Fertility: A Novel (3 page)

“That seems to be an efficient system. What if you had scanned in the wrong drug or the wrong dose?” Sarah asked.

“So glad you asked. Let me demonstrate how the system is set up to deal with those types of errors.”

The head pharmacist went through the same steps with the next incoming script, Furosemide, 20 mg, for an eighty-two-year-old male on Seven West. She intentionally retrieved Furosemide, 40 mg, from the bottom of unit six of the open shelving. When she scanned the bar code for the incorrect dosage, the computer gave an error message in a large, red font.

“So you see, the computer will not print out a label for an incorrect dosage. It’s as close to foolproof as a system can be,” Marsh said, quietly triumphant and delighted with the system she had personally championed with the hospital brass.

“I see,” Sarah said, reserving judgment. She’d been working on malpractice cases long enough to know that first appearances rarely told the whole story. Without a systematic investigation into what had happened fourteen hours earlier, Sarah would not be so quick to absolve the pharmacy of responsibility. “Thank you for showing me how your system works. It will help me as I conduct my interviews today.”

“I’m glad I can be of help in the investigation. Don’t hesitate to call if you have any questions.”

Sarah thanked Marsh again and walked quickly out the staff door to the corridor. She trotted down the hallway and skipped the elevator in favor of the stairs, hoping to have a few minutes to herself before her first interview.

CHAPTER FIVE

Sarah could feel the blood pulsing through her body when she returned to the conference room at 9:20. She had missed her morning swim, and the bit of exercise provided by the seven flights of stairs felt good. She jotted down a list of general, open-ended questions that would give the baby’s nurse the opportunity to tell her story. Doris Ostrom, the stenographer, nodded her readiness when they heard the knock on the door.

Sarah left her seat at the head of the long conference table and welcomed Joyce Hilker in, showing her to a seat kitty-corner to her own. She introduced herself and Doris and indicated that the interview would be digitally recorded, as well as transcribed. She started the recorder, stating who was present, the date and time of the interview and its purpose.

“Thank you for coming in, Ms. Hilker. I understand you were on duty last night and I know this is likely a scheduled day off for you.”

“Yes. I’m actually supposed to be off today and tomorrow. But I understand this has to be done — this interview, I mean.”

“We’ll try to get through this as quickly as possible so you can have the rest of the day to yourself.” Then Sarah gave her standard explanation for hospital employees being questioned after a medical error. “You understand that I represent the hospital. You, as its employee, are legally an agent of the hospital. So we are essentially on the same side — which is trying to discover the events that led to the overdose of the Arkin infant.”

The attractive — albeit tired-looking — middle-aged, blond, blue-eyed woman inhaled audibly and her cheeks reddened. Sarah wondered if she was going to break down. The nurse seemed to have a gentleness that Sarah hoped was something of a bona fide occupational qualification — a BFOQ in legalese — for the job of nursing. As Joyce Hilker struggled to compose herself, she said, “Of course. Everyone wants to figure this out.”

“Okay then, we’ll get started. Ms. Hilker, what were your duties yesterday, November tenth, in regard to the infant girl, Ariel Arkin?”

Hilker shifted in her seat as she began. “The baby girl was admitted to the floor from the ER around 3:45. I generally work a nine-hour shift, including a meal break. Given my hour commute each way, at my age that’s about all I can reasonably handle. I was originally scheduled to work until four, but the charge nurse, Jeannie Lopez, asked if I could add another shift — or at least half a shift — because we were down a few nurses. Some people had called in sick. I felt bad for Jeannie. She was up against it; we had a lot of very ill children on the floor yesterday. And my own kids are grown — both in college now. My husband can make a meal for himself. And we can certainly use the extra money…,” she hesitated for a moment, “…so I agreed to work until nine. I was assigned to the Arkin baby when she came up on the floor from the ER. That made her my seventh patient.”

Sarah broke in. “How many patients do you usually care for?”

“Ideally, I care for four or five. But we rarely have ideal conditions with the nursing shortage that everyone — not just this hospital — is experiencing. So I’d say six is my usual patient load.”

“Thank you. Please continue.”

