"It's sort of funny, but my eyes have been acting up. Everything looks sort of yellow. And lights have halos around them. I sort of figured I might be getting cataracts."
Cathy turned to Glenna. "Is that digitalis level back?"
"No, that takes a while to run. We do have the chemistries, though." She pulled a sheaf of lab slips from her pocket and handed them to Cathy.
One value jumped out at Cathy immediately. Nix's potassium was high. That went along with her presumptive diagnosis-digitalis intoxication. Cathy remembered Nix's medications included a beta-blocker, which would increase his digitalis blood level a bit. But to get symptoms like this he'd have to be taking much larger doses than she'd prescribed.
"Mr. Nix, have you been taking your digitalis the way I prescribed?" she asked.
"Of course. I'm not fool enough to pay a doctor for advice and then ignore it. I did just what you said, even when you had me taking twice as many as Doc Gladstone did."
That couldn't be right. She was certain she'd written for one tablet a day, a direct switch from Lanoxin to generic digoxin. But there would be time to look into that later. Right now, she had to lower Nix's digitalis level. "Glenna, see if the pharmacy has any Digibind."
"Digi- what?"
"Digibind. It's an IV preparation. Lowers digitalis levels. It may take five or ten vials. Get as much as they have. Stat, please!"
Glenna hurried away, and Cathy turned to Mrs. Nix. "I need your husband's prescription bottles. Would you get them for me?"
"Me? Now?" The woman seemed shocked. Undoubtedly, she'd long ago become accustomed to being waited on.
"Yes, now," Cathy said. "And hurry."
Mrs. Nix opened her mouth, but before she could say a word her husband snapped out, "Gail, do it!" She snatched up her purse and scurried from the room without a word.
Glenna almost bumped into Mrs. Nix in the doorway. She held up three small boxes. "The hospital pharmacy only had three vials. And they said it's really, really expensive. Are you sure you want to give it?"
Cathy hesitated. She didn't have a digitalis level to prove her diagnosis. On the other hand, the longer she waited, the more chance that Nix would get into real trouble, probably a rhythm disturbance of the heart. She had to act.
"Yes, give the first vial IV now. There's a special filter you have to use. It should be in the box."
Glenna set to work preparing the infusion.
"Who's the internist on call?" Cathy asked.
Glenna didn't look up from her work. "Dr. Baker. Shall I call him?"
Evan Baker, one of the doctors who had voted with Harshman against her. Cathy didn't want to give him a chance to see her possibly make a mistake, but protocol dictated that she call him in. She hoped her diagnosis was right-not only for Nix's sake, but for her own.
"Yes, please call Dr. Baker, but get the Digibind running first. It should go in over about half an hour. Follow it with another unless I tell you otherwise. I hope we'll have the digitalis levels back by then."
Cathy turned back to her patient. "Mr. Nix, you've got too much digitalis in your system. I need to reverse it before it causes problems with-"
Her eyes were drawn to the cardiac monitor as the pattern became more erratic, then the complexes settled into a rapid rate of almost two hundred beats per minute. Ventricular tachycardia. At that rate, there wasn't time enough for the heart to fill and empty efficiently. The coronary arteries would be starved for blood. If she didn't reverse it quickly, Nix would die.
Cathy opened the cabinet behind her and snatched out the material to start another IV, this one in Nix's left arm. As soon as it was in and running wide open, she snapped the top offa glass vial of Lidocaine and drew the contents into a large syringe. "I'm giving you something in your vein to slow your heart rate." Slowly, carefully, she injected the contents of the vial. No change in the heart tracing. Should she give amiodarone? No, not yet. Too toxic to risk it right now.
Glenna hurried back into the room. "The ward clerk's paging Dr. Baker."
"Good. Now I need your help. Mr. Nix has gone into V-tach. Get ready for a cardioversion."
"Doctor, I don't think you have privileges for that."
Cathy didn't have time to argue medical niceties. Seconds were precious. Still, she was pleased at how even her voice was. "Until Dr. Baker gets here, it's up to me to handle this. Set up the defibrillator."
Glenna quickly moved the crash cart to Nix's side. She whipped offthe yellow plastic cover and prepared the defibrillator.
