Natural Causes

by Michael Palmer

  “Not really. If we were in Beijing, folic acid, beta-carotene, cupric oxide, and many of the other components of our standard prenatal vitamins would be considered just as far out.”

  “Point taken. This hospital is certainly tailor-made for you, isn’t it.”

  “I know you have some misgivings, but I think we deliver the best patient care of any hospital in the city.”

  “Maybe so. We’re certainly becoming the leading hospital for treating active labor complicated by DIC, I’ll say that much for us.”

  Sarah’s beeper sounded, ordering her to call extension 2350.

  “That’s the birthing room,” she said. “I’ve got to go.”

  “Don’t worry about your trash. I’ll take care of it.”

  “Thanks. Andrew, do you think we should form some sort of committee to begin investigating these cases?”

  “I think that’s a splendid idea. If there’s one thing this hospital could use more of, it’s committees.”

  “I’m serious. I mean, it’s not like an epidemic or anything. But two such similar and unusual cases. It certainly makes you wonder. Well, as they say in the postal service, I’ve got a delivery to make. We’ll talk about all this more later, won’t we?”

  “You bet,” Andrew said.

  He watched until Sarah had left the cafeteria. Then he took an envelope from his lab coat pocket and tapped it thoughtfully against his palm.

  “Not two cases, m’dear,” he muttered. “Make that three.”

  CHAPTER 8

  THE SURGICAL SENIOR RESIDENTS’ OFFICE WAS AN eight-foot square, windowless box that had once served the Suffolk State Hospital as a storage closet. To Andrew Truscott, occupying the office at all, let alone sharing it with two others, was an indignity quite in keeping with those he already had to endure for being associated with the Medical Center of Boston. This should have been his year. He should have been chief resident and after that a staff surgeon on a tenure track. There was no justification for the flake who had been chosen over him. At any normal hospital it just wouldn’t have happened.

  After a year of postgraduate medical training in western Australia, he had met and married an American tourist and elected to move to the States. He expected the research and practice opportunities for a surgeon—and the income—would be much greater there. The Medical Center of Boston was not his first choice for a residency, but he was not disappointed to accept Eli Blankenship’s offer of a position. After all, he reasoned, it was still a Boston teaching hospital.

  Three months into his first year of surgical training at MCB, Truscott began discreetly searching for vacancies in the residency programs at other hospitals. But the only available slots were at borderline facilities with even less prestige than MCB. So he stayed.

  He detested Glenn Paris and the carnival-like atmosphere that surrounded the place. He disliked working at a hospital that so deemphasized clinical research that it was considered by many academicians to be something of a joke. And most of all, after investing five years of his life, he resented being passed over because he was, in the words of his department head, “too inflexible and intolerant.” He was then informed that there was neither the money nor the research/office space to keep him on staff when his residency was over. Cut loose by Crunchy Granola General: the final ignominy.

  Now Andrew Truscott sat in the tiny office, sipping orange juice from a Styrofoam cup and rereading a letter that had been routed to him by the head of the surgical service. Dated June 23, the letter was from the medical examiner’s office in New York City. It was the department head’s request that Andrew, as chairman of the surgical morbidity/mortality committee, look into the matter and recommend what departmental action, if any, was indicated.

  DEAR DOCTOR:

  First, let me apologize for the delay in getting this letter off to you. Budget cutbacks have hit our agency and greatly slowed the laboratory, cytologic, and clerical work necessary to complete a case. And unfortunately, our caseload continues to grow.

  The case I write you about is a twenty-four-year-old woman, Constanza Hidalgo, who was killed when the car she was driving was struck by a bus in November of last year. The details surrounding this case, and the findings of my department, are presented in the enclosed documents. As you will note, the woman appears to have been in active labor at the time of her death. Our laboratory and microscopic studies also indicate that she was suffering from an acute hemorrhagic disorder, most likely disseminated intravascular coagulopathy.

