgical history. She had a 24-to-48 hour history of fever, vomiting, and chills. Right before that, she’d had crippling abdominal pain but it had actually subsided a bit.”
Dr. Pittman maintained a serious look while he averted her gaze.
Annabel was glad she’d gone into the OR in the middle of the night; now the case had more meaning to her. Bob glanced at her with relief on his face that he’d been spared giving the presentation to the attending.
“As we prepared to take her to the OR for appendicitis,” Brandy said, “radiology gave us confirmation that she had a ruptured appendix. Antibiotics were started immediately. In surgery, the patient proved to have peritonitis and was hemodynamically unstable. Her appendix was removed, we cleaned out the abdominal cavity as much as possible, and also removed infected tissue.”
“I’d like the students to be aware,” Robby said, “what a severe infection she had. This is a classic example of the dreaded complications of appendicitis. As a matter of fact, we are starting to see decreased kidney function with her lab work.”
Robby nodded for Brandy to continue.
“As a few more hours elapsed after surgery, the patient remarkably stabilized and responded to small commands. Since she was tolerating breathing on her own, I extubated her two hours ago before rounds.”
“That must have been well thought out,” Dr. Pittman said, “to remove her breathing tube.” He looked around at the students. “What are the complications of any patient being intubated and on a ventilator?” he asked.
“Pneumonia,” Da’wan replied.
“Yes,” Dr. Pittman said. “That’s the most serious and common risk. The endotracheal tube allows bacteria to enter the lungs. What else?”
Annabel had stayed by anesthesia for a while last night and picked up on part of the attending’s discussion with the resident, Wilbur Gill. “Oxygen toxicity,” she said.
Robby’s lips parted in a smile and he gave her eye contact.
“That’s a more educated and unusual answer,” Dr. Pittman remarked, surprised. “If intubation is prolonged and there is a high percentage of oxygen being delivered, that is certainly a possibility.”
“Pneumothorax,” Da’wan added.
“Very nice as well,” Dr. Pittman said.
The attending then stayed quiet, letting them think of more possibilities. A nurse with a long black braid slipped behind the counter and looked at a monitor. She shook her head while Robby followed her gaze.
“I’ve been busy with another patient, Dr. Burk,” she said. “I wasn’t able to get in to Dolores Vega, but one of her leads must have come off. After she was extubated this morning, she was squirming around quite a bit.”
Robby nodded and, while Bob asked Dr. Pittman about lung damage when patients were on a ventilator, he also looked at the monitor. The nurse hurried away to Mrs. Vega’s room. Several seconds later, she appeared at the patient’s doorway hurriedly waving at Robby to come over.
Annabel watched as her chief resident responded to the nurse and disappeared inside the room; the next thing she knew, the nurse was back at the door. “Dr. Burk needs you all,” she said excitedly and then went back in, followed by the students.
Annabel went in first since she was the closest.
“I’m, I’m sorry,” the nurse was saying to Robby. “I was in the other room helping respiratory therapy for fifteen or twenty minutes. I didn’t know the patient was dead. I thought a lead or two had come off.” The words stuttered out of her mouth and she trembled. “I’m sure the monitor looked like that twenty minutes ago when I ran out to fetch a new suction catheter for the other patient.”
Robby looked at Dr. Pittman, the both of them thinking the same thing. They had even been standing outside for about fifteen minutes. With his fingers resting on Dolores Vega’s carotid artery, he shook his head. Dr. Wallace walked up and opened the patient’s eyelids to see an empty, bottomless stare.
“Dead still,” Robby mumbled under his breath.
Chapter 8
The senior doctors knew all the correct things to do and say about Dolores Vega’s death. Annabel waited with Da’wan and Ginny at the nurse’s station while the attending, Robby, and Brandy scurried around chirping orders, doing paperwork, and calling next of kin. Dr. Mack paced the floor nearby until Robby finally came over.
“I’m sorry I’ve forgotten about you all,” he said. “Dolores Vega was our last patient to see so rounds are officially over. You students are free to go.” He turned to Marlin Mack. “But don’t forget to check out your patients to the team on call.”
Robby’s shoulders sagged and his eyes lacked their usual luster. Annabel felt not only sad about the patient but unhappy for Robby, too; he’d poured his heart out into saving her from the ravages of a ruptured appendix.
