by Robin Cook
Mrs. Hargrave reached out and touched her shoulder.
"Anything you'd like to talk about?"
Marissa gazed up into the woman's face. There was warmth and sympathy in those gray-green eyes.
At first Marissa could only shake her head as she fought back tears.
"It's common for emotional problems to burden people involved with in-vitro," Mrs. Hargrave said.
"But it usually helps to talk about it. It's been our experience that part of the problem is the isolation the couples feel."
Marissa nodded in agreement. She and Robert had been isolated.
As the pressures mounted, they started avoiding friends, especially those with children.
"Has there been a problem between you and your husband?" Mrs. Hargrave asked.
"I don't mean to pry, but we truly have found it best for people to be open."
Marissa nodded again. She looked at Mrs. Hargrave's understanding face. She did want to talk, and with a few tears that she wiped away with the back of her hand, she told her about Robert's initial refusal to cooperate that morning, and their consequent quarrel. She told Mrs. Hargrave she was beginning to think they would have to stop the infertility treatments.
"It's been pure hell for me," Marissa admitted.
"And for Robert."
"I think it is safe to say that something would be wrong with you both if it weren't," Mrs. Hargrave said.
"It's stressful for everyone, even the staff. But you've really got to learn to be more open. Talk to other couples. That will help you learn to talk to each other and to be aware of each other's limitations."
"We are ready for Mrs. Buchanan," another nurse called through the door to the ultrasound room.
Mrs. Hargrave gave Marissa a comforting squeeze on her shoulder.
"You'd better get on with this," she said.
"But afterwards
I'll come back and we'll talk some more. How about it?"
"Okay," Marissa said, trying to muster some enthusiasm.
Fifteen minutes later, Marissa again found herself on her back in the ultrasound room, facing yet another painful and potentially risky procedure, She was lying supine with her legs straight out. In a few minutes her legs would be put up in the all-too familiar stirrups. Then there would be the disinfectant, followed by the local anesthetic. She cringed at the thought.
The room itself seemed scary. It was a cold, forbidding, futuristic environment filled with electronic instruments, some of which Marissa recognized and some she didn't. Multiple cathode-ray screens were set into the instrumentation. Mercifully, the foot-long egg-retrieval needle was kept out of sight.
The nurse-technician who had brought Marissa into the room was busy with preparations for the procedure. Dr. Wingate, who performed most of the clinic's infertility procedures including the in-vitro fertilization, had not yet arrived.
A knock on the door got the attention of the nurse-technician, who stepped over and opened it. Marissa turned her head to see Robert standing in the threshold.
Although the procedure room made him feel even more uncomfortable than it made Marissa feel, he forced himself to step into the high-tech room. He pointed over his shoulder for the nurse technician benefit.
"Mrs. Hargrave said I could come in for a moment," he explained.
The nurse-technician nodded, motioned toward Marissa, then went back to her preparations.
Robert gingerly walked over to the ultrasound unit and looked down at his wife. He was careful not to touch any of the delicate instrumentation, or Marissa herself, for that matter.
"Well, I did it," he said as if he had accomplished some major task.
"And now that my part's over, I'll be heading to the office.
Unfortunately, because of the stitches, I'm later than I planned.
So I've got to run. But I'll come back after the meeting and pick you up. If it looks like the meeting is going to run over, I'll call and leave word with Mrs. Hargrave. Okay?"
"Okay," Marissa said.
"Thanks for providing a sample. I appreciate it."
Robert wondered if Marissa was being sarcastic. He couldn't detect any irony in her tone.
"You're welcome," he said finally.
"Good luck with the egg retrieval. Hope you get a full dozen."
With a tentative pat on her shoulder, he turned and left the room.
Marissa felt tears welling up again, but she didn't know if they were from sadness or anger. She felt so terribly alone. Lately Robert had been so businesslike, even when it came to her. She was hurt that he could leave her to face such an ordeal alone.
