by Barbara Ebel
“What procedure?” Toby asked. He had a bad feeling about this.
Through experience, if Rick could help it, he had learned not to tell all patients the names of procedures. The technical terms only served to scare younger ones more than needed. He, however, did tell parents the name, description, risks, and other information of any procedure he performed on their child.
“We want to insert a needle between the bones in your spine and take out a small amount of fluid for analysis. I’ll go talk to your parents about it and be back.”
Rick turned to Bob. “You can stay with Toby for a few minutes. The rest of the team, go write your progress notes and be back bright and early tomorrow.”
“Dr. Mares,” Bob added tentatively, “Annabel Tilson would like to be here. Is that okay with you and Toby?”
Rick’s eyebrows rose. “Fine with me.” Toby nodded an okay.
Bob sat next to Toby’s bed and texted Annabel. “You’re welcome to come. Dr. Mares is getting parental permission, which shouldn’t be a problem.”
“I’m on my way.”
-----
Toby’s forearm trembled. For the last few days, he had done everything possible to tolerate his situation, not complain, and act like a grown-up person. Which he wasn’t. Missing the familiarity of his own bed and room, he was reduced to sleeping in a hospital. Nights were scary and uncomfortable and laden with strange sounds and strange people in the hallways. Most were hospital employees, but they came and went like he was some object of their eight-hour shift.
Besides the bulky cast on his leg and the futile attempts at physical therapy, he felt like crap and it was only getting worse. And within the last few minutes, he was stupefied about what Dr. Mares had said, but now, as he began processing it, he started to freak out. It was bad enough when the technicians were drawing blood from him and when the nurse had slipped in an IV, but the fear of having a needle stuck into his back was terrifying.
Bob remained silent. At least someone was with him, Toby thought, but the youth could no longer contain his worry over what would happen to him. His head and neck hurt and he wished he were home and buying school supplies like everyone else his age. No longer able to hold back his emotion, he started to cry.
Bob leaned in, propping his elbows on the bed. He patted the boy’s forearm. “Toby, what? What is it?”
“I’m scared. I want to go home.”
“I promise, we’ll take extra special care of you. First, we must find out what’s wrong, fix it, and then send you home. We must.”
“I don’t like needles.”
“I hear you. But this may be easier than you think. As opposed to the other needles you’ve had so far, Dr. Mares can use a baby needle to put some numbing medicine under your skin before he puts in the next needle to draw the fluid he needs. It’ll be a snap and Annabel and I will be with you the whole time.”
Toby grabbed a handful of his bed sheet and wiped his eyes. “Here,” Bob said, and handed him a tissue from the nightstand. The youth took a deep breath and his sobbing lessened. The more they waited for Rick and Annabel to appear, the more Toby calmed down.
-----
Annabel slipped in the door with the spinal tap tray and other medical necessities for Toby’s procedure
“Hi, you two,” she said. “Dr. Mares is waiting for your parents to arrive, Toby. They want to wait in the lounge while you have your procedure. And Dr. Mares asked me, since I was headed this way, to tell you something.” She looked at Bob, who nodded and placed the kit on the tray table.
“Do you mind if I tell him, Bob?”
“Absolutely not.”
“Dr. Mares and Dr. Palmer believe you have meningitis.” She paused to let the word sink in. Maybe or maybe not, Toby had heard the word before.
“That sounds bad. What does that mean?”
“Meningitis is an inflammation of the membranes that enclose your brain and spinal cord, inside your skull and the bony canal in your back.”
“Which is caused by an infection, Toby,” Bob added.
“Oh. So some germ is multiplying inside my head? That’s dangerous, isn’t it?”
“We’re right here with you,” Bob said, “and we’ll get to the bottom of what is causing it and what we can do about it. We want to nip it in the bud. How does that sound?”
“You better.” Toby kept from crying. He liked the fact that both medical students he liked and trusted were explaining it to him so that he could understand.
