Natural Causes

by Michael Palmer

  “Having seen ol’ Paris’s slides from that vantage for four years running, I thought I might try something a bit closer.”

  “Fine by me,” she said as they made their way down the steeply banked aisle of the amphitheater to the second row. “At our age we might as well begin learning how to deal with presbyopia and otosclerosis anyhow. Do you happen to know why the security check?”

  Truscott thought for a moment.

  “I’ll bet they’re searching for lunatics,” he said.

  “Lunatics?”

  “Anyone who would come to this affair who didn’t absolutely have to.”

  “Very funny.”

  “Thank you. I have no doubt our fearless leader will address the heightened security—either before or after his yearly recounting of the history of our august institution.” He thrust his jaw out in a caricature of Glenn Paris. “ ‘In 1951, at age fifty, Medical Center of Boston moved from the midcity to the outskirts in order to occupy the nine buildings which once comprised the Suffolk State Hospital, better known as the nut house. And although that transition was completed decades ago, it is still rumored that late at night, the ghost of Freddy Krueger scrubs up and stalks our operating rooms.…’ ”

  “Andrew, what is with you today? Is it the chief residency? Are you just angry at not getting it?”

  “Hardly.” Truscott’s sardonic laugh was unconvincing. “I’m angry about having my all-too-meager paycheck signed by a man who raffles off elective plastic surgical procedures, sends his residents on well-publicized house calls, and has closed-circuit TV put in delivery rooms.”

  “He’s raised thousands of dollars with those raffles and contests—probably hundreds of thousands. And most families love the chance to be part of a birth. We’ve become the second busiest OB service in the city.”

  Before Truscott could respond, Glenn Paris stepped forward and tapped on the microphone. Immediately 120 staff physicians, residents, nurses, and trustees fell silent.

  Glenn McD. Paris, the president of Medical Center of Boston, exuded confidence and success. He was only five feet eight, but many described him as tall. His jaw was as square as any Boston Brahmin’s, and the intensity in his gaze was arresting. He had been described by one supporter as a mix of equal parts Vince Lombardi, Albert Schweitzer, and P.T. Barnum, with a dash of Donald Trump thrown in. Axel Devlin, on the other hand, had once called him the most distasteful and dangerous affliction to descend on Boston since the British.

  Six years before, a desperate board of trustees had lured Paris away from a major hospital in San Diego that he had turned around in a remarkably short time. The deal they struck with him included the promise of a free hand in fund-raising and all hospital affairs, generous financial incentives, bonuses tied to any hospital profit, and the rent-free use of a Back Bay penthouse, donated to the institution some years before by a grateful patient. Paris had responded with a vigorous campaign to give the hospital a positive, easily definable image and to turn its red ink to black at all costs.

  In some ways, the man had succeeded. The hospital’s staggering debt had leveled off, if not lessened. At the same time, its increasing emphasis on whole-body medicine and personalized treatment had led to a growing reputation as a caring medical center.

  But there was still a lack of respect for the institution in many quarters, both public and academic, and the feeling among some trustees that before long, the hospital would simply have to move in other directions.

  “Good morning, troops,” Paris began. “I want to welcome you to the official beginning of MCB’s ninetieth year. The purpose of this annual kickoff is to introduce our new house staff and to help them feel at home.” He motioned for the new residents to stand and led a round of applause. “You should know,” he said to them, “that your group represents the best MCB has ever been matched up with in the national resident matching program.”

  Again applause. Several of the residents shifted uncomfortably, obviously wishing they could sit down. Paris, beaming as if he were showing off his children, kept them standing. The news of the high match—hospitals make their preferential list, prospective residents make theirs, and a computer does the rest—had been well publicized. But he was not one to miss the chance to milk such a success for all it was worth.

  Truscott leaned over toward Sarah. “Note how carefully fearless leader neglects to add that although the match is the highest in MCB history, it still ranks below any of the other Boston teaching hospitals.”