The Robert of today seemed so different from the man she had married so blissfully only a few years ago. in so many ways he was telling her that business came first; it was his identity and his escape. A single tear ran down into her ear. She closed her eyes tightly, hoping to block out the whole world. It seemed that her life was falling apart and there was nothing she could do to stop it.
"Excuse me, Dr. Wingate," Mrs. Hargrave said, stopping the doctor on his way into the ultrasound room.
"Could I have a brief word with you?"
"Is it. important Dr. Wingate asked.
"I'm late for Mrs. Buchanan."
"It's Mrs. Buchanan I want to discuss," Mrs. Hargrave said.
She held her head back. She was a tall woman herself, almost six feet. Even so, she looked slight next to Dr. Wingate's impressive bulk.
"Is it confidential?" Dr. Wingate asked.
"Isn't everything confidential?" Mrs. Hargrave said with a sly smile.
"True enough," Dr. Wingate said. He briskly walked down the hallway to his office. They entered a back door directly from the corridor, bypassing his secretary. Wingate closed the door behind them.
"I'll be brief," Mrs. Hargrave said.
"It's come to my attention that Mrs. Buchanan… actually, I should say Dr. Buchanan.
You do remember that she is a doctor, don't you?"
"Yes, of course," Dr. Wingate said.
"Dr. Carpenter told me that two years ago. It was a surprise, I recall. Dr. Carpenter only knew through reading it in the Globe.
"I think the fact that she is a physician herself should be kept in mind," Mrs. Hargrave said.
"As you know, doctors can be difficult patients at times."
Dr. Wingate nodded.
"At any rate," Mrs. Hargrave continued, "I believe she is suffering from a certain amount of depression."
"That's not unexpected," Dr. Wingate said.
"Almost all of our in-vitro patients experience depression at one time or another."
"There is a suggestion of marital discord as well," Mrs. Hargrave said.
"Even some talk about stopping after this cycle."
"Now that would be unfortunate," Dr. Wingate agreed, interested at last.
"Depression, marital problems, and the fact that she is a physician make me think we should perhaps alter the treatment protocol."
Dr. Wingate leaned against his desk, hooking a thumb under his chin and resting his nose on an index finger while he pondered Mrs. Hargrave's suggestion. She definitely had a point, and flexibility had always been an approach he'd advocated.
"She also witnessed the scene with Rebecca Ziegler," Mrs.
Hargrave added.
"That can only have contributed to her emotional distress. I'm very concerned about her."
"But she has been stable up until now," Dr. Wingate said.
"That's true," Mrs. Hargrave replied.
"I suppose it is the problem of her being a physician that makes me feel uneasy."
"I appreciate your concern," Dr. Wingate said.
"It's attention to detail that makes the Women's Clinic so successful. But I think it will be safe to continue as usual with Dr. Blumenthal-Buchanan.
She'll tolerate another couple of cycles, but perhaps it would be wise to recommend some in-house counseling for both her and her husband."
"Very well," Mrs. Ha
rgrave said.
"I'll suggest it to her. But as a physician, she might be resistant to such an idea."
With the matter decided, Dr. Wingate moved to the door and opened it for Mrs. Hargrave.
"Speaking of Rebecca Ziegler," said Mrs. Hargrave, "I trust she's being well taken care of?"
"She's reading her records as we speak," Dr. Wingate said, following Mrs. Hargrave into the hallway.
"Unfortunately, it will be upsetting for her."
"I can well imagine," Mrs. Hargrave said.
5
March 19,1990
11:37 A.M.
Dorothy Finklestein hurried under the overhead walkway and entered the brick courtyard of the Women's Clinic. As usual, she was late. She was always late. Her appointment for her annual exam had been scheduled for eleven-fifteen.
A sudden gust of wind caught the edge of her hat and lifted the brim. She reached up just in time to prevent the hat from sailing off her head. At the same time, something above caught her eye.
A high-heeled shoe was plummeting toward her. It landed near her, falling into a planter filled with rhododendrons..
