by Barbara Ebel
“Miss? Doctor?”
Annabel turned towards the lobby. A slender woman wearing a matching blouse and pants waved at her as she approached. Large glasses framed her wide face. “I’m Kathleen Chandler. Do you know which room my daughter is in?”
Annabel was surprised at her early arrival. “Yes. Right in here. She’ll be happy to see you before breakfast.”
The woman slipped her cell phone into her shoulder bag. “I couldn’t sleep; with coffee at a gas stop, it only took me two hours down the interstate. How is she doing?”
Annabel glanced inside without answering. Strange, she thought, that Mary didn’t stir. She should be awake by now and overwrought with joy that her mother stood at the door. But no high-pitched voice called out for them and no big brown eyes looked their way.
Kathleen brushed past her. She slid her bag down her arm, dropped it on the chair, and thought to make less noise in case her daughter startled to see her. She tiptoed around the bed. A concerned expression crossed her face. “Mary?”
Her voice rose. “Mary?”
Mrs. Chandler shook her daughter’s shoulder.
“She’s not breathing!”
Annabel ran over. Mary Chandler was not breathing. She also had no pulse.
-----
The simultaneousness of what happened next was sheer chaos with order. Annabel bellowed out for help and Room Six was invaded. Dr. Watson confirmed the absence of a palpable pulse in Mary’s carotid artery. And in the thick of it, somehow Emmett took charge of Kathleen Chandler and escorted her away from her daughter’s bedside.
As Ling Watson barked orders, the anesthesia resident, Kristin Fleming, took over at the head of the bed. As a respiratory therapist helped Kristin deliver oxygen and suction out Mary Chandler’s mouth, Ling threw a head pillow at Annabel.
Caleb Gash pulled up his sleeves. Annabel froze, clueless about the pillow.
“Displace the uterus, damn it,” Dr. Watson said.
Annabel startled. She put the information together that she knew about CPR and advanced cardiac life support. One difference, she figured, was that the heart compressions Caleb were about to deliver would not be effective unless the heavy uterus was displaced to the left. The gravid uterus, she thought, normally compresses the inferior vena cava … which impairs venous return to the heart and reduces cardiac output. Resuscitating Mary would be futile unless they relieved the compression.
She jumped straight to the bed and used the pillow as a wedge to keep their patient slightly to the left. Caleb shot her a glance, put his hands on the patient, and felt for the best hand position on the sternum.
On Dr. Watson’s orders, Sherry shut off the pumps and disconnected them so that a new bag of LR hung from a separate pole and Dr. Watson pushed drugs from the crash cart that had been shoved into the room. Sherry scribbled on a clipboard, documenting the drugs Ling injected.
Annabel’s heart pounded as hard as Dr. Gash seemed to project his palms into the young woman’s chest. What had happened here? Had Mary Chandler’s blood pressure skyrocketed over night with no one being aware … which caused her to stroke, seize, or have a heart attack? How often does preeclampsia cause a pregnant lady to die? This girl was way too young to die.
The scenario then struck her agonizingly hard. There was more than one patient here. What about baby Emma or Emmett?
-----
Before they called off further attempts at resuscitation, another M.D. showed up. The two OB/GYN residents relented to his questions and suggestions. Dialogue was sparse, however, as the minutes ticked by. The end result of their efforts was so horrid that it became difficult to speak.
Dr. Watson used the fetal monitoring equipment. Like mother … like baby. No spontaneous heartbeats occurred again for Mary Chandler and no fetal heart rates registered from the fetus.
“Call it,” the senior physician said. “Time of death … seven thirty-six.”
The respiratory therapist stepped back away from the bed. Kristin Fleming snapped off her blue vinyl gloves. Ling dodged her glance between the dusky dead patient and the new physician, and Dr. Gash somehow sneaked out the door.
Annabel backed up to the sink and pretended to wash her hands thoroughly. Clearly unnerved, Ling updated their attending. “Dr. Harvey, again … this was the preeclamptic patient, Mary Chandler, who I told you about yesterday.”
