Side Effects

by Michael Palmer

  "Over my dead body, " Engleson said as he raced down the hall to the stairs. "No way do you open that woman up without my being there." In less than a minute, he had joined Nixon in the scrub room. "The nurses said Stone Hands was trying to find you, " the woman said. "I was just finishing up a case down the hall when Denise grabbed me. Do I have to stay?"

  "You might want to learn from the master in there, " Engleson responded acidly, cleaning his fingernails with an orange stick. The intern smiled, nodded a thanks-but-no-thanks, and left him to finish his scrub.

  "Order a peach and you get a pear, " was Bartholomew's comment on the change in assistants. He laughed merrily at his own humor and seemed not to notice the absence of response from around the room. With Engleson handling sponges and hemostats, Bartholomew used an electric scalpel to make an incision from just below Beverly Vitale's navel to her pubis.

  The scalpel, buzzing and crackling like hot bacon grease, simultaneously sliced through the skin and cauterized bleeding vessels. Next, with the voltage turned up, he cut through a thin layer of saffron-colored fat to her peritoneum, the opaque membrane covering her abdominal cavity. A few snips with a Metzenbalim scissors, and the peritoneum parted, exposing her bowel, her bladder, and beneath those, her uterus. In a perfunctory manner, too perfunctory for Engleson's taste, the older surgeon explored the abdominal cavity with one hand. "Everything seems in order, " he announced to the room. "I think we can proceed with a hysterectomy."

  "No! " Engleson said sharply. The room froze. "I mean, don't you think we should at least consider the possibility of ligating her hypogastric artery? " He wanted to add his feelings about rushing ahead with a hysterectomy in a thirty-year-old woman with no children, but held back.

  Also unsaid, at least for the moment, was that the hypogastric ligation, while not always successful in stopping hemorrhaging, was certainly accepted practice in a case like this.

  Bartholomew was still guided by the old school-the school that removed a uterus with the dispatch of a dermatologist removing a wart. D. K.

  Bartholomew's pale blue eyes came up slowly and locked on Engleson's.

  For five seconds, ten, an eerie silence held, impinged upon only by the wheeze of air into the vacuum apparatus. The tall resident held his ground, but he also held his breath. The outburst by the older surgeon now, and there would be a confrontation that could further jeopardize the life of Beverly Vitale. Then, moment by moment, Engleson saw the blaze in Bartholomew's eyes fade. "Thank you for the suggestion, doctor,

  " the surgeon said distantly. "I think perhaps we should give it a try."

  The relieved sighs from those in the room were muffled by their masks.

  "You or me? " Engleson asked. "It… it's been a while since I did this procedure, " Bartholomew understated. "Don't worry, we'll do it together."

  In minutes, the ligation was complete. Almost instantly, the bleeding from within the woman's uterus began to lessen. "While we're waiting to see if this works, " Engleson said, "would you mind if I got a better look at her tubes and ovaries?"

  Bartholomew shrugged and shook his head. Engleson probed along the fallopian tubes, first to one ovary and then to the other. They did not feel at all right. Carefully, he withdrew the left ovary through the incision. It was half normal size, mottled gray, and quite firm. This time, it was his eyes that flashed. You said everything was in order.

  Bartholomew sagged. There was a bewildered, vacant air about him, as if he had opened his eyes before a mirror and seen a painful truth. The woman's right ovary was identical to her left. "I don't think I've ever seen anything quite like this, " Engleson said. "Have you? " No, well, not exactly-, Pardon?"

  "I said I hadn't either."

  There was an uncertainty, a hesitation, in the older man's words.

  He reached over and touched the ovary. "You sure? " Engleson prodded. "I … I may have felt one once. I'm trying to remember. Do you suggest a biopsy? " Engleson nodded. "A wedge section?"

  Another nod. The man's confidence was obviously shaken. By the time the wedge biopsy was taken, the bleeding had slowed dramatically. As Engleson prepared to close the abdominal incision over the uterus he had just preserved, he sensed the irony of what was happening tighten in his gut. The uterus was saved, true. A fine piece of surgery. But if the pathology in Beverly Vitale's ovaries was as extensive as it appeared, the woman would never bear children anyhow. "Denise, " he said, "could you find out who's on for surgical path this month, both the resident and the staff person, okay?"

