by Barbara Ebel
She looked straight at Bob and several people in the audience also acknowledged him. Annabel tried not to add to the attention he was receiving.
Shania went to a slide of a tick burrowed into someone’s thigh. “You see this one here. He’s plumper than the one in the picture I showed you before. As they suck blood, they engorge themselves and plump out; they can lose all their physical identity and their forefront can disappear into their host.
“A carpenter can pull a nail out of a wall with the opposite end of a hammer, but a victim of a tick is lucky to root out the vampire from his skin with a tweezer. It’s a death grip to the end.
“And the bacteria they carry? Take your pick: Ehrlichial species of bacteria with Ehrlichiosis, the rickettsia group of bacteria with Rocky Mountain Spotted fever, Borrelia burgdorferi bacteria with Lyme disease and so forth and so on.
“With Ehrlichiosis, our medical student was bitten by the lone star tick, a different tick than that which latched into our ICU patient. Symptoms for this disease include fever, headache, muscle pains, confusion, and low energy. Laboratory clues as to the diagnosis include a remarkable thrombocytopenia, leukopenia, and elevated LFTs. Diagnosis is also confirmed by the detection of antibodies, but you all must recognize that once a suspicion of this diagnosis is made, treatment should not be delayed. The appropriate dosage of Doxycycline for one to two weeks is the magic first line treatment.
“Unfortunately, the case fatality rate of Ehrlichiosis is up to two percent and, like Powassan disease, a patient may need hospitalization and care in an ICU. In this case, IV antibiotics may be needed.”
Shania tapped Alejandro on the wooden floor. “I am happy to report that Dr. Palmer is slowly getting better. Our support goes out to him to get back on track with his rotations.”
Dr. Enno glanced at the wall clock in the back of the room and raised the water cup to her lips. She flipped ahead to another slide, which made the audience cringe more than before - an adult bull dog – his poor body bombarded with plump ticks, some of which were too big to hold on any more and had plummeted to the floor.
“Since we also talk about preventative medicine besides treatment, I would be amiss to not include the measures which we should all take to help prevent tick bites. Part of my sneaky presentation right now is to stir the brain cells of you youngsters in training to do me a favor. In the future, you will be giving your patients the normal pitch to stay healthy with a good diet, exercise, routine medical care, etc., etc.”
She slid to the next slide, which showed a number of items. “Bring up year-round preventive measures with your patients against ticks. Tell families to avoid wooded, brushy areas if there is no need to be there, and to walk in the middle of hiking trails. Tell them about repellents with DEET, and tell them to cover as much of their skin with clothing as possible when they’re outside. There is even pre-treated clothing that repels ticks. Tell them to check for them on their bodies when coming inside and bathe carefully to find them or wash them off.
“Please, treat your family dog with preventive products and don’t let them end up like this fella. They are also susceptible to tickborne diseases and if you don’t treat them preventatively, ticks will be hitching a ride on your four-legged companions and coming into your home.
“Be cognizant of the area around your home. It is possible to apply pesticides in yard areas. Mow lawns frequently, remove leaf and wood clutter so as to not attract rodents, and think about fences, which discourage other unwelcome animals, such as the white-footed mouse that harbor ticks.
“I attest to adding some of these remarks to your patients when you deem it worthwhile and possible. An idiom from my day is ‘An ounce of prevention is worth a pound of cure.’ Alert your patients, especially during yearly wellness visits, of the growing problem with these diseases.”
Shania moved on to another slide. A long list. “My lecture time is up. You may want to jot some of these down but, if not, be aware of the many, many tickborne diseases in the United States besides the ones we dwelt on: Colorado tick fever, Anaplasmosis, Heartland virus, Tularemia, etc., etc. Don’t be afraid to reach out to the CDC in the future and keep up to date with the information that they post.
“Take note of your patient’s symptoms on presentation and never forget how important their social endeavors and recent travels are in the big picture. And remember … ticks aren’t going anywhere, except just about everywhere.”
