Natural Causes

CHAPTER 1

July 1, Changeover Day

IT WAS EXACTLY SEVEN POINT TWO MILES FROM SARAH Baldwin's North End apartment to the Medical Center of Boston. Today-a Monday-the roads were dry, the humidity low, and at six A.M., the traffic virtually nonexistent.

Sarah squinted up at the early-morning glare, getting a sense of the day. "Nineteen minutes forty-five seconds," she predicted.

She straddled her Fuji twelve-speedy, adjusted her safety helmet, and set her stopwatch to zero. Just fifteen seconds either way had become the allowable margin in the contest. More often than not, she won. Over the two years she had been commuting by bike to MCB, she had honed her accuracy by factoring into her average time as many arcane variables as she could remember on any given day. Tuesday or Thursday?… Add thirty seconds. Regular coffee at breakfast instead of decaf?… Deduct forty-five. Two nights in a row off call?… A full minute or more to the good. Today she also factored in the need to pedal hard enough to feel she had exercised, but not so hard as to break much of a sweat.

She glanced along the quaint row houses lining her narrow street, keyed her stopwatch, and shoved off. Once a near fanatic about fitness, she had now all but given up on formal workouts. Instead, she would push herself to the limit on the ride to work, shower at the hospital, and then change into her scrubs for rounds. But today nothing would be usual. At the Medical Center of Boston, as at most of the teaching hospitals around the country, this was July 1-Changeover Day.

For every physician in training in every specialty, Changeover Day marked a major rite of passage. Brand-new M.D.s stepping into hospitals as first-year residents. First-year residents one minute becoming second-year residents the next. For Sarah, the changeover would be from second-year resident in obstetrics and gynecology to third year. Suddenly more responsibility. Literally overnight, less supervision, especially in the operating room. It helped put some perspective on the tension she was feeling, to reflect on the fears she had dealt with on Changeover Day a year ago, or worse, the year before that.

Now, all things being equal, in another year Changeover Day would usher in Sarah's tenure as the chief resident of her department. On that day, in most situations, her decisions, her clinical judgment, would become the final word. It was a sobering thought. And although being a chief at a modest facility like MCB was hardly like being one at White Memorial or the other huge university hospitals, it was still impressive-especially considering that less than seven years ago, becoming a physician had been the farthest thing from her mind.

She dropped into third gear for the ride over Beacon Hill and then cruised into the Back Bay. Just a few blocks away was the huge, corner brownstone that had once housed the Ettinger Institute of Holistic Healing. As usual when she passed near that building, she wondered about Peter Ettinger-why had he never answered any of her calls or letters? Was he married? Was he happy? And what of Annalee, the West African girl he had adopted as an infant? She had been fifteen when Sarah left. Sarah had felt very close to her. It was still a source of sadness that their relationship had not survived.

Three years before, when she returned from Italy with her M.D. degree, Sarah had stopped by the institute. The place that had once been her home and the focus of her life was now six luxury condominiums. Peter's name was not among the residents. Months later she had learned of Xanadu, Peter's holistic community set in the rolling hills west of the city. She would drive out there sometime, she thought. Perhaps face-to-face they could set some things straight.

But she never did.

Distracted, Sarah cruised through a yellow light, drawing an obscene gesture from a cabby who was preparing to jump the green.

Be careful, she warned herself. Be very careful. The last place anyone should end up was in an emergency room on Changeover Day.

As she turned off Veteran's Highway onto the MCB access road, Sarah checked the time. More than twenty minutes already. She dismounted and decided to walk the final few hundred yards. Her little contest had no predictive significance that she had ever discerned. Nevertheless, she did make a passing mental note that this Changeover Day had begun with a loss.

Up ahead of her, picketers lined both sides of the drive, jeering those entering to work and occasionally joining in a ragged chant. MCB had gone a week or more without a demonstration-the longest span Sarah could remember. Now some group or other was on the warpath again. Sarah tried to guess which one. Nurses-RNs and LPNs-maintenance, transportation, security, dietary, clerical, physical therapy, nurse's aides, even house staff-at one time or another, each had run some sort of job action at the beleaguered institution. Today it was maintenance.

DOWN WITH GLENN PARIS… MCB = MORE COCK AND BULL… BETTER MANAGEMENT, NOT BETTER PROMISES… MCB NAY HMO YEA…

The placards were, in the main, professionally done. The messages on them ranged from snide to malicious.

Is PARIS BURNING? WELL WHY NOT?… PAY US OR FIX IT YOURSELF… YOU TRUST THIS PLACE WITH YOUR LIFE?!!!

Whatever their beef with MCB, Sarah noted, the maintenance workers had some money behind them.

"Nice day for a demonstration, eh?"

Andrew Truscott, a senior resident in vascular surgery as of today, fell into step beside her. Originally from Australia, Truscott had an acerbic wit, made even deadlier by an outback accent he could fine-tune from trace to dense. Now thirty-six, he was the only other resident Sarah's age. He was a difficult person to warm up to-rigidly traditional, opinionated, and too often facetious. But he was also a damn fine surgeon. The two of them had met the day she arrived at MCB and had quickly connected. At first Sarah expected that rapport-that sense of comrades-in-arms-to grow into a true friendship. But comrade-in-arms turned out to be as close as Andrew ever allowed anyone at MCB to get.