As Robby walked away, she thought about what he’d said … he’d ‘forgotten’ about them. Although he had important things to take care of, the students must not mean much to him. Especially her. She stared after him; even the way he moved made her hormones ramp up.
Annabel sighed; finally their call was officially over. She couldn’t wait to get home, shed the awful memory of the Munchausen’s debacle and Marlin’s verbal tirade against her, and squeeze in a much-needed nap. Unfortunately, she had a late afternoon gynecology appointment which she regretted scheduling so her rest had better be fast and effective.
When the four students got to the office, Ginny turned to Annabel. “Da’wan and I are retrieving the rest of our things from the call room. Are you coming?”
“I’m right behind you,” she responded.
Ginny and Da’wan left and, as Annabel passed Marlin, he put his hand on the front of her shoulder. “Not so fast,” he said. “Dr. Burk said I was to show you the ropes on discharging a patient. Your Munchausen’s patient to be exact. How could you forget her?”
Annabel cringed. No, she’d never forget Sharon Douglas. But, damn, she wished Robby had never said that earlier. He probably never would have mentioned that task for her if he’d known how long rounds were going to take. Now she longed for her nap even more. As Marlin continued to stare at her, he finally removed his hand.
“No, I didn’t overlook her,” Annabel said.
“As you know, I must check out patients to the call team … except for Mrs. Douglas, of course. So while I go do that, you can go to the call room like the others. When we’re both finished, we can meet back here and then go do the discharge together.”
“Okay, I won’t be long,” she nodded and promptly left to catch up with Ginny and Da’wan.
-----
Marlin Mack sat down in the office chair after Annabel left and pulled out his patient list. He rolled over to the desktop computer and printed out an extra copy. Hunching over it, he made important notes after each patient for the call resident. He wasn’t in a hurry. He’d gotten a decent amount of sleep during call since Brandy had had the long, nasty case and he hadn’t been pestered by calls from nurses for extra morphine doses or sleeping pills or that someone wasn’t peeing. Not only was he not in a rush, but he was going to see to it that he wasn’t and let Ms. Nepotism suffer the consequences.
After checking his watch, Marlin quickly got up. Annabel would be back any second. He beeped the call resident at the nurse’s station and, when he got a response, took the elevator to the ER. The other resident was waiting on the results of a CT. Marlin checked out all his patients to him and they talked about the pros and cons of their present rotation. By the time he left, his stomach growled. He’d only had coffee and a muffin earlier so for two reasons he headed to the cafeteria. First, he could get lunch out of the way. Second, it served as the perfect delay tactic to keep Annabel Tilson waiting on him.
The cafeteria had one of his favorite dishes, one they never seemed to botch up. He ordered the lasagna, grabbed garlic bread, salad, and a cold drink and brought his tray to an empty table. Eating now was no sweat off his time because he would have discharged the patient and eaten here anyway. And he could keep that favored, elite medical student waiting even longer.
As far as the patient anticipating her discharge, she didn’t matter in the least. She wanted to be in the hospital and had done all she could to get there. More than likely, she was busy dreaming up more aches and pains and illnesses to keep her right where she was. That could even mean a transfer to another medical service.
Marlin pulled apart the bread. Women like Annabel didn’t deserve their spot in medicine. He was sick and tired of seeing it because he had worked his ass off to get where he was. He thought back to the second year he wasn’t accepted to medical school; he had been taking a MCAT prep course with a bombshell of a blonde who wasn’t half as smart as him. He scored better than her when they took their exams and yet she was admitted to med school that year. When he found out she’d been dating a doctor who was best friends with someone on the admission’s committee, he had exploded with rage.
Dabbing the crusty bread into tomato sauce, he noticed an ambulance outside heading toward the ER. The wailing siren almost drowned out his beeping pager. He pulled the pager off his waist and looked at Annabel’s call. Rather than ignore it, he grinned and walked over to the phone. It was rather gutsy of her to call, he thought.
“Annabel,” he said when he reached her, “why are you calling?”
“I wanted to make sure I didn’t miss you,” she said, “because of Mrs. Douglas’s discharge.”
