Natural Causes

by Michael Palmer

  “No prior history of bleeding problems?” she asked Blankenship.

  “Absolutely none.”

  Stoddard thought for a few seconds. “We can’t wait for the lab. I think we hang up what platelets, blood, and plasma we can and heparinize her.”

  Randall Snyder and Heidi Glassman entered the room, both a bit breathless. Moments later Andrew Truscott arrived as well. Heidi took Sarah’s place at the bedside, while Truscott, Sarah, and Snyder stepped back to the doorway.

  “She’s in real trouble,” Sarah said.

  Snyder glanced at the fetal monitor.

  “So’s the baby,” he said. “Have you started Pitocin?”

  “In the ambulance. She’s still only five centimeters dilated.”

  “Jesus.”

  Truscott took a minute to examine Lisa’s arms, hands, and feet. Then, with impressive skill and speed, he injected some anesthetic into the skin at the side of her neck, located two bony landmarks with his fingertips, and slid a large-bore needle through the numbed spot directly into her internal jugular vein. Next he threaded a catheter through the needle and sutured it in place. A critical second IV route had been established.

  “One way or the other, I think we’re going to have to take her to the OR for that arm,” he said after returning to the doorway. “I still can’t tell about the left or her feet. Can you C-section her?”

  Snyder crossed to Helen Stoddard, held a brief, whispered conversation, and then came back shaking his head.

  “We may already be down to a mother versus fetus situation,” he whispered. “Helen and Eli have decided they can’t wait for laboratory confirmation of DIC. They’ve gone ahead with heparin. As things stand, they feel the girl has no chance of surviving a C-section.”

  Heparin for DIC. To Sarah, whose practice as a surgeon was built on a bedrock of meticulous attention to the control of hemorrhage, the treatment was a terrifying paradox: the intravenous injection of a powerful anticoagulant to a patient who was already in danger of bleeding to death. The theory was to administer the drug to break up the pathological clots and restore blood flow to the compromised extremities and vital organs. At the same time, continuous transfusions would be used to chase lost blood volume and replace clotting factors. It was a therapeutic balancing act of circus proportions, and one that too often was doomed to fail.

  Sarah looked at the woman she had cared for over the past seven months, now barely visible within the clutch of nurses, physicians, and technologists. In just minutes, Andrew had contributed greatly to everyone’s efforts. She had yet to contribute anything. True, she acknowledged, he and the other medical players in this drama were all senior to her. But Lisa Summer was still her patient, and there were things the two of them had worked on, things they could try, that might help as well—provided, of course, that Helen Stoddard and Eli Blankenship allowed them the chance.

  She excused herself and raced down to the subbasement where a series of rather dimly lit tunnels connected all of the MCB buildings. Her locker was on the fourth floor of the Thayer Building, which housed the administration offices on the first three floors and the house staff sleeping quarters on the top two. Sarah took the elevator up. Minutes later she bounded down the six flights and sprinted back through the tunnels toward the ER. Cradled in her arm was the mahogany box containing her acupuncture needles. The box had been a gift from Dr. Louis Han. She had first encountered Han, a Chinese-born Christian missionary, while teaching with the Peace Corps in the Meo villages north of Chiang Mai, Thailand. Until his death nearly three years later, he was her mentor in the healing arts. The inscription on the box, elegantly carved in Chinese by Han himself, read: THE HEALING POWER OF GOD Is WITHIN Us ALL.

  The moment Sarah stepped back into Room A, she sensed things had changed for the worse. A tube inserted into Lisa’s stomach through her nose was carrying a steady stream of blood into the suction bottle on the wall. Her urinary catheter was also draining crimson. Randall Snyder, his face ashen, stood by the fetal monitor, where the heartbeat of Lisa’s unborn child had dropped below the rate necessary to sustain life.

  “What’s happening?” Sarah asked, moving beside him.

  “I think we’ve lost him,” Snyder whispered. “We could go for a section right here and now, and maybe we’d still be in time for the baby. But Lisa would never survive.”

  “Is she going to anyhow?”

  “I don’t know. It looks bad.”