Still, Sarah enjoyed her contacts with the man, and had certainly benefited from his teaching. She also acknowledged to herself that had Andrew Truscott not been married, she would gladly have dusted off her feminine wiles to try and break down his reserve. As things stood, she was still without the solution to the nagging problem of how she was to become a competent surgeon herself without totally suppressing the need for love, companionship, sex, and whatever else of merit went with life beyond the hospital.

"What would Changeover Day at MCB be like without a few pickets, Andrew?" she said.

"Ah, yes. Changeover Day at the Medical Center of Boston. At the east wing we have a lineup of professional drug-seekers, duping the new residents with textbook performances of the passing of a kidney stone or the slipping of a lumbar disk. At the west wing, we have a lineup of disgruntled maintenance workers, looking to squeeze a few more bucks from this stone of a hospital. Ain't medicine grand?"

"MCB nay, HMO yea," Sarah said. "Since when are the maintenance workers into hospital politics?"

"Probably since someone told them they might actually get those bucks if Everwell took the place over."

"It's not going to happen."

Truscott smiled. "Try telling them."

For several years, the ambitious-some said avaricious-Everwell Health Maintenance Organization had been waiting and watching like a predatory cat as MCB staggered beneath a crippling weight of fiscal problems, labor unrest, and the controversy surrounding its emphasis on blending nontraditional healing with traditional medicine and surgery. By charter, a vote of the hospital trustees, if approved by the state Public Health Commission, would turn the hospital over to the definitely for-profit operation. And each job action, each piece of negative publicity, brought the unique institution closer to its knees.

"It's not going to happen, Andrew," Sarah said again. "Things have gotten better every year since Paris took over. You know that as well as I do. MCB has become one of a kind. People from all over the world come here for care because of the way we do things. We can't let Everwell or anyone else ruin that."

"Look, mate," Truscott said, his accent deepening, "if you're going to become impassioned about anything, you've got to turn in your surgeon's merit badge. That's the rule."

"You get just as impassioned about things as I do," Sarah said. "You're just too macho to let it show." She glanced past the demonstrators at the bicycle rack, which was empty save two rusted three-speeds, whose tires appeared to have been slashed. "I think the nurse's aides were a bit less physical during their strike," she observed. "It looks like my bike gets chained to the bed in the on-call room. Andrew, don't you have the feeling that someone other than the maintenance men has helped organize all this?"

"You mean Everwell?"

Sarah shrugged. "Possibly. But they're not the only candidate. Thanks to Axel Devlin, there are more than a few people who have the wrong impression about the way we do things here."

Devlin, a Herald columnist with an unabashedly conservative slant, had dubbed MCB Crunchy Granola General. He made it a frequent target of "Axel's Axe" in his popular Take It or Leave It column. As an M.D. with extensive training and expertise in acupuncture and herbal therapy, Sarah herself had been mentioned in the column on two occasions, not at all flatteringly. She never had figured out how Devlin learned of her.

"Who knows?" Andrew responded with no great interest. He nodded toward the dozen or so picketers. "They are a gnarly group, I'll say that for them. Not a tattooless deltoid in the bunch." He paused at the door marked Staff Only and turned to her. "Well, Dr. Baldwin, are you ready to pop up a level?"

Sarah stroked her chin thoughtfully, then took Truscott's arm.

"What options exist for me are either unacceptable or illegal, Dr. Truscott," she said. "Let's do it."

• • •

Fifty feet above the pristine mountain pool, Lisa Summer poised on the cliff's edge. But for the garlands of white lilies around her neck and her head, she was naked. The sun glinted off her long, perfect body and sparkled in her straw-gold hair. All around her, wildflowers billowed, blanketing the cliffs and cascading down the rocks beside the shimmering falls. High overhead a solitary hawk glided effortlessly against the cloudless, azure sky.

Lisa tilted her head back and let the sun warm her face. She closed her eyes and listened to the churning water below. Then, arms spread, she tightened her toes over the edge, took a final, deep breath, and pushed off. Wind and spray caressed her face as she floated more than fell past the falls, twisting and tumbling through the crystal air… downward… downward… downward…

"Hang in there, Lisa. Beautiful. Hang in there. The contraction's almost over. A minute ten… a minute twenty. That's it. That's it. Oh, you did great. You did just great."

Slowly Lisa opened her eyes. She was propped on the futon in her cluttered room, bathed in the rays of the early-morning sun. Heidi Glassman, her housemate, friend, and birthing coach, sat beside her, stroking her hand. Across from her, waiting, were the crib and changing table she had found at Goodwill and meticulously refinished.

The weeks of practice in class and at home were paying off. Lisa was now in her third hour of active labor, but thanks to the series of sensual images she had developed, the pain of every contraction so far had been easily subverted.

