Natural Causes

by Michael Palmer

  “I—I should have told you sooner, I guess,” Sarah responded.

  “Nonsense. I’m just a natural-born alarmist. I would suspect that you’re right—the low pressure will probably turn out to be due to a little dehydration. You bring the OB tray. I’ll bring the pedi one.”

  As they stepped from the car, they heard a siren, probably a block or so away. They were still on the tree belt when a police cruiser, strobes flashing, screeched around the corner and skidded to a halt behind the Volvo. A uniformed officer jumped out and, ignoring them, sprinted up toward the front door.

  “Excuse me,” Snyder called out as they hurried after the policeman, “I’m Dr. Randall Snyder from the Medical Center of Boston. What’s going on?”

  “I don’t know, Doc,” the officer said, panting. “But I’m glad you’re here. We got a nine-one-one call that a woman was in serious trouble here and needed an ambulance. One should be arriving any minute.”

  “The woman’s name?” Sarah asked, aware of a sudden knot in her chest.

  The policeman rang the bell several times and then began rapping on the glass panel of the front door.

  “Summer,” he said. “Lisa Summer.”

  … 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 …

  Randall Snyder’s words echoed in her thoughts as Sarah followed the policeman and Heidi Glassman up the broad staircase. From above, she could hear Lisa’s sputtering cough and cries of pain. And even before she entered the bedroom, she could smell the blood.

  Lisa, sitting splay-legged on her futon, was hemorrhaging from her nostrils and mouth. Fresh and drying blood covered the front of her nightgown and was spattered on the futon, floor, and wall. But even more disturbing to Sarah was the glazed fear in the girl’s eyes. It was a look she had seen only a few times before in her medical career, most recently in a fifty-year-old postoperative woman who was about to have a massive coronary. Within minutes that woman was in full, irreversible cardiac arrest.

  “It started shortly after I called you,” Heidi said as Sarah and Randall Snyder gloved, then knelt beside Lisa to begin their evaluation. “I would have called you back, but I was sure you were on your way. Everything was going fine—except for that blood pressure thing I told you about. Then all of a sudden Lisa began complaining of severe pain in her right arm and hand. During one of her contractions, she had bitten the inside of her cheek. At first there was just a little bleeding from the cut; then suddenly there was a lot. Just before you arrived she threw up, and it was all bright-red blood. I think what she threw up may have come from the back of her nose, but how do you tell?”

  “Her pressure holding?” Sarah asked as she locked Lisa’s left arm in hers and adjusted the cuff to take another reading.

  “It’s down a little more. About eighty systolic. I can’t hear it in her right arm at all.”

  Sarah glanced at Lisa’s right arm and immediately knew the reason why. She could tell that Snyder, who was feeling for a pulse over the radial artery at the wrist and the brachial artery in the crook of the elbow, knew as well. The arm, from at least the elbow to the hand, was dusky and mottled. The fingers were a deeper gray, the fingertips almost black. For whatever reason, the arteries and smaller arterioles supplying blood to that limb had become blocked. To a lesser extent, the blood flow to Lisa’s left arm and both legs seemed compromised as well.

  “Still eighty,” Sarah said. “Lisa, I know this is scary for you. But please, just do your best to stay as calm as you can while we figure things out. This is the man I told you about, Dr. Snyder. He’s my chief.”

  From a distance, they could hear the whoop of the approaching ambulance.

  “Wh—what’s happening to me?” Lisa asked, as bewildered as she was frightened.

  Sarah and her chief exchanged glances. Though the diagnosis needed laboratory confirmation, she knew he suspected, as did she, that they were witnessing the rapid evolution of DIC—disseminated intravascular coagulopathy—the most dramatic and horrifying of all blood-clotting emergencies.

  Sarah asked for a washcloth and handed it to Lisa.

  “Here, Lisa, blow your nose in this as hard as you can. Once we get the big clots out, the pressure you put on your nose will be more effective in stopping the bleeding.”