  A couple of months ago, one of my staff pathologists was attending a national meeting at which he heard another pathologist mention a case of fatal DIC complicating active labor. Quite incidentally, he returned to work and mentioned the case to me. The hospital at which that woman died was yours. I have been able to learn from contacting her family that Miss Hidalgo was also from Boston and was being followed in your outpatient department. Whether this is coincidence or not, I do not know.

  Please use the enclosed information in any way you wish, and do keep me posted of any developments. Certainly DIC occurs in some pregnancies, but in my experience not without a very obvious cause.

  Best regards,

  MARVIN SILVERMAN, M.D.

  Associate Medical Examiner

  Andrew opened the copy of Constanza Hidalgo’s MCB chart. The record dated back to the woman’s childhood, but contained no medical history of particular interest. Her prenatal appointments were kept without exception, and nothing in the clinic notes gave a hint as to the disaster awaiting her and her fetus.

  Truscott had already reviewed the chart several times since receiving Silverman’s letter. Now, though, he read even more carefully, running his finger down each page until he found a brief outpatient note dated August 10. The note read:

  Patient doing well and continuing part-time work as a waitress. Some complaints of fatigue, but no ankle edema, abdominal pain, urinary frequency, headaches, blurred vision, or unusual bleeding.

  P.E.—normal vital signs, unremarkable cardiac exam, no edema, 22 wk. uterine fundus. Fetal heart heard easily at 140/min.

  Impression: 22-week intrauterine pregnancy

  Plan: Ptnt. elects to switch from prenatal multivits to herbal supplements. Three month supply and instructions given.

  Return to Clinic: 4 wks.

  The note was signed: S. Baldwin, M.D.

  Truscott opened his briefcase and withdrew copies of the outpatient records of Lisa Summer and Alethea Worthington, the twenty-two-year-old woman who had gone into labor on the morning of April 4, had developed horrible DIC, and had essentially bled to death in the delivery room. Like Constanza Hidalgo, Alethea Worthington had been seen once in the obstetrics clinic by Sarah. And like both Lisa and Constanza Hidalgo, she had elected to take Sarah’s herbal prenatal supplements.

  Setting his feet on the corner of his desk, Truscott mulled over the situation. No doubt, the fact that each of the three DIC victims had taken Sarah’s herbal supplement was coincidence. She had seen dozens of patients—possibly hundreds—in the clinic during her two years at MCB, and most of them had gone on to perfectly normal deliveries.

  Still, he thought, until the actual cause of the DIC could be determined, the possibility of using the coincidence to further undermine the public confidence in MCB was most intriguing—especially in the hands of Jeremy Mallon. Truscott had almost not even bothered telling Mallon about the lights going out on Glenn Paris. But he had, and through Mallon, the attorney who represented the Everwell HMO, the information had found its way to Axel Devlin. The acid-penned reporter had done the rest.

  Truscott opened the Herald. He did not know how much Mallon would be paying him for the Changeover Day story, but the equivalent of two weeks’ salary was a decent guess. The money was certainly welcome. But more important was the matter of a letter from Everwell guaranteeing Andrew a surgical staff position should the HMO acquire the Medical Center of Boston. Mallon had been generous enough with his payments, but he had yet
to deliver on that promise. Perhaps this DIC business was just the lever Andrew needed to pry that letter loose.

  Truscott slid a Gaulois from the sterling cigarette case a former lover had given him, lit up, and then dialed Jeremy Mallon’s private line.

  “Greetings, Mallon, Truscott here,” he said. “I’m glad to see you made such quick use of the Changeover Day tape. Listen though. I have something more for you. Something quite good, actually.… No, I don’t want to discuss it over the phone.… That will be fine. Just fine. Oh, one more thing. A letter that was promised me.… Yes, precisely that letter. Have it with you when we meet, will you?… That’s splendid. Just splendid.”