-----
Annabel, Bob, and Stuart stepped off the curb into the parking lot.
“I bet that will be the first and last time you’re a subject in a grand rounds lecture.” Stuart raised his eyebrows at Bob.
“I hope that’s true,” Bob said.
“I, for one, am not going to easily forget her talk,” Annabel added.
“Being that our test taking for medicine is over,” Stuart said, “it was better yet to sit back and relax and not have a final exam hanging over our heads.”
Annabel and Stuart veered off to the right as Bob stayed straight. “I guess I’ll talk to you,” she mentioned, glancing back over her shoulder. “I hitched a ride with Stuart.”
“I can drop you off instead. The way I see it, I owe you some transportation.”
Annabel shrugged her shoulders.
“Go ahead,” Stuart said. “After all, studying for the test is over for both of you. Might as well enjoy social time.” He kept walking without checking on her decision.
Annabel caught up with Bob and they proceeded to his car. The beginning of the drive, Bob stayed shrouded in silence.
“You’re awfully quiet,” Annabel said. “Are you worried if you passed the written?”
He looked over. “Not only that. What Stuart said struck home. Our studying together for the final is over and I can’t impose on you for help anymore. I’m feeling well enough to take better care of myself through the tail end of this tick disease.”
“Hmm.” Annabel thought it out some more and also realized they wouldn’t be on the same rotation after medicine so, in essence, they wouldn’t be seeing each other at all. Unless they got a dog together and unless they arranged to do something together. And with conflicting schedules, how often would that be?
She frowned. Bob was too good of a friend to not hang out with on a regular basis.
“I see what you mean. I’m sorry you’re not finishing the week with us. But listen, I’ll keep you posted about the wards and my Powassan patient that I extubated today. Plus, let’s keep the discussion going about sharing a dog.”
A smile formed on his lips and she sighed with relief.
“At least you don’t have Jordan to contend with anymore.”
“Ha! So true.”
Bob weaved through the parking lot and to the front entrance of the hospital. Annabel scrambled out and passed in the front of the car. She gestured her hand for him to roll down his window.
“Thanks for the lift. You stay at home tomorrow and I’ll find out our test results in the morning after call. I’ll let you know. I’m going to miss sharing my chocolates with you for the rest of the week.”
She surprised herself and Bob too. She leaned in and gave him a mini gesture like a hug.
“Talk to you later.” She stepped back, turned, and disappeared into the hospital.
-----
“I’m impressed!” Annabel exclaimed, her eyes glued on Jae Nixon as she came around his bed in the ICU.
Jae was sitting up against the pillows in his bed and a tray table was in front of him. A food tray with a bowl of broth and a cup of applesauce was on top and Jae had a spoon to his lips. He slipped the contents down his throat and nodded.
“Dr. Burg said if I slide this down, sometime later today, one of you will take this out.” He patted the central line on his upper chest. “You’re the one who took that nasty tube out of me, so maybe you can whip this out too.”
“And I better check on all the lab work that was done on you this morning. We don’t want to tak
e things away without knowing the total picture.”
“I heard this disease I have can kill people.”
“The infectious disease doctor just gave a talk about that.”
“I’ve never been so popular. I wish it were under different circumstances.”
Annabel nodded. “You will come to learn that the tick that bit you is called Ixodes scapularis. You can blame him.”
“There are better living things to be intimate with.” He checked her expression to see if she was amused, and they both laughed.
“Do you remember me from before?” she asked.
He narrowed his eyes. “For sure. You drove me to the hospital … the first time. And now I’m certain.”
“Certain about what?”
“These latter days … I was going in and out of dreaming and, occasionally, I heard things going on around me. It was you who told me.”
He gave her a fixed gaze and imitated her. “It’s time to roust yourself awake and recover. I’m leaving the rotation soon, so I won’t be helping with your care anymore.”
Annabel’s eyes widened; she opened her mouth, but nothing came out.
