by Barbara Ebel
“You already are a madman, so you’re on your way to passing.”
Bob closed his eyes and shook his head with a grin. When he opened them, Annabel leaned over and took his empty container.
“If I have anything to do with it,” she said, “you are going to pass. We both are. Unless I’m on call, I’m going to help you out every night. And each day, I’ll tell you the clinical stories from the wards.”
She unwrapped her tucked-in legs. “Tonight, let’s take a crash course on hepatitis.”
-----
The next morning, Annabel sat behind a talkative driver on the way to the hospital. She wanted to tape his mouth shut. She had become such a regular customer of the transportation service that she could write out a preference list. The cars were never a problem because they were clean and the back seats roomy. Every driver streamed music; the genre was usually okay with her. She wasn’t picky, but the volume made all the difference in the world. Too loud made for a nerve-rattling drive, which she didn’t need at the crack of dawn.
In essence, the most important aspect came down to the driver. Once in a while, she’d hit the jackpot when a conversation began with an unusually interesting person and she’d hear interesting aspects of their life. At those times, she wished she could stay in the car and listen to more.
Overall, a respectable friendliness from the driver was the key, and a little light chit-chat was perfect. Too little or too much sapped her energy away from whatever it was she really wanted to think about.
And this morning, she thought about Bob and her date with Dustin that night. And as they pulled off the interstate, she wondered about Jae Nixon still in a coma and the woman who was holding all the cards for him to get better. If she ever considered infectious diseases as a specialty for herself, there would be no one better to shadow than Shania Enno. It was in her best interest to absorb as much as she could from the elderly woman.
She darted into the office, left her things, and headed to the ICU. In Jae’s room, she stumbled on the changing shift and heard the tail end of the night nurse’s report to the a.m. replacement. “I just changed out his Foley catheter and replaced a bag of IV fluids,” the husky nurse said. “This young man’s condition is depressing and I can’t wait to leave.”
Annabel nodded at them. She looked at the nurse’s clipboard at the bottom of the bed. Jae’s twenty-four-hour urine output was adequate. His vital signs were less robust than the day before, he still ran a fever, and she worried about his lungs. The longer he stayed on the ventilator, the greater chance that he’d end up with a respiratory infection. She knew … one thing could lead to another.
She finished a routine physical exam and spotted Dr. Enno at the main desk.
“Go grab your morning java,” the woman said, “and come back here and take a seat.”
Annabel filled a cup to the brim and came back. The woman rolled back the chair and crossed her ankles. Alejandro leaned against the counter between them.
“What is your personal thinking,” Dr. Enno wondered, “about the chosen antibiotic that Mr. Nixon is on … days ago and now?”
“It was done empirically, so it was justified,” Annabel responded truthfully, hoping the woman wasn’t annoyed at the team’s decision. “However, his condition has not changed, so it’s obviously not working.”
“Correct. In general, it takes at least three doses of an antibiotic to reach a steady therapeutic blood level, so if the correct agent is being used, a patient’s condition shouldn’t worsen after that but should begin to improve.”
Annabel pulled in closer and crossed her hands.
“He’s on an antibacterial and I don’t think Jae Nixon’s infection is coming from a bacterium.” She squinted her eyes at the open chart next to her. It was open to the lab work section.
“The rest of the LP results are back?” Annabel asked.
“Yes. The spinal tap shows a modest CSF pleocytosis count with predominant lymphocytes. This young man? It appears a virus is the catalyst for his profound illness. He most likely has viral meningitis.”
“Wait a minute,” Annabel said, dumbfounded. “I just realized … I thought, or we presumed, he had Leptospirosis.”
“No, my dear. Far from it. I wish he did.”
-----
Annabel sipped her coffee while Dr. Enno wrote a note in Jae’s chart. She needed to read what the doctor said so she could report it on rounds, but she hoped Dr. Enno would share more knowledge. She thought about Patty Caye and Jae’s dog. It had been reasonable to strongly consider Leptospirosis in Jae because of the dog’s diagnosis. They both shared similar symptoms and an environment ripe to pick up the disease.
