by Barbara Ebel
She knew firsthand about Meagan Helm, her atrial fibrillation and the careful care she received; the situation portrayed in the legal papers was distorted and histrionic.
Was this what she had to look forward to later in her career? Accusations of negligence when none existed? Accusations of carelessness and indifference which might make her throw in the towel?
No wonder Dr. Schott was being snippy and short-tempered, she thought. He knew the lawsuit had arrived and his mood had changed. Seeing this would make any doctor panic.
Footsteps approached. Donn walked in, he stopped, and his eyebrows went straight up.
Annabel startled and stood up straighter from the desk. “I … I was going to write out a note and leave it on your desk.”
“You must have seen the lawsuit. Some uniformed man served it on me like he was going to handcuff me and take me away.”
“I’m sorry.”
“No need to be sorry. It’s the attending’s and my problem. Dr. Mejia just has more experience with something like this than I do.”
Annabel nodded and stepped back from the desk.
Donn frowned and sat on the armrest of a small couch. “There should be a doctor’s support group or a continuing medical education series on how to deal with lawsuits. Medical school and residency doesn’t prepare us for this.”
“I hope you deal with this the best you can and that it never happens again.” She twisted her hands together. The minutes were ticking by and she hated to be late for Bob.
“Listen, I’m sorry for today,” Donn said. “I insinuated that you tried to get back at Jordan after he shined on the rotation because of Jae Nixon’s diagnosis and that you had lied about his cheating. He was wrong about the diagnosis. Another lesson to take away is that, until all the possible data and clues are in, we shouldn’t jump to a diagnosis. Many disease states mimic each other.”
“It certainly seems that way. I’ll remember.”
“Did you really see him with a medicine handbook during the test?”
“Yes, but I don’t feel comfortable telling you.”
“I understand.”
Annabel bit her lip. “Do you mind if I go now? I’m supposed to drive Bob to his doctor’s appointment.”
Donn scratched his chin. “I forgot all about that. Get out of here. Tell him good luck with his appointment. I hope Dr. Raymond finds out what’s wrong with him, and that he gets better. We all miss his smiling face. God knows, we’ve lost all spirit and the team atmosphere is dismal, mostly due to me … your despondent chief resident. I can’t fake my moods or my teaching style to act like everything is okay. It’s going to take me awhile to get over my initial reaction to these papers.
“Anyway, I didn’t mean to bring it up again. Go ahead.”
“Dr. Schott, your lawsuit came up this morning when I was talking to Dr. Enno. She’s a very nice and comforting lady. I think she wants to talk to you and be of help if she can.”
“Her soothing voice is enough to inspire me to meditate, which is a ridiculous thought, because who has the time for that? At least I’ll be bumping into her since she’s consulting on your patient.”
-----
Annabel jumped into her Nissan in the parking lot and drove straight to Bob’s apartment, slowing down through the school zones. His complex was family friendly with kids getting home from school and scrambling out of their parents’ vehicles, entirely different from the business and college types in her own neighborhood.
Bob’s door opened after she knocked and he stood there still wearing the pasty color he’d acquired since falling ill.
“How are you feeling?” she asked without moving.
“Partly cloudy.”
“I bet you’re exaggerating just to appease me. You’re more like fully overcast with thunder rumbling in the background.”
“If need be, I’d protect you under an umbrella.” He looked past her at what the weather was really doing. “Do I need a jacket?”
“You’ll be fine without one unless Dr. Raymond’s office has no heat on at all.”
“Forget it.” He stepped out and closed the door.
“Tell me where to go,” Annabel said when they buckled up in her car.
On the way, Bob directed her while she spilled out details about the entire day: Dr. Enno and Jae Nixon’s case, Dr. Mejia and Jordan, and Dr. Schott blowing up at her and then his lawsuit and apology.
“I hate to say it,” she said in the end, “but if you had to be absent from the wards, now is the time to do it. Out team has too much conflict.”
