Natural Causes

CROTALID (M IXED R ATTLESNAKE) VENOM -

The receipt, from a mail order laboratory supply house in Houston, was made out to her. Sarah dropped the vial into her clinic coat pocket and carefully tore open the FedEx package. There was no doubt in her mind what it contained. Polyvalent Crotaline Antivenin-twenty vials in all.

Badly shaken, Sarah stood alone by her open locker on the dimly lit fourth-floor corridor of the Thayer Building. In her pocket was quite likely the cause of Annalee's hellish, imminently lethal situation. In her hands was the cure. No one was likely to believe her story that both the empty poison vial and the packaged antidote had been placed in her locker by whoever had actually administered the venom to Annalee.

If her account of Andrew's death had strained her credibility around MCB, this latest tale would snap it.

It made much more sense to believe that Sarah had infused the rattlesnake poison in order to create a case of labor-induced DIC that was unrelated to her herbal supplement. That Annalee was supposedly her friend would impress no one-especially after Peter got through telling whatever version of their history he concocted. Why, then, had Sarah produced the antidote? Perhaps, some people would reason, she had intended to create a dramatic though sublethal condition, but had missed. Only when things were clearly on a downhill slide for Annalee had she come up with the antivenin-and the farfetched explanation that it had just shown up in her locker. Perhaps, others would claim, she had not initially cared whether the case was sublethal or lethal. But seeing Annalee's extreme distress had brought about a sudden change of heart.

The two groups might argue over nuances. But clearly, there was one and only one logical explanation for Sarah's miraculous, eleventh-hour discovery of both the cause and cure of Annalee's DIC. Sarah herself had to have administered the toxin in the first place. No one with half a brain would believe otherwise.

For a moment, the notion flickered through her mind simply to dispose of the empty vial and the antivenin. She could say that her locker had been pried open and her acupuncture needles stolen. No one except the person who had set her up would ever be the wiser. With luck and aggressive treatment, Annalee and her child-or at least one of them-might possibly survive. And as Randall Snyder had said, with a case of DIC unrelated to Sarah's herbal supplements, she would at last be off the hook. By the time Sarah was even aware of having that notion, she was bounding, three at a time, down the stairs to the tunnel, the precious FedEx box tucked beneath her arm like a football.

The scene in Annalee's room was much as it had been when Sarah sprinted off, except that hematologist Helen Stoddard was now conferring with Eli and Randall Snyder. Sarah groaned at the sight of her. Since their conflict over Lisa Grayson, they had passed in the halls and sat near each other at conferences, and not one word had been exchanged between them.

Well, Dr. Stoddard, Sarah thought as she approached the three treating physicians, if you thought I was a quack before, you're going to think I'm a positive lunatic now. And a homicidal lunatic at that!

"I need to speak with you all over here," Sarah whispered, motioning toward the only unoccupied corner of the room. "It's very important."

"Not again." Helen Stoddard moaned. "Eli, I thought you promised-"

"Helen, either shut up or leave," Eli snapped with uncharacteristic impatience. "This girl is in big trouble. We've got to do whatever we can to save her."

"What's going on?" Snyder asked. "Are you all going to give her the heparin or not?"

"Yes," Helen Stoddard said, quickly and definitively.

"I think you'd best hear what I have to say first," Sarah countered.

She briefly described what she found at her locker and showed the three physicians the contents of the FedEx package.

"I was concerned about Annalee's high temperature, the speed with which her symptoms were developing, and also the pattern of her twelve acupuncture pulses. Crotalid poisoning would explain all that."

"You're absolutely mad," Helen Stoddard said. "Someone purposely placed this in your locker? How on earth can you possibly expect us to swallow-"

"Dammit, Helen," Eli cut her off. "Would you just listen for once?"

The woman glared at him, then at Sarah. Then she whirled and stormed from the room. A moment later Peter Ettinger stormed in.

"What in the hell is going on here? Why did the hematologist leave that way?" he demanded.

Eli moved to confront him, but Sarah stopped the professor with a raised hand.

"Wait, Dr. Blankenship," she said. "Please. I know how important Annalee is to Peter, and I know how worried he is about what's going on. Let me talk to her for a second." She whispered a few words in Annalee's ear and then returned to the group. "Annalee says it's all right with her if he stays."

"Okay," Blankenship growled. "But one disruptive word, Ettinger, and you're out."

"Peter, Annalee has been poisoned," Sarah said. "Someone has injected crotalid venom either into her IV line or into the IV bag. I don't know enough about crotalid venom to know which or when it was done. But I am absolutely certain of what I'm saying. It is essential that we get this antivenin into her as soon as possible."

"This is insane," Ettinger said.

"How do we know the antivenin is what is in those vials?" Randall Snyder asked.

"Well, for one thing, they're sealed. For another, if this was anything but antivenin, there would be no sense in someone placing it in my possession."

"Assuming someone did," Peter said.

"Dr. Blankenship," Sarah asked, ignoring Ettinger, "do you know if there are any side effects to the antivenin?"

"An allergic reaction to the horse serum it's made in, I would think," Blankenship said. "Nothing else comes to mind."

"We can handle that."

"Here, let me see the package insert."

Randall Snyder glanced once again at the fetal monitor. "Eli, there's been a slight drop in the baby's pulse. You've got to decide."

"Crotalid poisoning," Peter said. "Sarah, you are really crazy."

"Ettinger, this issue has been decided," Eli warned, glaring at the taller man from beneath his massive brow. "Either go stand on the other side of the bed or get the hell out."

Peter hesitated and then rather meekly did as he was ordered. Eli quickly scanned the instructions and drew the contents of ten of the vials into a large syringe. Sarah explained the situation to Annalee. There was complete silence in the room as Eli slid the needle into the rubber port of the IV tubing and slowly discharged the cloudy liquid into her bloodstream.

The response to the antivenin was dramatic.

In less than five minutes, Annalee reported that the intense pain in her extremities had begun to abate. Twenty-six minutes after the injection, the bleeding from her nose and needle stick sites stopped completely. By early afternoon, her fever was gone and nearly all of her clotting studies and other laboratory tests were normal.

Six hours after the administration of the antivenin, Glenn Paris convened an emergency session of the executive committees of the hospital trustees and medical staff. After hearing the accounts of Randall Snyder, Eli Blankenship, Helen Stoddard, and the labor and delivery nurses, the participants voted unanimously to place Sarah Baldwin on immediate, indefinite, paid leave from the hospital and from her residency until the details of her involvement in Annalee's case became known with certainty.

• • •

The body had been in the morgue at the state medical examiner's office for three days before a definitive identification was made. Actually, body was not so apt a description of the remains as skeleton. A week before, the crew of a trawler, fishing seventy-five miles off the Massachusetts coast, had hauled it aboard along with several hundred pounds of haddock.

The skeleton had not a shred of clothing or tissue left on it, except for some cartilage on the ribs and in several of its joints. Still, the medical examiner was able to place the time of death within the past six months. He also had no problem classifying the death as a homicide. There were fracture/dislocations of two cervical vertebrae. The nature of the bony fragments strongly suggested blunt force. The ropes and diver's weights, still tied around the skeleton's extremities and what was once its midsection, removed what doubt remained.

Now, the ME inspected the dental X rays obtained from the Boston police. His dental forensics expert had just matched them with certainty to those films taken of the skeleton. He dictated his findings into a hand-held recorder and then called the BPD detective who had sent the X rays over.

"I think you can contact the missing man's family and tell them he is no longer missing," the medical examiner said. "Unfortunately, it would seem that your Dr. Truscott has done his last operation."