“One more thing,” Annabel added, “because the team thinks meningitis is the problem, but they don’t know what kind, they are going to restrict the number of visitors and you’ll be quarantined.”
“What do you mean?”
“You will be isolated from other patients or many visitors,” Annabel said.
“So that other people don’t accidentally catch what you may have,” Bob said.
When Dr. Mares came in, he began to set up for the procedure. Toby’s leg in a cast didn’t help matters, but with Annabel and Bob helping out, he managed to drain Toby’s cerebrospinal fluid into the necessary vials and hastened it off to the laboratory himself, ordering Bob and Annabel to leave and possibly go study.
-----
“You must be thinking what I’m thinking,” Bob said after both students stepped out from the hospital’s revolving doors to the sidewalk.
She glanced over. “I’m wondering if he has a bacterial meningitis, in which case Toby Owens could possibly die.”
“Haven’t we learned that with a bacterial meningitis, it’s onset would be quicker? In other words, he had symptoms a few days. If it were bacterial, he’d be much sicker already.”
“But we can’t exclude the possibility. Not everything is textbook. And what about the Powassan virus that the national park ranger had on our internal medicine rotation?”
“Possible but unlikely, since it’s really, really rare. Chances of two cases here in the area in such a short time would be crazy.”
“True. Let’s not jump to conclusions until the results of the spinal tap are back.”
“I’m going to walk Oliver when I get home. Want to come? Then I’m going to study; maybe you’d like to join me. After all, we’re both studying the same stuff. Unless, of course, you’re spending part of the day with Dustin.”
“You’re on.” She ignored the inclusion of Dustin in the conversation.
-----
Annabel pushed aside her sandwich plate with leftover kettle chips and picked her head up from a book while Bob made a chart inside a notebook. They methodically covered all the types of bacterial meningitis they could lay their hands on outside Pete’s Café. Oliver basked in the sunshine, tethered to the fence beside their table.
“This is the perfect day to do this,” Bob remarked. “Chances are, autumn will be here before we know it and this will be our last opportunity.”
“It is nice, isn’t it?”
“This is the perfect weekend.”
Annabel glanced down. Maybe not that perfect, she thought.
“Let’s look at your list of the most prevalent types of bacterial meningitis and then categorize them in the pediatric population.”
Bob read the five most common and Annabel dived into the specific incidence in young age populations. They rewrote what they came up with.
“Group B strep, strep pneumonia, Listeria monocytogenes, and E. coli are most prevalent in newborns,” Annabel said.
“So we’ll skip the newborn list since we’re dealing with an eleven-year-old. And babies and kids are again Group B strep, strep pneumonia and, in addition, Neisseria meningitides, and Hemophilus influenza type b.”
“Teens and adults are again Neisseria meningitides and strep pneumonia.”
“And they are still extremely prevalent in the older adult population, but we don’t need that information. In all probability, we can discount E. coli and Listeria monocytogenes in the newborn list too.”
Annabel drew an ast
erisk star beside what they had left. “If Toby has a bacterial etiology, then we’re down to primarily strep pneumonia, and Neisseria meningitides, and secondarily, H flu, and Group B strep.”
Oliver stood up and wagged his tail while sticking his head through the fence. “I can’t resist him,” Bob said. He plucked a residual piece of burger from his plate, leaned over, and opened his hand to the dog. The meat disappeared and Oliver continued to lick Bob’s hand.
Annabel laughed. “You asked for it.”
“That I did.” She handed him a napkin and he wiped off his hand.
“We need to go back to an important point, one which we talk about all the time, and that is risk factors. What are Toby’s risk factors for any of these infections?”
“Says here,” Bob said, “babies are at a huge disadvantage as far as a risk for bacterial meningitis, but more important to us would be if Toby had been involved in a crowded community setting.”
“Such as school, especially boarding at a college campus. But school hasn’t started for him yet. However, did you miss something in his history?”