“On the contrary. You’re making me jealous I’m not there. Your patient is an intriguing case, the likes of which you may never see again. You’re finishing up the rotation with a superficially pleasant team that is secretly dysfunctional with a backstabbing, self-righteous medical student; a dog-whisperer of an infectious disease consultant; a depressed, angry chief resident; and a gullible, flashy attending. There are two female residents who keep their personalities in check and a brilliant other medical student who would come out of a burning building unscathed.”
Annabel glanced over at him quickly and then laughed. “If anything is missing, it’s you.”
“Yeah.” He smiled back at her. “The biggest personality is missing.”
-----
Bob handed over his insurance information and filled out the paperwork in Dr. Raymond’s waiting room. Without much of a wait, a nurse called him back and Annabel stayed put. A man with an artificial leg sat across from her, the metal evident below the hem of his trousers, and a few seats down an old couple held hands and intermittently talked softly to each other like they were telling secrets.
Annabel placed her Internal Medicine Handbook on the table next to her and texted Dustin.
Looks like I’ll be ready by about 7, but I’ll keep you posted. I don’t want you waiting on me.
Annabel held her phone waiting for a response while the woman nearby talked to her partner. “I hope this doctor is older and wiser than that one last week. He was young enough to be my grandson.”
“Anyone is young enough to be your grandkid,” her spouse said.
Annabel and the man across from her smiled at each other as a ding sounded on her phone and Dustin’s response popped up.
As long as we continue to communicate, I’ll wait on you!
Thank you. Where are we going?
A restaurant downtown with a New Orleans flare. Do you like Cajun?
You bet. Is it dressy?
You always look dressy.
That’s not always true. You should see me sometimes.
I hope to.
She stifled a chuckle. His flirting via text messages was way more fun than reading medicine.
-----
The nurse left Bob’s room without telling him to take off his shirt and to put on any type of patient gown, so he considered himself lucky. He stepped up, sat on the white paper cover on the exam table, and glared at the certificates on the doctor’s wall: CME documents, resident certificates, and a state license. Not interesting reading material for most patients. The activity of simply coming in for the appointment made him feel extra tired, so he pulled out the footrest and lay back.
The door opened with a little swat and a big bald man with flat ears and a slow smile walked in. Bob pushed himself up and the two men shook hands.
“I’m Dr. Raymond. You’ve come to the right place. There is no room for illness when you’re a medical student.”
CHAPTER 18
Bob wrung his hands as he sat on the exam table in front of his new physician.
“Dr. Raymond,” Bob said, “I’m losing days on an internal medicine rotation, so I hope you’re as good a doctor as they say you are.”
“Who said that?”
“That’s the general consensus over at the V.A. Hospital.”
“Never trust what you hear.” He winked, read Bob’s vital signs, and pushed in the table extension so Bob could sit up. “N
ow, tell me what brought you in here to be poked and prodded on.”
“I am so tired, I can barely function. I’ve been knocked out on the couch for days. Along with that, I have mild body aches, but that may be because all I’m doing is lying around.”
“When did this start?”
“About one or two weeks ago.”
“Any major upsets in your life that could have catalyzed a depression?”
Bob shook his head slowly. “Nothing out of the ordinary and I am not depressed.”
“Any fever, headache, or chills?”
“Once in a while I run a low-grade temperature.”
“Nausea, vomiting, or diarrhea?”
“No, sir.”
“Confusion or a rash?”
“No, sir.”
Dr. Raymond deviated and asked him for a full family, social, and medical history, just like the students asked of their patients.
“Believe me, I’m a healthy guy,” Bob ended.
Contemplating, Dr. Raymond rubbed his ear and looked over Bob’s head. “Any of your patients come to mind that you could be mimicking their symptoms?”
“Not really. Before I left, I had the usual COPDers, diabetics, and cancer patients.”