  Lisa, still spitting crimson into a bucket, did as she was asked. Immediately the center of the washcloth was soaked with blood. But there were no clots. None at all. The diagnosis of DIC was now even more likely. For whatever reason, large numbers of tiny clots had begun forming within Lisa’s bloodstream. Those circulating microdots were beginning to join together and obstruct the arteries supplying blood to her arms and legs, placing the limbs in great jeopardy.

  Even more frightening than the circulatory blockage was the speed with which the abnormal clots were using up the factors necessary for normal blood coagulation. With those factors badly depleted, bleeding from any source was now life-threatening. And a fatal stroke caused by a cerebral hemorrhage was a terrifying possibility.

  “Lisa, I’ll explain what we think is going on in just a second,” Sarah said. “Has your water broken?”

  Lisa shook her head.

  “I’m very frightened,” she managed. “My hand is killing me.”

  “I understand. Just give us a moment.”

  Sarah looked over at her chief.

  “We need that ambulance to get here, we need an IV, and we need a hematologist or an internist—preferably both—waiting for us at MCB,” Snyder said.

  There was still the typical calmness in his voice, but his expression was grim. This would be the second case of DIC in a Medical Center of Boston active labor patient in less than three months. The previous case—not one of Snyder’s or Sarah’s—had died on the operating table as her physicians desperately tried to deliver her child by cesarean section. With hemorrhaging into the placenta, the infant was severely brain damaged by the time it could be extracted and was pronounced dead before its first week of life was through. The cause of the DIC had never been determined.

  “Lisa, please listen,” Snyder went on. “And please try not to be too frightened. We believe that something has caused your blood-clotting system to stop working properly. We need to get you to MCB for diagnosis and treatment as soon as possible.”

  “What something? What caused this?” she asked. “Will my baby be all right?”

  “We’ll know better about your baby as soon as we get a monitor on,” Snyder said. “At this moment I can hear its heartbeat clearly.”

  “His,” Lisa said hoarsely.

  “Pardon?”

  “His. Dr. Baldwin sent me for an ultrasound. His name’s going to be Brian.”

  They heard the ambulance siren cut off as it pulled up in front of the house.

  “Lisa,” Snyder said, “I know it’s not easy, but the more relaxed you can be, the slower your blood will flow, and the better chance we’ll have of stopping the bleeding. Is there someone you want us to call? Your parents? A brother or sister?”

  Lisa thought for a moment and then resolutely shook her head.

  “Heidi’s my family,” she said.

  “Okay. Sarah, do you want to go and call MCB?… Sarah?”

  Eyes closed, Sarah had placed her second, third, and fourth fingertips over Lisa’s left radial artery, trying to assess the six pulses located there, which were used only by acupuncturists and practitioners of traditional Chinese medicine. The left pulses reflected the condition of the heart, liver, kidney, small intestine, gallbladder, and bladder. Many times, especially in patients with vague, nonspecific complaints, careful palpation of the three superficial and three deep pulses at each wrist gave a clue as to the source of the symptom and helped direct placement of the acupuncture needles.

  “Oh, sorry,” she said. Her exam, influenced by Lisa’s agitated state and the profound disturbance in blood flow, was not revealing. And with n
o circulation at all on the right, there was little point in checking that side. “I’ll call Dr. Blankenship and have him waiting for us with someone from heme.”

  “Thank you.”

  The rescue squad raced into the crowded room. After a brief explanation from Randall Snyder, they hoisted Lisa onto their litter and set about establishing an IV in her left arm. Sarah started for the hallway phone.

  “Dr. Baldwin, don’t leave me,” Lisa begged.

  “I’ll be right back.”

  “Then please just tell me: Am I going to die?”

  Sarah hoped there would be more conviction in her voice than she was feeling at that moment.

  “Lisa, this is not the time for you to be thinking like that at all,” she said. “It’s very important that you stay centered and focused. You’ve got to be able to use that internal visualization stuff we’ve been working on. Do you think you can do that?”

  “I—I was doing it before all this started. Once I actually saw my cervix. I really did.”