Annabel dried her hands while Ling reiterated a thorough synopsis of the patient’s admission, diagnosis, and care. Both their moods were grim and serious; she felt grateful that she was only the medical student.
Dr. Harvey pulled the sheet up on Mary. “Obviously, she’ll go for an autopsy.” He carefully scanned the whole room and then pointed to the IV pumps with fluid bags above. “And send them to the lab for analysis.”
“They are just …” Ling started.
“Did I ask you what they are?” he asked. “I can read the labels.”
Annabel held back as Dr. Harvey, Dr. Watson, and Sherry exited Room Six. The stark white sheet outlined Mary’s pregnancy, now no more than a stillborn who never had a chance. A wave of sadness came over her like her chest was being squeezed. At least, she thought, this young woman would be buried or cremated with her fetus. They would be together forever.
In the hallway, Annabel saw Dr. Harvey and Ling duck into an empty room with a whimpering Kathleen Chandler. Their hands supported her under her armpits, leading the way, as if she would lose consciousness.
Someone pulled at her sleeve. It was Stuart Schneider.
“Didn’t you go home yet?” Annabel asked.
“I slept longer than I wanted. Sorry I didn’t give you a report when you arrived. However, not much went on and I slept much of the night.”
“Lucky you.”
He glanced up from the floor and practically whispered. “What happened?”
“The young girl with preeclampsia died,” Annabel began. The two students made themselves less conspicuous and huddled outside the room where the senior doctors had taken Mrs. Chandler. Over the next ten minutes she shared the events with him, telling him what transpired.
“Jeez,” Stuart said, shaking his head. The door finally opened and Dr. Harvey and Dr. Watson passed them. Kathleen Chandler stayed put. Her sobbing ramped up from inside the room while she placed a call.
“Mike,” Kathleen Chandler said into her cell phone. “I have the worst possible news.”
A pause ensued and Annabel and Stuart heard what came next. “I got here and … Mary … she died.”
On the other end, Kathleen’s husband responded to her with a long, silent pause, after which he said, “What did you say?”
Kathleen put her other hand on her lips as if to stop an onslaught of tears that were somehow going to flow from her mouth. “I said our daughter is dead. Downright dead.”
“That’s what I thought you said. It can’t be. Women don’t die because they’re pregnant, especially not our daughter.”
“Mike,” she cried, “you better get here.”
He controlled his disbelief and his anger. There was no doubt as to what she told him. His wife needed him. “I’m on my way.”
When Mike Chandler ended the call, his fury built up like a volcano ready to erupt. How could their only daughter be dead? How could she have died in a hospital where she went for help? Better yet, how did his sweet, immature daughter get pregnant to begin with? He still had a difficult time facing that fact in the first place.
-----
Stuart wrinkled his face at Annabel after listening to the one-sided conversation they just heard from the room. He shook his head, leaned into her, and spoke softly. “I’d better go.”
She nodded and he took off. Mrs. Chandler still hung back in the room; Annabel wondered if she’d ever come out.
Annabel hurried to the nurses’ station and, behind the desk, the door to the lounge was closed. Trusting her instincts, she figured it was shut tight for the senior doctors inside to be left undisturbed. Too bad he
r books were in there, she thought; she could use the time to read. However, she probably couldn’t concentrate on studying after what happened even if she tried.
“Best that you don’t go in.”
Emmett stood next to her, his eyebrows arching up while he leaned his elbows on the desk. “Dr. Harvey must be taking control in there. He gives them residents latitude until they mess up. Then he sets them straight again and everything goes back to normal. But this time, who the hell knows what happened.”
“You must see things,” Annabel said, “and notice which doctors are good … and which ones need improvement.”
“Oh yeah. Like the patients really love Dr. Harvey. Bedside manner and all.”