Once Cathy was sure the defib apparatus was ready, she bent over Nix, who lay on the gurney, sweating and pale. She tried to sound reassuring. "Mr. Nix, your heart rate is dangerously high. The way to slow it down is by delivering a shock. You'll feel a jolt, probably a brief pain. But it's necessary. Do I have your permission?"
Nix's voice trembled. "Anything, Doc. Do what you have to."
Cathy had done three or four of these in residency, always under supervision, always with a cardiologist looking over her shoulder. Now she needed an angel over her shoulder. Please, God, let it work.
How much? She searched her memory for the right setting. A hundred? No, not enough. She took the paddles from Glenna, slapped them together to spread the conductive gel."Two hundred joules."
Glenna turned the dial.
Cathy pressed the "Charge" button on the right paddle. Her voice was strong. "Clear."
Glenna stepped away. Cathy made sure she wasn't touching the table. She put the paddles on Nix's chest, said, "Brace yourself," and pushed the "Discharge" button on the left paddle.
Nix jumped and fell back, limp and sweating.
The complexes slowed, sputtered like a car burning lowtest gas, then resumed their race.
"Three hundred joules."
Glenna's voice was full of doubt. "Are you sure?"
Cathy hoped she was. "Yes. Just do it."
Again Glenna adjusted the dial. Cathy went through the routine and applied the current.
This time when Nix relaxed back onto the table, he appeared so lifeless Cathy was afraid she'd killed him. But when she looked up at the monitor, she saw a beautiful sight: normal complexes running across the screen at a rate of seventy-eight per minute.
"What's going on?" Evan Baker stood in the doorway, filling the room with his commanding presence.
Cathy had made reports like this so many times during residency she was a pro at it. "Doctor Baker, Mr. Nix came in with apparent digitalis intoxication. His potassium is up, but the digitalis level isn't back. I made a clinical diagnosis and started Digibind. He went into V-tach, unresponsive to Lidocaine. I cardioverted him, and he reverted to normal sinus rhythm after 300 joules."
Baker made no reply. He looked over the chart, asked a few questions, and listened to the patient's heart. Slowly, he folded his stethoscope and jammed it into the pocket of his suit coat before turning to Cathy. "I trust you realize that FP's don't have privileges for cardioversion."
Before Cathy could speak, the ward clerk hurried in waving a lab report slip. Baker snatched it from her, looked at it, and handed it to Cathy. "But I'm glad you were here. The digitalis level is 5.2."
Nix mumbled, "Is that-?"
"It's a toxic level, almost twice normal," Baker said. "And you're fortunate that Dr. Sewell treated you as she did." His next words made Cathy cringe. "Now, we have to find out how this happened."
Cathy nodded. She appreciated Baker's diplomatic choice of words in the presence of the patient. What he really meant was, "Who committed this act of malpractice?" Unfortunately, she already knew the answer to that question.
6
Cathy squirmed. not because the chair across from Marcus Bell's desk was uncomfortable. She'd sat in worse. But she'd never been in a more uncomfortable situation than this.
Marcus picked up Milton Nix's chart that Jane had hand-delivered less than an hour earlier. He opened it and read silently for a moment. "So, how do you think this happened?"
&nbs
p; Cathy squared her shoulders and sat up straighter. Time to take her medicine. "Mrs. Nix brought me the pill bottle. The label said, 'Digoxin, 0.25 mg. tabs. Sig: 2 tabs q day.' You can see that's not what I prescribed."
Marcus flipped the pages. "I can see it's not what's on your chart. But what was on the prescription? Is it possible that you got flustered about something, distracted maybe, and wrote it down wrong?"
"Marcus, part of my training included time with one of the best cardiologists in the country." Cathy regretted her tone as soon as the words were out. She took a calming breath. "I've written that prescription at least a hundred times, probably more than that. I wrote that script exactly the way you see it on the chart."
"What did Dr. Baker do?"
"Once he realized I'd made the right diagnosis-and probably saved Nix's life-Dr. Baker acted professionally. He agreed that Nix had a toxic level of digitalis in his system. He didn't imply I'd done anything wrong." Unlike you, she thought.