“Good point. I have to go back over his history. What if he went to some huge concert at a large venue in the last month? Or stayed at a summer camp for a week?”
“Exactly. Then there are medical procedures and conditions that would make a patient more likely to acquire it, but I don’t think his leg fracture or cast would be related, do you?”
Bob shook his head and peered at her textbook. “Last one is travel. Going somewhere a person doesn’t normally go, especially abroad.”
“Did you get any history about that? Actually …” Annabel stared across at Oliver and narrowed her eyes. “It’s not exactly like the family went to Belize, but Toby wore a Florida T-shirt the day he came into Dr. Gillespie’s office.” She gasped and put her hand to her mouth. “And his mother mentioned something.”
“What?”
“Toby mentioned muscle aches to Dr. Gillespie. His mother said she knew he didn’t want to miss any sports activities during the last few days of summer vacation but, at home, he had mentioned muscle pains since they returned from their Florida vacation.”
The two students pondered it over. “I agree,” Bob said. “Florida isn’t exactly exotic. But who knows what went on down there.”
CHAPTER 17
Heather Clark couldn’t decide on which miniature scone to select from the platter. “Becky, you’re too kind to start our Monday morning with these. The problem is which flavor to sample.
“You’re welcome, Dr. Clark. Don’t ‘sample.’ Just eat them whole. Making y’all happy right off the bat makes my job easier.”
Popping one in her mouth, Heather’s already full cheek puffed out even more. She chewed quickly as she focused on pouring a cup of coffee.
“I’m trying a blueberry,” Annabel said.“That was predictable,” Stuart said after he gulped down one with cranberries and nuts.
“Sometimes I am. We’ve been spending too much time on rotations together, Stuart. But I bet you would not have guessed this. Oliver won the mixed-breed dog show on Saturday. I had so much fun prancing him around the ring and what everyone kept saying about him turned out to be true. He’s a beautiful dog. Now Bob and I have bragging rights.”
“No way!” Heather spun around. “My sister shows dogs and hasn’t even won a ribbon in two years.”
Annabel chased down a bite with coffee. “Maybe it was beginner’s luck.”
“Did you and Bob celebrate or did you and Dustin celebrate?” Stuart asked.
“Dustin went home to de-stress from his work week, and Bob, Nell, and I ate junk food at the fair. Bob and I even ate at Pete’s and studied yesterday. So you could say we mixed business with pleasure all weekend. However, another striking event occurred this weekend too.”
Stuart gave her a long look as he held a second scone.
“Bob made up his mind. He was on call Friday night and popped into an orthopedic case because he needed to talk to the surgeon about a consult. Engrossed, he was able to watch an ORIF. Fell in love. Just like that. He says he’s going into orthopedics.”
“Get out. That wasn’t even on his list of possibilities.”
“Tell me about it.”
“Sometimes a certain specialty impresses you when you least expect it,” Heather said. “What about you two?”
“I need to do some soul searching because I’m not sure,” Annabel said. “And I’m running out of time. I’ll speak up for Stuart because he’s been bent on psychiatry all along.”
Stuart rinsed his hands at the sink. He turned sideways, his frame thin as a dime, and seemed to contemplate what he was going to say. “Over the weekend, I thought about changing.”
Annabel, Heather, and Becky stared at him.
“I like your patient population, Dr. Clark, as well as the specific area of medicine. I’m thinking of going into pediatrics or pediatric psychiatry.”
Annabel’s jaw dropped. “You are another surprise.”
“I’m tickled to death,” Dr. Clark said. “I hope my mentoring has made a difference in your decision.”
“You are an inspiration,” Stuart said, “as well as the kids who come to your office.”
“I’ll speak for the doctors,” Becky said, “when I say that you are invited to come back here to do elective time. Especially before you send in your residency applications.”
“I may take you up on that. I have plenty of elective time left in my schedule.”
Becky stepped to the doorway and motioned to Annabel. “Dr. Gillespie is here and is picking up the first patient’s chart. Better go join him.”
