Natural Causes

IATROGENIC: ILLNESS OR INJURY CAUSED BY THE

Now the chance was right there for him to belittle her judgment-to once again force his famous views on M.D.s and their methods down her throat. But he hadn't taken it.

Like Peter, she understood the miraculous potential in the relationship between healer and patient. She had great faith in the power of holistic methods to diagnose and treat. But unlike him, she had never viewed traditional medicine as a court of last-or no-resort. After all, she had once survived a nearly fatal ruptured appendix by getting airlifted to a U.S. military hospital and having emergency surgery.

Peter was forty-a dozen years older than she. That age difference, along with his imposing size-he was six feet four-his immense drive and material successes made holding her own in their relationship a challenge and asserting herself in it almost a pipe dream. But at last Peter had chosen to listen rather than to react: to understand that his way of doing things might not be the only way.

They took the following morning off from work and spent a good deal of it making love. By the time Sarah arrived at the institute to begin seeing a full afternoon of appointments, she was feeling more centered and positive about her life than she had in some time.

By three o'clock, though, she began wondering why she hadn't heard from the neurologist at White Memorial. At least some of his evaluation of Henry McAllister should have been completed by then. If her observations of the artist's motor problems were correct, an emergency CT scan and several other tests were in order. The physician had promised to call Sarah at her office as soon as he had anything to report.

Three-thirty… four… four-thirty…

She checked the time again and again as she worked her way through her clients. Finally, after the last of them had left, she called White Memorial.

"Miss Baldwin, I assumed you knew," the neurologist said.

"Knew what?" She felt a sudden, unpleasant tightness in her throat.

"When I arrived at the office this morning, there was a message waiting with my answering service from your Mr. McAllister. He called at, oh, ten o'clock last night to say that he had spoken with his own medical advisor and would not be keeping his appointment with me. I thought that by medical advisor he meant you."

"No," she said. "No, I'm afraid he meant someone else. Thank you, Doctor."

"Well, I'm sorry I couldn't have been of more-"

She was already lowering the receiver to its cradle. She stalked down the hall to Peter's office. He was leaning back in his chair, his feet up on the corner of his desk.

"Peter, why didn't you tell me last night that you called Henry McAllister?"

"I didn't think it was that important."

"Important? I probably gave myself an ulcer agonizing over the decision to refer him."

"Well, now you don't have to worry about it anymore." He lowered his feet to the floor.

"But you said I did the right thing."

"And you did. The right thing for you. But not necessarily the right thing for Henry."

"But how do you know? How could you tell him to cancel that appointment without even seeing him?"

"First of all, I don't believe there's much an M.D. can do that our people can't do as well or better. You know that. And second, I didn't tell him to cancel his appointment. I told him that he should use his judgment, and that no matter what he decided, I would be available to see him all day today. He need only call and set up a time to come in."

"And did he call?" She felt her pulse begin pounding in her temples. Her cheeks were burning. She wanted to leap over the man's desk and pummel the self-assuredness off his face. "Well, did he!"

Peter's expression tightened.

"I-I guess in all the excitement going on here today I forgot to check." He glanced at his message spindle and then called the receptionist. "It seems he didn't feel the need to call," he said as he hung up.

"Peter, you are really a son of a bitch. Do you know that?"

She whirled and hurried back into her office.

"Hey, easy does it, babe," he called after her. "Easy does it."

Henry McAllister's clinic record was on her desk. She dialed his number and let the phone ring a dozen or more times. Then she dialed 911. If she was wrong, she'd look like a fool. But there was no way she could let matters drop. For the first time in three years, she felt as if she were reacting to a challenging situation like Sarah Baldwin, and not like Peter Ettinger's flunky.

Peter was just coming out of his office as she raced past him, down the stairs, and out of the institute. He called to her, but she never even looked back.

McAllister lived in a South End loft about ten blocks away. She thought briefly about looking for a cab. Then she just gritted her teeth, clenched her fists, and sprinted off…

"So?" Alma Young asked.

