Vital Signs

4

Walking beneath the glass-enclosed walkway that separated the main clinic building from the overnight ward and emergency area, Robert and Marissa entered the brick courtyard and started up the front steps of the Women's Clinic. The particular color and pattern of the granite made Marissa think about all the times that she'd climbed the steps, facing innumerable "minor procedures." Involuntarily her footsteps slowed, no doubt a response conditioned by the collective pain of a thousand needle pricks.

"Come on," Robert urged. He was gripping Marissa's hand and had sensed her momentary resistance. He glanced briefly at his watch. They were already late.

Marissa tried to hurry. Today's egg retrieval was to be her fourth. She well knew the degree of discomfort she could expect.

But for Marissa the fear of the pain was less of a concern than the possibility of complications. Part of the problem of being both a doctor and a patient was knowing all the terrible things that could go wrong. She shuddered as her mind ticked off a list of potentially lethal possibilities.

Once Robert and Marissa were inside the clinic, they skirted the main information booth and headed directly to the In-Vitro Fertilization Unit on the second floor. They had traveled this route on several occasions, or at least Marissa had.

Stepping into the usually quiet waiting room with its plush carpet and tapestry-upholstered chairs, they were treated to a spectacle neither had been prepared to see.

"I am not going to be put off!" shouted a well-dressed, slim woman. Marissa guessed she was about thirty years old. It was rare in any of the clinic's waiting rooms to hear anyone speak above a whisper, much less shout. It was as surprising as hearing someone yelling aloud in a church.

"Mrs. Ziegler," said the startled receptionist.

"Please!" The receptionist was cowering behind her desk chair.

"Don't Mrs. Ziegler me," the woman shouted.

"This is the third time I've come in here for my records. I want them now!"

Mrs. Ziegler's hand shot out and swept the top of the receptionist's desk clean. There was the jolting shatter of glass and pottery as pens, papers, picture frames, and coffee mugs crashed to the floor.

The dozen or so patients waiting in the room froze in their chairs, stunned by the outburst. Most trained their eyes on the magazines before them, afraid to acknowledge the scene being acted out before their eyes.

Marissa winced at the sound of the breaking glass. She remembered the clock radio she had so wanted to smash not half an hour earlier. It was frightening to recognize in Mrs. Ziegler such a kindred spirit. There had been several times Marissa had felt equally pushed to the edge.

Robert's initial response to the situation was to step directly in front of Marissa and put himself between her and the hysterical patient. When he saw Mrs. Ziegler make a move around the desk, he feared she was about to attack the poor receptionist. In a flash, he shot forward and caught Mrs. Ziegler from behind, gripping her at the waist.

"Calm down," he told her, hoping to sound commanding as well as soothing.

As if expecting such interference, Mrs. Ziegler twisted around and swung her sizable Gucci purse in a wide arc. It hit Robert on the side of his face, splitting his lip. Since the blow did not dislodge Robert's grip, Mrs. Ziegler cocked her arm for yet another swing of the purse.

Seeing the second blow in the making, Robert let go of her waist and smothered her arms in a bear hug. But before he could get a good grip, she hit him again, this time with a clenched fist.

"Ahhhh!" Robert cried, surprised by the blow. He pushed Mrs. Ziegler away. The women who had been sitting in the area fled to the other side of the waiting room.

Massaging his shoulder, which had received the punch, Robert eyed Mrs. Ziegler cautiously.

"Get out of my way," she snarled.

"This doesn't involve you."

"It does now," Robert snapped The door to the hall burst open as Dr. Carpenter and Dr.

Wingate dashed in. Behind them was a uniformed guard with a

Women's Clinic patch on his sleeve. All three went directly to Mrs. Ziegler.

Dr. Wingate, director of the clinic as well as head of the in vitro unit, took immediate control. He was a huge man with a full beard and a slight but distinctive English accent.

"Rebecca, what on earth has gotten into you?" he asked in a soothing voice.

"No matter how upset you might be feeling, this is no way to behave."

"I want my records," Mrs. Ziegler said.

"Every time I come in here I get the runaround. There is something wrong in this place, something rotten. I want my records. They are mine."

"No, they are not," Dr. Wingate corrected calmly.

"They are the Women's Clinic records. We know that infertility treatment can be stressful, and we even know that on occasion patients displace their frustration on the doctors and the technicians who are trying to help them. We can understand if you are unhappy.

We've even told you that if you want to go elsewhere, we will be happy to forward your records to your new physician. That's our policy. If your new physician wants to give you the records, that's his decision. The sanctity of our records has always been one of our prized attributes."

"I'm a lawyer and I know my rights," Mrs. Ziegler said, but her confidence seemed to falter.

"Even lawyers can occasionally be mistaken," Dr. Wingate said with a smile. Dr. Carpenter nodded in agreement.