Annabel dumped the rest of her coffee down the sink, slipped on her white jacket, and trotted down the hallway. Dr. Gillespie peered over the chart at her and mumbled, “Another school physical. This one’s for a seventh grader.”
The exam room door opened and an overweight woman wearing an array of costume jewelry almost bumped into them.
“Hey, Dr. Gillespie. No use in staying in there; I didn’t stay for Aaron’s physical last year either. He’s old enough to see a doctor by himself and he’ll be driving before I know it too.” The mother of the patient nodded at Annabel and began scrolling through her iPhone as she took a seat in the waiting room.
Dr. Gillespie waddled in. “Welcome to your seventh grade physical, Aaron. Any complaints or health problems since the last time I saw you?”
“I’m great, Dr. Gillespie. Nothing’s wrong with me at all.” The long-limbed boy grinned and ran his hands through his hair like tossing a salad. He put an iPad to the side as George went through his record.
“This is Annabel,” Dr. Gillespie finally said. “She’s an advanced medical student learning about the field of pediatrics.” He put the chart down and gave the boy a long look for the “general appearance” of the physical exam and then examined his ears, nose, and throat. The youth wore nothing but a short gown and his lower legs dangled from bony knees at the end of the table.
“What sports have you been playing?” George asked as he picked up a reflex hammer.
Aaron smiled for the first time. “Over the summer, mostly basketball with my buddies.”
George nodded and tapped on Aaron’s knees with the hammer to evaluate his deep tendon reflexes. “Besides a short neuro evaluation,” he said to Annabel, “I spend a little extra time examining kids’ joints if they’re more involved with athletics.”
Annabel stayed by the back wall. “That must mean most kids Aaron’s age.”
“Pretty much.” Dr. Gillespie went on to check Aaron’s heart, lungs, and abdomen and asked him to stand down.
Annabel sighed. She hated to think it, but another somewhat boring school physical, which needed to be done, was out of the way. She took a baby step sideways to leave the room, and paused for Dr. Gillespie to give the okay.
But he wasn’t finished.
“You can lean over the table,” Dr. Gillespie said to Aaron. He put on a
glove, unscrewed the cap off a lubricant tube on the counter, and squirted some on his glove. The boy’s gown was tied in the back and the pediatrician widened the space between the cloth, below the tied bow.
Annabel began feeling terribly awkward as it became apparent what the senior doctor was going to do. She stepped from one foot to the other and couldn’t help but grimace. The adolescent placed his elbows on the examination table and bent his head down to stare at the black upholstery. He also grimaced in advance and Annabel gathered that Aaron was schooled in what was to come. It was not his first time.
Dr. Gillespie’s eyes widened. He began slowly and quietly humming. His vocals droned louder as he inserted his gloved, lubricated index finger into Aaron’s rectum and palpated.
Aaron squirmed and Annabel’s heart thumped against her chest with distress. The youth’s exam turned into a painful show, upsetting and disturbing her as she pinned herself against the wall. She wanted to focus on what she knew about pediatric healthy, routine physical exams because nowhere did she remember reading that a rectal exam was part of it.
But she couldn’t get past the scenario in front of her in the confined space of Dr. Gillespie’s exam room. Gillespie’s eyes appeared hungry and he seemed like he was ready to explode with excitement.
-----
When Dr. Gillespie left the exam room, he made a left turn and headed to his office. Annabel slinked to the room next to the kitchen and hurriedly opened her manual to the physical exam. Maybe she had missed something. She read and reread the systematic parts of the pediatric exam and nowhere did it mention a digital rectal exam for these patients unless, of course, there were specific complaints such as constipation, gastrointestinal bleeding, an abdominal mass, etc.
She poked her head around the corner. George’s office door still did not open, so she lowered herself into a chair while still holding the book. Reading the chapter highlights again shed no more light on the exact office circumstance she had just witnessed.
