Code Blue

by Richard MD Mabry

  "Dr. Sewell, are you prepared to assist me?" Arthur Harshman's tone implied that he was as likely to get help from a trained baboon as from this upstart family practice doctor.

  Cathy forced a smile. "Absolutely. May I go in and say hello to the Gladstones?"

  Harshman waved her request away as though he were shooing a particularly pesky fly. "I suppose so, but be quick.I've already spoken with them. I answered her questions, the permit's signed, and Ernest knows that I don't want him in the operating room looking over my shoulder. Don't do anything that might cause problems."

  Emma Gladstone lay on a gurney in the pre-op holding area. Her husband stood at her side, holding her hand and occasionally smoothing her hair. They both turned when Cathy slipped between the curtains that gave them the limited amount of privacy available in that setting.

  "Mrs. Gladstone, I just wanted you to know that I'm here.Is there anything I can do for you?"

  "Yes, dear. Will you pray with us? I think I'd feel much better if you did." Her reply so nonplussed Cathy that it took her a moment to process it.

  To Cathy's surprise, Dr. Gladstone nodded at his wife's request. In Cathy's home, her father's praying had been confined to a rote-memorized grace that he said at mealtimes, primarily, she suspected, to appease her mother. In her residency Cathy had encountered a few doctors who mentioned that they prayed before every operation, but like her colleagues she'd tended to dismiss them as a rather unusual minority in the profession.

  "I . . . I suppose so," Cathy stammered.

  "Ernest, will you pray first? Then Dr. Sewell can pray."Emma reached out her other hand, careful not to put traction on the IV taped to it, and grasped Cathy's hand.

  Dr. Gladstone cleared his throat. "Dear God, I love this woman. She's good and kind and the most caring person ever to walk this earth. Please carry her through this procedure safely. Give her the grace to tolerate whatever comes afterward, and help me be the kind of husband and helper she deserves." There was a moment of silence. Then Gladstone murmured, "And give skill and discernment to Arthur, Cathy, and all those who help them. In your name, Amen."

  Cathy was so startled by Dr. Gladstone's use of her first name that it took a gentle squeeze from Emma for her to stammer out her own prayer. "God, please help all of us through this. Help me to do my very best and to be worthy of the trust of these people. Amen."

  11

  MORE TRACTION." HARSHMAN TAPPED THE RETRACTOR WITH THE hemostat in his hand. "I need to see right here."

  Cathy pulled a bit harder. She'd bent over the operating table opposite the surgeon for over two hours and could hardly bear the pain in her back. Her head throbbed with every movement she made. The air conditioning in the operating room didn't come close to overcoming the heat from the high-intensity lights that glared down on the surgical field, and a constant stream of sweat trickled down her back.

  Cathy decided she had to risk the surgeon's wrath. She flexed her shoulders, even though it meant a momentary easing of the pressure she held on the retractor.

  "You're doing a nice job," she ventured.

  "I should hope so," he grumbled. "I've done dozens of these." He dropped a clamp onto the instrument tray. He straightened, took a deep breath, and used a gauze square to blot blood from the surgical area. "Did a fellowship in gynecologic oncology at M.D. Anderson. Some of us live in Dainger because the pace is slower, and we like the town. Not all of us here are incompetent old coots who couldn't make it in a larger medical center."

  Cathy realized she'd made exactly that assumption about Harshman. "I'm sorry. I—"

  Harshman tapped on the retractor with his finger, "Take that out now. I think the self-retaining retractor will be enough at this point." Then, like a flashback to her days as a resident, Harshman asked, "What's the most critical part of the operation to this point?"

  Cathy gave the answer automatically. "Avoiding damage to the ureter or bladder."

  "Have I come close to cutting either one?"

  "No. No, you haven't."

  "Good. Do you think you could have done this operation?"

  Cathy considered that for a moment. She'd known most of the steps, but there were a few points where she wasn't sure where Harshman's next cut would be, while his movements never appeared to be anything less than sure and certain. "No, I don't think so."

  "Do you think you deserve privileges to do a modified radical hysterectomy?"

