by Barbara Ebel
“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.
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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.
“What’s wrong?” Stuart asked, stepping next to her.
“May Oliver is here for an extra appointment.”
Stuart crinkled his forehead.
“The metastases from her lung adenocarcinoma are spreading rapidly and we’ve done all we can for her.”
“There’s still palliative medicine,” he said.
“So true. Jae Nixon’s situation is the same. We’re treating symptoms and not a diagnosis.”
Stuart gave her rare eye contact. “By the way, how is Bob today? Have you two texted yet?”
“Not yet, but we have come up with a plan. I’m going to stay with him at his place, starting tomorrow. He’s so wiped out, but I’ll help him study.”
“You are going above and beyond to help him out. If I can be of service, let me know. I’d be a wreck if I were him … not finishing medicine right now.”
“You’re so smart, Stuart. You could handle anything.”
“I may be test smart, but that doesn’t mean I’m going to be the best clinician. You may outdo me with that.”
Annabel waved his comment off with her hand and walked into May’s exam room while peeking at the note on the chart. The reason for her visit was “more coughing up blood.”
Thirty-two-year-old May Oliver sat hunched over on the exam table while her mother, Louise, stood behind the black-topped upholstery. Annabel greeted them both, the obvious sadness on their faces making her dread talking to them. May’s breaths were deep, her breathing labored.
“Here I am again,” May said. “I’m so glad you’re here.”
Annabel gave her a sincere half-smile. “I see your primary lung symptom has returned.”
“Yes. The hemoptysis. See … I’ve learned the terminology for my own medical problems. That’s how much time I’ve spent with doctors in all these past months.” May’s hand, frail and white as toothpaste, cupped Annabel’s.
“I’m finished seeing the cancer doctor,” she continued. “After treatments and the continuation of the brain and bone metastasis, I’m calling it all quits. I’m here for that reason. Not for you and your team to prescribe me antibiotics, or another bronchoscopy to stop the bleeding, or to put me in the hospital and pump in liquid nutrition.”
Annabel gulped and glanced at May’s mother. Louise fought to keep back a tear. May signaled for an emesis basin and Annabel handed her one from the counter. Her patient coughed up a wad of blood as well as green sputum.
“Let me listen to you,” Annabel said. “It looks like you’ve caught a lung infection as well.”
“I’m sure of it. Most likely pneumonia.”
Annabel listened to the front and back of her noisy chest, which made her think of a death rattle. She clipped a pulse oximeter onto May’s index finger and it registered ninety-two percent.
“May, you’re not getting enough oxygen. You should really be in the hospital.”
May shook her head as emphatically as she could … which wasn’t that much. Her eyes spoke for her. They enlarged and glared at Annabel.
“No.”
Annabel pulled over the stool, sat down, and fought back sad emotions. She had been part of May’s care team since she first showed up with her symptoms and was diagnosed. They’d shared similarities, including going through their pets’ deaths, and now May was calling it quits.
Annabel could not fault her and decided not to try and change her mind. May had been a trooper and had given trying to stay alive her best shot. It was time to let go and go out with grace, dignity, and acceptance of her final fate. Her adult life, at only thirty-two years old, had been full with a military deployment and as a manager of a coffee shop.
Annabel started to talk
but had to stop and breathe deeply; the situation was anguishing. May’s mother slid a tissue out of her purse and dabbed her eyes.
“Then what can we do for you?”
“I need to make it easier on my mom. I want to go back home and die there. Can you prescribe narcotics for me?”
Annabel faced her directly without judgment and kept silent as she thought about her request.
“Dr. Tilson, I do have some pain pills. Not enough. I’m being honest.”
“And I appreciate that. Dr. Burg will be in here; this is not something we condone. However, did you contact hospice yet?”
May shook her head.