  “For true?”

  “Blankenship let that one slip out at lunch last week.”

  Dr. Eli Blankenship, the chief of staff, was also the head of the MCB resident training program. It was his impressive knowledge of alternative healing and his enlightened attitude toward Sarah’s desire to blend her techniques that had convinced her to rank MCB number one on her match list. At the time, largely because of her unique background and high scores on the National Medical Boards, several more prestigious hospitals had already expressed interest in her.

  “Please sit down,” Paris said finally.

  “In 1951, at age fifty …” Truscott murmured.

  “Before going any further,” the CEO continued, “I want to address the heightened security to which you were all subjected this morning. Over the past year, too much of this hospital’s business has been finding its way to certain reporters and other special interests, who have gone out of their way to paint an unfavorable and damaging picture of the Medical Center of Boston. Some of these leaks involve the minor day-to-day errors—no, most are too trivial to be called errors—I should say problems in patient care which plague any hospital, and which are never shared with the public. Others involve exchanges at our staff meetings and conferences.”

  Sarah’s beeper went off, the readout summoning her to an outside call. Wishing she could have crawled to the end of the row rather than stand up directly in front of Paris, she made her way to the nearest auditorium phone.

  “All hospitals,” Paris continued, “are in competition to maintain their allotment of beds and to keep a reasonable percentage of those beds filled. And as you know, that competition is often intense. Hospitals as large and prestigious as White Memorial now advertise in the yellow pages. Negative publicity for MCB, especially groundless negative publicity, hurts every one of us. From now on, no unauthorized personnel will be allowed in our medical rounds or staff meetings. Further, anyone other than our public relations office who speaks about hospital business with the press will be asked to leave our employ …”

  Sarah listened for a minute to her call, gave some instructions, and returned to her seat.

  “One of my home birth patients is in active labor,” she whispered. “She’s still got a ways to go, but her bp’s a little low. I hope this program doesn’t run over.”

  “You’re doing home births yourself?” Truscott looked at her incredulously.

  “No, Andrew. I assure you, I only look dumb. Dr. Snyder will be coming out with me. This will be our second one.”

  Randall Snyder, the OB/Gyn chief, was one of those seated on the stage behind Glenn Paris. As Sarah nodded up toward him, she realized that Paris had stopped speaking and was glowering down at her.

  “Sorry,” she mouthed, color rushing to her cheeks.

  “Thank you,” Paris mouthed in return.

  He cleared his throat and took a sip of water. The silence in the hall was dramatic.

  “Believe me,” he went on finally, “this subversion from within is serious, serious business. As you know, outside interests and some more financially secure institutions have been just waiting for us to go under. Ours is an attractive facility with a wonderful location. But those folks are in for a rude awakening, my friends. A rude awakening. For some time now, I have been negotiating with a very well-endowed philanthropic group whose primary aim is the improvement of health care. We are currently on the home stretch of an extensive grant application. If that grant comes through—and at present
all the signs are right—MCB will have financial stability and a vast capability to grow. That was the goal I set with you six years ago, and today I am pleased to state that it is a goal well within our reach.”

  There was a smattering of applause, which gradually spread until all in the auditorium—including Andrew—had joined in.

  “That’s the spirit,” Sarah said to him.

  “My hands were getting cold,” Truscott replied.

  Behind the podium, Glenn Paris again was beaming.

  “Please don’t stop on my account,” he said as the response died down.

  “He’s a crafty one,” Truscott whispered beneath the laughter that followed Paris’s comment. “I’ll say that for him.”

  “He’s working a miracle.”

  “He’s hyping himself.”

  “Before I introduce those seated behind me,” Paris went on, “and while we are on the subject of outside interference in hospital business, I want to say just a few words about the gauntlet of demonstrators some of you were forced to traverse to get here this morning. Some on our maintenance staff are currently conducting an illegal job action which we have good reason to believe has been instigated and is being abetted by one of those operations committed to our demise. Mark me well. We shall not allow them to interfere one iota with patient care or any other business of this institution.” He pounded his fist on the podium for emphasis. “And that you can take to the bank!”