"Pardon?"

"So what happened to the sculptor? You can't leave me hanging like that!"

"Oh, sorry," Sarah said, uncertain of precisely how much of her thoughts she had actually shared. "Well, in that particular situation, if I had accepted that what I had already done was everything I could do, the man would probably have died. The police ended up breaking into his apartment. We found him unconscious on the floor. Two hours later he was in the operating room at White Memorial. He had a slowly growing malignancy-a meningioma, actually-on the right side of his brain. And as sometimes happens, he had begun bleeding into the tumor. Pressure was building inside his skull."

"Thank God you reached him in time." Alma gasped, genuinely relieved at the fate of a man whose crisis had occurred seven years before.

Sarah smiled at the nurse's reaction.

"I was allowed into the operating room to watch them take the tumor out. It was really incredible. That's when I decided I wanted to be a surgeon of some sort. Eventually I settled on OB/Gyn."

"And the other man? Your… um… friend?"

Sarah shrugged. "I moved out the next day, and we haven't spoken since."

"That's quite a story."

"And part of the reason that I'm never comfortable accepting that I've done all I can for a patient."

"Maybe. But I still say you'll be better off when you admit you're only human. Doctors today have remarkable capabilities, but they still aren't God. Never were, never will be. If you can't come to grips with the fact that in spite of your best efforts, some of your patients are going to lose their baby, or lose their arm, or both, or worse, then sooner or later this racket's going to eat you alive."

"I understand."

"Do you?"

"Yes. Yes, I do."

Alma Young reached over and gave Sarah a reassuring hug. "In that case, Dr. Baldwin, I don't want to see you beating up on yourself because a horrible condition you had nothing to do with took that girl's baby and arm. I want to hear you bragging from the rooftops about what you did yesterday to help save her life. It was big, big stuff for this hospital. And everyone who cares about MCB will be crowing right alongside of you. Got that?"

Sarah managed a smile.

"Cock-a-doodle doo," she said.

The doors to the SICU glided open, and Lisa was wheeled in by a transportation worker and a nurse. Andrew Truscott followed moments later. The night he had just spent in the OR showed in the faint shadows enveloping his eyes, but no one would have guessed that he was into his second straight day without sleep. It was a phenomenon Sarah had noticed in herself as well. With each passing year of surgical training, sleep deprivation had fewer biologic effects-as far as she could tell.

"How's she doing?" she asked.

"Not the most elegant of surgeries, those amputations. Sorry we couldn't pull off the alternative."

"You and me both. But I'll bet she's going to do all right from here on out."

"Well, what do you expect? You cured her with those spiffy little pins of yours."

"Nonsense." As often happened, Sarah was uncertain whether Andrew's sarcastic tone reflected his real opinion.

"Sarah, Dr. Truscott," Alma Young called out, "could one of you M. Deities please come help us transfer this girl?"

"I'll be right there," Sarah responded.

"That's grand, old shoe," Truscott said, "because I've got a consult I must do on Med Five. Why don't we plan to meet for coffee in the caf in, say, an hour. I have some questions to ask you about yesterday's magic show. Alma, the postop orders for our young charge are tucked under the mattress. Dr. Muscles, here, is coming to assist you straightaway."

With Sarah's help, Lisa was transferred from the recovery room stretcher to Bed 8. Then Sarah stepped aside as Alma and another nurse quickly hooked up Lisa's IV infusion pumps, cardiac monitor, and urinary catheter.

"She's all yours," Alma said, moving out of earshot. "It's going to be a long haul for her-especially with no money and no family support."

"I'll get social services on her case as soon as possible."

"You might consider a psych consult, too. She hasn't spoken a word to anyone since she heard about the baby."

"I know. Thanks, Alma. That's an excellent suggestion."

She moved over to the bedside. Lisa lay motionless, staring up at the ceiling. Her lips, still dotted by a few obstinate flecks of dried blood, were cracked and puffy. Her bandaged, shortened right arm protruded from beneath the starched sheet. As she talked, Sarah examined the site of the cesarean. Not once did Lisa respond.

