Fertility: A Novel Page 2

  Rick was too tired to argue. And that would give him at least a semblance of a night’s sleep. “That’s very thoughtful of you, Nancy,” he said, his voice heavy with sarcasm. “I am so glad you’re taking my needs into account in this investigation. And will you be scheduling me another day off this week to make up for today?”

  Howland wasn’t getting into that rat’s nest. She replied sweetly, “I’m sorry to say I have no authority to make those decisions or I’d be certain to give you another day off.” She paused, waiting to see if he’d make another smart comment. Relieved when he didn’t, she wrapped things up. “We’ll see you at 4:30 in room 700.”

  Rick’s fatigue led him to surrender. Had he some sleep under his belt, he would have kept up the repartee. Who knew? Maybe Nancy was a babe. And even if she wasn’t, maybe she’d be an eager and enthusiastic partner, which held a charm of its own. But for now, all his desires were folded into his need to lie down and close his eyes. He hung up, set his alarm for 4:15 and got into bed. In less than a minute he was breathing slowly and rhythmically, enveloped in the rapture of long-deferred sleep.

  CHAPTER THREE

  Mark Arkin awoke that Monday morning with his arm around his wife. He and Catherine had succumbed to their exhaustion on a loveseat in the family lounge of the pediatric intensive care unit — the PICU. They’d been up with Ariel much of Saturday night as she fussed with what looked to be a nasty diaper rash. It was the nanny’s day off, so they consulted the pile of baby books Catherine had amassed during her pregnancy. Then they applied ointment and kept her dry, but got no relief from the baby’s incessant crying until four on Sunday morning. When she awoke around seven, the crying began again.

  Mark Arkin didn’t remember anything like this from when he had been married to Linda. Maybe that’s because he had rarely been at home during their children’s first years — or, for that matter, their later ones. He had never had any qualms about the long hours he kept. There had been no way to scale his industry’s mountain while attending parent-teacher conferences and soccer games.

  This time was different, though. Mark had never thought he’d be one of those fools — an alter kocker in his mother’s parlance — who left a perfectly good wife for a new, younger model. He had been too busy amassing his fortune to chase skirts. Besides, he had been satisfied with Linda — who was both nice-looking and highly competent at running the family, the houses and their social life without any help from him. But when he met Catherine Malloy during an interview for an article she was writing for Fortune on his meteoric rise from the streets of Flatbush, he fell hard. At forty-seven he found himself besotted by the thirty-year-old natural beauty.

  It took a year of pursuit, including a legal separation from Linda, before Catherine would even entertain the idea of going out for a drink. She refused to sleep with him until his divorce was final for over a year — something about the “one-year rule” that she had heard from a radio psychologist. The titan of real estate was powerless to sway her. The truth was, her unavailability added to her allure. Mark was fifty years old before he finally won Catherine over. And here he was, two years later, married to the woman he was crazy about, and scared that their baby would die fifteen days after taking her first breath.

  As he sat on the loveseat, a terrifying thought crept into his consciousness: The nightmare with Ariel was retribution for what he’d done to Linda and their kids. But that was absurd. At the very least, it presumed some sort of balance in the universe, or, more improbable still, a wrathful god evening up the score. He had always pegged the notion of a “supreme being” as a scam, a way to keep the little people in line. He made big decisions every day, consequences be damned. When he walked away from his family, he had silenced the small but persistent inner voice of reproach by being generous. Linda got the houses in Scarsdale and the Hamptons, as well as alimony for the rest of her life. The kids got liberal child support until they were out of school, when their trust funds would kick in. Mark couldn’t help but pat himself on the back, thinking that most first families would thank their lucky stars to get such munificent treatment from a husband and father who moved on in his life.

  Still, here he was with Catherine. Through the night she had alternated between uncontrollable sobs and gentle crying until he finally persuaded her to try to sleep. It was his first victory at calming her, and he did it by telling her that if she got some rest, she would be in better shape to care for Ariel in the morning. Even as he made the case for sleep, he wondered if he was full of crap. Would Ariel even be alive in the morning? It was beyond him to understand how she could live to see another day after such an assault to her tiny body.

