When Cathy opened the door to the exam room, she thought the woman sitting there would be what one might get after a call to central casting to order up a bank executive. Modelthin, perfectly done makeup, straight black hair cut short and expertly styled. The woman wore a tailored Gucci suit. Glasses with frames by a name designer did little to hide calculating green eyes. No doubt about it. Ella Mae Mercer's presence was intimidating.
"Ms. Mercer? I'm Dr. Cathy Sewell. How can I help you?"
The woman rose gracefully from the straight chair in the corner of the examining room, unfolding her thin frame like a carpenter's rule and extending a hand with rings on three fingers. "Please, it's Ella Mae. I feel as though I've known you for ages, after hearing all about you from your father."
"That's nice to know. And let me thank you for what you've arranged about paying for the damage to my car."
Ella Mae waved offthe thanks as though it were a fly."Don't make me out to be altruistic. Will made it plain to me that if I couldn't make this work, he was prepared to file suit against both the bank and the insurance company. And, unfortunately, I could see that we were at fault."
"I still appreciate what you did. How did you make it work out?"
Ella Mae ticked offthe points on her manicured fingers."I was able to convince your insurance company that, if Will filed suit against them, they might end up being liable for the whole amount. After all, they'd failed to notify you in a timely fashion that you were into the grace period. Of course, I conveniently neglected to remind them that the initial error was ours."
"But that's-"
"It's called business, dear. Anyway, we carry liability coverage, and I was able to negotiate a settlement where our insurance carrier would share the burden. Long story short, you'll get two checks that will cover the damages. You'll sign a waiver, and everyone's happy." She shrugged. "Besides, I owed Will a favor."
Cathy's first impulse was to follow up on that remark. Had Will dated this woman? Was he still seeing her? And why should Cathy care, anyway? But she found that she did. Nevertheless, she moved on with her questions.
The new patient history form showed a chief complaint of "prescription refill." Cathy's eyes strayed over the rest of the form. Medications? Just a few: vitamins, hormones, and a commonly prescribed tranquilizer. One guess which of those Ella Mae wanted refilled.
"So how can I help you?" Cathy asked.
"I'm looking for a family doctor, and I believe I'd be more comfortable with a female, especially one who seems young enough to be knowledgeable about modern techniques."
"Fair enough. Can we ask your previous doctor for copies of your medical records? That way, I won't repeat tests needlessly, and it will help me get a better feel for your general health."
The temperature in the room seemed to drop. "No, let's start fresh."
"Why?"
Ella Mae ignored the question, and Cathy decided this woman was an old hand at the maneuver. "Why don't we do this? I'll make an appointment to come back for a full physical examination, including all the tests you might want, but it will have to be in a couple of weeks. This is a hectic time at the bank right now. That's one reason I'm here today. I need a new prescription for this." She held out an empty amber pill bottle bearing a label from a pharmacy in a neighboring town. "I haven't taken them in some time, but in the past they've helped me through some stressful periods, and I need them right now."
Cathy turned the bottle slowly in her hands, recognizing the name of the tranquilizer Ella Mae had listed among her medications. "I'm hesitant to prescribe these without any knowledge of your medical status, Ms. Mercer."
"Oh, don't give me the doctor-speak." Ella Mae's smile was obviously meant to take any sting out of the words. "I know that these are commonly prescribed, there are few if any contraindications to their proper use, they don't interact with the hormones and vitamins I take, and they're metabolized by the liver." She gestured at her spare frame. "I don't drink. I don't do drugs. And do I look like someone in liver failure? See any bulging belly? Are the whites of my eyes jaundiced?"
Cathy resisted the urge to argue. The woman was probably right. There really wasn't any medical contraindication to giving her a reasonable number of the pills, contingent on her return for a full physical within a couple of weeks. And Ella Mae had been more than helpful in resolving Cathy's problem with the insurance company. Cathy's mentor during her family practice residency had been clear about what to do at a time like this-a time when it wasn't prudent to put up a large fight to win a small battle.
Without further argument, Cathy reached for a prescription pad and carefully wrote out the prescription. "I'm giving you two weeks' worth. That's enough to allow you time to schedule a full physical examination. And please call if you experience any untoward side effects."
"May I have that bottle back? I use the empty ones to hold buttons."
After Ella Mae left, Cathy stood leaning against the examining table for a long moment. The woman didn't strike her as the type who saved buttons. No, she wanted that bottle back because she didn't want anyone else to see the information on it. But what had startled Cathy wasn't the name of the medication, nor the fact that Ella Mae had driven to the next town to have the prescription filled. What got Cathy's attention was the name of the prescribing doctor: Nolan Sewell.
Josh leaned forward in his chair and said, "Let's talk about what brought you back to Dainger."
Cathy squirmed, not because her own chair was uncomfortable, but because Josh's question brought back unpleasant memories. It was as though someone had given an extra tug at the shroud of depression that had been wrapped about her for the past several months. She reached for the carafe and tumbler on the end table, poured half a glass, and drank.
"Take your time." Josh appeared in no hurry, but apparently this was the direction their session would take today, and no amount of stalling would change that. "Tell me about Bob."
"Robert," Cathy corrected automatically. "Robert Edward Newell. Never Bob. Bob would be common, and Robert would rather die than be common." She swallowed. "Robert's a year older than me. We met when he was in the last year of an ophthalmology residency. I was completing my family practice training. We were at Parkland Hospital at the same time. I fell for him immediately. He was absolutely charming. His family had money, and the way he dressed and acted showed it. He was sophisticated and self-assured. I felt… I don't know. I guess I felt secure with him."
"And you became engaged."
"Yes. It seemed like love at first sight. We decided to get married in July, after we finished our residencies. He planned to set up a practice in Dallas and draw from the upper crust in Highland Park. I was slated to join a multispecialty group in North Dallas, but then I got an invitation to stay on at the medical school as Assistant Professor in the Family Practice Department."