"Did you bring up the dosing error?"
"I told him what I've told you," Cathy said. "Then he phoned Collins Pharmacy. Jacob pulled the prescription and read it back to him. It was exactly what was on the pill bottle."
"So you made a mistake. A big one."
She shook her head. "I couldn't believe it-still don't. I got on the phone and asked Jacob why he didn't call me to question the dosage. That's a lot of digitalis. He said that I underlined the strength and dosage. You know that's what we're supposed to do when we write for something unusual. It tells the pharmacist, 'Yes, I know. But I have a reason.'"
"Which pharmacist filled the prescription?"
"Jacob didn't know. But he said that either of them would probably figure I was giving Nix a high dose to convert a case of atrial fibrillation. So they filled the order just as it was written and that's the way Nix took it."
Marcus rose, turned toward the window behind his desk, and stood with his back to Cathy, his hands in his pockets."Cathy, you know I like you. I've been in your corner since you decided to come to Dainger to practice. But something like this is serious. The credentials committee may even revisit the status of your privileges. They could require you to practice under supervision for a while. Even suspend your privileges. In the meantime, you need to get Nix into the hands of an internist."
"Already done."
Cathy recalled the scene all too clearly. She and Evan Baker had talked in the hall, then gone back into the treatment room where Gail Nix stood wringing her hands over her husband. The IV bag containing the second vial of Digibind dripped steadily into Nix's vein. Depending on the results of the latest digitalis level, he might need more. The hospital pharmacy had already dispatched a driver to Fort Worth for several additional vials.
Cathy admired and appreciated the way Evan Baker put it. "Mr. and Mrs. Nix, you're fortunate that Dr. Sewell made the correct diagnosis and administered the proper treatment. However, she's told me she thinks that it would be best if a specialist directed your cardiac care for a while. Would you like me to give you the names of the internal medicine specialists in town? Or would you prefer that I stay on the case?"
Cathy realized she'd been sitting there with her eyes closed as she relived that scene. She opened them, took a deep breath, and looked Marcus in the eye. "Of course, they agreed to let him take over the case. I don't blame them. I realize that Dr. Baker could have made an issue with them about the prescription, but he didn't. I hope he'll be sympathetic when-and if-this becomes an issue. Until then, I plan to continue to practice the best way I know how, putting the best interests of my patients foremost."
Marcus stood, but remained behind his desk, the expanse of wood a reminder of the gulf between them right now."Cathy, I can't sweep this under the rug. For starters, you'll have to present this at the next Morbidity and Mortality Conference. You know the drill. The staffwill discuss why it happened, how it might have been prevented, if the treatment could have been better."
Cathy's face burned. There was no shame in having a patient die or experience a complication if you'd done everything you could to prevent it. But this M amp;M conference would make her look totally incompetent. Even a thirdyear medical student knew the proper maintenance dose of digitalis. Who might have tampered with Milton Nix's prescription? How could it have been done? And who could want to hurt her so badly that they risked a man's life to do it? Had the campaign to run her out of Dainger just escalated another notch?
"Mrs. Gladstone, I'm sorry we had to reschedule your appointment." Cathy pulled on gloves, seated herself on the rolling stool, and flipped up the sheet.
"No problem, dear. I understand." Emma Gladstone was the perfect example of maintaining one's dignity while draped in a sheet with both legs held in gynecologic stirrups."Remember, I've been married to a doctor for almost fifty years."
Cathy carried out the examination the way she would want hers performed: gently, carefully, with frequent explanations and assurances.
"Jane, I think we're through. I'll step into my office and dictate my findings. Would you help Mrs. Gladstone up? When she's dressed, I'll see her in my office."
Cathy closed her office door, dropped into her chair, and brushed a stray wisp of hair from her eyes. She started to reach for one of the textbooks behind her desk but paused with her hand halfway there. No need. She'd had an excellent rotation through the obstetrics and gynecology department at the medical center. She'd attended a postgraduate conference on gynecologic tumors just a month before moving to Dainger. The biopsies she'd taken would confirm it, but she knew carcinoma of the cervix when she saw it.