Jae smiled. “You see … I took your instructions to heart.”
“That really makes my day, Mr. Nixon.” She wrapped her hand around his empty applesauce container and pitched it into the garbage can. “Looks like that big bore IV is coming out tonight too.”
-----
Annabel and Stuart raced around all night between the ER and the medical wards and never made it to their call rooms. The best they did was sit down a few times on the couch. Dr. Schott postponed rounds for a short while so everyone could go freshen up, maybe even put on a fresh pair of scrubs.
With the pressure of the final exam over, Annabel knew after she made it home, she’d crash into bed as soon as possible. She took the allotted time and jumped into the shower in the call room, dressed, and headed back for rounds. Along with Dr. Burg the night before, they had taken Jae Nixon’s central line out. His electrolytes and blood counts were no worse for wear and they had written to have him transferred to a regular room in the morning.
Dr. Mejia joined them. All decked out in a sport’s coat and a crisp tie, he strolled up front with Dr. Schott. “Too bad you missed Dr. Enno’s lecture yesterday,” he said. “You should ask her for some kind of handout.”
“Rumor has it that it was a hit,” Donn said. “It better have been since I held up the fort here without my residents and students.”
Dr. Mejia turned his head toward Annabel and Stuart. “Bet you’re both going over to get your grades after this. I’ll let the cat out of the bag … you both passed.”
Annabel pumped her fist and Stuart nodded.
“I’m sure you want to know your scores,” Dr. Mejia said. “I’m not divulging those.”
They turned into the first room in the hallway off of the nurses’ station. Jae Nixon’s new room.
Jae grinned at the group and pointed at the lightweight checkered pajamas he was wearing. “Patty Caye left these off for me yesterday. I feel like a real person with one foot in the hospital and one foot going home.”
“Those legs will be leaving us before too long,” Dr. Schott said. “One step at a time.” He turned to Annabel. “How’s he doing this morning?”
“He was being moved, so I missed seeing him,” she said. “May I listen to Mr. Nixon now?”
“Yes, go ahead,” Donn said.
Annabel took her stethescope and listened to Jae’s lungs and heart. She checked his pulse and evaluated his respiratory rate.
“As good as before,” she said and smiled.
“Mr. Nixon,” the attending said, “you are fortunate. Not that you contracted the Powassan virus, but that you are recovering and have no neurological damage that we are aware of. Today we’re going to have a physical therapist evaluate you. A little therapy to motivate your muscles wouldn’t be a bad idea.”
“Thanks. On all counts. And I’m indebted to Dr. Tilson.”
After rounds ended, Annabel hitched a ride with Stuart over to the office. She scored well on the test. On par with Stuart. She couldn’t ask for more than that.
“What about Bob Palmer?” she asked the woman sitting at the desk.
The assistant licked her finger to separate a clump of papers. She was obviously proud of her role in holding the most desirous information of the day.
“Bob Palmer passed.” She turned her mouth down and showed Annabel the result. He hadn’t passed by much, but she was thrilled nevertheless. He would be too.
“Thanks,” Annabel said.
Outside, she called an Uber driver, and when she got home, she dived into bed before texting Bob.
CHAPTER 32
Annabel slept off her call with a long nap and woke to her darkening apartment as the afternoon light faded outside her window. She rubbed her eyes and reached over for her phone. There was no message from Bob. She texted him right away.
I crashed after coming home. You passed your test! We all passed.
She went into the bathroom, threw water on her face, and studied herself in the mirror. Her long hair needed a trim and her face could use some color. Having the entire upcoming weekend off after her medicine rotation, perhaps she could take a hefty outdoor run or walk and pick up some sunshine.
Her phone dinged and she glanced down.
I figured you were sleep deprived! Super! So what did I score?
Annabel twisted a lock of hair. Passed with a seventy-eight.
Yikes. That was close. Not like me.
Under the circumstances, she wrote, you deserve to give yourself some latitude.