“The baby was put in isolation because it had not yet been determined whether her staph infection was drug resistant. I used universal precautions, introduced myself to the baby’s parents and got her vitals, just as Dr. Smith came into the room.”

Sarah interrupted her again. “Excuse me. Could you define ‘universal precautions’?”

“Oh, I’m sorry,” the nurse said. “I put on a gown and gloves that are removed when leaving the patient’s room and disposed of in a special container for medical waste. The goal is to limit other patients’ exposure to pathogens as doctors and nurses go from patient to patient.”

“And do you recall what the baby’s vital signs were?” Sarah asked.

“I don’t recall exactly, but she had a temp and her heart rate was slightly elevated. I’d have to look at her chart to give you the exact information.”

Sarah once again thanked Hilker and asked her to continue.

“As I was saying, Dr. Smith — he’s a pediatric intensive care fellow — came into the room. He, too, was gowned and gloved as he examined the baby. When he took off the diaper and undershirt you could see the pus-filled lesions typical of an advanced staph infection. They seemed to originate in the diaper area and were spreading up the baby’s abdomen and back.

“Dr. Smith asked the parents for some history. Apparently the baby had been born at term, two weeks earlier in another hospital. Until — I guess it would be Saturday evening — the baby had had no health problems. The parents said they first noticed what looked like diaper rash on Saturday night. She became very irritable. They spoke with their pediatrician on the phone on Sunday, who recommended they come to the ER and have the baby evaluated.”

“What did Dr. Smith do after examining the infant and getting the baby’s history?” Sarah asked.

“Well, he explained to the parents that the type of infection the baby likely had — community acquired methicillin resistant staph — seems to be on the rise in otherwise healthy newborns. He said they would treat the baby with antibiotics to stop the infection in its tracks — I think that’s the phrase he used. The mother asked how she could continue nursing during the baby’s hospitalization. Dr. Smith explained that she could stay in the hospital with the baby. The mother said the baby had been too fussy to nurse throughout the day, so she was very full with milk — uncomfortably so. The doctor suggested she try again right after he completed his exam. He said if the baby wouldn’t take the breast, the mother could pump her milk. Then we could feed the breast milk to the baby through a nasal tube into her stomach.”

The nurse stopped for a moment, took a drink of water and then continued. “The parents seemed okay with that and then Dr. Smith turned to me. He told me he was ordering clindamycin for the baby, as well as a heparin lock flush. He said he wanted me to monitor how the baby was nursing. In the event that she refused to nurse, I was to get the mother a breast pump. Then he turned back to the parents and asked if they had any questions. They wanted to know how long the baby would be in the hospital. He said it would depend on how she responded to the clindamycin; with luck she could be home in a few days. He also told them he would be on call until midnight and that they should feel free to have him paged at any time.”

“Your ability to recollect the events is very impressive,” Sarah said with a genuine sense of appreciation for the nurse’s memory and cooperation.

“Well, I’ve been going over that scene in my mind all night, trying to get a sense of what could have happened….” Hilker trailed off and looked as though she might lose it again. Sarah asked if she needed a minute, but the nurse shook her head.

“Well, let me see. Just as Dr. Smith was removing his gown and gloves and disinfecting his hands, the mother asked how the baby could have gotten the infection. He said that the origin of the infection in cases like these is often unknown. There are theories as to how a baby can be exposed, but there is no definitive answer.”

They were interrupted by a knock on the door. A tall, good-looking black man dressed in nursing scrubs popped his head into the conference room.

“Hello, is Joyce Hilker in there? I’m her union rep, Cletus Jackson. Joyce has the right to representation in this interview.”

Sarah knew that the union rep was legally correct, that under the Supreme Court’s Weingarten ruling any unionized employee who might face discipline as the result of an interview with her employer had the right to have a union representative present. But Weingarten rights can be waived. The question was, would Hilker do so?

“I need to speak with Joyce before your interview continues,” Jackson stated firmly. It was clear he knew the nurse’s rights as well as Sarah did.

Although she was irked, Sarah showed no hint of her annoyance. “Of course.” She turned to the nurse and said, “Ms. Hilker, as Mr. Jackson states, it is your right to have him present at this interview. You can also waive that right. Would you like a moment to think about it?”

