Natural Causes

by Michael Palmer

  For a moment, Sarah thought the second surgeon was the same vascular man who had assisted Andrew on the earlier procedure. But as she pulled the small metal footstool over and stood on it to get a better view, she realized that the other doctor was not a vascular surgeon at all. He was Ken Browne, the chief of orthopedics. It was only then that Sarah saw the severed forearm and clawed hand resting on the metal tray beside the scrub nurse and realized that Browne and Andrew were not doing any delicate vascular procedure at all. They were aggressively paring down what remained of Lisa’s radius and ulna—the bones of her forearm—in preparation for the completion of a below-the-elbow amputation.

  Sarah felt her muscles go limp and, for just a moment, thought that for the first time in her life she was going to faint. Oh, Jesus, no. First the baby … now this was all she could think.

  Andrew glanced up and saw her.

  “You okay?” he asked.

  “Andrew, she was an artist. A potter. Her hands were … Hey, listen, I’m sorry. It’s just that I thought she was going to be all right.”

  “She probably will be … now,” Andrew responded somewhat wearily. “I’m sorry about having to do this, too. But impending gangrene is impending gangrene. There was really no choice.”

  “I understand.”

  But even as she said the words, Sarah knew that there was precious little of what had happened to Lisa Summer that she understood at all.

  CHAPTER 6

  THE SURGICAL INTENSIVE CARE UNIT WAS A TWELVE-BED ward with one-to-one or one-to-two nurse coverage throughout the day and night. Rarely was there an entire unit shift without at least one patient in crisis. And although, except in times of the most extreme urgency, the atmosphere in the SICU was subdued and quiet, it was never silent. Every minute of every day, the monitoring equipment, suction and infusion systems, and respirators droned white noise like the surge of ocean waves. It was here, even more than in the operating rooms, that the true life-and-death battles were waged.

  Sarah much preferred the OR to the day-to-day grind of caring for critically ill patients in the unit. But she did enjoy the camaraderie she had with the SICU staff.

  At seven-thirty the morning of July 2, six of the SICU bays were occupied. All twelve would be filled by the time the morning OR schedule was completed. Her eyes now gritty from lack of sleep, Sarah sat on the edge of the bed in bay eight, waiting for Lisa Summer to be brought up from the recovery room. The news from there, except for the obvious, was excellent. Lisa had sailed through her surgery with no excessive bleeding. In fact, her DIC was rapidly resolving, and circulation to her kidneys and legs as well as to her remaining arm now seemed unimpeded. It was as if, in some strange way, the performance of the cesarean section had relieved her hematologic crisis.

  Lisa’s life had been saved. Her womb, her senses, and her nervous system were intact, and she could walk. In time, she would learn to use her left hand better and to control whatever prosthesis was placed on her right. She might even find a way to continue expressing herself as an artist. She would begin to deal with her grief, and someday, perhaps, she would once again bear a child. In a purely clinical way, Sarah knew all these things were true. Still, she could not shake the reality that Lisa was her patient, and that not twenty-four hours before, she had excitedly been preparing to give birth.

  “You all right?”

  Sarah was sifting through a printout of the already substantial number of lab tests run on Lisa, searching for a clue—any clue—as to what might have caused the catastrophe. Startled, she looked up to see Alma Young, a seasoned SICU nurse, standing at the foot of the bed.

  “Oh, yeah, I’m okay, thanks. Just a little tired is all.”

  “That’s understandable. Well, your girl’ll be up in a few minutes. Recovery just called. Apparently she’s doing reasonably well, all things considered.”

  “That’s great,” Sarah said, with little enthusiasm. “I keep staring at these numbers, hoping that something I missed will suddenly leap off the page and explain what’s going on.”

  “Maybe you should just close your eyes and nap for a few minutes.”

  “I’m afraid that if I do that, my body will figure out it doesn’t have to feel the way it does right now, and I’ll be finished for the day.”

  “You know, the whole hospital’s talking about what you did yesterday. The ER nurses are saying that girl would have died for sure if you hadn’t stepped in and then held your ground against that hematologist.”

  “Then why don’t I feel better than I do about all that, Alma?”

  The older woman sat down on the end of the bed.

  “Because you’re a good doctor,” she said. “That’s why. You’re sensitive. You care about people’s suffering and pain—I mean really care.”

  “Thank you.”

  “But may I say something?”

  “Sure.”

  “Sometimes I think you care too much. You take it all too personally. Sitting here poring through those lab reports when you could be resting is a perfect example. That’s taking sensitivity one step too far. I’ve seen all kinds of residents—and nurses, too—come through here. One thing I’ve noticed that the really good ones all have in common is this little switch they can throw that lets them become totally objective when they need to be that way. You have everything it takes to be one of the really good ones, but I think sometimes you let all this get you down too much.”

  “You see that in me?”

  “I do. So do some of the other nurses. Our favorite sport is dissecting the residents, you know. We all really like you, Sarah; and we love working with you. But we worry about you, too. It’s as if you always think there’s something more you should be doing instead of just accepting that you can only do what you can do.”

  The nurse’s observations triggered a rush of images and emotions, most of them unpleasant, and all of them centering on Peter Ettinger.