Shania clipped her pen back on her upper pocket and wrapped her arthritic hand around Alejandro.
“Let’s talk about viral meningitis,” Dr. Enno said. “As always in medicine, we start with probabilities. What is most common. Do you have any ideas?”
“I believe I heard it this year. It stuck with me easily because my dad is a neurosurgeon and he’s mentioned it. The usual group of viruses would be groups of enteroviruses, notorious for many infections like colds and flu-like illnesses.”
“Remarkable,” Shania said. “Your dad’s knowledge rubbed off on you.”
“Dr. Enno, more remarkable is that you became a doctor way back when women in medicine were as rare as February 29th. What was that like?”
Her eyes shined and the wrinkles around them smiled. “Dear, it was difficult for them – the men – I mean. I was a nurse already, a born caregiver who earlier learned much from the American Indian ways of my father. I landed myself into a formal medical education with Alejandro at my side. Both of us are old.”
She leaned forward a bit and tapped Annabel. “I figured I was as smart and able to be a physician as any other person. Double the discrimination was hurled at me, but my skin was thick and tough. You know, the greater the struggles you go through, the stronger you become.”
Annabel agreed wholeheartedly and nodded. “You had your cane before you needed it?”
“Yes. Other people were not aware of it, but Alejandro made them take me more seriously. Somehow my piece of art, crafted by a Chippewa Indian, took them off guard. I also literally believed in the wise words of Teddy Roosevelt. ‘Speak softly and carry a big stick.’”
Annabel smiled. She wished she could sit with the woman all day.
“But back to viruses. Yes, enteroviruses are the common critters of viruses. There are two others you are aware of, I’m sure, but you may not know that they can cause meningitis.
“First, deserving of many people’s disgust, are the herpes or HSV viruses. Type I herpes simplex virus is responsible for the fiendish cold sore, the contagious oral virus we pick up as a child. It’s spread by infected saliva or by kissing your favorite aunt at a family reunion.”
Dr. Enno’s passion for her specialty rose from her small voice. “The virus travels inside the nerve cells into the cluster of nerve cells or ganglion and goes to sleep in a dormant state. When it wants to, it starts multiplying again and travels back along its previous path to the skin where it artfully creates blisters on a person’s lips.”
“People don’t like wearing Herpes I to a party,” Annabel quipped.
“If they can help it. Type II is also deserving of our loathing, but at least it stays out of sight.”
“Genital herpes,” Annabel said.
“Yes, that sexually transmitted disease - the one many people are walking around with and don’t know about. Last CDC statistics are that there are three-quarters of a million new cases per year in our country. Both viruses can cause encephalitis and meningitis, but Type II is more often the cause of meningitis.” Dr. Enno stopped and let that sink in.
“Secondly, another cause of viral meningitis comes from HIV. The human immunodeficiency virus can cause inflammation of the meninges during the early stages of the disease. We are clueless as far as Mr. Nixon’s sexual history or history of b
lood transfusions, so this is something we must consider. And, interestingly enough, viral meningitis sometimes is the first sign of an HIV infection, so if we identify it early, treatment can begin right away to thwart off the patient’s possibility of acquiring full-blown AIDS.”
Annabel nodded, grateful for the private lesson. For sure, she would share the information with Bob.
“I did read somewhere about tuberculous meningitis. I suppose that isn’t a possibility?”
“My index of suspicion is slim. Patients in that case may show up with nerve palsies and their CSF findings show an extremely low glucose, high protein levels, and a fairly meager white blood count. His CSF findings are not suggestive at all.”
Annabel marveled that Dr. Enno could summon up the exact lab profile of a disease just by mentioning it. It made her want to consider the specialty. However, Shania wasn’t the first attending she wanted to emulate.
“So,” Dr. Enno said, breaking into her thoughts, “I just ordered HIV testing, especially since one of my mantras is ‘adults with viral meningitis due to an unknown etiology should undergo an HIV test.’
