Natural Causes

CHAPTER 16

July 8

LYDIA PENDERGAST BENT AT THE WAIST AND SLOWLY, ever so slowly, stretched her hands downward toward the floor. To one side of the small examining room, Sarah, chiropractor Zachary Rimmer, and one of the pain unit nurses watched expectantly.

"Down and down she goes," Lydia said, "and where she stops nobody knows."

She was a sprightly woman in her early seventies who had become virtually bedridden by low back pain and stiffness. A number of orthopedists and neurosurgeons had pegged degenerative arthritic spurs as the cause of her disability. They cited the uncertainty of the corrective surgical procedure, as well as her age and the advanced condition of the spurs, as reasons why they could not operate. Finally, one of them had referred her to the MCB pain unit, a multidisciplinary clinic that was rapidly becoming known and respected throughout the Northeast.

Shortly after arriving at the hospital, Sarah had begun volunteering her acupuncture skills at the clinic. She usually managed half a day a week.

Lydia's fingertips touched the tile.

"Ta da," she sang, without straightening out. "Okay, now, Dr. Baldwin. This one's for you."

She shifted her feet slightly, continued down until her palms were flat on the floor, and waited until Sarah snapped a picture with the clinic's ancient Polaroid. Then, to the applause of her small gallery, she straightened up and curtsied.

"God bless you. God bless you all…"

Lydia Pendergast's words were echoing in her mind as Sarah carried her box of acupuncture needles up the stairs to the lockers on Thayer Four. A treatment success; a grateful patient; work to do. The day seemed almost normal-especially when measured against the two that had preceded it. There was still a coolness from many on the hospital staff that Sarah found unpleasant, but certainly not unbearable. And several times, just as she sensed she might be breaking down, someone would say something kind or encouraging. The annoying, persistent, and unconscionably rude press was another problem altogether. She had stopped answering her phone at home and had gotten the hospital operator to screen calls to her carefully.

It wasn't fun. But she knew that like all things, it would pass.

Sarah had opened her locker, and so was partially screened when the elevator doors glided open and Andrew Truscott stepped out. He hurried down the corridor and into 421, one of the sleeping rooms that Sarah frequently used. It was odd that Andrew would be taking a break at this hour, she mused, although it was close enough to lunchtime. Perhaps he was hoping to sleep off a headache or something.

She smiled at the thought.

One headache he would not be needing to sleep off was Sarah's reporting him to Glenn Paris. She had opted not to do so a few hours after their confrontation in Andrew's office, and had told him of her decision the following day. She had not expected him to thank her, and in that regard, she was not disappointed.

"You do whatever you want," he had said testily. "Without proof and with your current status in this hospital, I doubt Paris or anyone else would pay much attention to what you have to say."

Truscott was absolutely right, she knew. She had enough problems without getting into a his-word-against-hers battle with the impeccably proper senior surgical resident. Even so, she would have gone ahead and reported him if she'd thought it would help. If the leaks continued, she would no longer have a choice.

Sarah was about to close her locker when the elevator doors opened again. This time Margie Yates, a pediatric resident, stepped out. Yates, the mother of two, was married to a sweet guy who ran the hospital's social service office. She was bright and attractive, but she was also insecure and a terrible flirt. From behind her locker door, Sarah could not help but watch as Margie straightened her white clinic skirt, checked herself in a compact mirror, knocked softly on the door to room 421, and slipped inside.

Andrew and Margie Yates! Not really that much of a surprise, Sarah decided, as she gently closed her locker door and headed down the nearby stairs. Andrew seldom spoke of his wife or child. And Margie, from time to time, had been linked by rumor to other physicians at MCB. Both had huge egos and massive need for approval. Their tryst, unpleasant as it was to observe, made perfect sense.

Sarah picked up a tuna sandwich, chips, and pineapple juice in the cafeteria, and carried the lunch outside to one of the campus tables. First the admission of betraying his hospital, and now Margie Yates. Over the past few days, Andrew's stock had plummeted. She ate quickly and reentered the hospital through the surgical building. Andrew's name was being called out via the overhead page. He was wanted in room 227 stat. A first-year surgical resident named Bruce Lonegan raced past her and up the stairs toward the second floor.

"Hey, Bruce, what's going on?" she called.

"Don't know," he yelled back excitedly. "A ruptured triple A, maybe."

Triple A-an abdominal aortic aneurysm. Rupture of one was, perhaps, the ultimate surgical emergency. Even if she had pressing obligations on her service, which she did not for at least another hour, Sarah would have responded to any such call for help. Besides, she thought cattily, at this moment Andrew Truscott might not be in the greatest shape to perform emergency vascular surgery.

Room 227 was in the early stages of the organized chaos that accompanied crisis in a teaching hospital. Bruce Lonegan and another surgical resident were scurrying about an elderly gentleman who was in obvious, severe distress. He was unconscious or barely conscious, twitching about, and moaning.

"Get ten units crossmatched stat and be sure the OR is ready," Lonegan called out. "Art, get an arterial line in him. Somebody try and get a pressure! Dammit, where the hell is Andrew?"

