Medical Error pft-2

by Richard L Mabry

  "And you think someone got into your purse and stole your credit card information. Maybe got your DEA number off the ID card you carry." Nick pulled out his wallet and flipped through the plastic holders until he came to a small folded blueand-white card headed Controlled Substance Registration Certificate. "Do you carry yours in your wallet?"

  "I do, but probably for a different reason than you do. I'll bet you don't write many prescriptions."

  Nick nodded assent. "Not as a pathologist, no. Just occasionally, for friends or family."

  "Have you ever written for a controlled substance?"

  "One of my buddies wrenched his knee last Friday afternoon playing football. I wrote him for enough Tylenol with codeine to carry him through the weekend until he could see his regular doctor." Nick made the connection quickly. "And I had to look in my wallet to check my DEA number."

  "Right. On the other hand, I write prescriptions all day, and I have my number memorized."

  "Do you carry your card?" Nick asked.

  "I do, but for a different reason. I don't want it lying around where someone could get hold of it. I always thought it was safest to have it in my purse." Anna wadded up her napkin and shoved it into her empty glass. "Guess I was wrong."

  7

  Asthough in response to some unheard signal, the cafeteria began to empty. Office workers sighed and marched back to their desks. Doctors gulped their lunches and headed for surgery or clinics. Medical students snatched up their books and drifted out in groups of two and three, trading stories of terrible lecturers and fascinating patients.

  Anna looked at her watch. "I should go." She pushed back her chair and grabbed her purse.

  "What's on your agenda for this afternoon?" Nick asked.

  Anna wasn't sure she had a firm plan. And if she did, should she share it with anybody? Even Nick?

  "I smell rubber burning." Nick grinned. "Does it require that much thought to tell me what you're up to?"

  "Sorry." She created interlocking rings with the condensate on the bottom of her empty glass. "I'm not sure I have a plan, other than to snoop around and hope I can recognize a clue if I stumble across it."

  "Not much of a plan, but better than nothing I guess," Nick said. "How about dinner later tonight?"

  Anna gave him full marks for persistence, but tonight she wanted to be alone. She moved aside a stray strand of hair. "Sorry, Nick. Really, all I want is to pick up some fast food on my way home, sink into a bubble bath, and fall asleep reading the book that's been on my bedside table for a month."

  Nick nodded his understanding. "So, tomorrow?" He paused."No, wait. That's Saturday. I'm covering pathology tomorrow, and I don't want to interrupt our time together if I get called back. Sunday?"

  Anna felt the shadow of an idea form. The more she thought about it, the more she liked it. What could it hurt to ask?

  "Is the question too hard for you?" Nick asked. "Need to check your Palm Pilot? Trying to decide if we can be alone without a chaperone?"

  "No," Anna said. "Just thinking. Sunday would be fine. What did you have in mind?"

  "That's usually my only day to sleep in. How about brunch? Then we can play it by ear. A movie, walk around in the West End, maybe go out to the Arboretum?"

  Anna tried to hide her grin, but was afraid it showed in her eyes, if not on her lips. "Are you flexible about those plans?"

  "Sure. What do you suggest?"

  "Come by my apartment about ten-thirty Sunday morning. Go to church with me. Then we can have lunch and decide how we'll spend the rest of the day."

  To his credit, Nick only hesitated for a few seconds. "Sure. What's the dress code?"

  "Whatever you're comfortable wearing. Most men wear sport shirts. There are some in jeans. You'll see a smattering of coats and ties, mainly the older members."

  "What about you?"

  She grinned. "I'll be wearing a dress, but I don't think that's a good look for you. I'd stick with a sport shirt and slacks."

  Anna stood in the doorway to the outer office and watched her administrative assistant, Lisa, pound the keys of her computer into submission. Surely by now rumors of all kinds circulated through the department. Although Lisa had already voiced her support, Anna's stomach did a flip- flop as she wondered what kind of reception she'd get from others on the staff.

  Lisa's smile seemed genuine. "Dr. McIntyre. It's good to see you. Are you back at work now?"

  Anna forced a smile in return. "No, just here to clean out my mail and check my messages. I'm going to close my door. Buzz me on the intercom if it's urgent. Otherwise, pretend I'm not here."

  Safely hidden in her office, Anna shoved her purse into a desk drawer and covered it with a file folder. Did that make it safer from prying eyes and searching hands? She grimaced as she realized how ineffective her attempts at security had been in the past. Then again, old habits die hard.

  Anna tossed her white coat onto the chair on the other side of her desk and dropped into her swivel chair. Next she heeled offher shoes and shoved them under the kneehole of the desk where she could slip them back on if someone came in. She leaned back, ran her fingers through her hair, and willed her shoulder muscles to relax. M amp;M was over. One hurdle down, lots more to go.