Jane ushered Mrs. Gladstone into the office. Before she closed the door, her eyes met Cathy's. The sorrow and compassion there told Cathy that her nurse knew what the exam had revealed. "Do you need me, Dr. Sewell?"
Cathy appreciated the offer, but this was part of her job. She had to do it on her own. "No, thank you."
She motioned Mrs. Gladstone to a chair, then stared down at the pathology request on her desk. Cathy took a deep breath. This was never easy.
Mrs. Gladstone spoke first. "What kind of tumor is it, Dr. Sewell?"
Cathy's head snapped up. "What makes you say that?"
The patient shook her head and smiled. "You don't live with a doctor as long as I have without picking up bits and pieces of information. When a woman my age begins to have bleeding like that, it's a tumor. You took some biopsies-I'm presuming a four-quadrant biopsy of the cervix. Do you think it's invasive or in situ? Any masses in the adnexa? What can you tell me?"
"I think you have early carcinoma of the cervix," Cathy said. "The biopsies will confirm the grade. I don't feel any masses in the ovaries or tubes, but we'll want some imaging studies to confirm that. The treatment, if I'm right, would be either radiation or surgery. Personally, in your situation I'd favor surgery."
"There, that wasn't so hard, was it, dear?"
Harder than you'll ever know, Cathy thought. "We should have the results of the biopsy back in less than a week. Would you like for me to call your husband and give him my preliminary findings?"
"Oh, I'll wait until the results are back. Maybe I'll ask him to come with me on my next appointment. He rather likes you, you know."
This wasn't exactly the way Cathy wanted to make allies, but right now, she welcomed every one of them. "Just be thinking about who you'd like to see for treatment. We can send you to a specialist in Fort Worth or to the medical school in Dallas. I know good people at both places."
"Do you have privileges for this kind of surgery?" Mrs. Gladstone's voice held no trace of irony or guile. Apparently, her husband didn't share all his professional secrets with her.
"No, this is beyond what I normally do. If surgery is required, it would be best for a gynecologist to perform it. Do you want someone here in town?"
"Arthur Harshman is probably the best gyn specialist here. Of course, his manners are terrible, but Ernest says he's extremely capable. What I'd really like, though, is for
you to assist him. Maybe we can work on that."
"Mrs. Gladstone, I'm so sorry. If-"
Emma silenced Cathy with an upraised hand and the faintest shake of her head. She reached into her oversized purse and pulled out a small, worn leather volume.
"Please don't worry about me. This matter is in God's hands. There's story after story in here where Jesus tells us that God is in charge; we're all in His hands. I am. You are. So let Him take over. You just do your best."
Cathy sat at her desk, wondering if the air conditioning in the office had failed or the conversation with the pharmacist had triggered the sweat that trickled down her face.
"Lloyd, I really need to see that prescription." She held the phone so tightly that her hand cramped. She switched hands just in time to hear the answer.
"Afraid not, Cath-Dr. Sewell. I don't have the authority to let it out of the store. That would be up to Jacob."
Cathy waited but Lloyd Allen, the other pharmacist at Jacob Collins's pharmacy, didn't offer to help. Same old Lloyd she'd known in high school. If it wasn't to his benefit, forget about asking him.
"Lloyd, I thought you two were partners."
"Nope. Jacob bought the store from my father while I was in Oklahoma. Then he built this new building. Upgraded everything. That was about the time my wife divorced me, so I moved back here and he hired me."
"It must seem strange working for someone else in what was once your dad's place," Cathy said.
"I don't really want to talk about it. And the answer's still the same about the prescription-that's up to Jacob."
"May I speak with him, please?"
There was no answer, just silence, punctuated by mumbling in the background. In a couple of minutes, Cathy heard a series of bumps, probably the receiver hitting the counter as someone dropped it.
She recognized the next voice she heard, even though Cathy had last heard Jacob Collins's distinctive whine in high school. Jacob had been on par with their class academically, but light years behind her and most of her classmates in the social graces. Jacob hadn't fit in with any crowd. He'd asked Cathy out once. It had been all she could do not to laugh. She'd tried to let him down easy, but she had the impression that the hurt lingered for a while.
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