  "Right away."

  Engleson glanced at the peaceful face and tousled hair of the young cellist. Some women try for years to get pregnant, never knowing whether they can or not, he thought. At least you'll know. Glumly, he began to close. Twenty minutes later, the two surgeons shuffled into the doctor's locker room. "Dr. Bartholomew, have you been able to remember where you might have encountered ovarian pathology like this woman's?"

  "Oh, yes, well, no. I… what I mean is I don't think I've ever seen anything like them."

  "You look as if you want to say something more."

  "I may have felt something like them once. That's all."

  "When? On whom? " There was some excitement in Engleson's voice. D. K. Bartholomew, MD, Fellow of the American College of Surgeons and Diplomate of the American College of Obstetrics and Gynecology, shook his head. "I… I'm afraid I don't remember, " he said. "What are you talking about?"

  "It was surgery for something else. Maybe removal of a fibroid tumor.

  The ovaries felt like this woman's did today, but there was no one around to consult, and I think I had another case or two left to do and …"

  "So you just ignored them and closed?"

  "I felt they were probably a normal variant."

  "Yeah, sure. Did you mention them on your operative note?"

  "I… I don't remember. It might have been years ago."

  The wall telephone began ringing. "Dr. Bartholomew, " Engleson said, allowing the jangle to continue. "I don't think you should operate anymore." With that he turned and snatched up the receiver. "Dr.

  Engleson, it's Denise. I called pathology."

  "Yes?"

  "I couldn't find out who the resident is on surgicals, but the staff person is Dr. Bennett."

  C'Good."

  "Excuse me?"

  "I just said that's good. Thanks, Denise."

  "Thank you for what you did in there, Doctor. You made my day."

  Kate's back was arched over the pillows beneath her hips as Jared knelt between her legs and used her buttocks to pull himself farther inside her. Again and again he sent jets of pleasure and pain deep into her gut and up into her throat. Her climax grew like the sound of an oncoming train-first a tingle, a vibration, next a hum, then a roar. With Jared helping, her body came off the pillows until only her heels and the back of her head were touching the carpet. Her muscles tightened on him and seemed to draw him in even deeper. He dug his fingers into the small of her back and cried out in a soft, child's voice. Then he came, his erection pulsing in counterpoint to her own contractions. "I love you," he whispered. "Oh, Katey, I love you so much." Gently, he worked his arms around her waist, and guided her onto her side, trying to stay within her as long as possible. For half an hour they lay on the soft living room carpet, their lover's sweat drying in the warmth from the nearby wood stove. From the kitchen, the aroma of percolating coffee, forgotten for over an hour, worked its way into the sweetness of the birch fire. A cashmere blanket, one of the plethora of wedding gifts from Jared's father, lay beside them. Kate pulled it over her sleeping husband and then slipped carefully from underneath. For a time, she knelt there studying the face of the man who had, five years before, arranged to have himself and a dozen roses wheeled under a sheet into her autopsy suite in order to convince her to reconsider a rebuffed dinner invitation. Five years. Years filled with so much change-so much growth for both of them. She had been a nervous, overworked junior faculty member then, a
nd he had been the hotshot young attorney assigned by Minton/Samuels to handle beleaguered Metropolitan Hospital. The memory of him in those days-so eager and intense brought a faint smile.

  Kate reached out and touched the fine creases that had, overnight it seemed, materialized at the corners of her husband's eyes. "A year, Jared? " she asked silently. "Would a year make all that much difference? You understand your own needs so well. Can you understand mine?"

  Almost instantly another, far more disturbing question arose in her thoughts. Did she, in fact, understand them herself?

  Silently, she rose and walked to the picture window overlooking their wooded backyard. Superimposed on the smooth waves of drifted snow was the reflection of her naked body, kept thin and toned by constant dieting and almost obsessive exercise. On an impulse, she turned sideways and forced her abdomen out as far as it would go. Six months, she guessed, maybe seven. Not too bad looking for an old pregnant lady.