  The word “bank” was still reverberating throughout the amphitheater when a set of power lines was crossed, causing the main electrical generator at MCB to short out. The backup system, supplying electricity to the operating rooms, ICUs, and part of the emergency ward, kicked in immediately. But the amphitheater, which was windowless, was thrown into instant, stygian darkness.

  The kickoff program for Changeover Day was over.

  CHAPTER 3

  IF SARAH HAD A ROLE MODEL IN HER PRACTICE OF OBSTETRICS and gynecology, it was her chief, Dr. Randall Snyder. From his soft-spoken manner to his gray Volvo sedan, everything about the man was fatherly and reassuring. Now in his mid-fifties, he still approached his solo practice with exuberance and compassion. When a new technique or treatment in his field was announced, he would be one of the first in line to learn it. If an uninsured clinic patient had a problem pregnancy, he would accept her as his private patient without a word about payment.

  Today Randall Snyder was taking time from his busy schedule to drive Sarah to the Jamaica Plains section of the city. There he would assist her in performing a home delivery on a twenty-three-year-old unwed woman with no health insurance and an inordinate fear of doctors and hospitals.

  “How do you do it?” Sarah asked as they drove.

  “Do what?” Snyder turned down the volume on the Bach cantata he was playing on the tape deck.

  “Keep on doing medicine the way you do without letting it get to you?”

  Snyder stifled most of a smile. “Do you want to define ‘it’?”

  “Oh, you know—the peer reviews and the lawyers, and the insurance companies and government telling you what you can and can’t charge for your work; the mountains of paperwork, and the constant threat that you’ll offend some vindictive or imbalanced patient who’ll lodge a complaint about you or sue you.”

  “Oh, that ‘it,’ ” Snyder said. “Sarah, as far as I’m concerned, you’re not even talking about the real stress on this job: the cases that don’t come out right, the people with untreatable illness, the people who die in spite of everything we do.”

  “But that’s medicine. The other stuff is … is …”

  “Is medicine, too. It’s part of the package. Believe me, I’m not the serene machine a lot of people make me out to be. But neither do I go home after a day’s work and beat my wife because I haven’t hit the lottery or written the best-seller that will enable me to get out of the profession. I can handle the things you’re talking about because by and large I still love what I do, and feel damn lucky to have been given the chance to do it. Why are you asking about all this? Are you having trouble?”

  “Not trouble exactly. Oh, turn right at the next corner.”

  “Got it. Knowlton Street, you said, right?” “Yes.”

  “I know the way. Now go on.”

  “You know that before I went to med school I worked in a holistic healing center.”

  “Of course. I’ve been to some of your presentations. Interesting stuff. Very interesting.”

  “My training was in herbal medicine and acupuncture. But some things happened that made me feel I needed to broaden the skills I had.”

  Some things happened. The understatement of the week, Sarah thought. She debated going into the details of her final clash with Peter Ettinger, but quickly realized that this was hardly the time or place to unearth that worm.

  “Well, our techniques in the holistic center had their limitations,” she went on. “I don’t question that. But there was a certain, I don’t know, call it innocence about our goals and the way we did things—most of us, anyway. Each day we went to work and were able to concentrate almost exclusively on doing what we could for our patients.”

  “And?”

  “Well, as far as I can tell, medicine as I’m being trained to practice it now is often as much about money and liability as it is about patients. We order millions and millions of dollars in marginal or unnecessary tests so that our backsides will be covered if we end up in court. Meanwhile, government agencies, thinking they’re saving money, are telling us how long we’re allowed to keep patients with a given illness in the hospital. So what if an elderly lady here or there gets sent home too soon after a hysterectomy and falls and breaks her hip? We’re talking statistics here—actuarial tables and percentages. Not flesh and blood.”