“Besides the fact that you can pick up anything nasty in a hospital, were you anywhere suspicious or out-of-the-ordinary lately? And where do you go for recreation?”
“The last time I went out of town, it was to Tennessee with the female medical student in your lobby. She’s fine and the time line doesn’t fit. I haven’t been to the gym in a month. The only other place I went was for a run in a park garden and along the river with my same friend.” He scrunched his forehead. “That was two weeks ago.”
The doctor pulled an ophthalmoscope from his pocket and shined it in Bob’s eyes. “Have your eyes been red?”
Bob shook his head, Dr. Raymond went on with his examination, and then sat on a stool. He leaned over and ticked off little boxes on two lab sheets. “Follow me.”
Outside, he handed the sheets to a lab tech, and pointed Bob into their room. Bob rolled up his sleeve and a woman drew a couple of vials of blood. He went back to the exam room and waited.
Sitting there with nothing active to do, Bob worried more about Annabel being late for her date than what the doctor would say when he came back. If he had a say in the matter, he thought, he wished Annabel didn’t have a date, and that her relationship with Dustin Lowe had not resurfaced.
Twenty minutes later, at the close of office hours, Dr. Raymond came back in. “I think I know your diagnosis,” he said confidently, “but I don’t think you’ll be finishing your rotation. You need rest to gain back your strength and, based on clinical signs and symptoms, I will not withhold treatment to wait on confirmatory tests. I’m starting you on antibiotics.”
Bob’s shoulders sagged with the thought of being pulled from medicine. And did Dr. Raymond really know the diagnosis and treatment?
“Antibiotics for what?”
“Ehrlichiosis.”
Bob squinted and shook his head. “I never heard of it. What is it?”
“You’re carrying a disease caused by Ehrlichial bacteria, of which there are at least three species known to affect humans.”
“Any ideas about how I got it?”
Dr. Raymond’s wide chest heaved with a sigh. “From the bite of an infected tick. Specifically, the lone star tick.”
Bob stared with disbelief. “This is crazy. What I mean is … I am not aware of being bitten by a tick. And don’t they only come out in summer?”
Dr. Raymond sat on his stool. “Half of the infected people who develop Ehrlichiosis never find a tick on themselves and never remember being bitten. The victim can be clueless because the bite can be painless, the little bugger can be brushed off, or it falls off. But the damn tick takes a nip out of you. Not all ticks end up clinging onto human flesh like a rock climber to a summit.”
Bob scratched his neck just thinking about the beastly little things. His eyes grew wide as he sensed a strong deja vu.
“Wait a minute. I mentioned a recent run. I did a stupid thing and sat down on the ground - right against tall weeds along an embankment down by the river. I remember being itchy with something bugging me on my upper back, behind my right shoulder.”
Dr. Raymond grinned. “I bet the weather was unseasonably mild too.”
Bob rolled his eyes and nodded. “I guess my fortunate luck finally failed me.”
“Not yet. We’re going to get a handle on this before you suffer a more severe course with life-threatening symptoms. Or a prolongation which requires hospitalization and IV antibiotics. There is even up to a 2% fatality rate with this disease.”
“Dr. Raymond, you’re scaring me to death. What did my lab work show?”
“I made you a copy.” He handed over the CBC with a differential and all the chemistries.
Bob scanned it with dismay, and reread it again.
“Thrombocytopenia, leukopenia, and elevated LFTs,” Dr. Raymond said. “Classic, especially that deplorable platelet count, in the context of everything else.”
“Only if someone smart and perceptive like you puts this whole clinical picture together,” Bob acknowledged. “I can’t believe these numbers are mine. What antibiotics do you suggest? And will it be a definitive treatment?”
“The first line of treatment is Doxycycline - for seven to fourteen days. I expect you’ll start showing clinical improvement, but you may not be up to your old self for a few weeks. The stamina you need right now for the rest of your rotation will not exist.”