"How did Robert feel about that?"
"He was thrilled. A wife on the med school faculty. A society practice. It was perfect for him."
"So what changed your mind?"
Cathy thought back to that day, and she felt her stomach clench like a fist. "Robert wanted me to move in with him. At first I was naive enough to think he just wanted me to save money on rent, but he had more in mind than that. I said no."
"Why?"
"Guilt? Fear? I'm not sure. My parents made sure I attended church as a child, and I guess a lot of it rubbed off on me. It didn't seem right. But more than that, I didn't want sex to be the only reason we were together. I couldn't let our marriage start out that way."
"How did he react?" Josh asked.
"I thought he accepted it. In retrospect, maybe he just made other plans."
Josh displayed a perfect poker face. No judgment, no taking sides. His expression invited her to continue.
"One night I dropped by Robert's apartment unannounced. I'd had a wonderful day and wanted to share the stories with him. I rang the doorbell, but there was no answer. His car was outside, so I knew he was home. I rang again. Then I knocked… knocked again… and again. Finally the door opened." She squeezed her eyes shut, but the film continued to run in the projector of her mind. "But it wasn't Robert. It was Carrie, one of the nurses in the Parkland operating room. She had on the robe I'd given Robert for Christmas. Her hair was a mess, her lipstick smeared. I barged past her and saw Robert coming out of the bedroom, buttoning his shirt."
"And?"
Cathy opened her eyes and looked at Josh. "He said, 'This isn't what you think.' But it was. I knew exactly what it was."
Josh nodded a fraction of an inch.
Cathy finished the water in her glass. "I pulled offmy engagement ring and threw it on the floor. Then I went back to my apartment and cried all night. The next morning I went to the head of the family practice department and told him I couldn't stay in Dallas."
"Did you hear from Robert?"
"He called, but I wouldn't answer. He sent me flowers, and I threw them in the garbage. He wrote letters, but I wrote 'Return to Sender' on the envelopes and dropped them back in the mail."
Cathy leaned back, exhausted. Why did Josh insist on dragging out all these hurtful memories? Her father, Carter, Robert. She tried to make her mind go blank. She wanted to escape, but instead the synapses clicked to make the awful connection. Self-assured, larger than life, someone she could depend on. And they'd let her down. Every one of them.
She looked up at Josh, and it was as though he could read her mind-see the way she'd connected the dots.
He uncrossed his legs and stood. "Think about that. I'll see you next week."
Cathy was surprised at the name on the chart of the next patient. Could this be Dr. Gladstone's wife? Cathy always got a bit antsy when treating the family of another doctor. There was a saying in medicine: complications only happen to nice patients and doctors' families. She hoped it wouldn't hold true here. She took a deep breath and opened the door to the treatment room. "Mrs. Gladstone, it's a pleasure to meet you. How may I help you?"
The older woman sitting in the patient chair beside the examination table was plainly but neatly dressed. Her silver hair was perfectly styled. The lenses of her rimless glasses had a slight pink tint, but that didn't hide the worry in her eyes.
"I've been having some female problems. Dr. Baker has been my doctor for years, but he doesn't do any gynecology. Besides that… " She managed to look both demure and embarrassed. "Besides that, I've always thought I'd be more comfortable with a woman doctor."
Cathy was a bit unsettled that her gender apparently had figured into the decision more than her professional abilities. Nevertheless, she simply nodded and began taking Mrs. Gladstone's history. "Why don't you tell me specifically what symptoms you've been having and when they started?"
Just then, Jane tapped on the open door. "Excuse me, Doctor, but you have an emergency call."
Cathy excused herself and hurried to her office. She punched the blinking button on her phone. "Dr. Sewell."
"Doctor, this is Glenna Dunn in the ER. Your patient, Milton Nix, is here. He's complaining of weakness and nausea. His pulse is irregular, and his blood pressure is all over the place."
Cathy's mind kicked into full diagnostic mode. This could represent any one of several things, some of them extremely serious. "Draw blood for electrolytes, sugar, BUN. And get a digitalis level. Do an EKG. I'm on my way."
On her way back to the exam room, Cathy asked Jane to get Milton Nix's chart for her. "Mrs. Gladstone, I'm terribly sorry. I have an emergency. Would you like to wait, or can we reschedule your visit?"
"It's all right. I quite understand about emergencies. You'll never know how many dinners I've eaten alone because of them. It will be fine to-"
"Jane," Cathy called. "Would you schedule Mrs. Gladstone back as soon as possible? Tomorrow if it works for her. A new patient exam including a pelvic. I have to go."
In less than five minutes, Cathy strode into the ER of Summers County General Hospital. A nurse intercepted her and introduced herself as Glenna Dunn. "He's in here," she said, directing Cathy into Treatment Room One. Cathy hesitated at the door, recalling the last time she'd been in this room. But this time she was in charge.
Milton Nix lay sweating on a gurney, his shirt off. An IV ran in his right arm, and a blood pressure cuffencircled his left. A cardiac monitor above his head showed a green line of complexes racing across the screen.
A buxom bottle-blonde, presumably Nix's wife, leaned over him, fanning him with a magazine. She was younger than her husband, but makeup and expensive clothes made it difficult for Cathy to tell just how much. She guessed there'd been a number of nips and tucks in the woman's past.
"Mr. Nix, tell me about it." Cathy took the clipboard from Glenna and scanned the scant information. "When did you get sick? What are you feeling?"
Mrs. Nix opened her mouth, but Nix silenced her with a look. "I've been offmy feed for a week or so," he said. "No appetite. Food didn't taste good. Today I vomited several times. And I seem to be getting weaker all the time."
"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.