"You are welcome to view your records. Why don't you come with me and we'll let you read over the whole thing. Maybe that will make you feel better."

"Why wasn't that opportunity offered to me originally?" Mrs.

Ziegler said as tears began to stream down her face.

"The first time I came here about my records, I told the receptionist I had serious questions about my condition. There was never any suggestion

I would be allowed to read my records."

"It was an oversight," Dr. Wingate said.

"I apologize for my staff if such an alternative wasn't discussed. We'll send around a memo to avoid future problems. Meanwhile, Dr. Carpenter will take you upstairs and let you read everything. Please." He held out his hand.

Covering her eyes, Mrs. Ziegler allowed herself to be led from the room by Dr. Carpenter and the guard. Dr. Wingate turned to the people in the room.

"The clinic would like to apologize for this little incident," he said as he straightened his long white coat.

A stethoscope was tucked into a pocket, several glass petri dishes in another. Turning to the receptionist, he asked her to please call housekeeping to clean up the mess on the floor.

Dr. Wingate walked over to Robert, who'd taken the handkerchief from the breast pocket of his suit to dab at his split lip.

"I'm terribly sorry," Dr. Wingate said as he eyed Robert's wound. It was still bleeding, although it had slowed considerably.

"I think you'd better come over to our emergency facility," Dr.

Wingate said.

"I'm okay," Robert said. He rubbed his shoulder.

"It's not too bad."

Marissa stepped over for a closer look at his lip.

"I think you'd better have it looked at," she said.

"You might even need a stitch. A butterfly, maybe," Dr. Wingate said as he tipped Robert's head back to get a better view of his lip.

"Come on, I'll take you."

"I don't believe this," Robert said with disgust, looking at the bloodstains on his handkerchief.

"It won't take long," Marissa urged.

"I'll sign in and wait here."

After a moment's hesitation, Robert allowed himself to be led from the room.

Marissa watched the door close behind him. She could hardly blame Robert if this morning's episode added to his reluctance to proceed with the infertility treatment.

Marissa was suddenly overwhelmed by a wave of doubt about her fourth attempt at in-vitro fertilization. Why should she dare hope to do any better this time around? A feeling of utter futility was beginning to bear down on her.

Sighing heavily, Marissa fought back new tears. Looking around the waiting room, she saw that the other patients had calmly retreated to the pages of their magazines. For some reason,

Marissa just couldn't force herself back in step. Instead of approaching the receptionist to check in, she went over to an empty seat and practically fell into it. What was the use of undergoing the egg retrieval yet again if the failure was so certain?

Marissa let her head sink into her hands. She couldn't remember ever feeling such overwhelming despair except when she'd been depressed at the end of her pediatric residency. That was when Roger Shulman had broken off their long-term relationship, an event that ultimately led her to the Centers for Disease Control.

Marissa's mood sank lower as she remembered Roger. In late spring their relationship had still been going strong, but then out of the blue he had informed her he was going to UCLA fora fellowship in neurosurgery. He wanted to go alone. At the time she'd been shocked. Now she knew he was better off without her, barren as she was. She tried to shake the thought. This was crazy thinking, she told herself.

Marissa's thoughts drifted back a year and a half, back to the time she and Robert decided to start their family. She could remember it well because they had celebrated their decision with a special weekend trip to Nantucket Island and a giddy toast with a good Cabernet Sauvignon.

Back then they both thought conceiving would take a matter of weeks, at the most a couple of months. Having always guarded so carefully against the possibility of becoming pregnant, it never occurred to her that conceiving might be a problem for her. But after about seven months, Marissa had begun to become concerned.

The approach of her period became a time of building anxiety, followed by depression upon its arrival. By ten months she and Robert realized that something was wrong. By a year they'd made the difficult decision to do something about it.

That's when they'd gone to the Women's Clinic to be seen and evaluated in the infertility department.

Robert's sperm analysis had been the first hurdle, but he passed with flying colors. Marissa's first tests were more complicated, involving X-ray study of her uterus and fallopian tubes.

As a physician Marissa knew a little about the test. She'd even seen some pictures of the X-rays in textbooks. But photographs in books had been no preparation for the actual experience. She could remember the test as if it had been yesterday.

"Scoot down a little farther," Dr. Tolentino, the radiologist, had said. He was adjusting the huge X-ray fluoroscopy unit over Marissa's lower abdomen. There was a light in the machine, projecting a grid onto her body.

Marissa wriggled farther down on the rock-hard X-ray table.

An IV was hooked into her right arm. She'd been given a bit of Valium and was feeling lightheaded. In spite of herself she was mildly apprehensive that she might suffer a second drug-induced nightmare.

"Okay!" Dr. Tolentino said.