  Fifteen minutes later, when the phone rang, Kate was ricocheting around the kitchen preparing brunch. The edge of her terry-cloth robe narrowly missed toppling a pan of sweet sausages as she leapt for the receiver, answering it before the first ring ended. Nevertheless, through the door to the living room, she saw Jared stir from the fetal tuck in which he had been sleeping and begin to stretch. "Hello, " she answered, mentally discarding the exotic plans she had made for awakening her husband. "Dr.

  Bennett, it's Tom Engleson. I'm a senior resident on the Ashburton Service at Metro. Do you remember me?"

  "Of course, Tom. You saw me at the Omnicenter once. Saved my life when Dr. Zimmermann was away."

  "I did? " There was a hint of embarrassment in his voice. "What was the matter?"

  "Well, actually, I just needed a refill of my birth control pills. But I remember you just the same. What can I do for you? " Her mental picture of Engleson was of a loose, gangly man, thirty or thirty-one, with angular features and a youthful face, slightly aged by a Teddy Roosevelt moustache. "Please forgive me for phoning you at home on Sunday."

  "Nonsense."

  "Thank you. The reason I'm calling is to get your advice on handling a surgical specimen. It's one you'll be seeing tomorrow, a wedge section of a patient's left ovary, taken during a hypogastric artery ligation for menorrhagia."

  "How old a woman? " Reflexively, Kate took up a pen to begin scratching data on the back of an envelope. So doing, she noticed that Jared was now huddled by the wood stove with Roscoe, their four-year-old almost-terrier and the marriage's declared neutral love object. "Thirty,

  " Engleson answered. "No deliveries, no pregnancies, and in fact, no ovaries."

  "What?"

  "Oh, they're there. But they're unlike any ovaries I've ever seen before. Dr. Bartholomew was with me-the woman is his patient-and he has never seen pathology like this either."

  Kate pulled a high stool from beneath the counter and wrapped one foot around its leg. "Explain, " she said. "Well, whatever this is is uniform and symmetrical. We took a slice from the left ovary, but it could just as well have been the right. Shrunken, the consistency of… of a squash ball-sort of hard but rubbery. The surface is pockmarked, dimpled."

  "What color? " Kate had written down almost every word. "Gray. Grayish brown, maybe."

  "Interesting, " she said. "Does what I've described ring any bells?"

  "No. At least not right off. However, there are a number of possibilities. Any idea as to why this woman was having menorrhagia?"

  "Two reasons. One is a platelet count of just forty-five thousand, and the other is a fibrinogen level that is fifteen percent of normal."

  "An autoimmune phenomenon? " Kate searched her thoughts for a single disease entity characterized by the two blood abnormalities.

  An autoimmune phenomenon, the body making antibodies against certain of its own tissues, seemed likely. "So far, that's number one on the list,

  " Engleson said. "The hematology people have started her on steroids."

  "Was she on any medications?"

  "Hey, Kate." It was Jared calling from the living room. "Do you smell something burning?"

  "Nothing but vitamins, " Engleson answered. Kate did not respond.

  Receiver tucked under her ear, she was at the oven, pulling out a tray of four blackened lumps that had once been shirred eggs-Jared's favorite. "Shit, " she said. "What? " Both Jared and Tom Engleson said the word simultaneously. "Oh, sorry. I wasn't talking to you." A miniature cumulonimbus cloud puffed from the oven. "Jared, it's all right, " she called out, this time covering the mouthpiece. "It's just … our meal. That's all."

  "Dr. Bennett, if you'd rather I called back…"

  "No, Tom, no. Listen, there's a histology technician on call. The lab tech on duty knows who it is. Have whoever it is come in and begin running the specimen through the Technichron. That way it will be ready for examination tomorrow rather than Tuesday. Better still, ask them to come into the lab and call me at home. I'll give the instructions myself. Okay?", Sure. Thanks."

  "No problem, " she said, staring at the lumps. "I'll speak to you later."