Despite her haste, Dorothy stopped as her eye traveled upward, tracing the shoe's trajectory. At the very top story of the Women's Clinic, six floors up, her gaze became transfixed by what looked like a woman sitting on a window ledge, her legs dangling over, her head tilted down as if she were studying the pavement below. Dorothy blinked, hoping her eyes were deceiving her, but the image remained: it wasn't her imagination, it was a woman on the ledge-a young woman!
Dorothy's blood ran cold as she watched as the woman seemed to inch forward, then pitch headfirst in a slow somersault. The woman fell like a life-sized doll, picking up speed as she passed each successive floor. She landed in the same planter as her shoe, hitting with a dull thump like a heavy book dropped flat on a thick rug.
Dorothy winced em pathetically as if her own body had suffered the fall. Then she screamed as the reality sank in. Pulling herself together, she ran toward the planter without any idea of what she would do. As a buyer for a large Boston department store, she had scant training in emergency first aid, although she had attended a CPR course in college.
A few passersby responded to Dorothy's scream. After recovering from their initial shock, several followed her to the planter.
Someone else ducked back into the clinic to sound an alarm.
Arriving at the edge of the planter, Dorothy stared down in horror. The woman was on her back. Her eyes were open and they stared skyward, focused on nothing. Not knowing what else to do, Dorothy bent down in the bushes and started to give mouth-to mouth resuscitation. It was apparent to her that the woman was not breathing. She blew into the woman's mouth several times, but she had to stop. Turning her head, she vomited her coffee break blueberry muffin. By then, a doctor in a crisp white jacket had arrived.
"Of course I remember you," Dr. Arthur said.
"You were the woman who was so sensitive to ketamine. How could I forget?"
"I just wanted to be sure you wouldn't use it again," Marissa said. She hadn't recognized Dr. Arthur at first since he'd not treated her since the biopsy. But after he'd started her IV, something jogged her memory.
"All we need today is a little Valium," Dr. Arthur reassured her.
"And I'm going to give you a little right now. This should make you pretty sleepy."
Marissa watched him inject the drug into the side port of her IV. Then she rolled her head straight. Now that the egg retrieval was about to begin, her attitude about the procedure had changed from fifteen minutes earlier. She was no longer ambivalent.
As the Valium hit her system, Marissa's mind calmed, but she didn't sleep. She dwelt on the thought of her blocked tubes and what might have caused the blockage. Then she began to consider the different procedures she had undergone. She, remembered how she felt waking up from the general anesthesia after her laparoscopy.
As soon as she was lucid, Dr. Carpenter had told her that her tubes appeared so scarred that microsurgery was totally out of the question. He said that all he'd been able to do was take a biopsy. He let her know then that her only chance for a baby was in-vitro fertilization.
"Are we ready?" a booming voice called.
Marissa lifted her head, raised heavy eyelids, and looked up at the bearded face of Dr. Wingate. Lying back, she tried to dissociate herself from her body to cope with her anxiety. Her mind wandered back to her visit to Dr. Ken Mueller in the department of pathology at the Memorial after her laparoscopy. The Women's Clinic frequently sent some of their specimens to the Memorial to confirm their diagnoses. Marissa had been told that her fallopian tube biopsy had been forwarded there.
Hoping to maintain her anonymity, Marissa had searched for her slides herself. Shed knew that the Women's Clinic used her social security number as her case number.
Once Marissa had the slides, she sought out Ken. They'd been friends since medical school. She asked him to look at the microscopic sections for her, but didn't say they were hers.
"Very interesting," Ken said after a brief scan of the first slide.
He sat back from the microscope.
"What can you tell me about the case?"
"Nothing," Marissa said.
"I don't want to influence you. Tell me what you see."
"Sort of a quiz, huh?" Ken said with a smile.
"In a way," Marissa said.
Ken went back to the microscope.
"My first guess is that it's a section of fallopian tube. It looks as if it's been totally destroyed by an infectious process."
"Right on," Marissa said with admiration.
"What can you say about the infection?"
For a few minutes Ken silently scanned the specimen. When he finally spoke, Marissa was stunned.
"TB!" he announced, folding his arms, "Tuberculosis?" Marissa almost fell off her chair. She'd expected nonspecific inflammation, never TB.