  "Dr. Harshman, I never asked for anything like that. I recognize that I'm a family practitioner, and I'm proud of it.But, if you'd read the letters I presented to the committee you'd know that I had a great deal of exposure to obstetrics and gynecology during my FP residency. Actually, I originally planned to go into OB-Gyn, but I changed my mind.What I want now are privileges to perform deliveries. You'll notice that I didn't ask for C-section privileges, even though I've had the training. I recognize that there are competent obstetricians available in town, and they should be doing those cases. I'm not about to steal your patients. I only want to offer more complete care to my patients, especially the women, many of whom would prefer a female physician."

  She saw Harshman's mask move as he opened his mouth to respond, but that response never came.

  A nurse holding a phone message slip hurried into the room. "Dr. Harshman, your OB patient, Karen Pearson, is in the emergency room. She's cramping and spotting. What do you want to do?"

  For a moment, Cathy thought Harshman hadn't heard.He picked a pair of blunt-nosed scissors offthe instrument tray beside him and began dissecting in the depths of the operative site.

  Just as Cathy was about to speak, Harshman looked up from his work. "I know you've seen her, Dr. Sewell. You know about her case. Now she's at term and she's bleeding.The baby's a breech, so I'd scheduled her for a C-section.What would you do?"

  "Is there any sign of fetal distress?"

  The nurse didn't seem to know whom to address, so she swiveled her gaze between the two surgeons. "Fetal heart tones were one fifty when she came in. They've dropped to one ten."

  Cathy didn't hesitate. "This could be an abruptio placenta or a prolapsed cord. Whatever the cause, there's definite fetal distress. She should have a stat C-section."

  Harshman nodded once, then turned to the nurse. "I can't leave this patient. Is Dr. Gaines available?"

  "He had to drive to the hospital in Bridgeport to handle an emergency there." The nurse didn't throw up her hands, but her voice conveyed the same message.

  "Cathy, how many C-sections have you done as surgeon?"

  "More than half a dozen—fewer than a dozen. And I've watched and assisted on maybe ten more."

  "Contact Dr. Steel," Harshman told the nurse. "Tell him I need him to scrub up and assist me in finishing this case.Then call Dr. Bell. He'll have to scrub with Dr. Sewell. She'll be doing an emergency C-section on Mrs. Pearson."

  Cathy bent over the hospital bed, struggling to make her voice comforting and confident at the same time. "Karen, you need an urgent C-section. The baby is in trouble. Dr.Harshman's in surgery and can't drop out. He's asked me to do it. The nurse has told you what it involves, the risks involved. Will you give me permission to do the case?"

  Karen Pearson looked up at Cathy. Despite her grimace of pain, there was serenity in her eyes. "Of course. I've been praying that you'd deliver my baby. I didn't really want it to be an emergency, but if that's what it takes, I'm okay."

  Cathy nodded to the nurse who stood at the head of Karen's bed. "As soon as the permit's signed, get her up to surgery." She looked down at Karen again. "I'll do my best for you."

  "That's all anyone can ever do," Karen said through clenched teeth. "Remember that."

  In the women's dressing room, Cathy exchanged her sweat-sodden scrub suit for a clean one. By the time she strode into the pre-op holding area, the anesthesiologist had wheeled Karen into the operating room. He turned and asked, "Epidural or general?"

  Cathy didn't hesitate. "No time for an epidural. General. I want h
er under the moment I'm gowned and ready."

  Marcus Bell hurried up, pulling on a surgical cap. He picked a mask out of the box above the scrub sink. "Fill me in. All I know is that you're doing an emergency C-section on one of Arthur Harshman's patients at his request, and you need me to assist."

  Cathy adjusted her own mask and began the scrubbing up process that numerous repetitions had made automatic.She explained the situation to Marcus, who, to his credit, listened without interruption or argument.

  "When was the last C-section you did?" he asked, when Cathy had finished her explanation.

  "Not quite a year ago."

  "That's about five years ahead of me. Do you recall all the details?"