  Truscott hung up, gathered the Xeroxed records together, and locked them in his briefcase. Of all the payoffs from Mallon, this promised to be the sweetest. That his disclosures might cause problems for Sarah Baldwin troubled him very little. As a surgeon, she was as capable and self-assured as any woman he had known in medicine. But she also represented everything he found distasteful about the Medical Center of Boston. And now, with this Lisa Summer thing, there would be no living with her or the rest of the oddball element at the hospital. She and her cronies were basking in the sunlight of her success like a herd of overfed sheep. The timing was perfect to seed the clouds for a little rain.

  Besides, Sarah’s ego had survived the other tidbits about her he had fed to Mallon. It would survive this batch as well. The real prizes at stake were Glenn Paris and his hospital sideshow. Already wounded and weakened, their survival was not nearly so certain.

  As he headed out to check on his service, Andrew Truscott was singing softly to himself “Oh, MCB is falling down, my fair lady …”

  CHAPTER 9

  July 5

  SARAH HAD NEVER MUCH LIKED GETTING DRESSED UP. As far as she could tell, that displeasure dated back to Sunday mornings in Ryerton, the rural New York town where she was raised. Her mother, perhaps responding to the stigma of having had a daughter out of wedlock, spent at least an hour each Sunday getting her ready for church. Sarah’s dresses were pressed and perfect, her shoes spotless. Her hair was often braided half a dozen times before every strand was deemed in place. And always—at least until the early symptoms of her mother’s Alzheimer’s disease began to appear—the outfit was topped with a large, white bow.

  Now Sarah twisted and turned before her bedroom mirror, trying to assess the third—or fourth—in the series of outfits she had tried on. It was eight o’clock in the morning. In fifteen minutes her cab to the hospital was due. Two days before, instigated no doubt by Glenn Paris and his PR department, the story had broken in both Boston papers about how eastern and western medicine had joined forces at the Medical Center of Boston to save the life of a young woman. However, the positive publicity for MCB was short-lived.

  A day later, a small article, under no byline, had appeared in the Herald. Unnamed but reliable sources had reported that the unusual and cataclysmic obstetrical bleeding complication was not the first but the third such to occur in an MCB patient within the past eight months. And unlike Lisa Summer, the source further related, both of the previous cases had died.

  Glenn Paris’s rapid response to the story had been to schedule a press conference for nine o’clock on the morning of July 5. With Independence Day being relatively slow for news, his carefully prepared statement was carried by every Boston radio and television station. Presenting at the session, he announced, would be Drs. Randall Snyder and Eli Blankenship, chiefs of the departments of obstetrics and internal medicine at MCB, and Dr. Sarah Baldwin, the resident who had contributed so uniquely to saving the life of Lisa Summer.

  At eight-fifteen, when the doorbell rang, Sarah was wearing leather flats, a gathered madras skirt, a beige cotton blouse, and a hand-embroidered Burmese belt, topped by a loose-fitting turquoise blazer. Her major concession to the formality of the occasion was wearing panty hose—not comfortable in any month, but even less so in July.

  “Coming,” she shouted into the intercom.

  She snatched up the ornate brass earrings fashioned for her by an Akha craftsman and slipped them in place as she hurried down the stairs. Though she admired Glenn Paris, being a performer in one of his extravaganzas was not Sarah’s style. But the report of a third DIC case in an MCB patient did demand a quick, reassuring-but-informative response from the hospital. And Paris felt she could help accomplish that. What had been a curiosity with the first patient, then a serious concern with the second, had suddenly become a terrifying priority.

  The cabbie let her off on the street side of the Thayer Building. Glenn Paris met her in his outer office and greeted her warmly. As always, he was noticeably well dressed. Today, his tan suit, sky-blue shirt, and red power tie seemed tailor-made for television. He appeared somewhat tense, but there was a confident, dedicated energy about him that Sarah found disarming and attractive. It was the same sort of aura that had initially drawn her to Peter Ettinger.

  “Sarah, do you have any idea who might have leaked this information to the Herald?” Paris asked.

  “No, sir.”

