Natural Causes

CHAPTER 5

July 2

SARAH ORDERED THE OPERATING TABLE UP TWO INCHES and screwed sterile handles into the parabolic overhead lights. Her eyes burned a bit; she'd been up and running for twenty-four hours without so much as a catnap. But her concentration, as always when she was in the OR, was as sharp as her scalpel. After centering the focused beams, she cradled the blade in her right hand, minutely adjusting its position until it felt a part of her. With her left, she tensed the skin along what had been the upper margin of the pubic hair escutcheon. Then, with a single, steady stroke, she opened the abdominal wall and separated the thin saffron layer of subcutaneous fat. She next handled what few bleeders there were by snapping each with a hemostat and touching the steel instrument with an electrocauterizer. Finally she cut the peritoneal membrane, exposing the bulging, gravid uterus.

"Everything all right?" she asked the anesthesiologist. "Stable."

"Okay, here we go."

Sarah scored the surface of the uterus with her scalpel, then made a small opening in it. Inserting her index fingers, she pulled the beefy muscle fibers apart. Then, with the touch of her blade, she opened the amniotic membrane.

"We're in," she said at the first gush of amniotic fluid. "Suction, please."

Time now was critical. The powerful uterus could clamp down at any moment, making the delivery of the baby within it anything but routine. For ten seconds Sarah's breathing, and it seemed her heart as well, stopped as she felt deep in the pelvis for the baby's legs, trying at the same time to assess the position of the umbilical cord. Gently her fingers closed about the spindly legs and drew them up through the incision. Next the torso and gently, ever so gently, the shoulders and arms. Finally she cradled the eggshell skull in her palm and guided it up through the incision. And just like that, the infant was born.

Quickly Sarah cleared its nose and mouth with a suction bulb. Moments later the expectant hush of the delivery room was pierced by the newborn's bleating cry. And instantly the tension in the room evaporated.

"It's a girl, Kathy," Sarah said too flatly. "A beautiful girl. Congratulations. Dad, if you'll step around over here, you can cut the cord."

The father, just out of high school, sidled over nervously, did as she instructed, and then hurried back to the head of the bed where his young wife was alternately crying and laughing for joy. Swallowing at the sudden, unpleasant fullness in her throat, Sarah handed the perfect newborn over to the pediatrician. She hoped no one in the room could tell how close she was to tears herself-tears not of joy but of sorrow for the stillborn death of Brian Summer some seventeen hours before.

It was six o'clock in the morning, following an incredibly stressful, roller-coaster day and night during which Sarah had presided at two normal vaginal births and now this breech-presentation cesarean. But shortly after one o'clock the previous afternoon, the exhilaration of playing a major role in slowing Lisa Summer's bleeding had given way to the inestimable sadness of assisting in the extraction of her baby-dead before they had even reached the delivery room.

Like the infant of the previous DIC patient, Brian Summer had succumbed to massive bleeding within the placenta and premature separation of the placenta from the uterine wall. Had he been delivered even half an hour earlier, he might have survived. The agonizing choice, though, had been to channel all efforts toward saving Lisa, who almost certainly would have bled to death had the procedure not been delayed.

With an unfamiliar sense of distraction and detachment, Sarah watched her hands deliver the young woman's placenta, then begin closing the incisions she had made. The decision to try to save Lisa's life had been the correct one. Nevertheless, acceptance of the outcome was not coming at all easily. Sarah was preparing to place the skin clips when the circulating nurse from surgery came up behind her.

"Sarah, Dr. Truscott wanted me to tell you that they've taken Lisa Summer back into the OR," he whispered.

Oh, no, she thought. "Do you know what's going on?"

"Well, apparently the anticoagulation and the heparin flush haven't cleared the blockages in her arm. I'm not sure what Dr. Truscott plans to do now."

"Thank you, Win. I'll be over as soon as I can. Kathy, we're almost done. The pediatrician just signaled to me that your baby's perfect. Her Apgar score is nine. Ten is tops, but we only give that to babies who come out playing a violin. He'll bring her over to you in just a moment."