  Sarah hesitated for a moment, and then worked her way to where Helen Stoddard and Eli Blankenship were standing.

  “Can I please speak with you both?” she asked.

  For an instant, she thought Stoddard was going to dismiss her. Then, perhaps remembering Sarah was one of Blankenship’s hand-picked residents, the hematologist moved to one side of the room. Blankenship followed.

  “I’d like to try to stop Lisa’s bleeding,” Sarah said.

  “And exactly what do you think we’re trying to do?” Stoddard asked.

  Sarah felt the muscles in her jaw tighten. She had never forced her abilities and techniques on any resident or faculty member who didn’t request them. But Lisa was her patient, and conventional therapy did not seem to be working.

  “Dr. Stoddard, I know you don’t have a great deal of regard for alternative healing,” she said, struggling to keep her voice steady. “But I only want the same thing you do. I want Lisa to make it. For the last four or five months, while we were getting ready for her home birth, Lisa and I have been working on some self-hypnosis and internal visualization. I think she’s really gotten quite good at both.”

  “And?” Stoddard’s expression was ice.

  “Well, combined with acupuncture, we might be able to use Lisa’s own power to slow her bleeding down. Provided, that is, you are willing to give her enough protamine to neutralize the heparin.”

  “What?”

  “If we succeed in slowing her bleeding enough to be able to C-section her, you can start the heparin again to work on dissolving her clots.”

  “This is ridiculous.”

  Sarah took a calming breath. Over four years of medical school and two years of training, she had never had a clash of this sort with a professor. But there could be no backing down. “Dr. Stoddard, Lisa’s pressure is dropping, her bleeding is getting worse, and it may already be too late for the baby.”

  “Why, you arrogant, ignorant—”

  “Just a minute, Helen,” Blankenship cut in. “You can say anything you want when this is over, but right now we have a girl who is going down the tubes, and we’ve got to focus on her. Dr. Baldwin is right. The heparin’s not doing anything for the clots yet, and it’s sped the bleeding up to the point where we’re falling behind in our transfusions.”

  “Do this and I’m off this case,” Stoddard said.

  “Helen, you’re one of the best hematologists I’ve ever known, and one of the most dedicated doctors. I can’t imagine you ever allowing anything to get in the way of what’s best for a patient.”

  “But—”

  “And deep down, you know that the few minutes it will take Sarah, here, to try what she knows will make little difference to the outcome.”

  “But … all right, dammit. But after this is over, regardless of what happens, this hospital had better clarify its policy on medical quackery, or I am off the staff.”

  “We’ll do that, Helen. I promise. We’ll do that. Sarah, how can we help?”

  “Well, first give Lisa the protamine.”

  “Helen?”

  “Damn you, Eli. Okay, okay.… This is ridiculous,” she muttered as she headed back to administer the heparin antidote. “Absolutely ridiculous.”

  “Now,” Sarah continued, sensing her pulse beginning to race, “please just leave Heidi with me, pull as many people away from the bedside as possible, and keep all noise to a minimum.”

  “Done. Anything else?”

  “Just one. Please turn off the overhead lights.”

  Lisa cr
ied out as another contraction took hold. Sarah stroked her forehead, then knelt beside her.

  “Lisa, close your eyes and listen to me,” she said softly. “We’ve got work to do. This is the moment we practiced for in all those sessions. Do you understand?… Good. Let’s just start with the easy things, the scenes, okay? Use them during your contractions. I’ll help you, and Heidi is here to help you, too. In between contractions, I want you to concentrate on my voice and start trying to visualize what is happening in your bloodstream and your heart. Everything’s moving too fast … too fast. There may be blood clots forming there, too, clogging your arteries. Try to relax and see them, too. Just relax.… Just relax.…”

  Heidi continued whispering in Lisa’s ear as Sarah briefly consulted a thin, frayed booklet. Having assured herself of the acupuncture points she wanted to stimulate, she set her first needle by twisting it in just below Lisa’s left collarbone. Then, one at a time, she set five more of the steel needles in various points, trying to compensate for the limitations placed on the technique by Lisa’s bandages and supine position.