  “Alma,” Sarah said, “I’ve never been much good at accepting my limitations. In fact, if I didn’t always think there was more I could do for a patient, there’s a good chance I’d never have ended up as an M.D.”

  “What do you mean?”

  Sarah laughed uncomfortably. “Do you have a few hours?”

  There was concern in Alma Young’s eyes.

  “Actually,” she said, “I’m completely caught up until our friend Lisa arrives.”

  Sarah thought for a time before responding. She had always been a private person. And the compartmentalization of her life—high school in upstate New York, college in a Boston suburb, the Peace Corps in Thailand, Peter and the Ettinger Institute, medical school in Italy, and now this residency—had made it easy for her to stay private. In each place she had begun to develop friendships, but none of those relationships, except with her mentor, Dr. Louis Han, was strong enough to survive the next move. And gradually she began to find that when asked to talk about herself—even when she felt inclined to do so—she simply didn’t. Or couldn’t.

  Now, a woman with whom she had worked for more than two years seemed genuinely interested in who she was and how she was reacting to this most difficult case. Perhaps it was time to open up a bit.

  “A number of years ago,” she said finally, “—ten, actually—I was living in the mountains in northern Thailand, building a clinic while I was teaching and studying acupuncture and herbal medicine. An older man became my friend and my mentor. It was—you know—the father-I-never-had sort of thing. Well, he died rather suddenly. And soon after, a man quite like him, although much younger, passed through our village. He was brilliant and dashing, and interested in the same things I was. At the time, he was already world renowned in many areas of alternative healing.

  “Well, within a month, I was back in the States, living with him and his daughter, and working at his institute.…”

  Sarah debated sharing Peter’s name, but decided there was no reason to do so. “For almost three years I lived with him and the teenage daughter he ha
d brought back from Africa when she was a baby and adopted. For those three years I was the closest thing she had to a mother. Although, as I said, this man and I worked together at his institute, as far as he was concerned, I always worked for him, not with him. When the event I’ll tell you about happened, he had actually asked me to marry him. But this dark side of him—an enormous, insatiable ego, and an inflexibility that frightened me—had begun to surface more and more in our life.”

  “Go on, please,” Alma said.

  “He had a patient, a sculptor, whom he had quite literally cured of a case of rheumatoid arthritis that the man’s doctors had labeled incurable.”

  “How did he do it?”

  “Oh, dietary changes and herbs, plus some of the same sort of techniques I used yesterday with Lisa. The man went from being a cripple to playing racquetball every day.”

  “Amazing.”

  “Not to us it wasn’t. Alternative healing cures many, many patients that western physicians have given up on. We M.D.s still don’t have much of a handle on the mechanism of disease, you know. Our microscopes get bigger and bigger, and the things we can look at get smaller and smaller. We prescribe penicillin without giving it much thought. But we still don’t know why Person A got the strep throat we’re treating, or why Person B didn’t.

  “Anyhow, my friend went away for a month and left me in charge of his patients. He was treating the sculptor for headaches with herbs, acupuncture, and chiropractic adjustments. I saw the man several times and felt more concerned about him each time. He said his headaches were better, or at least no worse, but he seemed to me to be walking funny. And believe it or not, his smile seemed off center as well.”

  “That sounds like trouble.”

  “That’s what I thought. I called White Memorial and spoke to a neurologist who wanted to see him at eleven the next morning. My friend was due home from Nepal that night, but I decided his patient needed to be seen no matter what. So I made the arrangements. That may sound like an easy decision, Alma, but it wasn’t. There was still the matter of explaining why I would go against everything my friend believed in—”

  Sarah could not remember the last time she had shared with anyone that final, horrid day with Peter. But Alma Young was such a wonderful listener that the story came with surprising ease. And although Sarah told it rather quickly, the pieces she actually voiced were only snippets of what she was remembering.…

  The night that resulted in so much torment had actually felt magical. Peter listened quietly and attentively to her account of the referral of the sculptor, Henry McAllister. Peter’s response—the response she had so dreaded—was, in essence: Hey, listen. I left you responsible for the institute because you are a responsible person. You saw what you saw, made a decision, and went with it. What could possibly be wrong with doing that?

  Later that evening they made love—consuming, passionate love, the way it had been in the beginning.

  Peter had come through—for her and their sputtering relationship. She knew it wasn’t easy for him. He honestly believed that, on balance, traditional western medicine had become so lost in science, competitive pharmacology, and dehumanizing technology that it now did more harm than good. In fact, above his desk was a placard engraved:

  IATROGENIC: ILLNESS OR INJURY CAUSED BY THE

  WORDS OR ACTIONS OF A PHYSICIAN

  Now the chance was right there for him to belittle her judgment—to once again force his famous views on M.D.s and their methods down her throat. But he hadn’t taken it.

  Like Peter, she understood the miraculous potential in the relationship between healer and patient. She had great faith in the power of holistic methods to diagnose and treat. But unlike him, she had never viewed traditional medicine as a court of last—or no—resort. After all, she had once survived a nearly fatal ruptured appendix by getting airlifted to a U.S. military hospital and having emergency surgery.