“I’d like to talk with Joyce for a moment so she can make an informed decision — as is her right,” he said to Sarah, emphasizing his last words. Then he turned his attention to the nurse. “Joyce, let’s have a word out in the corridor.” It was more of a command than a suggestion.

The nurse hesitated for a moment and then said to Sarah, “I’d like to confer with Clete. It’ll only take a few moments.” She left the conference room, closing the door behind her. Sarah turned off the recorder and gave Doris a “Who-needed-this?” look.

* * *

When the nurse returned, she had Cletus Jackson at her side. Sarah welcomed him to the table, suggesting that he sit next to Joyce Hilker. He unclipped a pen from his yellow legal pad and got ready to take notes. Sarah turned on the recorder and stated that the nurse’s union representative, Mr. Cletus Jackson, had joined the interview. She hoped the tenor of the interview wouldn’t be critically altered by his presence, all the more so now that they were getting close to the point where the heparin had been introduced to the baby.

Sarah asked Doris to read back the last paragraph of the interview. Doris read the portion of Hilker’s statement about Dr. Smith’s discussion of the unknown origins of staph infections in newborns. That seemed to reorient both Sarah and the nurse. They were ready to proceed.

Sarah asked, “What happened after the doctor’s explanation?”

“He reminded them again that they should feel free to contact him throughout the evening, and then he left to enter the orders for clindamycin and heparin lock flush into the baby’s computerized chart.”

“And what did you do?”

“Well, I asked the mother if she wanted to try nursing the baby. I could tell that she was getting quite uncomfortable. A nursing mother has to nurse — or pump — or she risks getting mastitis. I put a new diaper on the baby and swaddled her in a receiving blanket.

“As the mother opened her blouse and nursing bra, I saw her left breast was quite red — and apparently engorged with milk. I asked her if she had been nursing successfully until the baby became ill. She said she had, but that she usually had more milk than the baby seemed to need. I asked her if I could look at her breast more closely. The father got really jumpy then and asked if there was something wrong. I explained that a nursing mother who couldn’t empty her breasts could run into problems and I asked again if I could take a look. The mother agreed. I asked her to remove her bra, which she did. And that’s when I saw that she, too, had white pustules typical of a staph infection on the inside and underside of her left breast. Her right breast appeared engorged, but was of normal color.”

The image of the inflamed, infected breast made Sarah squirm. It crossed her mind that she would have made a terrible doctor, given her aversion to suffering. She was only too happy to set aside the image of the diseased breast by asking Hilker what she did at that point.

“Well, the mother told me she hadn’t noticed any white pustules earlier in the day. She seemed horrified, as did the dad. I knew Dr. Smith would want to see the mother’s breast and would likely want a culture from one of the pustules. I also knew it was unlikely he’d want the mother to nurse the child, given her condition. So I rang the call button and Tracy, the LPN I was teamed with yesterday, came to the door. I told her to get Dr. Smith back ASAP, which she did.”

Sarah thought to ask for Tracy’s surname, but then she remembered Nancy Howland was already on the case. “And when Dr. Smith saw the mother?” Sarah prompted.

“He was very concerned, but calm and patient, as he generally is with the patients and their families. He said sometimes newborns get staph from contact with their mothers; some people carry staph on their skin or in their nasal passages. Babies and their mothers can have concurrent infections. Apparently, this was the case here.”

“Had the baby’s antibiotic — let me see, clindamycin — or the heparin been administered at this point?”

“No, Dr. Smith had left to order it, but it hadn’t yet arrived on the floor.”

“So what did Dr. Smith do, if anything, for Mrs. Arkin?”

“He said that the mother would also have to be put on an antibiotic regimen. He told the parents that he wanted to consult with one of the hospital’s lactation specialists, but he thought it was probably best for her not to nurse the baby at that time. He said they could give the baby formula if need be. Then the mother got upset. Very upset. She said she couldn’t believe this was happening. Her husband tried to comfort her. Then he got kind of pushy and told the doctor to get that lactation specialist in the room right away. Dr. Smith said he’d do what he could and asked me to page the specialist. I took off my gown and gloves, disinfected my hands and left the room to page the consultant.”