Chapter 7 - The Costly Mistake
The mistake was Grace's.
It came on the ninth day of the investigation, after Adrian Vasquez had been discharged and before Commander Whitfield had been charged, and it came because Grace had been awake for nineteen hours and because she had spent nine days being told by everyone around her that she should let the investigators do the investigating and that she should go home and rest and that everything was going to be fine.
She did not go home and rest.
She went to Commander Whitfield's office.
She went to his office because she wanted to look at him. She wanted to look at the man who had altered a chart for a six-year-old boy. She wanted to see his face when he walked into the room and saw her standing there.
It was a mistake. She knew it was a mistake before she did it. She did it anyway.
She walked into his office at 18:00 on a Friday evening.
He was not there. She had known he would not be there — he was on administrative leave, the OSI had told her, and he was not allowed to enter the hospital building. But his office was still his office. The door was unlocked. The lights were on. The desk was cluttered with papers and with a coffee cup and with a photograph of a woman and two children.
She stood in the middle of his office.
She looked at the photograph.
She looked at the coffee cup.
She looked at the papers on the desk, which were the papers that the OSI had left behind when they had executed their warrant, and which were the papers of a physician who had spent three years signing charts that were not his to sign.
She stood there for eleven minutes.
Then she heard footsteps in the corridor.
She turned.
Commander Marcus Whitfield was standing in the doorway.
He was fifty-two years old. He was a tall man with gray hair and a careful face. He was wearing civilian clothes — a polo shirt and slacks — and he was holding a small cardboard box and he looked, for one moment, exactly like a man who had come to his office to collect his personal effects.
He looked at her.
She looked at him.
"Lieutenant Holloway," he said.
"Commander."
"You are not supposed to be in this office."
"Neither are you, sir."
Whitfield did not move.
"I am here to collect my things," he said. "The OSI has authorized it. There is a duty officer at the end of the corridor who signed me in. Do you want to check?"
"No, sir."
"Then why are you here?"
Grace looked at him.
"I am here to look at you," she said.
Whitfield set the box down on the desk.
He walked toward her.
He stopped three feet away.
"You are the nurse who kept the second chart," he said.
"Yes, sir."
"Do you know what you have done?"
"Yes, sir."
"Do you know that I have served in the United States Navy for twenty-eight years? Do you know that I have been the supervising physician of this department for six years? Do you know that I have published in three journals and spoken at four conferences and trained forty residents who are now practicing physicians in this Navy?"
"Yes, sir."
"Do you know that when this is over, my career is going to be over? My pension is going to be gone. My family is going to be embarrassed. My children are going to read about this in a newspaper. And all of that is because a nurse on my ward kept a second chart."
Grace did not look away.
"Yes, sir," she said. "And a six-year-old boy is alive because a nurse on your ward kept a second chart. I know that too."
Whitfield's face went very still.
"Do you know what I think?" he said.
"No, sir."
"I think you are a self-righteous little nurse who has convinced herself that she is a hero. I think you are going to spend the rest of your career telling this story. I think you are going to be a guest at every nursing conference in the country. And I think that when you look back on this — when you are sixty years old and retired and living in a house in San Diego — you are going to realize that you destroyed a man's career to save one child who would have been fine anyway."
Grace looked at him.
"Commander," she said, "you are wrong about two things. First, I am not going to spend the rest of my career telling this story. I am going to spend the rest of my career being a nurse. That is the whole career. That is the whole life. I am not a hero. I am a nurse. And I am going to keep being a nurse for as long as the Navy lets me. Second, you are wrong about the child."
"I am wrong about the child."
"You are wrong about the child. Adrian Vasquez would not have been fine. He was on four liters of oxygen when I came on shift at 03:00 in the morning. He had two oxygen desaturation events overnight. His right lower lobe was consolidating. If he had been discharged at 14:00 that afternoon, he would have decompensated at home at some point in the next twelve hours. And his father — a twenty-four-year-old petty officer with no car and no wife and no family within a thousand miles — would have had to decide whether to call 911 or to drive him to the emergency room himself. And by the time he made that decision, the child would have been in respiratory failure."
Whitfield did not say anything.
"Commander," Grace said, "I have been a nurse for nine years. I have seen twelve children die. I can name every one of them. I can tell you their birthdays and their parents' names and what the weather was like on the day they died. I am not going to watch a thirteenth child die because a physician needed a bed."
Whitfield looked at her.
"You are going to regret this," he said.
"No, sir," Grace said. "I am not."
She walked past him.
She got as far as the door.
"Lieutenant Holloway," Whitfield said.
She turned.
"There is a duty officer in the corridor," he said. "I signed in. If you report that I was in this office — if you report that I spoke to you — the OSI is going to wonder whether you went to this office to look at me or whether you went to this office to confront me."
Grace looked at him.
"I went to this office to look at you, sir," she said. "And I am going to tell the OSI exactly that. Because I do not lie. Not even when lying would be more convenient."
She walked out of the office.
She was shaking by the time she got to the parking lot. She sat in her car for twenty minutes before she could turn the key.
May you like
But she had done it. She had looked at him. She had said what she needed to say.
And she was not going to regret it.