"Hi, Lisa, welcome to the ICU… Are you having much pain?… Well, just be sure to tell the nurses if you do. You don't have to talk to me or anyone else until you're ready… I'll just say a few things for now, then I'll leave. The bleeding and clotting problems seem to be gone. That means no more transfusions…" Sarah looked for some spark of understanding in the woman's eyes but saw none. "Lisa," she went on finally, "you know we all feel terrible about what's happened to you and…" She took a calming breath. "… and to Brian. We're going to do everything in the world to help you deal with all this, and to find out why it happened. Please try to be strong…"

Sarah waited half a minute for a response. Then she brushed Lisa's cheek with the back of her hand. "I'll be back to check on you a little later."

She turned away, thinking that somewhere there had to be an explanation for all of this. Two such similar cases in one hospital in just a few months. Somewhere there was an answer. And, she promised herself, whatever she had to do to find that answer, she would do.

She glanced back at the young artist lying in bay eight and tried, with little success, to fathom what it must be like to endure such sudden, inexplicable tragedy. Then she headed out of the SICU. There were forty-five minutes remaining before she was to meet Andrew, and she had a dozen patients to see on morning rounds.

• • •

"Where are you going?"

"Just out."

"Just out has never been an acceptable answer to that question, and it is not an acceptable answer tonight."

"Daddy, I'm eighteen years old. The other kids don't-"

"You are not like the other kids. You are not supposed to be like the other kids."

"But-"

"You are an eighteen-year-old who plays polo, vacations in Europe, and will be attending Harvard in the fall and, most of all, who has a twenty-million-dollar trust fund waiting for her when she turns twenty-five. That is not like the other kids, and it never will be. Now, who were you going to see tonight?"

"Daddy, please…"

"Who? That… that greaseball, low-life Chuck you think likes you for your spirit and your soul? He was voted best-looking boy in his high school class, he expects to make it as a model and isn't even planning on going to college. Did you ever stop to wonder why such a boy would suddenly become attracted to a Stanhope Academy girl who not only has absolutely nothing in common with him but is forty pounds overweight to boot?"

"Daddy, stop. Please stop."

"I will not. These are things you've got to hear. Things you've got to know. Your wonderful Chuckie is dirt. He spends almost every night when you're not sneaking off to be with him shacked up with a cheerleader named Marcie Kunkle. The pictures my man took of the happy couple are right upstairs in my desk. Would you like to see them?"

"You had someone follow him?"

"Of course I did. I'm your father. It's my job to protect you until you have enough sense and experience in the world to be able to protect yourself."

"How could you?"

"Honey, listen. You know that I love you. That man is interested in one thing and one thing only. Money. That's the name of the game. And the sooner you learn that, the better. You are who you are. And the only way you're ever going to be sure a man really cares for you is when he has more money than you do."

"You bastard."

"Don't you dare speak to me like that!"

"You bastard! You fucking bastard! You ruin everything for me. Everything!… Don't touch me… You touch me, and I swear you'll never see me again."

"Go to your room."

"Go to hell."

"Come back here. Right now."

"Go to hell… Let me go! I told you not to touch me! Dammit, let me go!… I hate you!… I hate you!"

"Lisa, wake up. It's the nurse. Lisa, you're all right. You've got to stop screaming… That's it. That's better now. Much better."

Lisa Summer's eyes fluttered open. Everything was blurred. Gradually the concerned face of the nurse came into focus.

"You were having a nightmare," Alma Young said. "Anesthesia does that to some people."

Lisa averted her eyes and once again stared at the ceiling.

"Can I get you anything? Some ice chips? Something for pain?… Okay. I'll be here if you need me."

Alma Young partially closed the curtains on each side of the bed and returned to the nurses' station.

Behind her, softly, Lisa began to cry.

"Daddy," she said. "Oh, Daddy."