  The always-efficient Lisa had her mail and messages sorted into neat piles centered on her blotter. Anna started by signing operative reports, summaries, and professional letters. Then came the patient information: tissue reports, lab and X-ray, referral summaries. She initialed them all and dictated a few chart notes and instructions for Lisa to pass on to her clinic nurse. The ease with which she'd been able to slip back into her professional persona and forget her other problems didn't surprise her. Her colleagues often kidded that Anna wouldn't notice the start of World War III if she were struggling with a diagnostic problem.

  When she was satisfied she'd dealt with the most urgent matters, Anna slipped her feet into her shoes and opened the office door. "Lisa, I'm going down to the break room to get a soft drink. May I bring you something?"

  "Oh, no thank you. I was just there for some coffee." Lisa gestured to the Styrofoam cup on her desk.

  Anna, like all the other faculty members, generally left her office door open, assuming that her administrative assistant would be at her desk to guard against unwanted visitors. Now Anna saw the fallacy in that assumption. The assistants were away from their desks several times a day: coffee, restroom breaks, trips to the supply room, lunch. Anna closed her office door behind her and waited until she heard it click before she left.

  Once she returned to her desk, Diet Coke in hand and shoeless again, Anna decided to tackle her stack of journals before it reached a critical stage and toppled over. She was marking an article with a Post-It note and a scribbled reminder when she heard noise in the outer office. Voices chattered in the hall. A file cabinet closed. Anna looked at her watch and nodded a silent understanding of what was going on. The assistants were leaving. No doubt, Lisa was even now retrieving her purse and preparing to make a quick exit.

  Even though they didn't punch a time clock, the administrative assistants came and went with a regularity that was unwavering: In the office by eight a.m. Half an hour for lunch in staggered shifts, with the phones always forwarded for uninterrupted coverage. Out the door by four-thirty. In another ten minutes or so, all the department offices would be empty.

  By quarter to five Anna should have the whole department to herself. Then she could nose around the offices without interruption or the need for explanation. She wasn't sure what she'd find, or even what she was looking for, but she was determined to try. She dawdled at her desk for another fifteen minutes, and when she emerged the office staffers were long gone. Of course, the doctors were still in clinic or the operating room and would be for another hour or more. The cleaning people wouldn't come in until later. Now was the time for Sherlock McIntyre to prowl. Anna wished she had Nick, her own private Watson, at her side so she could bounce ideas offof him. That is
, if she had any ideas.

  It wasn't dark, and Anna knew that there were other people in the building, but still the deserted hallways and offices felt creepy as she wandered systematically through them. Nothing struck her. No one came by and whispered, "I stole your personal information." She had no inspirations. Maybe this detecting was more difficult than it seemed on TV.

  Then Anna glanced into the office complex shared by two doctors, Joe Leach and Allen McClay. The outer office was vacant, and their assistant's desk was unoccupied. Dr. McClay's office door was closed, but the door to Dr. Leach's inner office was open. Anna was sure both those doors had been closed when she walked by earlier. She edged into the outer office.

  Through the open door of Dr. Leach's office, she heard drawers opening and closing. Someone was in there. Maybe Leach had finished his surgery and was rummaging for something in his always disorganized files. She tiptoed closer just as her chairman, Neil Fowler, emerged from the office with a file folder tucked under his arm. He closed and locked the door before he looked up and saw Anna.

  If he was startled, Fowler didn't show it. "Hi, Anna. I thought things went fairly well at M amp;M, didn't you? I hope you don't think I was cutting you off, but I was afraid that Linda was about to launch into a harangue on how they used to do things in Boston, and I didn't want to give her a chance."

  Anna knew she should probably agree and move on. Don't take a chance on antagonizing the chairman. But instead, she said, "Dr. Fowler, what were you doing in Joe's office?"

  Fowler held up the file folder. "I needed some of the data he's collecting for a paper we're writing together."

  "But how did you get in? I passed by here earlier and his door was locked."

  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 g
ets 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.

  "Let me look at a couple more sections, but I think I've got something for you."

  "Is there a malignancy in those nodes?" Frank asked.

  "Nothing that I've seen. Let me ask you. What did this kid's chest X-ray look like?"

  "Nothing special," Frank said. "One radiologist thought his hilar nodes were prominent, another one said it wasn't anything."

  "Did you do a serum calcium?"

  "I don't recall. Probably. We did a full chem panel." There was a pause and the sound of voices in the background. "Read those numbers offto me, would you?" Another pause. "Say that again?"