“And, regarding herpes or HSV, a treatment exists, so like what we did before with the anti-bacterials, we will start empiric treatment. The drug is acyclovir, so we will begin that immediately. I advised your medical team in my note.”
Annabel felt like now a substantial search was beginning, especially since Leptospirosis and a bacterial cause was out of the picture. “My chief resident will be starting rounds soon. I will relay your assessment and plan to the resident, Dr. Burg, and Dr. Schott.”
“Yes,” she said and frowned. “Dr. Schott. He’s suffering from the shock of hearing ‘see you in court’ for the first time.”
“He’s pretty freaked out.”
“For him, and if it ever happens to you, the best advice to think about is from Robert Frost. ‘The only way out is through.’”
Annabel nodded. “I’ll be off this rotation, but I hope he has a good outcome or that the lawsuit goes away.”
“I will speak with him privately. Now, back to our task at hand.” She sat straighter and ignored Alejandro. “Dr. Tilson, I gave you my clinical summation. However, the viruses we discussed usually cause a bout of meningitis in a patient, the patient is treated to ease their symptoms, and they may or may not have a recurrence. In other words, these viruses rarely cause a patient to end up on life support.”
She tapped Alejandro on the floor. “Jae Nixon spiraling into a coma makes me uneasy.”
Dr. Enno’s last remark made Annabel shudder as she left for rounds. She wished she knew more about the ranger, but she may never get the opportunity if he doesn’t wake up soon.
CHAPTER 17
“Dr. Mejia is joining us for rounds this morning,” Dr. Schott said over his shoulder as the team took off down the hallway. “Annabel, we’ll start in the ICU with your patient.”
“I have a lot to report about Jae Nixon,” she said. “I don’t want you and Dr. Burg to be blindsided. Would you like me to tell you first?”
“No,” he said curtly. “It can wait.”
Annabel and Stuart walked side-by-side. “Where’s Jordan?” she asked.
“Good question. Our team is shrinking by the day. However, I bet you can do without him. Seems to be bad blood between both of you since that lecture when you mentioned his cheating.”
Dr. Schott abruptly stopped and spun around. “The cheating he did … now I want to know the details.”
Stuart remained silent and Dr. Burg and Dr. Watt stood clueless.
Annabel swallowed hard. “I don’t think I should talk about it.”
“Come out with it. There will be no repercussions for what you tell me, that I can promise. And more than likely, no consequences for Jordan. My footing as chief resident is already shaky. Besides cheating being wrong, there should be no reason whatsoever for someone on this team to be doing it.”
Annabel closed her eyes for a second. She was no snitch, but she didn’t have a choice. The team waited for her response.
“Jordan had an open medicine handbook in his lap during the mid-term exam.”
“Are you saying that because he figured out Jae Nixon’s disease?” Donn’s cheeks flushed and he exhaled forcefully. “Is there some kind of rivalry going on here?”
Annabel reeled with his outburst. “No, I …”
“Society’s cream of the crop – medical students – behaving like kindergarteners?”
Donn’s voice was too high for the hallway and a woman visitor distanced herself as she passed.
Annabel held her tongue while her heart pounded. He asked her to come clean, she did, and now she was being penalized for it. She didn’t dare try to defend herself again. In fact, she thought, there was nothing at all that she should be defending herself for. Anger started to rise from her gut while Dr. Schott’s glare became less intense.
Donn turned around, and with a heavy foot, walked ahead through the ICU automatic doors. The team stayed so close they almost collided when he stopped within eyesight of Jae … lying motionless on the bed in the middle of all the medical equipment.
The swoosh of the doors sounded again and Dr. Mejia and Jordan Maldonado came prancing in. The attending wore a bold maroon tie and Jordan had his hand wrapped around his cell phone. Annabel wondered how Jordan managed to be with the attending.
“Good morning,” Dr. Mejia said, rubbing his hands in front of him. “Dr. Burg, why don’t you present an update on Mr. Nixon.”