  An eerie silence had taken over the room, broken only by the muted churning of the suction apparatus and the soft beep of the cardiac monitor.

  “Look,” Sarah heard someone whisper. “I think the bleeding’s letting up already.”

  Sarah glanced at the suction bottle. In fact, the drainage did seem to have significantly lessened.

  “Lisa, relax,” Sarah said again, pleasantly but firmly. “Slow your heart … slow your blood … and just relax. You have the power.…”

  One minute passed. Then another. Lisa lay motionless now, her eyes closed. A contraction hit, visibly knotting her abdomen. She remained motionless and serene.

  “Her heart rate’s down from ninety to fifty, Sarah,” Blankenship said. “The oozing from her IV and venapuncture sites may have stopped altogether. Randall, do you want to get ready?”

  “Everything’s set,” Snyder said. “Anesthesia’s standing by upstairs. Just say the word.”

  The nasogastric tube was now draining only small amounts. All oozing had stopped. Carefully Sarah twisted out the six acupuncture needles. For ten seconds, fifteen, all was quiet.

  “Go for it,” she said.

  CHAPTER 5

  July 2

  SARAH ORDERED THE OPERATING TABLE UP TWO INCHES and screwed sterile handles into the parabolic overhead lights. Her eyes burned a bit; she’d been up and running for twenty-four hours without so much as a catnap. But her concentration, as always when she was in the OR, was as sharp as her scalpel. After centering the focused beams, she cradled the blade in her right hand, minutely adjusting its position until it felt a part of her. With her left, she tensed the skin along what had been the upper margin of the pubic hair escutcheon. Then, with a single, steady stroke, she opened the abdominal wall and separated the thin saffron layer of subcutaneous fat. She next handled what few bleeders there were by snapping each with a hemostat and touching the steel instrument with an electrocauterizer. Finally she cut the peritoneal membrane, exposing the bulging, gravid uterus.

  “Everything all right?” she asked the anesthesiologist. “Stable.”

  “Okay, here we go.”

  Sarah scored the surface of the uterus with her scalpel, then made a small opening in it. Inserting her index fingers, she pulled the beefy muscle fibers apart. Then, with the touch of her blade, she opened the amniotic membrane.

  “We’re in,” she said at the first gush of amniotic fluid. “Suction, please.”

  Time now was critical. The powerful uterus could clamp down at any moment, making the delivery of the baby within it anything but routine. For ten seconds Sarah’s breathing, and it seemed her heart as well, stopped as she felt deep in the pelvis for the baby’s legs, trying at the same time to assess the position of the umbilical cord. Gently her fingers closed about the spindly legs and drew them up through the incision. Next the torso and gently, ever so gently, the shoulders and arms. Finally she cradled the eggshell skull in her palm and guided it up through the incision. And just like that, the infant was born.

  Quickly Sarah cleared its nose and mouth with a suction bulb. Moments later the expectant hush of the delivery room was pierced by the newborn’s bleating cry. And instantly the tension in the room evaporated.

  “It’s a girl, Kathy,” Sarah said too flatly. “A beautiful girl. Congratulations. Dad, if you’ll step around over here, you can cut the cord.”

  The father, just out of high school, sidled over nervously, did as she instructed, and then hurried back to the head of the bed where his young wife was alternately crying and laughing for joy. Swallowing at the sudden, unpleasant fullness in her throat, Sarah handed the perfect newborn over to the pediatrician. She hoped no one in the room could tell how close she was to tears herself—tears not of joy but of sorrow for the stillborn death of Brian Summer some seventeen hours before.

  It was six o’clock in the morning, following an incredibly stressful, roller-coaster day and night during which Sarah had presided at two normal vaginal births and now this breech-presentation cesarean. But shortly after one o’clock the previous afternoon, the exhilaration of playing a major role in slowing Lisa Summer’s bleeding had given way to the inestimable sadness of assisting in the extraction of her baby—dead before they had even reached the delivery room.