"Thank you, Doctor. Oh, thank you so much."

Sarah taped a bandage over the incision and stripped her gloves off as she backed away from the table.

"We're all very happy for you," she said.

She left the delivery floor and headed toward the surgical building. Twice during the short walk she was stopped-first by a nurse, then by a medical resident-and congratulated for the job she had done on Lisa.

"The whole hospital's talking about it," the resident said. "You really opened a lot of eyes to the potential of alternative healing. My medical degree's a D.O. from the school of osteopathy in Philly. All of a sudden, for the first time, really, the other medical residents are asking me about my education-about what sorts of things we study that the people in traditional medical schools don't. People who only paid lip service to nontraditional methods are suddenly very interested in them."

The man's words should have been a tonic. But today they did little to alleviate Sarah's sense of impotence. All of her training plus hundreds of thousands of dollars' worth of equipment and personnel had been unable to save Lisa Summer's baby. This was not the first time she had agonized through the loss of patients' pregnancies and newborns. That people die was the most basic tenet of medicine, and on a purely intellectual level, it was a truth she understood. But for whatever reason, her emotional response to this loss seemed impervious to knowledge or logic.

She pictured her old office/treatment room on the second floor of the Ettinger Institute. She had been no less involved in caring for people in those days than she was now. But that world-that serene, uncomplicated, highly personal interaction with patients-seemed light-years away.

The difference, purely and simply, was the degree to which technology and science-whatever that really was-dominated western medicine. At times, and this was certainly one of them, it felt as if she had traded in flying on a hang glider for piloting a jet.

Her reason for leaving the Ettinger Institute was the inflexibility and eventually the intolerable behavior of Peter Ettinger. But her decision to obtain an M.D. degree went far deeper than that. She had felt that when she became a physician, many of the limitations and resulting frustrations of her professional life would disappear. Instead, despite all the equipment and her newly acquired technical skill, her limitations seemed just as frustrating, and those frustrations just as limiting.

There were four women now on the hospital's surgical staff and three female surgical residents. Still, there was only one surgeons' locker room, and it remained for men only.

Sarah discarded her maroon OB scrubs in the nurses' locker room, slipped on a sea green pair, and replaced her shoe covers, hair guard, and mask. Twelve hours had passed since she had watched Andrew Truscott probe and irrigate the main arteries supplying Lisa's right arm. Their goal was to remove as much clot as possible and to hope that anticoagulant irrigation took care of the rest. Now, apparently, they needed to do more-perhaps a major dissection of the blocked vessels.

Sarah entered the OR through the scrub room. Lisa, now in an operating room for the third time in less than twenty-four hours, was already anesthetized and intubated. Her face was deceptively peaceful. A low drape across her neck separated her head and the anesthesiologist from the surgical team. On the other side of the drape, Andrew and another surgeon, both on the same side of the table, were focused on Lisa's arm.

For a moment, Sarah thought the second surgeon was the same vascular man who had assisted Andrew on the earlier procedure. But as she pulled the small metal footstool over and stood on it to get a better view, she realized that the other doctor was not a vascular surgeon at all. He was Ken Browne, the chief of orthopedics. It was only then that Sarah saw the severed forearm and clawed hand resting on the metal tray beside the scrub nurse and realized that Browne and Andrew were not doing any delicate vascular procedure at all. They were aggressively paring down what remained of Lisa's radius and ulna-the bones of her forearm-in preparation for the completion of a below-the-elbow amputation.

Sarah felt her muscles go limp and, for just a moment, thought that for the first time in her life she was going to faint. Oh, Jesus, no. First the baby… now this was all she could think.

Andrew glanced up and saw her.

"You okay?" he asked.

"Andrew, she was an artist. A potter. Her hands were… Hey, listen, I'm sorry. It's just that I thought she was going to be all right."

"She probably will be… now," Andrew responded somewhat wearily. "I'm sorry about having to do this, too. But impending gangrene is impending gangrene. There was really no choice."

"I understand."

But even as she said the words, Sarah knew that there was precious little of what had happened to Lisa Summer that she understood at all.