“Sebastian,” Dr. Schott said, “the student is privy to the latest on Jae Nixon, if you don’t mind.”
Everyone turned to Annabel. She didn’t want to sound haughty about announcing the fact that her patient didn’t have Leptospirosis; she wanted them to figure it out themselves. Dr. Schott didn’t need any more fodder to lump her into a kindergarten class or “I told you so” type of behavior.
“Mr. Nixon’s condition remains the same,” she said, “in a comatose state, with a fever, and with less robust blood pressures. His lungs are staying clear. There’s no sign of a urinary infection with the catheter and urine output is just adequate. I want to bring up nutritional support, so I don’t forget, with something like TPN. If that will soon be a possibility?”
She didn’t wait for an answer and no one interrupted.
“Mr Nixon’s CSF results came back with a modest pleocytosis count with predominant lymphocytes. Along with the fact that the antibiotics were not working, Dr. Enno D/Cd them, and started him on acyclovir for the possibility of HSV and she also wants to rule out HIV.”
Dr. Mejia patted his comb over one time and maintained his seriousness. Jordan’s face registered puzzlement and his mouth fell open.
“That means he does not have Leptospirosis?!” Dr. Mejia said. “We barked up the wrong tree?”
“Barking is the correct word,” Annabel said. “It was the rangers’ dog at the national park who came down with a serious case of Leptospirosis. However, it was a strong possibility that our patient could have acquired the responsible bacteria as well - either from the dog or because of the environment and the rodent population where they live.”
Jordan’s iPhone plummeted from his hand. A loud thud sounded on the durable, institutional floor, and then a crack. Everyone looked down. The device was lying facedown. Dr. Maldonado made a pathetic sound as he crouched down and picked it up.
Jordan Maldonado couldn’t believe it. The female ranger’s conversation he overheard in the cafeteria was about a dog! How could he swallow that he’d jumped to conclusions and assumed it was also the male ranger? Worse than that, the brownie points he had earned with the attending, whose profession and recommendation he’d give his right arm for, may be demoted.
And shit, he thought, staring into his hands at his seven-hundred-dollar iPhone where he lived on social media when he wasn’t studying. It was cracked like a pane of glass straight across the front face.
“Well, well,” Dr. Sch
ott said. “Looks like two things have been eliminated this morning. Although there were similarities, like Jae Nixon having a biphasic history of symptoms, Leptospirosis and a bacterial infection are stricken from his possible diagnoses. And, secondly, Dr. Maldonado’s GD phone, where his thumbs are always planted, has died.”
-----
Annabel never read one word of medicine all day. She made sure she revisited all her patients in the afternoon, all her notes were written, and she acquired every possible lab result.
Even though he blew up at her before, Annabel assumed Dr. Schott had not changed his mind about letting her leave at three o’clock. She did not find him in the team’s office which meant she had to traipse over to his private room. She had to confirm and tell him she was leaving, but dreaded talking to him alone.
When she arrived at his office across the pedway, his door was ajar. She rapped, pushed it all the way, and found the room empty. He must be around, she thought, and decided to go in. She stepped to his desk for a piece of paper to write him a note.
She feared what she saw when she eyed the open documents on top, a torn official-looking manila envelope next to them; it was a stapled cluster of court papers.
Walter Helm, Sally Helm, and Susan Helm, Plaintiffs vs. Donn Schott, M.D. and Sebastian Mejia, M.D.
Annabel glanced down the front page, reading bits and pieces.
Said doctors treating our mother, Meagan Helm, mismanaged and failed to prescribe her the appropriate medications for her discharge after an uncomplicated short hospital stay. Lack of such medications caused, directly, the death of Meagan Helm, who had no chance of resuscitation after dying a swift and horrid death. Only Dr. Schott and Dr. Mejia had the knowledge and the ability to avert said occurrence and they failed to act responsibly or with diligence and care, and, instead, acted with overt negligence.
Annabel read another paragraph and shuddered. It all sounded horrendous, like the two doctors were wanted criminals. Were all medical lawsuits like this one?
