Richard Mabry - Code Blue

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?"

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."