“You have the right to die pain-free, May, and with dignity. That’s what hospice is all about. It would be perfect for you because of the limited time left for you. It is a team approach and those compassionate people will help both you and your mom and dad get through this. They can prescribe the correct pain medication dosages that you will require to be pain-free and comfortable. Spiritually, I also believe their care will be important.”
Louise Oliver took her daughter’s hand. “We did hear about it some time ago. All the doctors lately, however, focus on getting rid of May’s metastases and symptoms, not on the actual end of life.”
A small rap sounded on the door and Melody Burg entered. She glanced at all three of them. “You all appear gloomy and grave, but life can’t be all that terrible. What brought you in, Mrs. Oliver?”
“Hemoptysis again,” May said. “However, Dr. Tilson just addressed my concerns and wishes. I am going to leave now with my mother and don’t want any other suggestions or care. May I please have a prescription to call on hospice care?”
“The pulse oximeter registers ninety-two percent,” Annabel said, “and here are her vital signs.” She gave Melody the chart. “And she finished all treatments suggested by the oncologists.”
“Are you both sure?” Melody asked May and Louise.
“Yes,” May said.
“Then we won’t stand in your way. The prescription will be at the front desk on your way out.”
Melody left, but Annabel lingered. Simultaneously, May and Annabel leaned forward and embraced.
“I’m so sorry,” Annabel said, choking on her words.
“Don’t be. The cycle of life is different for each of us.”
As Annabel stood straight again, she nodded at Louise. If she looked again at May, she would not be able to contain her tears. She stepped out without glancing back and knew she’d never see the ninety-five-pound woman again.
-----
Annabel carried a dinner tray to a cafeteria window table where Melody and Chineka sat with Stuart. Dr. Schott was close behind and they both took the end chairs.
“Thanks for breaking away at the same time,” Donn said to everyone. “We can kill two birds with one stick. Talk about patients and get our meal over with.”
Jordan appeared and nestled next to Donn. “Too bad we think of food that way – getting it over with.”
“So true,” Chineka said. “The only eating I ever really enjoy is outside of the hospital.”
Annabel peeled the top bread slice off her sandwich and frowned. “This is supposed to be a BLT sandwich, but I need a microscope to see the lettuce. It’s a good thing I ordered a side salad and cole slaw.”
Donn imitated her frown. “These green beans are boiled down to mush. As the hours of the day increase, the food quality decreases.”
“The food in the morning doesn’t start out too palatable either,” Stuart said.
“Food aside,” Donn said, “how was clinic?”
“We survived,” Melody said. “Everything was manageable, so we didn’t need to call you. Better yet, how did your deposition go?”
“I hope that was my first and my last. Every word out of my mouth was typed by the reporter at the head of the table. It was nerve racking and most of the questions by the prosecuting attorney were accusatory, mean, and nasty.”
“Sorry,” Melody said. “We all think your treatment of Meagan Helm’s atrial fibrillation was appropriate.”
“Thanks. You know, hearing other docs say that is important to me. Otherwise, I’m really questioning what I did.”
Annabel shook her head. “No way, Dr. Schott. You and Dr. Mejia give stellar care.” She paused her fork. “By the way, May Oliver came in today and we referred her to hospice.”
Donn grimaced and shook his head. “She’s way too young, but you did the right thing. And how did Jae Nixon’s central line go?”
“Annabel nailed it,” Melody said with a smile.
“I’m glad to hear that. I’m going through a crisis and I appreciate a team that doesn’t need to be micromanaged.”
CHAPTER 22
Jae Nixon’s experience lying in the ICU bed with something painful in his throat wasn’t always the same.
He had no idea how long he’d been in the present situation. It seemed like such an incredibly lengthy amount of time that sometimes he thought this was his whole life. Sometimes he couldn’t even tell if the visions in his head were fake dreams; made up for his entertainment.
Maybe the main character in them wasn’t really him; maybe he had not experienced the events depicted in his concocted mirages.
