Natural Causes

CHAPTER 3

IF SARAH HAD A ROLE MODEL IN HER PRACTICE OF OBSTETRICS and gynecology, it was her chief, Dr. Randall Snyder. From his soft-spoken manner to his gray Volvo sedan, everything about the man was fatherly and reassuring. Now in his mid-fifties, he still approached his solo practice with exuberance and compassion. When a new technique or treatment in his field was announced, he would be one of the first in line to learn it. If an uninsured clinic patient had a problem pregnancy, he would accept her as his private patient without a word about payment.

Today Randall Snyder was taking time from his busy schedule to drive Sarah to the Jamaica Plains section of the city. There he would assist her in performing a home delivery on a twenty-three-year-old unwed woman with no health insurance and an inordinate fear of doctors and hospitals.

"How do you do it?" Sarah asked as they drove.

"Do what?" Snyder turned down the volume on the Bach cantata he was playing on the tape deck.

"Keep on doing medicine the way you do without letting it get to you?"

Snyder stifled most of a smile. "Do you want to define 'it'?"

"Oh, you know-the peer reviews and the lawyers, and the insurance companies and government telling you what you can and can't charge for your work; the mountains of paperwork, and the constant threat that you'll offend some vindictive or imbalanced patient who'll lodge a complaint about you or sue you."

"Oh, that 'it,' " Snyder said. "Sarah, as far as I'm concerned, you're not even talking about 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."

"But that's medicine. The other stuff is… is…"

"Is medicine, too. It's part of the package. Believe me, I'm not the serene machine a lot of people make me out to be. But neither do I go home after a day's work and beat my wife because I haven't hit the lottery or written the best-seller that will enable me to get out of the profession. I can handle the things you're talking about because by and large I still love what I do, and feel damn lucky to have been given the chance to do it. Why are you asking about all this? Are you having trouble?"

"Not trouble exactly. Oh, turn right at the next corner."

"Got it. Knowlton Street, you said, right?" "Yes."

"I know the way. Now go on."

"You know that before I went to med school I worked in a holistic healing center."

"Of course. I've been to some of your presentations. Interesting stuff. Very interesting."

"My training was in herbal medicine and acupuncture. But some things happened that made me feel I needed to broaden the skills I had."

Some things happened. The understatement of the week, Sarah thought. She debated going into the details of her final clash with Peter Ettinger, but quickly realized that this was hardly the time or place to unearth that worm.

"Well, our techniques in the holistic center had their limitations," she went on. "I don't question that. But there was a certain, I don't know, call it innocence about our goals and the way we did things-most of us, anyway. Each day we went to work and were able to concentrate almost exclusively on doing what we could for our patients."

"And?"

"Well, as far as I can tell, medicine as I'm being trained to practice it now is often as much about money and liability as it is about patients. We order millions and millions of dollars in marginal or unnecessary tests so that our backsides will be covered if we end up in court. Meanwhile, government agencies, thinking they're saving money, are telling us how long we're allowed to keep patients with a given illness in the hospital. So what if an elderly lady here or there gets sent home too soon after a hysterectomy and falls and breaks her hip? We're talking statistics here-actuarial tables and percentages. Not flesh and blood."

"Sarah, you are too young to be so jaded."

"Dr. Snyder, I wish there was something I was still too young to be-anything at all; and you know I'm not jaded. I feel I've made the right decision in becoming an M.D. And I love being a doctor. Sometimes I just wish it all was a little more, I don't know, pure."

Randall Snyder chuckled.

"Ivory Soap is ninety-nine and forty-four one-hundredths percent pure," he said, turning onto Knowlton. "Nothing involving human beings even comes close to that-especially not in our racket. But, listen, I do understand what's troubling you, and I promise we'll continue this discussion sometime soon, perhaps over dinner at our place. For now, you should know that you're on your way to being a heck of a doctor-exactly the sort of person I would like to have as a partner in my practice."

"Why, thank you." Sarah could not mask her surprise-or pleasure. It was the first time she had heard Randall Snyder even intimate he might be considering bringing in an associate, let alone her.

"File that one away for the time being," Snyder said. "Sometime later this year, if you want, we'll sit down and talk business. It's okay to take a hard look at the less appealing sides of our profession, as long as you don't get paralyzed by what you see. And for God's sake, don't go putting anyone on a pedestal-especially me." He pulled to the curb in front of number 313. "Now, before we go in, how about giving me a thumbnail on our patient."

The concise, highly stylized presentation of a medical case was emphasized more, perhaps, than any other skill during Sarah's training. As a student, she would often lie in the bathtub, oblivious to the progressively cooling water, as she used a stopwatch and a dozen or more repetitions to perfect her next morning's case presentation. Now the technique was second nature.

"Lisa Summer is a twenty-three-year-old unmarried artist, gravida two, para zero, spontaneous a.b. three years ago. LMP ten-two."

Second pregnancy, no deliveries prior to this one, a miscarriage, last menstrual period nine months before. Randall Snyder nodded for Sarah to proceed.

"This pregnancy has been unremarkable in every respect. There has been a thirty-pound weight gain from a base weight of one oh six. At exam one week ago, fetus was in vertex position-head was engaged, probably left occiput anterior.

"Except for the usual childhood diseases, Lisa has a negative medical history. She is a nonsmoker and drinks occasionally. No other meds except for the natural prenatal supplement I prescribe."

"Ah, yes," Snyder said. "The mysterious Baldwin mix. I was at the departmental conference last year when you spoke of it. Sometime soon I would like to learn more. Please continue."

"Family history is scant. No relationship with her parents at present; no relationship with the father of the child."

"Oh, my."

"Her coach is a woman friend who's a nurse. Apparently, as a child, Lisa had a bad experience of some sort in a hospital. Now she's terrified of them."

"Ergo the home birth."

"That's one of the reasons. Lisa's sort of-I don't know-she's very secretive about herself, and very mistrustful of people."

"Even you?"

"Not as much as at first, but yes, even me."

"Well, then, supposing we go on in and try to turn that around."

Sarah gathered up the covered tray of equipment and obstetrical instruments.

"One more thing," she said. "Heidi, the birth coach, said that Lisa's pressure has been dropping slightly and that it's become harder to hear in her right arm than her left. The last systolic I know of was eighty-five, just as Glenn was starting his talk. The highest, a few hours before that, was one ten."

"And what do you make of that?" Snyder asked.

"Low-normal for this stage of labor, I would say. When she called me, Heidi reported that Lisa looked fine. So it's probably nothing."

Sarah saw concern in Snyder's eyes and immediately sensed that she had not taken the report seriously enough.

"The actual number may be low-normal," he said, "but in my experience, not many labor patients have that sort of pressure drop at this stage."

"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 no 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?