"What makes you say that?" she asked.
"Look in the field," Ken told her.
Marissa gazed into the scope.
"What you are looking at is a granuloma," Ken said.
"It's got giant cells and epithelioid cells, the sine qua non of a granuloma.
Not a lot of things cause granulomas. So you have to think of TB, sarcoid, and a handful of funguses. But you'd have to put TB at the head of the list for statistical reasons."
Marissa felt weak. The idea that she had any of those diseases terrified her.
"Can you do any other stains to make a definitive diagnosis?"
Marissa asked.
"Sure," Ken said.
"But it would help to have some history on the patient."
"Okay," Marissa. said.
"She's a healthy Caucasian woman, mid-thirties, with a completely normal medical history. She presented with asymptomatic ally blocked fallopian tubes."
Reliable historian?" Ken questioned as he chewed the inside of his lip.
"Completely," Marissa said.
"Negative chest X-ray'," "Completely normal."
"Eye problems?"
"None."
"Lymph nodes?"
"Negative," Marissa said with emphasis.
"Except for the blocked tubes, the patient is completely normal and healthy."
"GYN history normal?" Ken asked.
"Yup!" Marissa said.
"Well, that's weird," Ken admitted.
"TB gets to a fallopian tube via the bloodstream or the lymphatics. If it's TB, then there has to be a nidus somewhere. And it doesn't look like fungus without some hyphae or something. I'd still say TB is the leading contender. Anyway, I'll do some additional stains…"
"Marissa!" called a voice, bringing Marissa back to the present.
She opened her eyes. It was Dr. Arthur.
"Dr. Wingate is about to inject the local anesthesia. We don't want you to suddenly jump."
Marissa nodded. Almost immediately she felt a number of points of stinging p
ain, but they faded quickly and she went back to her musing, remembering her panicked visit to an internist the same day that she'd seen Ken. But a complete work-up had failed to find anything wrong except for a positive PPD test, suggesting that she indeed had had TB.
Although Ken tried numerous other tests on Marissa's slide, he found no organisms, TB or otherwise. But he stuck by his original diagnosis of a tuberculous infection of the fallopian tube despite Marissa's inability to explain how she could have picked up such a rare illness.
"Dr. Wingate!" a harried voice called. Marissa's attention was again brought back to the present. She turned her head. Mrs.
Hargrave was at the ultrasound-room door.
"Can't you see I'm busy, for chrissake?" Dr. Wingate snapped.
"I'm afraid there has been an emergency."
"I'm doing a bloody egg retrieval!" Dr. Wingate shouted, venting some of his frustration on Mrs. Hargrave.
"Very well," Mrs. Hargrave said as she backed out of the door.
"Ah, there we go!" Dr. Wingate said with satisfaction. His eyes were glued to the cathode-ray-tube screen.
"Want me to see what the emergency is?" Dr. Arthur asked.
"It can wait," Dr. Wingate said.
"Let's get some eggs."
For the next half hour, time seemed to crawl. Marissa was sleepy but unable to sleep under the torturous probing.
"All right," Dr. Wingate said at last.
"That's the last of the visible follicles. Let me take a look at what we've gotten."
Laying the probe aside and stripping off his gloves, Dr. Wingate disappeared with the nurse-technician into the other room to examine the aspirate under a microscope.
"Are you okay?" Dr. Arthur asked Marissa.
Marissa nodded.
Within a few minutes, Dr. Wingate came back into the room.
He had a broad smile.
"You were a very good girl," he said.
"You produced eight fine-looking eggs."
Marissa breathed out audibly and closed her eyes. Although she was happy about getting eight eggs, it hadn't been a good morning. She felt drugged and exhausted and, with the stress of the procedure gone, Marissa soon lapsed into a troubled, drugged sleep. She was only vaguely aware of being moved to a gurney and being transported across the glass-enclosed walkway to the clinic's overnight ward. She woke up briefly to help switch herself from the gurney to a bed where she at last sank into a deeper, Valium-induced sleep.
