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?"
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.
Whiney or not, Jacob's words were full of conviction. "Dr. Sewell, I can't let you have the prescription. Milton Nix's attorney has already called to warn me about keeping it safe."
Cathy tried to keep her tone steady. So Nix already had an attorney. "Jacob, how about if I come by and look at the prescription there? Would you do that? This is important."
"Okay, come by today, and I'll let you see it, but you can't touch it." Jacob made it sound as though he were letting her see the Dead Sea Scrolls.
"Can you make a photocopy?" Cathy asked.
"Sorry. I'll let you see the prescription, but that's all."
The conversation had nowhere to go after that, but Cathy decided she'd at least try to be pleasant. It couldn't hurt to have this man on her side. "How's your family?"
There was no spark in Jacob's voice as he replied. "Sherri's fine. You remember Sherri Clawson? She was in your class. We have two kids."
Find something to compliment him on. "I drove to the cemetery recently and passed your house. It's really nice."
"Thanks. It could be nicer if- Never mind. You can come by this afternoon, and I'll pull the prescription out of the file."
As Cathy hung up the phone, some long-buried incident from her days in high school niggled at her. It seemed to her as though it was about Jacob. Or was it Lloyd? Was there something-some grudge from the past-that would lead either of them to manipulate one of her prescriptions just to put her in a bad light, even though it might kill a patient?
She was anxious to see the prescription. After that she wanted to talk with the person who filled it. Jacob had made it plain that, with only a two-man crew, they didn't bother to make that notation on the prescription or the bottle. Cathy knew it was good pharmacy practice to keep those records, but she got the impression that Jacob made the rules for Collins Pharmacy.
Persistent rumors. Economic pressure. Delayed hospital privileges. Now a prescription with a mistake a third-year medical student wouldn't make. Was this part of the ongoing campaign to drive her away? Or had her paranoia progressed to the next stage: out of touch with reality?
She stood up to walk out of her office when another thought hit her and she dropped into her chair. What if she had experienced a dissociative reaction when she wrote that prescription? What if she'd thought one thing and wrote another? That would explain the discrepancy between what she'd charted and what was on the prescription. She was no psychiatrist-she'd have to ask Josh about it to be sure- but as she recalled, dissociative reactions were common in patients with schizophrenia.
"That's your last patient," Jane said. "For the day and for the week. What are your plans? Will you promise to relax this weekend?"
Cathy handed the file to Jane and shrugged out of her white coat. "Promise. After I stop by the pharmacy, I'm going home and collapsing into a hot bath. Then tomorrow I think I'll take a drive in the country and get away from everything."
"How about Sunday?"
Cathy's initial impulse to dissemble died quickly. By Monday, everyone would know anyway. "I'm going to church with Will."
"Good. Enjoy your weekend."
Cathy retreated to her office and sat there with her eyes closed. The noises of drawers shutting and doors closing finally died away. She heard Jane call, "Night," before silence settled in.
Cathy decided she needed to talk with Josh about her mistake. She wanted him to evaluate her, assure her that her mind wasn't really slipping. Did it merit a phone call now? No, it could wait until her regular session next week.
She opened her eyes and leaned forward, pressing her hands to her temples to still the pounding. She hoped Josh could help her. She started to run down the list of available antipsychotic drugs.
"Stop it," she said out loud. "Stop thinking you can be your own doctor."
Still, the symptoms paraded through her mind like a marching army: A constant sense that someone was out to get her. Actions that were out of character for her. Emotions that went up and down like a roller coaster. Cathy reached for a tissue and dabbed at the tears that rolled down her cheeks. Now she knew what the writer meant when he referred to the "dark night of the soul." A permanent midnight had descended on her heart and soul. She wished she still believed that God heard and answered prayer. Right now, though, all she could do was cry.
Whoever designed Jacob Collins's drugstore had done a bang-up job: wide aisles, bright lighting, and attractive displays. Judging from the number of people lined up at the two cash registers, the merchandising efforts had paid off. Now Cathy could see how Jacob afforded that big house.
The pharmacy department repeated the modern look of the rest of the store. Despite growing up in a doctor's family, despite being a physician herself, Cathy had never been beyond the mysterious wall of frosted glass and faux marble that blocked out the public. Behind these barriers, men in white or pale blue smocks took prescriptions passed to them by anxious hands and dispensed bottles full of hope in return. Like elves in Santa's toy assembly line, they bustled back and forth, pulling bottles from the hundreds on the shelves and measuring out pills and capsules into little containers before slapping computer-generated labels on them. Now Cathy would step through the looking glass herself.