“Unless you’ve skipped out, we’re still going to do that.” He looked over at his tray of food and grinned again. “As a matter of fact, I can teach you another one of those top ten OR sayings Dr. Burk and I mentioned. It’s ‘I’ll be there in ten minutes.’ So, I’ll be there in ten minutes.” He hung up.
-----
Earlier, Annabel had walked back to the call room in a hurry to retrieve her things. What a pain that Dr. Mack now said they still needed to discharge her Munchausen’s patient.
When she got to their little room, Da’wan and Ginny were already gone. She grabbed her bag and locked the call room behind her. When she retraced her steps to the office, she sat on the couch and glanced at her watch; twenty minutes crawled by. Crossing her legs and sliding towards the armrest, she felt like closing her eyes. She was dead tired and sitting comfortably made it more difficult to stay awake. Her head bobbed and she straightened up with a jolt. But as the minutes ticked by, she worried herself more awake. It began to look as though she’d miss a nap at home and barely get to her doctor’s appointment.
An hour and a half elapsed, making Annabel rehash and get angrier about the entire first day she’d spent on call and the fact that it wasn’t even over yet. The more she deciphered it, the more she simmered over Marlin Mack. In essence, she still had a lot to learn and could have been smarter with Mrs. Douglas’s situation. But it was Mack who was kindling all her trouble. The more she thought about him, the more he inflamed her temper.
What if he sneaked away and left me hanging, she thought, and then deliberated calling him. She finally paged him and tactfully mentioned the discharge of their patient. “I’ll be there in ten minutes,” he said.
Annabel sat down again, happy that he’d finally be on his way and that she had learned another OR phrase. But as she twiddled her thumbs, she grew depressed and hungry. She decided to dash downstairs to the cafeteria and grab the easiest thing - even a granola bar - and eat it on the way back upstairs to meet him.
Downstairs, cafeteria staff were taking away hot lunch entrees and wiping off counters. She spied a fruit stand and grabbed a banana. At the register were bags of trail mix and she snagged one of those, too. She thought of Bob; his chocolate espresso beans would go over nicely right now.
As Annabel handed the cashier her credit card to pay, she did a double take at the white-coated doctor eating in the cafeteria by himself. Sure enough, it was Marlin Mack. She took her items and stepped to the outskirts of the tables and chair
s. Peeling the banana, her blood boiled as she watched him leisurely eating lunch. It was overkill that he told her he’d be ‘ten more minutes,’ and why was he eating anyway? If he wasn’t planning on doing the discharge soon with her, why didn’t he at least tell her to go eat? The more she thought about it, the more his delay appeared to be on purpose.
Finishing the fruit, her instincts told her to avoid him in the cafeteria. He may drag his feet more if he realized she knew where he was. And she’d be curious if he gave her an explanation about his delay. So she headed back to the office and finished four ounces of trail mix by the time Marlin showed up.
“It must be nice to sit around,” he said, “and not have the responsibility of a resident or chief resident.”
Annabel glanced at his stare. “I should be studying or sleeping. But learning to do a discharge with you has been the priority for the last few hours.”
“Even though Robby told you to do that with me, you believe you should be studying or sleeping instead? I’m sure he’d love to know that.”
Annabel felt disgust rising in her throat. If he told Robby something false about her attitude, she would want to crawl under a rock. “I meant instead of doing nothing, all of us students have our own designated responsibilities as well. And I do hope to catch lunch before dinner time.”
“You will miss meals because patients come first.”
“Not in your case,” she mumbled.
“What did you say?” he barked.
“Nothing. Just clearing my throat.”
-----
Back on the wards, Marlin told Annabel to fetch Mrs. Douglas’s chart. They went to a small, empty family consultation room and he told her to retrace her steps back to the desk and get ‘form’ discharge orders. After two more trips for paperwork, she sat next to him. He wrote out all the orders for the patient to follow up with psychiatry, to continue any home medications, and resume activity and diet as before. After each sheet was filled out, he passed them to her to look at. At the end, he took out his cell phone and began texting. Another ten minutes ticked by. He finally told her to bring all the material to the nurses at the desk. Then he told her to visit Sharon Douglas one more time and let her know that orders were now written. He walked out of the room and disappeared down the back staircase.
