Natural Causes

CHAPTER 4

SIX OF THE NINE SUFFOLK STATE HOSPITAL BUILDINGS originally purchased by the Medical Center of Boston were still in use. Two of the others had been razed and replaced with parking facilities. The third, a crumbling six-story brick structure with the name CHILTON etched in concrete over its entrance, had been abandoned and boarded up when Sarah began her training, and remained so-a mute reminder of the hospital's ongoing financial difficulties.

The Chilton Building and garages were separated from the rest of the hospital by a broad, circular drive. Enclosed within the loop was an expansive, grassy courtyard, dotted by some shrubbery and half a dozen molded plastic picnic tables. Vehicle access to "The Campus," as Glenn Paris had named the area, was restricted to those administrators and department heads with parking slots, and to emergency room traffic.

The ride from Knowlton Street to MCB, spearheaded by the sirens of the police cruiser and rescue squad, took fifteen minutes. Seated beside Lisa Summer in the back of the lurching ambulance, Sarah heard the driver radio ahead that a Priority One patient was on the way. She pictured the guard, suddenly puffed with importance, scurrying to open the security gate and move all traffic aside.

Lisa's contractions, now occurring every four minutes or so, were forceful and prolonged. However, Sarah's gentle exam had disclosed a cervix that was still only four centimeters dilated-far from being ready for delivery. The bleeding from her nose and mouth was, if anything, more brisk. And although her left hand and both feet still had some warmth and capillary blood flow, her right arm was now pallid and lifeless from the elbow down.

"Hang on, Lisa," Sarah urged. "We're almost there."

As they turned onto the MCB access road, Sarah reviewed her knowledge of DIC. Having never encountered a severe case of it during her training, her understanding was essentially what she had gleaned from a lecture or two in med school, some reading, and an occasional conference. Rather than being a single, specific disease, the condition was an uncommon complication of many different sorts of injuries or illnesses. Surgery, shock, overwhelming infection, massive trauma, drug overdose, toxins, abrupt separation of the placenta-any of a number of insults to the human body could result in DIC. And in part because of the severity of the predisposing condition, full-blown DIC was, more often than not, fatal.

But Lisa Summer was neither injured nor ill. She was a healthy young woman at the end of a totally uncomplicated pregnancy. Perhaps this wasn't DIC after all, Sarah thought.

The siren cut off as they neared the hospital. Sarah did a quick blood pressure check and exam and began mentally preparing the presentation she would give to Dr. Eli Blankenship. It was her job to present the facts in a totally unbiased manner, carefully avoiding her own diagnostic impression or any other leading statements. Until a diagnosis was proven, assuming one to the exclusion of others was foolish and potentially very dangerous. Assume makes an ass of u and me was the way one professor had stressed that principle.

Eli Blankenship, perhaps the sharpest medical mind in the hospital, would combine her information with his observations. He would then come up with an approach to diagnosis and treatment. Meanwhile, if therapy could not be held off until a definite diagnosis could be made, they would simply have to say a quiet prayer and forge ahead with what measures seemed likeliest to help.

In this case, with two lives already hanging by a thread, it was unlikely they could wait for any laboratory results before instituting treatment. And the treatment for DIC was, itself, life-threatening. All in all, Sarah knew, it was going to be one hellish day for Lisa Summer and the dozens of physicians, nurses, and technologists who would be battling to save her and her baby.

And all the while, swirling about that struggle would be the persistent, gnawing question of why?

As they backed up to the emergency room's receiving platform, Sarah could see Eli Blankenship waiting by the ER door. As always, she was struck by the man's appearance. Had she, without knowing, been challenged to name his vocation, her first guesses might well have included tavern bouncer, stevedore, or heavy machine operator. MCB's chief of staff was a bull of a man, less than six feet tall but with a massive chest and head that were separated by a token neck. He was bald save for a dark monk's fringe. But beneath his expansive forehead, his eyebrows were thickets, and his muscular arms were like Esau's. Even clean shaven at the outset of a day, he seemed to have a persistent five o'clock shadow.