  “Sarah, you are too young to be so jaded.”

  “Dr. Snyder, I wish there was something I was still too young to be—anything at all; and you know I’m not jaded. I feel I’ve made the right decision in becoming an M.D. And I love being a doctor. Sometimes I just wish it all was a little more, I don’t know, pure.”

  Randall Snyder chuckled.

  “Ivory Soap is ninety-nine and forty-four one-hundredths percent pure,” he said, turning onto Knowlton. “Nothing involving human beings even comes close to that—especially not in our racket. But, listen, I do understand what’s troubling you, and I promise we’ll continue this discussion sometime soon, perhaps over dinner at our place. For now, you should know that you’re on your way to being a heck of a doctor—exactly the sort of person I would like to have as a partner in my practice.”

  “Why, thank you.” Sarah could not mask her surprise—or pleasure. It was the first time she had heard Randall Snyder even intimate he might be considering bringing in an associate, let alone her.

  “File that one away for the time being,” Snyder said. “Sometime later this year, if you want, we’ll sit down and talk business. It’s okay to take a hard look at the less appealing sides of our profession, as long as you don’t get paralyzed by what you see. And for God’s sake, don’t go putting anyone on a pedestal—especially me.” He pulled to the curb in front of number 313. “Now, before we go in, how about giving me a thumbnail on our patient.”

  The concise, highly stylized presentation of a medical case was emphasized more, perhaps, than any other skill during Sarah’s training. As a student, she would often lie in the bathtub, oblivious to the progressively cooling water, as she used a stopwatch and a dozen or more repetitions to perfect her next morning’s case presentation. Now the technique was second nature.

  “Lisa Summer is a twenty-three-year-old unmarried artist, gravida two, para zero, spontaneous a.b. three years ago. LMP ten-two.”

  Second pregnancy, no deliveries prior to this one, a miscarriage, last menstrual period nine months before. Randall Snyder nodded for Sarah to proceed.

  “This pregnancy has been unremarkable in every respect. There has been a thirty-pound weight gain from
a base weight of one oh six. At exam one week ago, fetus was in vertex position—head was engaged, probably left occiput anterior.

  “Except for the usual childhood diseases, Lisa has a negative medical history. She is a nonsmoker and drinks occasionally. No other meds except for the natural prenatal supplement I prescribe.”

  “Ah, yes,” Snyder said. “The mysterious Baldwin mix. I was at the departmental conference last year when you spoke of it. Sometime soon I would like to learn more. Please continue.”

  “Family history is scant. No relationship with her parents at present; no relationship with the father of the child.”

  “Oh, my.”

  “Her coach is a woman friend who’s a nurse. Apparently, as a child, Lisa had a bad experience of some sort in a hospital. Now she’s terrified of them.”

  “Ergo the home birth.”

  “That’s one of the reasons. Lisa’s sort of—I don’t know—she’s very secretive about herself, and very mistrustful of people.”

  “Even you?”

  “Not as much as at first, but yes, even me.”

  “Well, then, supposing we go on in and try to turn that around.”

  Sarah gathered up the covered tray of equipment and obstetrical instruments.

  “One more thing,” she said. “Heidi, the birth coach, said that Lisa’s pressure has been dropping slightly and that it’s become harder to hear in her right arm than her left. The last systolic I know of was eighty-five, just as Glenn was starting his talk. The highest, a few hours before that, was one ten.”

  “And what do you make of that?” Snyder asked.

  “Low-normal for this stage of labor, I would say. When she called me, Heidi reported that Lisa looked fine. So it’s probably nothing.”

  Sarah saw concern in Snyder’s eyes and immediately sensed that she had not taken the report seriously enough.

  “The actual number may be low-normal,” he said, “but in my experience, not many labor patients have that sort of pressure drop at this stage.”