Dr. Baldwin called the process internal and external visualization. It was, she had told Lisa, a modest form of self-hypnosis-a technique that, if practiced diligently, would enable Lisa to make it through even difficult labor and delivery without any anesthesia or other drugs. For some contractions, Lisa used external visualization to send herself soaring off her mountain cliff or for a wondrous undersea ride on the back of a dolphin. For others, she used internal visualization to see the actual muscles of her womb and the baby boy within, and to mentally buffer them both with thick cotton batting.

"How're you doing?" Heidi asked.

"Fine. Just fine," Lisa said dreamily.

"You look very peaceful."

"I feel wonderful."

Unaware she was doing so, Lisa slowly opened and closed her hands.

"Five minutes apart for nearly an hour. I think it may be time to call."

"There's time," Lisa said. She closed her eyes for a few seconds. "I don't think I've even started to dilate yet."

Her mind's eye saw her cervix clearly. It was just beginning to open.

"Want me to check?" Heidi asked.

Heidi was a nurse who had spent several years on an OB floor. Now she was poised to assist Dr. Baldwin with the home birth.

"I don't think there's any need," Lisa said, rubbing her fingers now.

"Something the matter?"

"No. My hands feel a little stiff, that's all-"

"Might be retained water. Let me check your blood pressure."

Heidi slipped a blood pressure cuff around Lisa's arm and set her stethoscope over Lisa's brachial artery. The pressure, ninety over sixty-five, was a bit lower than it had been, although still in the normal range for early labor. Heidi mulled over the change, then decided it was of no significance. She wrote the pressure down in her notebook and made a mental note to check it again in ten or fifteen minutes.

"Who's going to win the pool?" Lisa asked.

"Assuming it's today?"

"Oh, it's going to be today. You can count on it."

"In that case, Kevin will be thirty dollars richer."

Kevin Dow, a painter, was another of the residents of 313 Knowlton Street. There were ten of them in all. Most were artists or writers, and none of them made much money. They called their living arrangement a commune, and in that light shared almost everything. Lisa, who sold her pottery and occasionally refinished old furniture, had lived in the massive, gabled house for almost three years. And although she had twice slept with one of the men in the commune, she felt certain the child within her was not his and had made that clear to him from the outset, much to his relief.

In fact, who the father was, or was not, did not matter to Lisa one bit. The baby would be raised by her and her alone. He would be raised in simplicity, with love and patience and understanding, and without the pressure of expectations.

With Heidi's assistance, she stood and walked over to the window. Her right arm felt tired and heavy.

"Can I get you anything?" Heidi asked.

Lisa absently rubbed at her shoulder as she stared out at a squirrel that was leaping deftly along a series of branches that seemed far too pliant to hold it.

"Maybe some cocoa," she said.

"Coming up… Lisa, are you okay?"

"I-I'm fine. I think another one's about to hit. How long has it been?"

"Five minutes, three seconds."

"I think I'll do this one standing."

Lisa leaned forward and braced herself against the sill. Then she breathed deeply, closed her eyes, and tried to send her mind inside her body. But nothing happened-no images, no sense of peace, nothing-nothing except pain. She was trying too hard, she thought. She had to be centered-that's what Dr. Baldwin had taught her-centered and prepared for each contraction. For the first time she felt a nugget of fear. Maybe she didn't know how bad it was going to get. Maybe she didn't have what it takes.

She gritted her teeth and stretched her arms and legs tightly.

"How long?" she asked.

"Forty seconds… fifty… a minute… a minute ten…"

The intensity of the contraction began to lessen.

"A minute twenty. You okay?"

"I am now," Lisa said, backing away from the window and settling down on the futon. Her forehead was dotted with sweat. "That one was a bear. I wasn't ready."

Lisa swallowed and tasted blood. She probed with her tongue and found the small rent she had made by accidentally biting down on the inside of her cheek. The pain of the contraction was now completely gone, but the weird ache in her arm and shoulder persisted.

Heidi left the room and returned just in time for the next contraction. With Heidi's help and better preparation, Lisa found this contraction was much more manageable. Heidi slipped on the blood pressure cuff and once again took a reading. Eighty-eight over fifty, and even harder to hear than before.

"I think we should call," she said.

"Is everything okay?"

"Everything is fine. Your pressure's fine. I just think it's time."

"I want this to be perfect."

"It will be, Lisa. It will be."

Heidi stroked Lisa's forehead and then went to the phone in the hall. The drop in pressure was minimal, but if it was the start of a trend, she wanted Dr. Baldwin on hand.

Across the street, in front of 316 Knowlton, Richard Pulasky crouched behind his car as he disengaged the high-powered telephoto lens from his Nikon. He had gotten at least two good face shots of the girl, he felt certain. Maybe more. He pulled the frayed photo of Lisa Grayson from his pocket. The girl in the picture didn't look exactly like the woman in the window, but close enough. It was her, and that was that. Six months of work had just paid off big-time. Half the private dicks in town had taken a crack at finding the girl, but Dickie Pulasky had actually pulled it off.

Grinning to himself, Pulasky slid into his car through the passenger-side door. With any luck, he would be pocketing a fifteen-grand payoff within the week.