Of the man's physical attributes, only his eyes-a pale, penetrating blue-gave hint to his genius. He was board certified in infectious disease and critical care as well as internal medicine. But he was also respected as a humanist, expert at chess and contract bridge, and well versed in the arts. As a teacher, no one at MCB was more open and respectful of the views and approaches of students and residents, and no one taught them more effectively.

Blankenship, already gowned and gloved, met the stretcher as the rescue squad pulled it from the ambulance, and immediately took Lisa's hand and introduced himself to her. From the other side of the litter, where she was keeping pressure on Lisa's nose, Sarah could see that with that first touch, the medical chief had already begun his examination and assessment.

By the time they reached Room A, one of three major medical/trauma rooms, Sarah had nearly completed her case presentation. Blankenship had the phlebotomist from the laboratory waiting to draw blood for them as well as an OB nurse with a fetal monitor. With a nod, he motioned them both into action. At that moment, blood began to ooze through the gauze wrap protecting Lisa's intravenous line. Blankenship noted the development with no change in his expression.

"Now, Lisa," he said evenly, "I'm going to ask you to be patient with us and to forgive us if it seems we're not keeping you abreast of what's going on. You've got several different things going on here at once, involving several different systems of your body. In a few more seconds, you aren't going to be able to tell all the doctors working on you without a scorecard. The main ones besides me will be Dr. Helen Stoddard, who's a blood specialist, and Dr. Andrew Truscott, who's a surgeon. Her job will be to help us stop this bleeding, and his will be to get in another intravenous line and tend to your arm, which right now is not getting enough blood. And of course, we'll have Dr. Baldwin and Dr. Snyder standing by to deliver your baby as soon as we can get you stabilized."

"Is the baby all right?" Lisa asked.

Blankenship looked over at the OB nurse, who nodded toward the fetal monitor. The fetal heart rate was higher than optimum, often an early sign of trouble.

"The baby's under some stress," he said. "We're watching that very closely."

At that moment, the hematologist swept into the room. Helen Stoddard, also a full professor, was a department chief at another hospital and a sometime consultant at MCB. Unabashedly from "the old school," as she liked to say, she had been openly critical of MCB's coddling up to "fringe players"-her term for practitioners of alternative medicine. During one hospital-sponsored seminar, she had been one of the panelists arguing against incorporating any techniques unproven by scientific methods. Blankenship and Sarah were part of the opposition, advocating the use of certain empirically proven treatments such as acupuncture and chiropractic, and careful scientific evaluation of those and others.

"Where do we stand, Eli?" Stoddard asked without so much as a glance at Sarah.

"Studies are off, ten units ordered."

"Platelets and plasma as well?"

"As many of each as we can get."

Helen Stoddard completed a rapid exam of Lisa's skin, mouth, and nail beds. The gauze surrounding the IV was now saturated. Blood dripped from it onto the stretcher sheet and floor. The venapuncture site from which blood had been drawn was also oozing.

"No prior history of bleeding problems?" she asked Blankenship.

"Absolutely none."

Stoddard thought for a few seconds. "We can't wait for the lab. I think we hang up what platelets, blood, and plasma we can and heparinize her."

Randall Snyder and Heidi Glassman entered the room, both a bit breathless. Moments later Andrew Truscott arrived as well. Heidi took Sarah's place at the bedside, while Truscott, Sarah, and Snyder stepped back to the doorway.

"She's in real trouble," Sarah said.

Snyder glanced at the fetal monitor.

"So's the baby," he said. "Have you started Pitocin?"

"In the ambulance. She's still only five centimeters dilated."

"Jesus."

Truscott took a minute to examine Lisa's arms, hands, and feet. Then, with impressive skill and speed, he injected some anesthetic into the skin at the side of her neck, located two bony landmarks with his fingertips, and slid a large-bore needle through the numbed spot directly into her internal jugular vein. Next he threaded a catheter through the needle and sutured it in place. A critical second IV route had been established.