  “I believe you. That’s great. Well, now you’ve got to start doing it again. Concentrate on seeing your bloodstream and the structures within your hands. It’s very important. I’ll help you once we reach MCB. Dr. Blankenship, the internist who will be treating you, is a wonderful doctor. I’m going to call him now. He and a hematologist will be waiting for us. Together we’ll get on top of this thing.”

  “Promise?”

  Sarah swept some errant wisps of hair from Lisa’s damp forehead.

  “I promise,” she said.

  “IV’s in,” one of the rescue squad announced. “Ringer’s lactate at two-fifty. You want her sitting up like this, Doc?”

  Snyder nodded. “Sarah, why don’t you let me make that call, and you ride to MCB in the ambulance with Lisa. I’ll bring Heidi with me.”

  As she accompanied the rescue squad out of the house, doing what she could to stem the flow of blood from Lisa Summer’s nose and mouth, Sarah tried to remember what she could of the other woman who had developed DIC. Normal pregnancy, normal labor right up to the final stage, then a sudden, catastrophic alteration of her body’s coagulation system. Just the way it was happening today.

  And as she helped load Lisa into the ambulance, the question that had confounded that woman’s doctors burned in Sarah’s mind: Why?

  CHAPTER 4

  SIX OF THE NINE SUFFOLK STATE HOSPITAL BUILDINGS originally purchased by the Medical Center of Boston were still in use. Two of the others had been razed and replaced with parking facilities. The third, a crumbling six-story brick structure with the name CHILTON etched in concrete over its entrance, had been abandoned and boarded up when Sarah began her training, and remained so—a mute reminder of the hospital’s ongoing financial difficulties.

  The Chilton Building and garages were separated from the rest of the hospital by a broad, circular drive. Enclosed within the loop was an expansive, grassy courtyard, dotted by some shrubbery and half a dozen molded plastic picnic tables. Vehicle access to “The Campus,” as Glenn Paris had named the area, was restricted to those administrators and department heads with parking slots, and to emergency room traffic.

  The ride from Knowlton Street to MCB, spearheaded by the sirens of the police cruiser and rescue squad, took fifteen minutes. Seated beside Lisa Summer in the back of the lurching ambulance, Sarah heard the driver radio ahead that a Priority One patient was on the way. She pictured the guard, suddenly puffed with importance, scurrying to open the security gate and move all traffic aside.

  Lisa’s contractions, now occurring every four minutes or so, were forceful and prolonged. However, Sarah’s gentle exam had disclosed a cervix that was still only four centimeters dilated—far from being ready for delivery. The bleeding from her nose and mouth was, if anything, more brisk. And although her left hand and both feet still had some warmth and capillary blood flow, her right arm was now pallid and lifeless from the elbow down.

  “Hang on, Lisa,” Sarah urged. “We’re almost there.”

  As they turned onto the MCB access road, Sarah reviewed her knowledge of DIC. Having never encountered a severe case of it during her training, her understanding was essentially what she had gleaned from a lecture or two in med school, some reading, and an occasional conference. Rather than being a single, specific disease, the condition was an uncommon complication of many different sorts of injuries or illnesses. Surgery, shock, overwhelming infection, massive trauma, drug overdose, toxins, abrupt separation of the placenta—any of a number of insults to the human body could result in DIC. And in part because of the severity of the predisposing condition, full-blown DIC was, more often than not, fatal.

  But Lisa Summer was neither injured nor ill. She was a healthy young woman at the end of a totally uncomplicated pregnancy. Perhaps this wasn’t DIC after all, Sarah thought.

  The siren cut off as they neared the hospital. Sarah did a quick blood pressure check and exam and began mentally preparing the presentation she would give to Dr. Eli Blankenship. It was her job to present the facts in a totally unbiased manner, carefully avoiding her own diagnostic impression or any other leading statements. Until a diagnosis was proven, assuming one to the exclusion of others was foolish and potentially very dangerous. Assume makes an ass of u and me was the way one professor had stressed that principle.

  Eli Blankenship, perhaps the sharpest medical mind in the hospital, would combine her information with his observations. He would then come up with an approach to diagnosis and treatment. Meanwhile, if therapy could not be held off until a definite diagnosis could be made, they would simply have to say a quiet prayer and forge ahead with what measures seemed likeliest to help.