  Like the infant of the previous DIC patient, Brian Summer had succumbed to massive bleeding within the placenta and premature separation of the placenta from the uterine wall. Had he been delivered even half an hour earlier, he might have survived. The agonizing choice, though, had been to channel all efforts toward saving Lisa, who almost certainly would have bled to death had the procedure not been delayed.

  With an unfamiliar sense of distraction and detachment, Sarah watched her hands deliver the young woman’s placenta, then begin closing the incisions she had made. The decision to try to save Lisa’s life had been the correct one. Nevertheless, acceptance of the outcome was not coming at all easily. Sarah was preparing to place the skin clips when the circulating nurse from surgery came up behind her.

  “Sarah, Dr. Truscott wanted me to tell you that they’ve taken Lisa Summer back into the OR,” he whispered.

  Oh, no, she thought. “Do you know what’s going on?”

  “Well, apparently the anticoagulation and the heparin flush haven’t cleared the blockages in her arm. I’m not sure what Dr. Truscott plans to do now.”

  “Thank you, Win. I’ll be over as soon as I can. Kathy, we’re almost done. The pediatrician just signaled to me that your baby’s perfect. Her Apgar score is nine. Ten is tops, but we only give that to babies who come out playing a violin. He’ll bring her over to you in just a moment.”

  “Thank you, Doctor. Oh, thank you so much.”

  Sarah taped a bandage over the incision and stripped her gloves off as she backed away from the table.

  “We’re all very happy for you,” she said.

  She left the delivery floor and headed toward the surgical building. Twice during the short walk she was stopped—first by a nurse, then by a medical resident—and congratulated for the job she had done on Lisa.

  “The whole hospital’s talking about it,” the resident said. “You really opened a lot of eyes to the potential of alternative healing. My medical degree’s a D.O. from the school of osteopathy in Philly. All of a sudden, for the first time, really, the other medical residents are asking me about my education—about what sorts of things we study that the people in traditional medical schools don’t. People who only paid lip service to nontraditional methods are suddenly very interested in them.”

  The man’s words should have been a tonic. But today they did little to alleviate Sarah’s sense of impotence. All of her training plus hundreds of thousands of dollars’ worth of equipment and personnel had been unable to save Lisa Summer’s baby. This was not the first time she had agonized through the loss of patients’ pregnancies and newborns. That people die
was the most basic tenet of medicine, and on a purely intellectual level, it was a truth she understood. But for whatever reason, her emotional response to this loss seemed impervious to knowledge or logic.

  She pictured her old office/treatment room on the second floor of the Ettinger Institute. She had been no less involved in caring for people in those days than she was now. But that world—that serene, uncomplicated, highly personal interaction with patients—seemed light-years away.

  The difference, purely and simply, was the degree to which technology and science—whatever that really was—dominated western medicine. At times, and this was certainly one of them, it felt as if she had traded in flying on a hang glider for piloting a jet.

  Her reason for leaving the Ettinger Institute was the inflexibility and eventually the intolerable behavior of Peter Ettinger. But her decision to obtain an M.D. degree went far deeper than that. She had felt that when she became a physician, many of the limitations and resulting frustrations of her professional life would disappear. Instead, despite all the equipment and her newly acquired technical skill, her limitations seemed just as frustrating, and those frustrations just as limiting.

  There were four women now on the hospital’s surgical staff and three female surgical residents. Still, there was only one surgeons’ locker room, and it remained for men only.

  Sarah discarded her maroon OB scrubs in the nurses’ locker room, slipped on a sea green pair, and replaced her shoe covers, hair guard, and mask. Twelve hours had passed since she had watched Andrew Truscott probe and irrigate the main arteries supplying Lisa’s right arm. Their goal was to remove as much clot as possible and to hope that anticoagulant irrigation took care of the rest. Now, apparently, they needed to do more—perhaps a major dissection of the blocked vessels.

  Sarah entered the OR through the scrub room. Lisa, now in an operating room for the third time in less than twenty-four hours, was already anesthetized and intubated. Her face was deceptively peaceful. A low drape across her neck separated her head and the anesthesiologist from the surgical team. On the other side of the drape, Andrew and another surgeon, both on the same side of the table, were focused on Lisa’s arm.