Vital Signs

1

An agonizing screech of metal scraping against metal jangled Marissa Blumenthal's already frayed nerves as the aging MBTA subway train strained to navigate the sharp turn into the Harvard Square station in Cambridge, Massachusetts. Marissa closed her eyes for a moment in a vain attempt to shield herself from the grating racket as she clutched an upright pole. She wanted to get out of the train. Besides peace and quiet, she needed fresh air.

Wedged among a crowd of six-foot-plus giants, five-foot Marissa felt more claustrophobic than usual. The air in the subway car felt oppressively warm. It was a rainy February day and the damp smell of moist wool added to her discomfort.

Like everyone else in the train, Marissa tried to avoid eye contact with the people pressed up against her. It was a mixed crowd. Harvard Square attracted both ends of the spectrum. To Marissa's right was an Ivy League lawyer-type with a black ostrich briefcase, his nose buried in a,crisply folded copy of The Wall Street Journal. Directly in front of her was a fetid breathed skinhead, outfitted in a denim jacket from which the sleeves had been cut. He had clumsily tattooed swastikas on each knuckle of his hands. To her left was a massive black man with a ponytail of dreadlocks, wearing gray sweats. His sunglasses were so dark that Marissa could not see his eyes as she furtively glanced in his direction.

With a final lurch that all but sent Marissa to the floor, the train stopped and the doors slid open. Breathing a sigh of relief, Marissa stepped out onto the platform. Normally she would have driven her car from her office and left it under the Charles Hotel, but she wasn't sure how she would be feeling after her minor surgical procedure, so she'd decided it was more prudent to take the T. There had been talk of her having some kind of sedative or intravenous painkiller, an idea that Marissa was not averse to.

She freely admitted that she was not good with pain. If she was groggy after the anesthesia, she thought it best not to drive.

Marissa hurried past a trio of street musicians playing for commuters' donations and quickly went up the stairs to the street. it was still raining so she paused briefly to raise her folded umbrella.

Marissa buttoned her trench coat and held her umbrella tight as she traversed the square and headed up Mount Auburn Street.

Sudden gusts of wind foiled her attempt to stay dry; by the time she reached the Women's Clinic at the end of Nutting Street, a plethora of raindrops were sprinkled across her forehead like beads of perspiration. Beneath the glass-enclosed walkway that spanned the street and connected the main building of the clinic to its overnight ward and emergency facilities, Marissa shook her umbrella and folded it closed.

The clinic building was a postmodern structure, built of red brick and mirrored glass, which faced a bricked courtyard. The main entrance was off the courtyard and was reached by a wide run of granite steps.

Taking a deep breath, Marissa climbed the front steps. Although as a physician she was accustomed to entering medical facilities, this was the first time she was doing so as a patient, coming in not just for an examination but for surgery. The fact that it was minor surgery had less of a mitigating effect than she'd imagined. For the first time Marissa realized that from a patient's point of view, there was no such thing as "minor" surgery.

Only two and a half weeks earlier Marissa had climbed the same steps for a routine annual Pap smear only to learn a few days later that the results were abnormal, bearing the grade CIN #1. She'd been genuinely surprised, having always enjoyed perfect health. Vaguely she'd wondered if the abnormality had anything to do with her recent marriage to Robert Buchanan. Since their wedding, they had certainly been enjoying the physical side of their relationship a great deal.

Marissa grasped the brass handle of the massive front door and stepped into the lobby. The decor was rather stark although it reflected good taste and certainly money. The floor was surfaced in dark green marble. Ficus trees in large brick planters lined the windows. In the middle of the room was a circular information booth. Marissa had to wait her turn. She unbuttoned her coat and shook the moisture from her long brown hair.

Two weeks previously, having received the surprising result of the Pap smear, Marissa had had a long phone conversation with her gynecologist, Ronald Carpenter. He had strongly recommended the colposcopy-biopsy procedure.

"Nothing to it," he'd said with conviction.

"Piece of cake, and then we know for sure what's going on in there. It's probably nothing. We could wait for a while and do another smear, but if it were my wife, I'd say do the colposcopy. All that means is looking at the cervix with a microscope."

"I know what a colposcopy is," Marissa had told him.

"Well, then, you know how easy it is," Dr. Carpenter had added.

"I'll give the old cervix a good look, snip out a tiny piece of anything suspicious, and that will be it. You could be outta here in an hour. And we'll give you something in case there's any pain. In most centers they don't give any analgesia for biopsies, but we're more civilized. It's really easy. I could do it in my sleep."