  In this case, with two lives already hanging by a thread, it was unlikely they could wait for any laboratory results before instituting treatment. And the treatment for DIC was, itself, life-threatening. All in all, Sarah knew, it was going to be one hellish day for Lisa Summer and the dozens of physicians, nurses, and technologists who would be battling to save her and her baby.

  And all the while, swirling about that struggle would be the persistent, gnawing question of why?

  As they backed up to the emergency room’s receiving platform, Sarah could see Eli Blankenship waiting by the ER door. As always, she was struck by the man’s appearance. Had she, without knowing, been challenged to name his vocation, her first guesses might well have included tavern bouncer, stevedore, or heavy machine operator. MCB’s chief of staff was a bull of a man, less than six feet tall but with a massive chest and head that were separated by a token neck. He was bald save for a dark monk’s fringe. But beneath his expansive forehead, his eyebrows were thickets, and his muscular arms were like Esau’s. Even clean shaven at the outset of a day, he seemed to have a persistent five o’clock shadow.

  Of the man’s physical attributes, only his eyes—a pale, penetrating blue—gave hint to his genius. He was board certified in infectious disease and critical care as well as internal medicine. But he was also respected as a humanist, expert at chess and contract bridge, and well versed in the arts. As a teacher, no one at MCB was more open and respectful of the views and approaches of students and residents, and no one taught them more effectively.

  Blankenship, already gowned and gloved, met the stretcher as the rescue squad pulled it from the ambulance, and immediately took Lisa’s hand and introduced himself to her. From the other side of the litter, where she was keeping pressure on Lisa’s nose, Sarah could see that with that first touch, the medical chief had already begun his examination and assessment.

  By the time they reached Room A, one of three major medical/trauma rooms, Sarah had nearly completed her case presentation. Blankenship had the phlebotomist from the laboratory waiting to draw blood for them as well as an OB nurse with a fetal monitor. With a nod, he motioned them both into action. At that moment, blood began to ooze through the gauze wrap protecting Lisa’s intravenous line. Blankenship noted the development with no change in his expression.
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  “Now, Lisa,” he said evenly, “I’m going to ask you to be patient with us and to forgive us if it seems we’re not keeping you abreast of what’s going on. You’ve got several different things going on here at once, involving several different systems of your body. In a few more seconds, you aren’t going to be able to tell all the doctors working on you without a scorecard. The main ones besides me will be Dr. Helen Stoddard, who’s a blood specialist, and Dr. Andrew Truscott, who’s a surgeon. Her job will be to help us stop this bleeding, and his will be to get in another intravenous line and tend to your arm, which right now is not getting enough blood. And of course, we’ll have Dr. Baldwin and Dr. Snyder standing by to deliver your baby as soon as we can get you stabilized.”

  “Is the baby all right?” Lisa asked.

  Blankenship looked over at the OB nurse, who nodded toward the fetal monitor. The fetal heart rate was higher than optimum, often an early sign of trouble.

  “The baby’s under some stress,” he said. “We’re watching that very closely.”

  At that moment, the hematologist swept into the room. Helen Stoddard, also a full professor, was a department chief at another hospital and a sometime consultant at MCB. Unabashedly from “the old school,” as she liked to say, she had been openly critical of MCB’s coddling up to “fringe players”—her term for practitioners of alternative medicine. During one hospital-sponsored seminar, she had been one of the panelists arguing against incorporating any techniques unproven by scientific methods. Blankenship and Sarah were part of the opposition, advocating the use of certain empirically proven treatments such as acupuncture and chiropractic, and careful scientific evaluation of those and others.

  “Where do we stand, Eli?” Stoddard asked without so much as a glance at Sarah.

  “Studies are off, ten units ordered.”

  “Platelets and plasma as well?”

  “As many of each as we can get.”

  Helen Stoddard completed a rapid exam of Lisa’s skin, mouth, and nail beds. The gauze surrounding the IV was now saturated. Blood dripped from it onto the stretcher sheet and floor. The venapuncture site from which blood had been drawn was also oozing.