  She replied with more assurance than she felt. "I know enough. Between us, we'll get through it. We have to. That woman's baby is struggling—fetal heart tones down to ninety now—and we have to get her delivered."

  This was it. Go time. Cathy looked around her. The anesthesiologist stood by at the head of the operating table. Dr.Denny, the pediatrician, sat in a corner, ready to take the baby. Marcus took his place across from Cathy, his eyes conveying no message at all. Karen lay on the operating table, her bulging belly tinted a strange orange-brown by the prep solution and outlined in a surreal square by the green draping sheet.

  "Everybody ready?" Cathy paused. "Karen, we'll take good care of you and your baby. I promise." She nodded at the anesthesiologist. "Let's go."

  In a few moments, Karen was under. The clock had started to run. Cathy had less than ten minutes to get the baby.

  "Fetal heart rate?" she asked.

  "Holding at a hundred."

  Cathy had a decision to make. Did she have time to make a low "bikini" incision across Karen's abdomen or should she save precious minutes by using the long vertical incision employed years ago? Cosmetic result or safety for the baby? Plastic surgery could minimize scars. If she were on that table, she'd say, "Hurry. Save my baby."

  She reached out her hand. The scrub nurse slapped a scalpel into it. "Vertical incision." Cathy fixed Marcus with a look that she hoped carried the authority she didn't feel."Get a sponge in one hand, cautery in the other, keep up with the bleeding."

  "But —"

  Cathy's eyes dropped to the operative field. "Marcus, I have a reason for everything I do, but I don't have time to explain. I'm the surgeon. Help me. That's what assistants do."

  he plunged the scalpel into the taut flesh of Karen's abdomen. As layer after layer yielded to her dissection, SCathy wondered if her words had offended Marcus. She was surprised to realize that she didn't care. Her priority right now was to do what was best for Karen Pearson and her baby. She'd worry about her relationship with Marcus and all the other doctors on the stafflater. If practicing good medicine and putting the patient first got her ridden out of Dainger on a rail, so be it.

  "Down to the uterus. Let's get a self-retaining retractor in."

  As he had since her initial exchange with him, Marcus complied without comment. To his credit, he'd been an excellent assistant, anticipating her moves and working in smooth tandem with her.

  "I'll make a low fundal incision, then extend it with scissors.The presentation's a footling breech. I know how to do the extraction, but I'll need a second set of hands to do it."

  She sent a look at Marcus. He nodded once.

  "Fetal heart rate has dropped to eighty-five."

  "Here we go," Cathy responded.

  Cathy let reflexes, muscle memory, and hours of midnight study take over. In seconds, the uterus was open, the amniotic sac incised, and she reached for the baby. "Dr.Denny, are you ready?"

  The pediatrician moved closer to the table. "All set."

  The information flashed through Cathy's mind like the words on an electric sign. The largest part of a baby is the head. For a C-section, make the incision big enough to deliver the head and there's no problem with the rest. In this case, the baby's legs would come out first, the head last.She'd have to guess at the incision size. Halfway through the extraction, Cathy saw that her incision hadn't been large enough. "Scissors." She held out her hand, palm up, and felt the firm slap of the instrument.

  "Do you—?"

  Her eyes never left the operative field. "Marcus, I know what I'm doing."

  "Fetal heart rate is eighty."

  The words spurred Cathy on. She dropped the scissors and slid her hand down along the baby's head. Words memorized by rote now were turned into action. Hand onto the face, finger in the mouth. Turn a bit. "A little more traction on the legs please."

  There! The baby was free. And there it was—a prolapsed umbilical cord, a kink that cut offthe blood supply from mother to child. Cathy clamped and cut the cord and handed the baby offto the pediatrician.

  As she worked to complete the procedure, her ears waited for that most wonderful of sounds, the cry of a newborn.There was the gurgle of the suction bulb as Dr. Denny cleared the baby's mouth and nose. A moment of silence, then more suctioning. She was aware of murmuring between the pediatrician and the nurse assisting him. As Cathy was about to turn back toward the bassinet, she heard it. Faint at first, then stronger. The insistent cry that signaled a healthy set of lungs.

