Richard Mabry - Code Blue

"Anything else?"

"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.

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.