“I saw what you did … escorting the patient’s mother, Kathleen Chandler, out of the chaos. That was a thoughtful gesture on your part.”
“Yeah. I come in handy once in a while.”
“She told me, you know. Mary Chandler. She had made up her mind for sure; she planned on naming her baby Emma or Emmett.”
He turned to her with a gleam of moisture in his eyes. “A kid named after me. Like being handed a gift. I would have had something to brag about after all these years.”
-----
It dawned on Annabel that she shouldn’t just be standing there. She had never gotten any farther than Mary Chandler’s room. There were other patients to see on the floor.
The door to the lounge jerked open and Ling tapped the secretary on her shoulder. “I need to start filling out the death certificate and other paperwork.”
The seated woman anticipated her question and handed her a stack of papers bound together with a pink paperclip.
“Thanks,” Ling said and noticed Annabel. “You might as well come in.”
Annabel trotted in after Ling, and her senior resident closed the door again. Dr. Watson sat at the round table and spread the papers beside Mary Chandler’s chart. Caleb left the couch and joined her.
“You must be the new student,” the attending doctor said. “I’m Doctor Harvey.”
“I’m Annabel Tilson.”
“I heard a good word about you from your internal medicine attending. I also got wind that your father is an esteemed neurosurgeon in Nashville.”
His introductory remarks were unexpected; she was at a loss for words. He poured a cup of coffee from a pot shoved on the far end of the counter. “Would you like some?”
“No thank you,” she said, finding her tongue again.
Dr. Harvey stirred in a packet of sugar and motioned her to the couch. He appeared to be a solid sixty years old and wore a toupee that looked like it would blow off with a sneeze. His shoulders sagged off his light build and he wasn’t wearing a white coat. She figured he had rushed there after being summoned to the emergency and wasn’t quite prepared to be on the delivery ward.
“The residents will fill out the paperwork, the young Mary Chandler will be picked up for the morgue, and I suppose her mother is going to be glued to the waiting room until her husband arrives. Maybe as we sort things out, we’ll have some answers for them.
“You oversaw your first patient with preeclampsia. In our field, it is a pregnancy complication that we treat with utmost respect and diligence. Hence, did we do something to fail in the care of our patient?”
CHAPTER 10
Ling and Caleb continued with their official paperwork while Dr. Harvey gave Annabel more of his attention. He dreamed up questions for her slowly and methodically like the way he sipped on his coffee.
“The diagnostic criteria for preeclampsia is hypertension, edema, and protein in urine or proteinuria, but do you know what they used to call it?”
“No, sir.”
“Toxemia of pregnancy. Don’t use that term, however, because toxemia is a misnomer. There is no toxin circulating around these women’s blood and causing preeclampsia.
“Overall, what is the incidence of hypertensive disorders in pregnancy in the US?”
As she blinked, Annabel drew a blank. “I’m not sure.”
“Estimates are between three and ten percent. What causes most patients to die from eclampsia?”
Annabel wanted to make a stab at guessing, but she figured it would be worse to come up with a ludicrous answer. She shrugged her shoulders.
“Pulmonary edema. With no evidence of that on Ms. Chandler’s chest X-ray or by auscultation, this is a unique case and off the bell-shaped curve of normalcy.
“Okay, here’s an easy one. What is the last of the three major signs of preeclampsia to appear?”
“Edema?”
A muscle twitched near Dr. Harvey’s eye. “No. It was the third criteria we talked about. Proteinuria, primarily albumin.
“Since you don’t seem to know much about your previous patient’s illness, maybe you are aware of what to look for, say, in clinic visits, before a patient develops the hypertension?”
Annabel crunched up her face and wanted to crawl under the table. Ling glanced at her, her lips twisted in a wry smile.
“I’m not sure what you’re looking for,” she answered.
“Dr. Tilson, when your patients are seated before you, it will have nothing to do with what I am looking for. It is all about reading about your patients while you are managing them; watching and learning every single day of your medical school journey.”