"Perfect." The grid was centered just south of her umbilicus. Dr. Tolentino threw a few electrical switches and the cathode tube monitor of the fluoroscopy unit gave off a light-gray glow. Going to the door, Dr. Tolentino called for Dr. Carpenter.

Dr. Carpenter entered along with a nurse. The two of them were wearing the same sort of heavy lead apron Dr. Tolentino had on to shield his body from ambient radiation. Seeing such heavy protective gear made Marissa feel all the more exposed and vulnerable.

Marissa could feel her legs being lifted and parted to be placed in stirrups. Then the end of the table dropped away so that her backside was perched on the very edge.

"You'll feel the speculum now," Dr. Carpenter warned.

Marissa clenched her teeth as she felt the instrument slip inside of her and spread.

"Now you are going to feel a prick," Dr. Carpenter said.

"I'm going to put in the local anesthetic."

Marissa bit her lip in anticipation. True to Dr. Carpenter's warning, she felt a sharp stab localized somewhere in her lower back.

"And again," Dr. Carpenter said.

He injected her in several locations, explaining to her that he was giving her a para cervical block to anesthetize the cervix.

Marissa breathed out. She hadn't realized she'd been holding her breath. All she wanted at that moment was for the study to be over.

"Just a few minutes more," Dr. Carpenter said as if reading her mind.

In her mind's eye Marissa could see the long, scissor-shaped instrument with its jaws shaped like two opposing fangs. She knew those fangs were about to bite through the delicate tissue of her cervix.

But Marissa felt no pain when she heard the sharp metallic sound of the instrument handles lock, just a sensation of pressure and a pulling. She could hear Dr. Carpenter talk to both the nurse and Dr. Tolentino. She heard the X-ray machine go on and could just barely see part of an image that had appeared on the fluoroscopy screen.

"Okay! Marissa," Dr. Carpenter said, "as I explained earlier, the Jarcho cannula is now in place and I'm about to inject the dye. You'll probably feel this a bit."

Marissa held her breath again, and this time the pain came. It was like a severe cramp that built to the point that she could not keep from moving.

"Hold still!" Dr. Carpenter commanded.

I can't," Marissa moaned. Just when she thought she couldn't bear the pain for a moment longer, it abated. She let her breath out with relief.

"The dye didn't go anyplace," Dr. Carpenter said with surprise.

"Let me take a spot film," Dr. Tolentino said.

"I think I can just make out the dead ends of the tubes here and here." He was pointing at the screen with a pencil.

"Okay," Dr. Carpenter said. He then told Marissa they were going to take an X-ray and for her to stay still.

"What's wrong." Marissa asked with concern. But Dr. Carpenter ignored her or didn't hear. All three people disappeared behind the screen. Marissa looked up at the huge machine suspended over her.

"Don't move," Dr. Tolentino called out.

Marissa. heard a click and a slight buzz. She knew that her body had just been bombarded by millions of tiny X-rays.

"We are going to try again," Dr. Carpenter said as he returned.

"This might hurt a little more."

Marissa gripped the sides of the X-ray table.

The pain that followed was the worst she'd ever experienced.

It was like a knife thrust into her lower back and twisted. When it was over she looked at the three people grouped around the fluoroscopy screen.

"What did you find?" Marissa questioned. She could tell from Dr. Carpenter's face that something was abnormal.

"At least we know now why you haven't been making babies," he said solemnly.

"I couldn't get dye into either of your tubes, And I really pushed-as you probably felt. Both of them seem to be sealed as tight as a drum."

"How could that be?" Marissa asked with alarm.

Dr. Carpenter shrugged.

"We'll have to look into that. Probably you had some infection. You don't remember anything, do you?"

"No!" Marissa said.

"I don't think so."

"Sometimes we can find the cause of blocked tubes and sometimes we can't," Dr. Carpenter said.

"Sometimes even a high fever as a child can damage them." He shrugged and patted her on the arm.

"We'll look into it."

"What's the next step?" Marissa asked anxiously. She already felt guilty enough about being infertile. This puzzling discovery about her tubes made her wonder if she could have picked up anything from one of her former lovers. She had never been loose, not by any stretch of the imagination, but she'd had sex, especially with Roger. Could Roger have given her something?

Marissa's stomach was in knots.

"I'm not sure this is the time to talk about strategy," Dr.

Carpenter said.

"But we'll probably recommend a laparoscopy and perhaps evena biopsy. There's always the chance that the problem is amenable to microsurgery. If that doesn't work or isn't feasible, there's always in-vitro fertilization..

"Marissa!" Robert called harshly, abruptly bringing Marissa back to the present.

She lifted her face. Robert was standing in front of her.

"What are you doing?" Robert asked, his frustration all too apparent.

"I asked after you and the receptionist said you hadn't even checked in."

Marissa got to her feet. Robert was looking at his watch.