  Try as he might, he couldn’t shake the idea of retribution. What was happening to them and to their baby was too monstrous to be a random accident. For the first time since he was in grade school, he felt guilt. It was a sickening feeling. And the tears that fell silently on Catherine’s hair frightened him as much as anything that had happened over the past day and night.

  CHAPTER FOUR

  Julie Bonner’s office was nothing if not efficient. When Sarah returned to the conference room adjacent to John Mess’s office, Nancy Howland, Bonner’s assistant, was waiting for her. Howland informed Sarah that the pharmacist who’d filled the order and the baby’s nurse, Joyce Hilker, would be coming in for interviews. Howland had left messages for the pediatric fellow, Dr. Smith, and the attending physician, Dr. Cho. She asked if Sarah wanted to interview the licensed practical nurse that had been teamed with Joyce Hilker on Sunday. Sarah thanked Howland for taking initiative and told her to contact the LPN as well as the charge nurse for the floor. She figured she could fit all of them in — and in cases like these, time was of the essence. She had to interview each of the major players before they had a chance to think too carefully about a cover, or to coordinate their stories.

  After she and Doris Ostrom got themselves set up in the conference room, Sarah thought about how she could use the time before her first interview at 9:30. She decided to lay eyes on the pharmacy to see how orders were dealt with via the new computerized system. She asked Howland for directions and then suggested she let the pharmacy know Sarah was on her way.

  * * *

  The hospital pharmacy was actually smaller than she had imagined, but it hummed with what appeared to be the well-coordinated activity of about a dozen people in white jackets. Double doors led to the outpatient pharmacy, staffed by another four workers. Within the pharmacy there were row upon row of open shelves with more medications than Sarah had ever imagined possible. There was also a walk-in cooler for the medications that had to be kept refrigerated. As Sarah scanned the clean, well-lit room, a blond, middle-aged woman wearing a white jacket and white clogs approached.

  “You must be the attorney Julie’s office just called about. I’m Joanne Marsh, head of the hospital’s pharmacy,” she said, extending her hand. “Glad to meet you.”

  “I’m Sarah Abadhi,” she said, shaking hands with the head pharmacist. Sarah noticed the Pharm.D. following Joanne Marsh’s name on her ID tag, indicating her doctorate in pharmacology.

  “Please, let me know how I can be of help in your investigation. This is the type of error I’ve spent my career trying to prevent. Believe me when I say I’m eager to know how this mistake happened.”

  Sarah was taken by her frankness and her straightforward demeanor. “I thank you in advance for your cooperation. It’s clear that it’s in everyone’s interest to keep errors like the one that occurred yesterday to a minimum. You could help me by demonstrating how a doctor’s order is processed by the pharmacy. I’d like to familiarize myself with the system.”

  “I’d be happy to. We put our Bar Code Medication System — BCMA —– into operation just last week. We have orders constantly arriving on our system. Let me take you through the entire process from arrival of the order to departure through the pneumatic tubes.”

  Marsh was as efficient as she was confident when e
xplaining the system. She used the first order of the incoming computerized requests as an example. “Let’s see. A doctor on Four North has requested Effexor XR, 150 mg, for an eighty-nine-year-old female patient. I’ll bring up the patient’s profile to see what other medications she’s taking. As you can see on the screen, there are no possible drug interactions, so we can fill the script without calling the floor to speak with the patient’s nurse.”

  Then Marsh walked Sarah over to unit five of the large array of freestanding, open shelves and, using a stepstool, brought down from the highest shelf the large, brown, bubble-sealed Effexor capsules. Returning to the computer terminal, she scanned the bar code on the Effexor package and printed out a label with the patient’s name and ID number, the prescribing doctor’s name and ID number, the dosage and the date. Once the label was affixed to the cardstock portion of the Effexor packaging, the head pharmacist indicated on the screen that the order was filled. Before five minutes had elapsed, the order was put into a clear plastic capsule that would wend its way through the pneumatic tubes to Four North and the eighty-nine-year-old woman awaiting her antidepressant medication.

  “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 t
hat 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.”