He crunched the empty cup in his hands. “Before hypertension sets in with these patients, there is a first sign that is quite dependable. A weight gain of more than two point two pounds in a week or six point six pounds in a month is often regarded as significant. An astute clinician following patients along prenatal clinic appointments will pick up on this sudden excessive weight gain.”
Jammed into a spot that she couldn’t dig out of, Annabel swallowed hard. He was supposed to be asking her about the physiologic changes of a neonate, but how was he supposed to know that? Ling offered no mention of tying her up with a different reading assignment the night before and Annabel felt cornered to not mention it to her attending.
“Since you exhibit a hole in your knowledge starting out on this rotation, please be aware that during pregnancy, a gradual increase in weight is normal … a half a pound to a pound per week.”
Dr. Harvey rose and went over to make more fresh coffee. He shook his head, wondering how Annabel was given such complimentary accolades from other medical professionals.
-----
The residents peeled away from Mary Chandler’s medical and legal documentation of death and Dr. Harvey signed a few of their sheets. “Let’s make quick rounds together,” he said, stretching his arms out to the side, “and then I’m leaving for the office.”
They visited three patients and, each time, Dr. Gash properly summarized the patient as they cluttered up the hallway. Annabel hung on every word, now feeling more ready than the previous day on how to present obstetric patients. These patients were different than recapitulating surgery, psychiatry, or internal medicine patients.
They went outside Bonnie Barker’s room. “Perhaps Dr. Tilson can tell you about Ms. Barker,” Ling said, “although I don’t think she’s seen her patient yet today.”
Dr. Harvey held the patient’s chart and peeked at Annabel’s note from yesterday. He eyed Ling suspiciously. “Under this morning’s circumstances, did you stop in on your patients yet?”
Ling shook her head.
“Makes you all even,” he said. “Let’s hear it, Annabel. I realize the patient came in before you started the rotation, but you had the opportunity to familiarize yourself with her case and write a progress note on her.”
Annabel’s confidence finally inched up with the new attending and she plunged into her presentation. “Ms. Barker is an eighteen-year-old white female who was gravida one para zero on admission, at full term, with a negative prenatal course and history. Yesterday, she delivered vaginally, and after the placenta was delivered, she experienced significant vaginal bleeding, estimated to be at least one thousand ccs.
“The residents did a bedside uterine massage, but with continued bleeding, they took her to the OR. She was resuscitated with IV fluids and doses of oxytocin. Her diagnosis was uterine atony.”
She thought ahead but was unsure as to how much detail Dr. Harvey wanted. After all, she was not presenting a whole initial history and physical. Then she thought about the woman’s newborn, so she decided to include the baby too.
“The pediatrician was called; the baby’s initial evaluation or Apgar scores were something like seven and eight. I believe the pediatricians are monitoring her and doing some testing.”
Dr. Harvey attempted to shove some of his shirt’s loose fabric, which hung around his belly, into his pants, but it didn’t work.
“Much better,” Dr. Harvey said.
Better than what? Annabel wondered. Better than the wrong impression he formulated about her?
“So what are the risk factors for uterine atony?”
Annabel didn’t have a clue.
“Working with me, it’s better to be straight, such as ‘I don’t know.’”
Annabel cringed. However, she liked a straight-forward doctor. “I don’t know.”
“Uterine atony is always on obstetric exams. There are two opposite risk factors: a rapid labor and/or delivery … or a prolonged labor. The rest of them are overdistention of the uterus, an intraamniotic infection, high parity, which we don’t see often anymore, oxytocin use during labor, and magnesium sulfate.”
Annabel wished she could rattle off information like that. At the least, she better understand it all by the time she took her second official board exam or USMLE - United States Medical Licensing Examination. That test, Step 2, would be a two-day exam in the fourth year of medical school. The three Step exams were weed eaters … they pulled the lower tier of student or resident test takers and gobbled them up with cordless weed trimmers.