Marissa had always liked Dr. Carpenter. She appreciated his offhand, easygoing manner. Yet his attitude about a biopsy made her appreciate the fact that surgeons viewed surgery in a fundamentally different way than patients did. She wasn't concerned about how easy the procedure was for him. She was concerned about its effect on her. After all, above and beyond the pain, there was always the possibility of a complication.

Yet she was reluctant to procrastinate. As a physician, she was well aware of the consequences of putting off a biopsy. For the first time, Marissa felt medically vulnerable. There was a remote but real possibility that the biopsy might prove to be positive for cancer. In that case, the sooner she knew the answer, the better off she'd be.

"Day surgery is on the third floor," the receptionist said cheerfully in response to Marissa's question. "just follow the red line on the floor."

Marissa looked down at her feet. A red, a yellow, and a blue line ran around the information booth. The red line led her to the elevators.

On the third floor, Marissa followed the red line to-a window with a sliding glass panel. A nurse dressed in a standard white uniform opened the panel as Marissa approached.

"I'm Marissa Blumenthal," Marissa managed. She had to clear her throat to get it out.

The nurse found her folder, glanced at it briefly to see if it was complete, then extracted a plastic ID bracelet. Reaching across the countertop, the nurse helped Marissa secure the bracelet.

Marissa found the procedure unexpectedly humiliating. From about the third year in medical school, she'd always felt in control in a hospital setting. Suddenly the tables were turned. A shiver of dread passed through her.

"It will be a few minutes," the nurse intoned. Then she pointed to some double doors.

"There's a comfortable waiting room just through there. Someone will call you when they are ready." The glass panel slid shut.

Dutifully Marissa went through the doors into a large, square room, furnished in a nondescript modern style. About thirty people were waiting. Marissa felt the stare of silent eyes as she self-consciously hurried to an empty seat at the end of a couch.

There was a view of the Charles River across a small green park. Silhouetted against the gray water were the leafless skeletons of the sycamore trees that lined the embankment.

By reflex, Marissa picked up one of the glossy-covered magazines from the side table and absently flipped through the pages.

Surreptitiously she glanced over the top of the magazine and was relieved to see that the eyes of the other people in the room had gone back to their own magazines. The only sound was of pages being turned.

Marissa stole quick glances at some of the other women, wondering what they were there for. They all seemed so calm. Surely she couldn't be the only one who was nervous.

Marissa tried to read an article on upcoming summer fashion trends, but she couldn't concentrate. Her abnormal Pap smear seemed like a hint of internal betrayal: a warning of what was to come. At thirty-three years old, she had been having the barest exterior reminders of getting older, like the fine lines appearing at the outer corners of her eyes.

Focusing for the moment on the many ads that filled the women's magazine in her hands, Marissa gazed at the faces of the sixteen- and seventeen-year-olds who populated them. Their youthful, b1cmish-free faces seemed to mock her and make her feel old beyond her years.

What if the biopsy was positive? What if she had cancer of the cervix? It was rare but not unknown in women her age. Suddenly the possibility bore down on Marissa with a crushing intensity.

My God! she thought. If it was cancer, she might have to have a hysterectomy, and a hysterectomy would mean no children!

A dizzy feeling spread through Marissa, and the magazine in her hands momentarily blurred. At the same time her pulse began to race. The thought of not having children was anathema to her.

She'd married only six months previously, and although she hadn't planned on starting a family immediately, she had always known that children would eventually be a big part of her life. If it turned out that she could not have children, she hated to consider the consequences, both for herself and for her husband.

And until that very moment, waiting for the biopsy that Dr.

Carpenter said would be "a piece of cake," she'd never given the possibility serious thought.

All at once Marissa felt hurt that Robert had not been more concerned and that he had taken her at her word when she'd said she'd be perfectly fine going to the clinic by herself Looking around the room again, Marissa saw that most of the other patients were accompanied by their spouses or boyfriends.

"You're being ridiculous," Marissa silently chided herself as she tried to keep her emotions in check. She was surprised and a little embarrassed. It was not like her to be so hysterical. She liked to think she wasn't easily upset. Besides, she knew that Robert couldn't have come with her even if he'd wanted to. That morning; he had an important meeting of the executive staff of his health care management, investment, and research company. It was a critical meeting that had been planned months in advance.

"Marissa Blumenthal!" a nurse called.

Marissa jumped up, placed the magazine on the side table, and followed the nurse down a long, blank white corridor. She was shown into a changing room with an inner door opening into one of the procedure rooms. From her vantage point in the changing area, Marissa could see the table with its gleaming, stainless steel stirrups, "Just to be on the safe side," the nurse said as she twisted Marissa's wrist to check her ID. Satisfied she had the right patient, she patted some clothes on a bench and added: "Slip into this Johnny, slippers, and robe and hang your clothes in the closet. Any valuables can be locked in the drawer, When you're done, go in and sit on the examining table." She smildd. The woman was professional, but not without warmth. She closed the door to the hall behind her.