"How can I help?" Sarah asked as the overhead page again urged Andrew to the room.

"This guy's Andrew's patient," Lonegan said. "He came in about three or four days ago for an elective aneurysm repair. He was in some heart failure, so the medical people had us delay his surgery while they got that under control. He was scheduled for the OR tomorrow. A nurse just walked in and found him like this. His pressure's way down. He's out of it. His belly seems tense. It's got to be the triple A leaking. Dammit, are they beeping Andrew as well as voice paging him?"

At that moment, Sarah remembered that there was no overhead page on the Thayer sleeping floors. Andrew obviously hadn't given the room number to the operator. If his beeper was turned off, no one would know how to reach him. No one except me. She picked up the bedside phone and suggested the operator try ringing Thayer 421.

"If Dr. Truscott doesn't answer, please call me back immediately," she instructed.

Lonegan and the other resident had been joined by someone from internal medicine. It was clear the patient was losing ground. Lonegan had been a practicing M.D. for exactly one week. Without the senior vascular surgery resident, he was lost. And he looked it.

"Andrew's pager may not be working," Sarah said, realizing that she had to take over until someone more senior or surgically specialized arrived. "I've given the operator some instructions on reaching him. Meanwhile, be sure of your lines, get some fluids into him, use a Doppler stethoscope to check what pulses you can, catheterize him, and have everything ready in the OR. Why is he twitching like that?"

"His blood pressure's only about sixty," the medical resident said. "That's why."

Although she admitted to herself that the internist might be right, Sarah did not feel comfortable with that explanation. She had seen many patients in shock, some of them in full-blown seizure because of it. But something here was different from those cases. Without making any show of it, she carefully checked the old man's acupuncture pulses. Several of them felt weak and thready. She was not experienced enough to know the exact significance of her findings, but she sensed that whatever was happening was more generalized than a leaking artery-perhaps some sort of metabolic derangement.

The phlebotomist had just finished drawing the man's blood. Sarah pulled the woman aside.

"Have them run a complete chem screen, please," she said. "As absolutely fast as they can. Especially electrolytes, sugar, calcium, phosphorus, and magnesium."

The bedside phone rang. Sarah snatched it up, listened for a moment, and then set the receiver back down.

"Dr. Truscott will be here in just a minute," she said.

It was almost five minutes before Andrew charged into the room. By that time the anesthesiologist was at the bedside, some incompletely crossmatched blood was being pumped in, and transportation was standing by outside the room, awaiting the dash to the OR. The patient's family had also been called and told about his turn for the worse. Emergency as opposed to elective repair of the aneurysm lowered his chances of survival considerably.

"Sorry, everyone," Truscott said, immediately taking control. "My damn beeper went belly up."

Ignoring Sarah completely, he rapidly assessed the old man's physical status and then ordered transportation into the room. Next he turned to his intern, who gave a nervous, somewhat garbled account of what had transpired.

"I have the OR on standby," Lonegan concluded. "Blood is off for chemistries and crossmatch."

"That's good, old boy," Truscott snapped, listening once again to the man's abdomen with his stethoscope. "Because we're going to be cutting skin before you can say 'Tie me kangaroo down.' "

Transportation rushed into the room and began transferring the patient to a litter. Only then did Truscott turn to Sarah.

"So, what brings you down here, Doctor?" he asked. "Is this man having some gynecological problems on top of everything else?"

One nurse laughed out loud. Sarah kept her cool by reminding herself that she cared too little for the man to allow him to upset her in any way.

"I thought you might be a little tired and in need of a little extra help," she said. "I knew you were, um, resting in room 421. I was at my locker when you went in. That's how the page operator knew where to find you."

Truscott's face paled. The corners of his mouth twitched.

"Thank you for that," he managed. "You certainly have been kind to me lately."

"Think nothing of it," Sarah responded, her eyes fixed steadily on his.

The team had finished loading the old man onto the litter. Truscott motioned them to the OR with a flick of one hand. In seconds the room was empty, save for Sarah and one nurse. The floor, littered with bloody pads and gauze wrap, needle guards, rubber gloves, IV tubing boxes, and the like, looked like a war zone. Sarah gloved and began picking up some of the litter.

"I'll take care of this," the nurse said.

"Why, are you more trained for this job than I am?"

The nurse smiled. "Thanks," she said.

At that moment, the phlebotomist raced into the room carrying a computer printout.

"Where is everyone?" she asked breathlessly.

"Gone to the OR. Why?"

The technician handed over the printout.

"His magnesium level is zero point four," she said. "The supervisor said to tell you they've run it twice and-"

Sarah was no longer paying attention. She glanced at the phone, thought better of it, and then raced from the room. A magnesium level of 0.4, far below normal, would explain the clinical picture entirely. It was life-threatening in any circumstance, but would be fatal if not corrected before surgery. The cause, she guessed, might be the old man's intolerance to the vigorous diuretic treatment that was being used to correct his heart failure.