  “Neither does anyone else I’ve talked to. A letter about the Hidalgo case comes in from the New York City Medical Examiner to our chief of surgery. He sends copies to pathology, obstetrics, hematology, internal medicine, the morbidity and mortality committee, and then, almost as an afterthought, to me. No sooner do I read about the case in my copy of the letter, than I read it in the damn paper. Now, isn’t that just something! Each of the people I have spoken with gave a Xerox of the letter to one or more others. At last count, any of twenty-five or thirty people could have leaked it. They all say they had no idea it was that important. Not important! Well, I’m going to get him, Sarah. This time whoever it is has gone too far. Mark my words, I’m going to get him.”

  “I’m sure you will,” Sarah said softly.

  Although she understood his anger, she was not comfortable with it. She came close to reminding him that, regardless of the source of the news leak, regardless of the negative publicity, something very serious and frightening was going on. And the Medical Center of Boston did seem to be right in the middle of it.

  When they left the building on the campus side, they saw a fairly large number of people—hospital staff, reporters, and one television camera crew—streaming across toward the auditorium.

  “Looks like we’re going to have quite a turnout,” Paris said. “That’s good. We’ve got to let the public know we’re on top of this thing. Our foundation grant is looking very good, but it’s not a lock. Negative publicity can still hurt us.”

  “Have you met with any members of the medical staff yet?” she asked, hoping to bring him back to the real issue at hand.

  “Dr. Blankenship and I have been huddled almost continually since this article broke. I have an old friend who’s an administrator at the Centers for Disease Control in Atlanta. I put Eli in touch with him, and he tells me they’re trying to get someone up here in time for—”

  Paris stopped short, his hand raised to keep her silent. He motioned her into the shadow of the outpatient building. Ahead of them, just at the corner of the building, a well-dressed man with a briefcase in one hand was engrossed in intimate conversation with one of the hospital’s maintenance workers. Two days before, the maintenance staff’s wildcat job action had crumbled before Paris’s threat to fire everyone involved. Fliers damning his action were subsequently posted throughout the hospital. And although they were all back at work, none of the maintenance staff had moved to take them down.

  “You know that guy in the suit?” Paris whispered.

  Sarah shook her head. The man, perhaps in his early forties, had a slight build, blow-dried hair, and a distinctively aquiline profile. The diamond in the ring on the small finger of his left hand was easily noticeable from where they were standing, some fifty feet away.

  “I would say he’s either a car salesman or a lawyer,” Sarah said.

  “What he is, is scum,” Pari
s responded. “But he is a lawyer. And as a matter of fact, he’s also an M.D.”

  “I’m impressed.”

  “Don’t be. His name’s Mallon. Jeremy Mallon. Ever heard of him?… No? Good. He’s a bigtime ambulance chaser who is also on retainer for Everwell. I think he even owns a piece of their action. For months now, I’ve suspected he’s been behind some, if not all, of the trouble we’ve been having. This little tête-à-tête we’re watching goes a long way toward proving me right.”

  Suddenly Mallon caught sight of them. A word from him sent the maintenance worker scurrying off in the other direction. Paris moved in quickly, with Sarah a few feet behind.

  “You son of a bitch,” Paris snapped. “I knew it was you.”

  “I have no idea what you’re talking about,” Mallon said unctuously. “And I would caution you to watch what you call anyone in public.”

  Even if Paris had not prejudiced her, Sarah knew she would have instantly disliked the man.

  “That power failure was no damn accident,” Paris raged. “Neither was that bogus strike. I thought it, now I know it. I hope you paid that worm well, shyster, because as of now, he’s out of a job.”

  Paris had raised his voice enough so that several of those headed toward the auditorium stopped to watch. Two MCB administrators, one of whom Sarah recognized as Colin Smith, the hospital’s chief financial officer, hurried toward them.

  “Paris, you’re way out of line,” Mallon said. “I don’t need to make any trouble for you. You do a perfectly good job of that all by yourself.”

  “Get out of here right now.”

  “Nonsense. There’s a publicly announced press conference that I want to attend. It will be fascinating to see how you plan to tiptoe around the fact that this place is becoming a death house.”

  “Why, you filthy—”

  The two administrators stepped in front of Paris before he could lunge at the man.