Marissa stepped out of her clothes. The floor was cold on her bare feet. As she struggled to tie the straps of the Johnny behind her, she acknowledged how much she liked the staff at the Women's Clinic, from the receptionists to her doctor. But the main reason she patronized the clinic was because of its private status and the consequent confidentiality it had to offer. Now that she was having a biopsy, she was even more thankful for her choice. Had she gone to any one of the major Boston hospitals, especially her own hospital, the Boston Memorial, she would have undoubtedly come in contact with people she knew.

Marissa had always been careful to keep her private life private.

She never wanted personal matters like birth control, annual pelvic exams, a couple of episodes of cystitis and the like to be topics of gossip with her colleagues. And even if people didn't talk, she did not want to worry about passing her GYN man in the hospital corridor or in the hospital cafeteria.

The flimsy robe, the open-backed hospital Johnny, and the paper slip-on slippers completed Marissa's transition from doctor to patient. With her ill-fitting slippers flopping, she padded into the procedure room and sat on the edge of the examining table as instructed by the nurse.

Glancing around at the usual accoutrements which included an anesthesia machine and cabinets of instruments, her panic swelled anew. Beyond her fear of the procedure, and the possible need for a hysterectomy she kept reminding herself was remote, Marissa now felt a strong intuition of disaster. She realized how much she had come to prize her life, particularly in the last few years. Between her new husband, Robert, and her recent acceptance into a fine pediatric group, her life seemed to be going almost too well. She had so much to lose; it made her terrified.

"Hello there, I'm Dr. Arthur," a burly man said as he entered the room with a purposeful flourish, clutching a handful of cellophane-covered packages and an IV bottle.

"I'm from anesthesia, and I'll be giving you something for your upcoming procedure.

Allergic to anything?"

"Nothing," Marissa assured the man. She was glad for the company, relieved to have someone take her away from her own thoughts.

"We'll probably not need this," Dr. Arthur said as he deftly started an IV in Marissa's right wrist.

"But it's good to have it just in case. If Dr. Carpenter needs more anesthesia, it can be given easily."

"Why would he need more anesthesia?" Marissa asked nervously.

She watched the droplets of fluid fall in the micro pore filter. She'd never had an IV before.

"What if he decides to do a cone biopsy rather than a punch?"

Dr. Arthur replied as he slowed the IV to a mere trickle.

"Or if he decides to do any more extensive procedure? Obviously we'd have to give you something in addition. After all, we want this to be as pleasant as possible."

Marissa shuddered at the term "more extensive procedure."

Before she could stop herself she blurted out, "I want to make it absolutely clear that I only signed a consent for a biopsy and not anything more extensive like a hysterectomy."

Dr. Arthur laughed, then apologized for finding her reminder humorous.

"No need to worry on that score," he said.

"We certainly don't do hysterectomies in the minor procedure room."

"What will you be giving me?" Marissa asked sheepishly.

"You want to know the specific drugs I'll be using?" Dr.

Arthur asked.

Marissa nodded. No one at the clinic knew she was a doctor, and Marissa preferred it that way. When she'd first signed up for the clinic's services, she'd filled out a form which only asked for her employer. She'd listed the Boston Memorial since at the time she was taking a year of fellowship in pediatric endocrinology.

The fact that she was a physician wasn't a secret and if they asked her, she'd certainly have told them. But no one had asked, a fact she took as further confirmation of the kind of confidentiality she had come to expect of the clinic.

Dr. Arthur looked puzzled for a moment, shrugged, then replied.

"I'll be using a mixture of a small amount of Valium and a drug called ketamine." He then cleaned up the remains of the IV paraphernalia.

"It's a good little cocktail. It's great for pain, and it has the added appeal of occasionally providing a touch of amnesia."

Marissa was aware of ketamine. It was used frequently at the Boston Memorial for dressing changes with burned children. But she wasn't aware of its use in outpatient settings. When she mentioned this to Dr. Arthur, he smiled paternalistic ally

"Been doing a little reading, huh?" he teased. Then he warned:

"Remember, a little knowledge is a dangerous thing. Actually, the outpatient environment is the most common use for the drug." He stared at Marissa.

"My, you do seem a little tense."

"I've been trying to fight it," Marissa admitted.

"I'll give you a hand," Dr. Arthur offered.

"Let's give you a little taste of Valium and ketamine right now." He went to fetch a syringe from the cabinet.

"This biopsy stuff is a piece of cake," he called over his shoulder.