  "Shirred eggs? " Jared, wrapped in the cashmere blanket, leaned against the doorway. Roscoe peered at her from between his knees. Kate nodded sheepishly. "I sort of smelled the smoke, but my one track brain was focused on what this resident from the hospital was saying, and somehow, it dismissed the smoke as coming from the wood stove. I… I never was too great at doing more than one thing at once."

  "Too bad you couldn't have chosen to let the resident burn to a crisp and save the eggs, " he said. "Next time."

  "Good. Any possibilities for replacements"

  "Howard Johnson's?"

  "Thanks, but I'll take my chances with some coffee and whatever's in that frying pan. You sure that wasn't Yoda on the phone?"

  "Jared…"

  He held up his hands against her ire. "Just checking, just checking," he said. "Come on, Roscoe. Let's go set the table." Kate noted the absence of an apology, but decided that two in one day was too much to ask. More difficult to accept, however, was Jared's apparent lack of interest in what the call was about. It was as if by not talking about her career, her life outside of their marriage, he was somehow diminishing its importance. In public, he took special pride in her professionalism and her degree. Privately, he accepted it as long as it didn't burn his eggs. Almost against her will, she felt frustration begin to dilute the warmth and closeness generated by their lovemaking. She walked to where her clothes were piled in the living room and dressed, silently vowing to do whatever she could to avoid another blowup that day. Minutes later, the crunch of tires on their gravel driveway heralded a test of her resolve. Roscoe heard the arrival first and bounded from his place by the stove to the front door. Jared, now in denims and a flannel work shirt, followed. "Hey, Kate, it's Sandy, " he called out, opening the inside door. "Sandy? " Dick Sandler, Jared's roommate at Dartmouth, had been best man at their wedding. A TWA pilot, he lived on the South Shore and hadn't been in touch with them for several months. "Is Ellen with him?"

  "No. He's alone." Jared opened the storm door. "Hey, flyboy, " he called in a thick Spanish accent, "welcome. I have just what you want, sefior, a seexteen-year-old American virgin. Only feefty pesetas." Sandler, a rugged Marlon Brando type, exchanged bear hugs with Jared and platonic kisses with Kate, and then scanned what there was of their brunch.

  "What, no bloodies?"

  Kate winced before images of the two men, emboldened by a few "bloodies, " exchanging off-color jokes she seldom thought were funny and singing "I Wanna Go Back to Dartmouth, to Dartmouth on the Hill." Invariably, she would end up having to decide whether to leave the house, try to shut them off, or join in. When Ellen Sandler was around, no such problem existed. A woman a few years older than Kate, and Sandy's wife since his graduation, Ellen was as charming, interesting, and full of life as anyone Kate had ever known. She was a hostess with poise and grace, the mother of three delightful girls, and even a modestly successful bus
inesswoman, having developed an interior design consulting firm that she had run alone for several years from their home and more recently from a small studio cum office in town. Sandy, with his flamboyance, his stature as a 747 captain, and his versitile wit, was the magnet that drew many fascinating and accomplished people into the Sandlers' social circle. Ellen, Kate believed, was the glue that kept them there. "So, Sandy, " she said, dropping a celery stick into his drink and sliding it across the table, "what brings you north to Boston?

  How are Ellen and the girls? " It was at that moment that she first appreciated the sadness in his eyes. "I… well actually, I was just driving around and decided to cruise up here. Sort of a whim. I… I needed to talk to Jared… and to you."

  "You and Ellen? " Jared's sense of his friend told him immediately what to ask. "I… I'm leaving her. Moving out." Sandler stared uncomfortably into the center of his drink. At his words, Kate felt a dreadful sinking in her gut. Ellen had stated on many occasions and in many ways the uncompromising love she bore for the man. How long had they been married, now?

  Eighteen years? Nineteen, maybe? "Holy shit, " Jared whispered, setting a hand on Sandler's forearm. "What's happened?"

  "Nothing. I mean nothing dramatic. Somewhere along the way, we just lost one another."

  "Sandy, people who have been married for almost twenty years don't just lose one another, " Kate said. "Now what has happened? " There was an irritability in her voice which surprised her. Jared's expression suggested that he, too, was startled by her tone. Sandler shrugged.