  Peter was forty—a dozen years older than she. That age difference, along with his imposing size—he was six feet four—his immense drive and material successes made holding her own in their relationship a challenge and asserting herself in it almost a pipe dream. But at last Peter had chosen to listen rather than to react: to understand that his way of doing things might not be the only way.

  They took the following morning off from work and spent a good deal of it making love. By the time Sarah arrived at the institute to begin seeing a full afternoon of appointments, she was feeling more centered and positive about her life than she had in some time.

  By three o’clock, though, she began wondering why she hadn’t heard from the neurologist at White Memorial. At least some of his evaluation of Henry McAllister should have been completed by then. If her observations of the artist’s motor problems were correct, an emergency CT scan and several other tests were in order. The physician had promised to call Sarah at her office as soon as he had anything to report.

  Three-thirty … four … four-thirty …

  She checked the time again and again as she worked her way through her clients. Finally, after the last of them had left, she called White Memorial.

  “Miss Baldwin, I assumed you knew,” the neurologist said.

  “Knew what?” She felt a sudden, unpleasant tightness in her throat.

  “When I arrived at the office this morning, there was a message waiting with my answering service from your Mr. McAllister. He called at, oh, ten o’clock last night to say that he had spoken with his own medical advisor and would not be keeping his appointment with me. I thought that by medical advisor he meant you.”

  “No,” she said. “No, I’m afraid he meant someone else. Thank you, Doctor.”

  “Well, I’m sorry I couldn’t have been of more—”

  She was already lowering the receiver to its cradle. She stalked down the hall to Peter’s office. He was leaning back in his chair, his feet up on the corner of his desk.

  “Peter, why didn’t you tell me last night that you called Henry McAllister?”

  “I didn’t think it was that important.”

  “Important? I probably gave myself an ulcer agonizing over the decision to refer him.”

  “Well, now you don’t have to worry about it anymore.” He lowered his feet to the floor.

  “But you said I did the right thing.”

  “And you did. The right thing for you. But not necessarily the right thing for Henry.”

  “But how do you know? How could you tell him to cancel that appointment without even seeing him?”

  “First of all, I don’t believe there’s much an M.D. can do that our people can’t do as well or better. You know that. And second, I didn’t tell him to cancel his appointment. I told him that he should use his judgment, and that no matter what he decided, I would be available to see him all day today. He need only call and set up a time to come in.”

  “And did he call?” She felt her pulse begin pounding in her temples. Her cheeks were burning. She wanted to leap over the man’s desk and pummel the self-assuredness off his face. “Well, did he!”

  Peter’s expression tightened.

  “I—I guess in all the excitement going on here today I forgot to check.” He glanced at his message spindle and then called the receptionist. “It seems he didn’t feel the need to call,” he said as he hung up.

  “Peter, you are really a son of a bitch. Do you know that?”

  She whirled and hurried back into her office.

  “Hey, easy does it, babe,” he called after her. “Easy does it.”

  Henry McAllister’s clinic record was on her desk. She dialed his number and let the phone ring a dozen or more times. Then she dialed 911. If she was wrong, she’d look like a fool. But there was no way she could let matters drop. For the first time in three years, she felt as if she were reacting to a challenging situation like Sarah Baldwin, and not like Peter Ettinger’s flunky.

  Peter was just coming out of his office as she raced past him, down the stairs, and out of
the institute. He called to her, but she never even looked back.

  McAllister lived in a South End loft about ten blocks away. She thought briefly about looking for a cab. Then she just gritted her teeth, clenched her fists, and sprinted off.…

  “So?” Alma Young asked.

  “Pardon?”

  “So what happened to the sculptor? You can’t leave me hanging like that!”

  “Oh, sorry,” Sarah said, uncertain of precisely how much of her thoughts she had actually shared. “Well, in that particular situation, if I had accepted that what I had already done was everything I could do, the man would probably have died. The police ended up breaking into his apartment. We found him unconscious on the floor. Two hours later he was in the operating room at White Memorial. He had a slowly growing malignancy—a meningioma, actually—on the right side of his brain. And as sometimes happens, he had begun bleeding into the tumor. Pressure was building inside his skull.”

  “Thank God you reached him in time.” Alma gasped, genuinely relieved at the fate of a man whose crisis had occurred seven years before.

  Sarah smiled at the nurse’s reaction.

  “I was allowed into the operating room to watch them take the tumor out. It was really incredible. That’s when I decided I wanted to be a surgeon of some sort. Eventually I settled on OB/Gyn.”

  “And the other man? Your … um … friend?”

  Sarah shrugged. “I moved out the next day, and we haven’t spoken since.”

  “That’s quite a story.”

  “And part of the reason that I’m never comfortable accepting that I’ve done all I can for a patient.”

  “Maybe. But I still say you’ll be better off when you admit you’re only human. Doctors today have remarkable capabilities, but they still aren’t God. Never were, never will be. If you can’t come to grips with the fact that in spite of your best efforts, some of your patients are going to lose their baby, or lose their arm, or both, or worse, then sooner or later this racket’s going to eat you alive.”