Richard Mabry - Medical Error

He pulled a ring of keys from his pocket, jingled them, and grinned. "Master key for all the doors in the department. I'm the chairman. Remember?"

Anna made some conversational gambit-she wasn't even sure it made sense-and retreated back to her office. She closed the door and leaned against the desk. Of course the chairman would have a master key. She hadn't even thought of that. But how many more were floating around the department? She could hear it now. "Hey, Neil. Let me borrow your key. I need to get into my office, and I forgot mine." Then a quick wax impression-wasn't that the way they did it in the mystery novels? -and pretty soon locked doors presented no challenge.

She chided herself for letting her suspicions run wild. It was hard enough to think that an assistant might yield to the temptation to lift a few prescription pads and copy down a doctor's DEA number in order to turn it into cash or satisfy personal needs. But would another physician do that? No, surely not. On the other hand, she couldn't rule out that possibility.

Well, she'd learned something anyway. Probably more than she wanted to know. And the pool of suspects was larger than ever.

Anna closed the chart and tossed it into the rolling wire cart beside her, on top of all the others that were to be refiled. She shrugged her shoulders, flexed her fingers, and wiggled her toes. She felt as though she'd gone five rounds with a welterweight fighter. She was sore, discouraged, and painfully aware of her shortcomings.

The room was quiet except for an occasional muttered curse as a resident or staffphysician struggled to complete long overdue dictation. The Medical Records Department might seem to be a minor cog in the operation of a large medical center like Southwestern, but Anna realized how much power the records staffwielded. How many times had she waited while a misfiled chart was located? How often had she hurried over to this basement room to sign charts and do dictation so her name would come offthe dreaded "suspended" list-unable to operate or even admit patients until she'd completed the paperwork that seemed ready to bury her and her colleagues at any minute?

This time she'd come here voluntarily to wade through the charts of almost a hundred patients in search of a clue to the identity of the person who had co-opted her name and DEA number. And it had been a total bust. The names were just that-names. She'd been able to remember a few cases, put faces and scenarios with them, but that hadn't helped. Even though some of her patients weren't the type of people she'd want to go out for coffee with, she couldn't picture any of them being involved in a scheme to produce hundreds of forged narcotics prescriptions.

Anna felt her joints creak as she stood and stretched. The more information she gathered, the less she seemed to know and the wider the circle of suspects grew. She'd thought about going public at the M amp;M conference with the information about the second "Eric Hatley," the one whose treatment in the ER had led to the administration of Omnilex to her patient. For a moment she questioned her decision to hold back that information-information that would have justified the antibiotic choice she and Luc had made. But this feeling tickling the back of her mind, a feeling that one of her colleagues was tied into the whole identity theft mess, was too strong to ignore. And she didn't want to warn them offuntil she had more data.

The problem was how to find the facts that would clear her name. And right now, she had no clue.

Nick stared at the cartoons playing on the TV set in the surgeon's lounge. Bad enough that he had to be here on a Saturday morning to do a frozen section, but wasn't there anything decent to watch while he waited? Apparently not.

The intercom startled him. "We're sending the specimen around right now, Nick."

"Okay, Frank. I'm on my way. Call you when I know something."Nick looked up at the TV in time to see the Roadrunner outwit Wile E. Coyote yet again. To the accompaniment of a triumphant "beep, beep," Nick pushed up from the sofa and strode quickly out of the room.

The routine for a frozen section was straightforward enough. The circulating nurse would hurry to the surgical pathology laboratory with tissue taken by the surgeon. The technician mounted the material and froze it with a special machine called a cryostat, then used a microtome, an instrument that looked like a miniature meat slicer, to shave offthin sections from the specimen onto a microscope slide. The tech stained the sections, the pathologist examined them under a microscope, and in a matter of minutes the surgeon could have his answer and proceed with surgery. Easy enough-when it worked well. Today it didn't.

First the cryostat proved balky, refusing to freeze the specimen properly. Nick had no clue about how to make the instrument do its job, but apparently this wasn't the first time the pathology tech had encountered such a situation. After a prolonged bit of tinkering with the refrigerant source, the tech finally got the specimen frozen into a hard block, ready to section.

Then the microtome acted up. Theoretically, the paper-thin sections were supposed to fall offthe edge of the blade onto the glass microscope slide with only a gentle nudge from a soft brush. Instead, they came offcrinkled like the bellows of an accordion, and no amount of teasing would straighten them out. A bit more adjusting, a new microtome blade, and finally the tech was able to apply stain to the specimens and pass them to Nick.

Nick took the first slide and gently blotted the excess stain from around the edges before he slid it onto the stage of the microscope. He scanned the entire section under low power, correlating the images projected onto his retina with the story the surgeon had given him.

"Sixteen-year-old boy," Frank Crawford had said, "presented to the emergency room with abdominal pain, fever, and vomiting. We confirmed an intestinal obstruction and treated him conservatively, but he didn't respond. Now we think he's infarcting part of his small bowel."

"Okay, so the blood supply to that area's been cut off, and he's getting gangrene of the bowel. Not usual, but nothing you haven't seen before," Nick said. "You'll resect that segment, hook everything back up, and he'll most likely recover. What's so special that you think you'll need a frozen section?"

"This doesn't make sense. He doesn't have any of the factors that usually cause intestinal obstruction. And on the CT scan of the abdomen, he's got a bunch of prominent nodes."

"So take some for biopsy. Culture, histology, special stains. I'll make sure all that gets done. Why do you need an answer during surgery?"

"Nick, I've got a bad feeling. Of course, we'll send specimens for all that stuff, but while we're in there I need to be sure this isn't some type of malignancy. It may alter what we have to do."

Frank called it a bad feeling, and Nick didn't argue. After all, he'd experienced and responded to those same gut feelings. A layperson might call them hunches. For a doctor, Nick figured they were the result of disparate facts, stored in some far recess of the frontal lobe, laced together by the subconscious. So here he was, spending his Saturday morning with his eye glued to a microscope.

Nick examined the section of node under low power magnifi cation: definite inflammatory changes, but nothing to suggest a cancer. Then his eye was drawn to one area in particular. He scanned it yet again. The pattern was unique, and the diagnosis fit the clinical picture. Just one more thing to con- firm it. Quickly, he swiveled the lens to a higher power. Yes, definitely a non-caseating granuloma. And there was another one. And another.

"What've you got, Nick?" The voice over the intercom was tinny, but still plainly identifiable as Frank's. He was an excellent surgeon, but not known for his patience. Nick knew from experience that Frank had a true "surgeon's mentality." Figure it out, cut it out, move to the next case.