"Wait for me back here," Jacob Collins said. "I've got to take care of a problem at the front of the store." He punched a four-digit code into the lock and pushed the Dutch door open for Cathy before hurrying off.
She stepped inside and looked around. Large stock bottles of every kind of medication were arranged in alphabetical order on shelf after shelf. One shelf looked different, though. Set at eye level, it featured a display of pharmacy implements from a prior era. She recognized several glass and ceramic mortar and pestle units for grinding substances into a smooth powder. A shiny brass balance scale stood in the center of the shelf, its weights arranged in an orderly row in an open walnut case beside it. At the end of the shelf she spied another small wooden case, open to display a group of metal dies and pegs. She had no idea what that was, but the display was impressive.
"What are you doing back here?"
Cathy looked around to see a stocky woman whose most notable feature was flaming red hair that appeared to owe its distinctive color to Clairol rather than genetics.
"I'm waiting for Jacob. I'm Dr. Cathy Sewell."
"Oh. Sorry, I should have recognized you." The woman's tone softened. She moved a step closer. "Sherri. Sherri Collins." She extended her hand. "I was Sherri Clawson when we were in school."
Cathy took the hand, while her mind conjured up a yearbook picture, and decided that the years had not been kind to her classmate. When she was in high school, Sherri had a figure that turned the heads of all the boys and was the envy of all the girls. Back then, when most of the kids still wore glasses, Sherri had contact lenses-blue contacts that complemented her faultless complexion and long, light brown hair.
The yearbook picture faded. Long-buried memories scrolled through Cathy's mind. Two senior girls vied for Homecoming Queen in a close race. Too close. That changed after a few words whispered in the right ears: "Oh, Sherri would be a great Homecoming Queen. After all, she's on close terms with almost the whole football team-very close."
During halftime at the Homecoming Game, every eye in the stadium followed Cathy as quarterback Will Kennedy escorted her to the center of the field to receive her crown. Runner-up Sherri Clawson trailed behind, escorted by second-string tackle, Jacob Collins.
Cathy forced the images back into hiding and smiled."Sorry I didn't recognize you. It's been a while. Jacob told me you two were married."
Sherri's eyes narrowed. "As soon as Jacob graduated from high school," she said. "After we married, I got a job in the drugstore. I wanted to go to college, but someone had to make a living." She made a face. "We lived with Jacob's parents to save money, and he commuted to his pre-med classes at TCU."
"I didn't know he'd gone pre-med." Cathy could have cut out her tongue. Obviously, Jacob hadn't gotten into medical school.
By this time, Sherri looked like she'd chewed and swallowed a lemon. "Medical school didn't work out. So Judge Lawton pulled a few strings, and Jacob got into pharmacy school."
Cathy decided that no good could come from going farther down this road. "He seems to be doing well now."
Just then Jacob hurried in. "Sherri, why don't you go up front and get a Coke out of the machine? Get one for me too. I'll only be a few minutes here."
"Sure," Sherri said. "Nice seeing you, Cathy." She wheeled and hurried away.
Jacob eased onto a high stool at the chest-high work counter. "Let's get this done. I'm in a hurry."
"I appreciate your letting me see the prescription." Cathy pulled up another stool next to the pharmacist, careful not to disturb the pill containers and prescriptions lying on the counter. "It's really important."
"Let me find it." He pulled open the top drawer of one of the half-dozen small filing cabinets arranged under his workspace. He thumbed through the prescriptions in practiced fashion before pulling one out with a flourish usually reserved for rabbits emerging from a magician's hat."I hope you realize that I can't let it out of my sight. Matter of fact, when you're through, I plan to seal it in an envelope and lock it in my safe. I suspect it will be an important piece of evidence in the near future."
Cathy ignored the jab and focused on the slip of paper in front of her. Little by little, like a child peeking between her fingers at a scary movie, she let her eyes move across the prescription. The top line carried the notation "Milton Nix (DOB 6-29-57)." Cathy's NPI number was handwritten in the space at the bottom right. One refill was authorized. An X appeared in the box for "generic may be dispensed." Her signature at the bottom left no doubt about who had written the prescription: Catherine Sewell, MD.
When she could no longer put it off, Cathy directed her gaze to the body of the prescription. As with all her prescriptions, the information was printed in a bold hand.
DIGOXIN TABS 0.25 mg
DISP: [# 30]
SIG: 2 TABS Q DAY
Two tablets a day of a medication twice as strong as was needed. Milton Nix would be taking four times the normal dose of the heart medication. It looked like her printing. It looked like her signature. But then she realized what was wrong, and she knew this wasn't the prescription she'd written for Milton Nix in her office.
Maybe she wasn't losing her mind. Maybe someone really was out to get her. And they'd almost killed Nix in the process.