  "Nice work, Doctor. It's a boy."

  Cathy stood beside Karen Pearson's recovery room bed and watched the woman's eyelids twitch, then open slowly.

  "You and your son are doing fine," Cathy said.

  Karen reached out her hand, wincing as tension on the needle in her wrist pricked her. "Thank you, Dr. Sewell. See, God brought us both through it just fine."

  "I— Thank you, Karen. Now, you get some rest. I need to go help another doctor."

  Cathy shucked out of her surgical gown and hurried to report to Harshman. She paused just inside the door and said, "Mrs. Pearson's doing fine. Footling breech with a cord prolapse. The FHT had dropped to eighty by the time we got the baby out. Healthy little boy."

  "Good. We're almost through here. Dr. Steel's done a fine job assisting," Harshman said.

  Cathy was thinking that he was too polite to add, "Better than you did."

  Instead, Harshman said, "I must admit that I was a bit hesitant to send you offto do that emergency C-section.Glad you got through it."

  "Thank you. Would you like me to tell Dr. Gladstone that everything is going well here?"

  "Yes, please do. I'll be out in about fifteen minutes to talk with him."

  She was halfway through the door when she heard his last words. They stopped her in her tracks.

  "Good job, Cathy."

  The anesthesiologist had said his good-byes and headed for home. Dr. Denny stopped by long enough to change into his street clothes and offer his congratulations on a successful C-section. Now Cathy and Marcus sat in the deserted surgeons' lounge, side by side on the sagging sofa. Their feet rested on a coffee table littered with the detritus left by previous occupants: discarded surgical masks and caps, pink message slips with cryptic scribbling, and pads of hospital progress notes. Cathy sipped from a cup of vile-tasting coffee.She hadn't wanted it, but Marcus had presented it like a peace offering.

  "Thanks for the coffee," Cathy said.

  Marcus nodded. "You're welcome."

  Marcus was obviously walking on eggshells, so Cathy decided to try easing the tension. "I appreciate your scrubbing with me. I couldn't have done it without you."

  "Happy to help, although there wasn't much choice. The case needed to be done stat, and I was probably the most logical candidate to scrub in."

  A thought crossed her mind. "Are you angry that Harshman didn't ask you to do it?"

  The wait before his answer told Cathy what she needed to know. Marcus blew on his coffee, tasted it, and made a face. "I don't really know. I guess my first thought was that I was more qualified to do it than you are. But, as it turned out, I was wrong."

  "You didn't pay any attention to those letters about my qualifications, did you?" She felt the anger boiling up.Maybe it was time to get all th
is out in the open. "You know, you're just like the other men on the committee. You had your mind made up before that meeting that I would have the same privileges as every GP who's practiced in Dainger since the hospital opened. Never mind that I'm a residencytrained, board-certified family practitioner with undeniable qualifications and excellent recommendations. It was a foregone conclusion that, because I'm a woman, because I grew up here in the shadow of my father—a real doctor—there was no way I could ever be as capable as you men." She put the Styrofoam cup onto the table with enough force to slosh coffee onto everything, wishing it were a china mug so she could slam it down.

  Marcus tossed his half-full cup into the trash. "No, no. I know you're qualified. It's just that I have to remain neutral in these things. If I take a side, I automatically end up with half the doctors on the staffmad at me."

  Cathy rose and bent down until she was almost noseto-nose with Marcus. "And that's why you didn't want me to speak up at the credentials meeting. And why you didn't vote. You were unwilling to risk making someone on the committee mad. This way, the only person you disappointed was me. And you figured you could make that up by taking me out to dinner. Is that my price? A nice dinner? I'm insulted. Even Judas got more than that!"

  Marcus was still talking when Cathy turned and stalked into the women's dressing room. She tried to slam the door behind her, but the automatic closer thwarted her efforts, easing it closed with a soft whoosh. Oh, well. She figured this wouldn't be the last time she had some strong words for Dr. Marcus Bell. Next time, she'd make her exit a bit more emphatic.

  12