“I can’t believe this,” Bob pouted.
“I took an extra vial of blood for specialized laboratory testing. Your immune system should be producing antibodies to Ehrlichia by now if that is what’s streaming around in your circulatory system. Like I mentioned, my index of suspicion is high, so I will not withhold treatment. Also, by the way, Ehrlichia cannot even be detected by blood cultures.”
A shudder ran up Bob’s spine. The more Dr. Raymond talked, the more he wanted to purge himself of the awful bacteria zipping through his bloodstream.
“Thank you,” Bob said, “for your help. I’m fortunate I came in to see you. I better not take up any more of your time.”
“No problem.” He tapped Bob’s chart in his hand and opened the door as Bob stepped down.
The front office was quiet as most of his staff had left. “By the way,” Dr. Raymond said, “you are correct. I see one or two Ehrlichiosis cases a year and they show up in June and July. However, cases do pop up during any month of the year, especially with the slow northern progression of this tick population from the southeastern and southcentral United States. Due to global warming.”
Bob nodded while clutching the lab results.
“Make a follow-up appointment in a week,” the doctor said and poked his head into the front office window. “You two ladies leave when you’ve checked out Bob Palmer. I’m going back to my office. I need to contact the CDC with a reportable case of Ehrlichiosis and confirm it when the remaining labwork comes back.”
-----
Annabel paced the office waiting room after sitting too long. Finally, Bob came out and he tried to force a smile.
“Uh-oh,” she said. “What did he tell you?”
Bob twisted his face with disapproval. “You know what a normal platelet count is, right?”
“Sure. 150 to 400 in the usual reference range units. Thrombocytopenia, a low platelet count, is less than 100. And susceptibility for hemorrhagic bleeding conditions is a count less than 50. Why?”
“My platelet count is 40.”
“What! Are you serious?”
“No kidding.” He handed her the yellow sheet with all his lab values. In dark capital letters next to his platelet count was the word “LOW.”
“Oh no,” she mumbled. “This is awful.”
She handed the paper back to him and sank into a chair. “Don’t bump into anything. Y
ou’ll bruise or crack open your skin and bleed to death.”
“I agree. Now is your opportunity to punch me, make me bleed like water from a hose, and get away with murder.”
“I don’t think so, and don’t mention or even think about such a thing. Does he have any concrete suggestions about your diagnosis?”
“Ehrlichiosis.”
“Ehrlicy what?”
“A disease caused by ticks.”
“No way. Impossible.”
“I thought the same thing, but I probably had one crawl into my shirt the day we went for a run. Down by the Ohio. From the weeds.”
She shook her head, not wanting to believe it, and dragged out her Internal Medicine Handbook. After checking in the index, she shook her head more emphatically the second time. “Your disease isn’t in our book.”
“Ha! Because Ehrlichiosis is rare and doesn’t make the cut for a standard student’s textbook.”
“I should say.”
Annabel realized … she was the one who dragged him for a run. “This is partly my fault.”
“No way. Shit happens.”
“Only to me. Not you.”
Bob pointed to the exit door, she stood up, and they ambled out.
“Is there a treatment?” she asked.
“Yes, doxycycline, but I’m not going to feel better overnight. I’m off the rotation for sure. However, I should still try and pass the final.”
Annabel thought about it as they stopped in front of her car. “I can help you to the end. We can study the same stuff. Are you open to me half moving in with you? Crashing on your couch so I don’t have to go back and forth?”
Bob raised his eyebrows. “That’s too much to ask.”
“No, really. It could work. I would even have available parking in your complex, so I don’t have to call Uber to take me back and forth. We can pack in the studying and try and do better than Stuart. We just have to make sure you don’t overdo it, take breaks, and get adequate rest and sleep. Look at it this way … it would help me focus too.”
“Okay. I won’t argue. When your mind is made up about something, I doubt if it will budge. Plus, I’d love your company.”