"One way or the other, I think we're going to have to take her to the OR for that arm," he said after returning to the doorway. "I still can't tell about the left or her feet. Can you C-section her?"

Snyder crossed to Helen Stoddard, held a brief, whispered conversation, and then came back shaking his head.

"We may already be down to a mother versus fetus situation," he whispered. "Helen and Eli have decided they can't wait for laboratory confirmation of DIC. They've gone ahead with heparin. As things stand, they feel the girl has no chance of surviving a C-section."

Heparin for DIC. To Sarah, whose practice as a surgeon was built on a bedrock of meticulous attention to the control of hemorrhage, the treatment was a terrifying paradox: the intravenous injection of a powerful anticoagulant to a patient who was already in danger of bleeding to death. The theory was to administer the drug to break up the pathological clots and restore blood flow to the compromised extremities and vital organs. At the same time, continuous transfusions would be used to chase lost blood volume and replace clotting factors. It was a therapeutic balancing act of circus proportions, and one that too often was doomed to fail.

Sarah looked at the woman she had cared for over the past seven months, now barely visible within the clutch of nurses, physicians, and technologists. In just minutes, Andrew had contributed greatly to everyone's efforts. She had yet to contribute anything. True, she acknowledged, he and the other medical players in this drama were all senior to her. But Lisa Summer was still her patient, and there were things the two of them had worked on, things they could try, that might help as well-provided, of course, that Helen Stoddard and Eli Blankenship allowed them the chance.

She excused herself and raced down to the subbasement where a series of rather dimly lit tunnels connected all of the MCB buildings. Her locker was on the fourth floor of the Thayer Building, which housed the administration offices on the first three floors and the house staff sleeping quarters on the top two. Sarah took the elevator up. Minutes later she bounded down the six flights and sprinted back through the tunnels toward the ER. Cradled in her arm was the mahogany box containing her acupuncture needles. The box had been a gift from Dr. Louis Han. She had first encountered Han, a Chinese-born Christian missionary, while teaching with the Peace Corps in the Meo villages north of Chiang Mai, Thailand. Until his death nearly three years later, he was her mentor in the healing arts. The inscription on the box, elegantly carved in Chinese by Han himself, read: THE HEALING POWER OF GOD Is WITHIN Us ALL.

The moment Sarah stepped back into Room A, she sensed things had changed for the worse. A tube inserted into Lisa's stomach through her nose was carrying a steady stream of blood into the suction bottle on the wall. Her urinary catheter was also draining crimson. Randall Snyder, his face ashen, stood by the fetal monitor, where the heartbeat of Lisa's unborn child had dropped below the rate necessary to sustain life.

"What's happening?" Sarah asked, moving beside him.

"I think we've lost him," Snyder whispered. "We could go for a section right here and now, and maybe we'd still be in time for the baby. But Lisa would never survive."

"Is she going to anyhow?"

"I don't know. It looks bad."

Sarah hesitated for a moment, and then worked her way to where Helen Stoddard and Eli Blankenship were standing.

"Can I please speak with you both?" she asked.

For an instant, she thought Stoddard was going to dismiss her. Then, perhaps remembering Sarah was one of Blankenship's hand-picked residents, the hematologist moved to one side of the room. Blankenship followed.

"I'd like to try to stop Lisa's bleeding," Sarah said.

"And exactly what do you think we're trying to do?" Stoddard asked.

Sarah felt the muscles in her jaw tighten. She had never forced her abilities and techniques on any resident or faculty member who didn't request them. But Lisa was her patient, and conventional therapy did not seem to be working.

"Dr. Stoddard, I know you don't have a great deal of regard for alternative healing," she said, struggling to keep her voice steady. "But I only want the same thing you do. I want Lisa to make it. For the last four or five months, while we were getting ready for her home birth, Lisa and I have been working on some self-hypnosis and internal visualization. I think she's really gotten quite good at both."