So true. Anyway, all I have to do now is make up my missed ward time.
And that’ll be easy! Later…
Annabel went into the bedroom and put her phone to bed on the charger. She studied the tree outside her window before closing the blinds. With no breeze outside, it was placid and sleepy, like it waited for the true stirrings of spring. In essence, she felt as tranquil as the view outside her window. Fulfillment from the third year of medical school rotations was beginning to escalate and she realized that she was beginning to think more and more like a doctor.
She closed the blinds and turned back to the kitchen, where she threw together a sandwich and a glass of milk.
-----
Late the next morning, Annabel peeled away from a nurses’ station and headed to the cafeteria for lunch. On the ground floor, however, was the physical therapy department. Therapists sometimes worked with patients in the hallways near their rooms, but she’d never stepped into their central work room. She deviated passed the cafeteria entrance and read “P.T.” on a sign outside a large double door. Stepping inside, a few chairs made up a waiting area, and a man at a central desk signed in the outpatients.
She glanced around for Jae Nixon. A male therapist stood alongside the ranger as he walked slowly on the treadmill. He wore a gray T-shirt with a national park emblem. His biceps flexed as he held the hand grip, but his arms lacked the sharp tone they had when he first appeared in the hospital. His scissor-sharp haircut had also grown out and appeared less defined and sculptured.
“Well, look at you,” Annabel said.
Jae furrowed his brow and nodded at her. “He’s killing me. Like making a bear run a marathon after sleeping for a month.”
“No, no, no,” the therapist said. “We’re going to do thirty minutes max. Only ten minutes of walking here, and the rest of the time, we’ll work on your muscle memory. Give those arms and legs something to do. But I can see your analogy with a sleeping bear.”
Jae tilted his head toward Annabel. “She’s a medical student that egged me on to wake up.”
“Aren’t you the lucky one?! She’s pretty enough to wake up to.”
Annabel’s cheeks reddened. The therapist, as well as Jae, were both appealing on the eyes and flirting with her. She smiled at the compliment and didn’t take it as sexist. Harmless flirting, she
thought, was good for the soul and a person’s ego.
She waved her hand at them. “I couldn’t resist popping in. Dr. Schott said if you handle today and tomorrow’s P.T., your lab work is normal, and you’re eating and feeling acceptable enough to go home, then we’re springing you.”
“Then I’m almost out of here. I believe work is not out of the question next week … but I would take it slow. They still have enough coverage at the park through this weekend.”
The therapist slowed the pace of the treadmill down further and then it stopped. Jae stepped off.
“Since you students are off this weekend, why don’t you and your friend visit the Taft National Historic Site? Volunteers or Patty will be giving tours and I could show you around too. I won’t overdo it. I promise.”
Annabel gave it serious thought and rubbed her hands together. “What a perfect idea. I’ll ask Bob Palmer.”
Jae gave her a thumbs-up.
“Now … I’ll get out of your way.” She paraded to the cafeteria, piled a salad on a plate, and went to a table. First things first, she thought. She couldn’t wait to text Bob with Jae’s recreational idea.
Want to go to that national park with me on Saturday where my patient works? He wants to show us around. I’ll drive!
She drizzled a packet of blue cheese dressing over the salad fixings and kept one eye on her phone.
Sounds great, he answered. Pop into my apartment first. I have something for you.
? Pick you up at one.
-----
Friday afternoon was both joyous and sad as Annabel and Stuart mingled in the office with Donn, Melody, and Chineka. The two students had chipped in for two boxes of cream-filled donuts that morning and one box still sat half full. All their work for the day was finished.
“I’ve never had this high an attrition rate on my service.” Donn shook his head. “The loss of fifty percent of my students was a big deal. Except for Jordan, however, I’m proud of the work you all did. If I become an attending and stay with the university, I’ll most likely run into either of you in your first year of residency. Your stepping stone to whatever specialty you go into.”