Overall, when spotty segments of lucidness crept into his brain, he wrapped his mind around the fact that he was in some kind of a medical situation and that the events which rolled across his thoughts were like some kind of YouTube video and were indeed a segment of his past.
Maybe the streaming content had some significance, but it remained difficult to figure out or to make sense of it at some higher brain level.
Was he being drugged? Or experimented on? Like right now ... three women in pale blue cotton outfits busied themselves around him. One of them tilted his head to the side, which made the hard thing in his throat get slightly yanked. That hurt.
It became more difficult to see the other two as they poked around in a container on the tray table. One of the young women seemed more familiar to him. For some reason, her fingers slid along his right collarbone while the other woman did most of the talking.
Ouch, he thought as he felt pressure and pain where she stopped moving her fingers on his right upper chest. She forced something into his skin. Why were they torturing him? He wished he wasn’t having one of his rare mentally clearer moments; he could do without this. He tried to divert his brain to something else and not be with them in the present.
Jae drifted further into himself. A combination of past knowledge, events, and situations formed in his brain. In certain clumps of time while the two women hovered immensely close to him, he travelled deeper into his mind with more intelligible knowledge about who he was and what he did. He replayed recent events from his past:
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Hunting was one of Jae’s passions outside of his work as a national park ranger. For him, it combined multiple purposes into one. His deer hunting with a bow and arrow was a substantial and skillful sport and the whole ordeal took place out in nature, where he felt most at home.
Of course, he never overhunted for venison he wouldn’t eat; hunting let him put his own needed food on the table. None of the venison went to waste. At times, hunting deer also helped cull the species population when officials determined their density in an area had become too thick.
Jae was super methodical with his gear checklist. He stood on his wooden porch between the front door of his cabin and his Silverado, which he’d backed up to the front step. He was ready to begin his arduous process.
He considered his checklist the forerunner to packing every possible piece of essential gear. As he well knew, there was nothing worse than getting out to a deer stand and realizing he’d forgotten an important knife, or a deer scent, or God forbid, water. In his opinion, being unprepared was a sign of an immature, half-cocked, impulsive hunter. For him, those days were gone.
Besides, this was the very end of the deer hunting season and he de
pended on his empty freezer space being filled with venison for the rest of the winter after this trip. He could taste it now, and, no matter how he prepared it, he enjoyed what he thought of as his “man meal.”
Already dressed out in his hunting boots and insulated parka, he checked off his stacked items and carried them, stored or un-stored in gear bags, to his pick-up truck. The big stuff went in the back cargo area. He packed the smaller items, such as binoculars, a compass, and flashlight, on the seat and floor of the cab.
Jae double-checked his archery equipment in the pickup bed. Present and accounted for, he thought. He locked his cabin door, strolled over to Patty’s place, and petted Curley and Twist, who had already come out to seek the fresh air. He beamed when she opened the door. She woke earlier than usual because she told him to stop by before leaving.
“I’m out of here before dawn like I planned,” he said. “I’ll be back no later than late afternoon. If you don’t see me cruise in by then, send out the cavalry. I’ll try not to be grumpy at work next week if I wasn’t successful and have nothing to show.”
“You’ll be fine. I have faith in you.” Dressed for work, she held a mug of coffee. “Need a cup for the road?”
“Thanks for asking. I’m good.” He turned and waved like a kid going off to summer camp.
Because Jae followed a dependable protocol, he was a successful bowhunter. Prior to this late-in-the-season expedition, he had scouted out his hunting area in the woods early and often.
He was no amateur.
He practiced archery often and simulated real conditions by outfitting himself fully in the heavy gear he used during a real hunt. The dry run imitated military boot camp … you had to practice in ungodly simulated conditions to be effective on the real battlefield.
As Jae drove the last back road into his hunting area, he smiled. He exuded confidence because of his preparedness; not one hunter he knew studied the habits and life cycle of these whitetails like he did. Their movements and body language were as familiar to him as a nursing baby to a mother.