"And?" Stoddard's expression was ice.

"Well, combined with acupuncture, we might be able to use Lisa's own power to slow her bleeding down. Provided, that is, you are willing to give her enough protamine to neutralize the heparin."

"What?"

"If we succeed in slowing her bleeding enough to be able to C-section her, you can start the heparin again to work on dissolving her clots."

"This is ridiculous."

Sarah took a calming breath. Over four years of medical school and two years of training, she had never had a clash of this sort with a professor. But there could be no backing down. "Dr. Stoddard, Lisa's pressure is dropping, her bleeding is getting worse, and it may already be too late for the baby."

"Why, you arrogant, ignorant-"

"Just a minute, Helen," Blankenship cut in. "You can say anything you want when this is over, but right now we have a girl who is going down the tubes, and we've got to focus on her. Dr. Baldwin is right. The heparin's not doing anything for the clots yet, and it's sped the bleeding up to the point where we're falling behind in our transfusions."

"Do this and I'm off this case," Stoddard said.

"Helen, you're one of the best hematologists I've ever known, and one of the most dedicated doctors. I can't imagine you ever allowing anything to get in the way of what's best for a patient."

"But-"

"And deep down, you know that the few minutes it will take Sarah, here, to try what she knows will make little difference to the outcome."

"But… all right, dammit. But after this is over, regardless of what happens, this hospital had better clarify its policy on medical quackery, or I am off the staff."

"We'll do that, Helen. I promise. We'll do that. Sarah, how can we help?"

"Well, first give Lisa the protamine."

"Helen?"

"Damn you, Eli. Okay, okay… This is ridiculous," she muttered as she headed back to administer the heparin antidote. "Absolutely ridiculous."

"Now," Sarah continued, sensing her pulse beginning to race, "please just leave Heidi with me, pull as many people away from the bedside as possible, and keep all noise to a minimum."

"Done. Anything else?"

"Just one. Please turn off the overhead lights."

Lisa cried out as another contraction took hold. Sarah stroked her forehead, then knelt beside her.

"Lisa, close your eyes and listen to me," she said softly. "We've got work to do. This is the moment we practiced for in all those sessions. Do you understand?… Good. Let's just start with the easy things, the scenes, okay? Use them during your contractions. I'll help you, and Heidi is here to help you, too. In between contractions, I want you to concentrate on my voice and start trying to visualize what is happening in your bloodstream and your heart. Everything's moving too fast… too fast. There may be blood clots forming there, too, clogging your arteries. Try to relax and see them, too. Just relax… Just relax…"

Heidi continued whispering in Lisa's ear as Sarah briefly consulted a thin, frayed booklet. Having assured herself of the acupuncture points she wanted to stimulate, she set her first needle by twisting it in just below Lisa's left collarbone. Then, one at a time, she set five more of the steel needles in various points, trying to compensate for the limitations placed on the technique by Lisa's bandages and supine position.

An eerie silence had taken over the room, broken only by the muted churning of the suction apparatus and the soft beep of the cardiac monitor.

"Look," Sarah heard someone whisper. "I think the bleeding's letting up already."

Sarah glanced at the suction bottle. In fact, the drainage did seem to have significantly lessened.

"Lisa, relax," Sarah said again, pleasantly but firmly. "Slow your heart… slow your blood… and just relax. You have the power…"

One minute passed. Then another. Lisa lay motionless now, her eyes closed. A contraction hit, visibly knotting her abdomen. She remained motionless and serene.

"Her heart rate's down from ninety to fifty, Sarah," Blankenship said. "The oozing from her IV and venapuncture sites may have stopped altogether. Randall, do you want to get ready?"

"Everything's set," Snyder said. "Anesthesia's standing by upstairs. Just say the word."

The nasogastric tube was now draining only small amounts. All oozing had stopped. Carefully Sarah twisted out the six acupuncture needles. For ten seconds, fifteen, all was quiet.

"Go for it," she said.