Marissa nodded without enthusiasm. She had already tired of the pastry metaphor. The fact was that she was nervous, and despite having felt a bit better when Dr. Arthur first appeared, now she felt decidedly worse. His offhand manner of referring to more extensive procedures had not left her feeling reassured.

Again, her intuition began sending out alarms of imminent disaster.

Marissa had to fight against the irrational urge to flee.

"I'm a doctor," she silently repeated to herself over and over again.

"I shouldn't be feeling like this."

The door to the hall burst open. In swept Dr. Ronald Carpenter dressed in surgical scrubs which included a hat and a mask.

With him was a woman also in scrub clothes although her mask was draped down over her chest.

Marissa recognized Dr. Carpenter immediately despite the mask. His bright, crystal-blue eyes and tanned skin were unmistakable.

"This is only a biopsy?" Marissa questioned nervously.

Dr. Carpenter was dressed for major surgery.

"Miss Blumenthal is nervous about having a hysterectomy," Dr. Arthur explained, snapping the side of a needle to release the air bubbles. He returned to Marissa's side.

"Hysterectomy?" Dr. Carpenter asked with obvious confusion.

"What are you talking about?"

Dr. Arthur raised his eyebrows.

"I think our patient here has been doing a little reading." He picked up the IV tubing and injected the contents of the syringe. Then opened the IV to flow rapidly for a moment.

Dr. Carpenter stepped over to Marissa and put his hand on her shoulder. He looked into her dark brown eyes.

"We're only doing a simple biopsy. There's been no talk of a hysterectomy. If you are wondering about my clothes, I've just come from surgery.

The mask is because I have a cold and don't want to spread it to any of my patients."

Marissa looked up into Dr. Carpenter's bright blue eyes. She was about to reply when the blue brought back a memory that she'd been long suppressing: the terror of being attacked in a hotel room in San Francisco a few years earlier and the horror of having to stab a man repeatedly to save her own life. At that moment the episode came back to her with such startling clarity, she could actually feel the man's hands around her throat. Marissa started to choke. The room began to spin and she heard a buzzing noise that gradually got louder.

Marissa felt hands grabbing at her, forcing her down on her back. She tried to fight since she felt she could breathe easier if she were upright, but it was to no avail. Her head touched the examination table, and as soon as it did, the room stopped spinning and her breathing became easier. Suddenly she realized her eyes were closed. When she opened them, she was looking up into the faces of Dr. Arthur, the woman, and the masked face of Dr. Carpenter.

"Are you okay?" Dr. Carpenter asked.

Marissa tried to speak but her voice wouldn't cooperate.

"Wow!" Dr. Arthur said.

"Is she ever sensitive to the anesthetic!"

He quickly took her blood pressure.

"At least that's okay. I'm glad I didn't give her the whole dose."

Marissa closed her eyes. At last she was calm. She heard more conversation, but it sounded as if it were someplace in the distance and didn't involve her. At the same time she felt as if an invisible lead blanket were settling over her. She felt her legs being lifted, but she didn't care. Then the voices in the room receded further. She heard laughter and then a radio. She felt instruments and heard the sound of metal hitting metal.

She relaxed until she felt a cramp like a menstrual cramp. It was pain but not normal pain in that it was more alarming than uncomfortable. She tried to open her eyes but her lids felt heavy.

Again she tried to open her eyes but quickly gave up. It was like a nightmare from which she could not awaken. Then there was yet another cramp, sharp enough to bring her head off the examining table.

The room was a drug-induced blur. She could just make out the top of Dr. Carpenter's head as he worked between her draped knees. The colposcope was pushed to the side on his right.

The sounds of the room still came to her as if from a great distance, although now they had a peculiar, echoing quality.

People in the room were moving in slow motion. Dr. Carpenter raised his head as if he could sense her eyes on him.

A hand grasped Marissa's shoulder and eased her back. But as she lay down, her numbed mind replayed the blurred image of Dr. Carpenter's masked face and, despite her drugged state, a shiver of terror coursed through her veins. It was as if her doctor had metamorphosed into a demon. Instead of his eyes being crystal blue, they had become distorted. They appeared to be made of black onyx as dense as stone.

Marissa started to scream but she held herself in check. Some part of her brain was rational enough to remind her that all her perceptions were being altered by the medication. She tried to sit up again to take another look for reassurance, but hands restrained her. She fought against the hands, and once again her mind took her back to the hotel room in San Francisco when she'd had to fight with the killer. She remembered hitting the man with the telephone receiver. She remembered all the blood.

Unable to contain herself any longer, Marissa screamed. But no sound came out. She was on the edge of a precipice and slipping. She tried to hold on but she slowly lost her grip, failing into blackness….