"Come on!" he said as he turned and headed over to the receptionist's desk. Marissa followed. She gazed at the sign behind the desk. That was the one that said: YOU ONLY FAIL WHEN YOU GIVE UP TRYING.

"I'm sorry," the receptionist said, "with all the excitement, I've been in a dither. It didn't dawn on me that Mrs. Buchanan hadn't checked in."

"Please!" Robert said.

"Just let the doctors know she is here."

"Certainly!" the receptionist said. She stood up.

"But first I want to thank you for your help earlier, Mr. Buchanan. I think that woman was about to attack me. I hope you weren't hurt badly."

"Only two stitches," Robert said, mellowing to a degree.

"I'm fine." Robert then lowered his voice and, after a furtive glance around the waiting room, asked: "Could you give me one of those, errrr… plastic containers?"

"Of course," the receptionist said. She bent down and opened a file drawer. She produced a small, graduated, red-topped plastic container and handed it over. Robert palmed it.

"Ah… this will make it all worthwhile," Robert whispered sarcastically to Marissa. Without a second glance at his wife, he strode off toward one of the doors leading into a series of cubicle like dressing rooms.

Marissa watched him go, lamenting the widening gulf separating them. Their ability to communicate, especially where their feelings were concerned, was reaching a new low.

"I'll let Dr. Wingate know you're here," the receptionist said.

Marissa nodded. Slowly she walked back to her seat and sat down heavily. Nothing was working out. She wasn't getting pregnant and her marriage was disintegrating before her eyes. She thought about all the business trips Robert had been taking of late. For the first time since she'd been married, Marissa wondered if he could be having an affair. Maybe that was the reason behind this sudden talk of not providing a sperm sample. Maybe he'd been giving samples out elsewhere.

"Mrs. Buchanan!" a nurse called from an open doorway, beckoning for Marissa. to follow her.

Marissa got to her feet. She recognized the nurse, Mrs. Hargrave.

"Are you ready to harvest those eggs?" the woman asked brightly as she got a robe, a Johnny, and slippers for Marissa. She had an English accent similar to Dr. Wingate's. Marissa had asked her about it once. She'd been surprised to learn that Mrs.

Hargrave was Australian, not English.

"An egg retrieval is just about the last thing in the world I want to do just now," Marissa admitted with dejection.

"I really don't know why I'm putting myself through this."

"Feeling a little depressed, are we?" Mrs. Hargrave asked as gently as she could.

Marissa didn't answer. She merely sighed as she took the clothes from Mrs. Hargrave and started into the changing room.

Mrs. Hargrave reached out and touched her shoulder.

"Anything you'd like to talk about?"

Marissa gazed up into the woman's face. There was warmth and sympathy in those gray-green eyes.

At first Marissa could only shake her head as she fought back tears.

"It's common for emotional problems to burden people involved with in-vitro," Mrs. Hargrave said.

"But it usually helps to talk about it. It's been our experience that part of the problem is the isolation the couples feel."

Marissa nodded in agreement. She and Robert had been isolated.

As the pressures mounted, they started avoiding friends, especially those with children.

"Has there been a problem between you and your husband?" Mrs. Hargrave asked.

"I don't mean to pry, but we truly have found it best for people to be open."

Marissa nodded again. She looked at Mrs. Hargrave's understanding face. She did want to talk, and with a few tears that she wiped away with the back of her hand, she told her about Robert's initial refusal to cooperate that morning, and their consequent quarrel. She told Mrs. Hargrave she was beginning to think they would have to stop the infertility treatments.

"It's been pure hell for me," Marissa admitted.

"And for Robert."

"I think it is safe to say that something would be wrong with you both if it weren't," Mrs. Hargrave said.

"It's stressful for everyone, even the staff. But you've really got to learn to be more open. Talk to other couples. That will help you learn to talk to each other and to be aware of each other's limitations."

"We are ready for Mrs. Buchanan," another nurse called through the door to the ultrasound room.

Mrs. Hargrave gave Marissa a comforting squeeze on her shoulder.

"You'd better get on with this," she said.

"But afterwards

I'll come back and we'll talk some more. How about it?"

"Okay," Marissa said, trying to muster some enthusiasm.

Fifteen minutes later, Marissa again found herself on her back in the ultrasound room, facing yet another painful and potentially risky procedure, She was lying supine with her legs straight out. In a few minutes her legs would be put up in the all-too familiar stirrups. Then there would be the disinfectant, followed by the local anesthetic. She cringed at the thought.

The room itself seemed scary. It was a cold, forbidding, futuristic environment filled with electronic instruments, some of which Marissa recognized and some she didn't. Multiple cathode-ray screens were set into the instrumentation. Mercifully, the foot-long egg-retrieval needle was kept out of sight.

The nurse-technician who had brought Marissa into the room was busy with preparations for the procedure. Dr. Wingate, who performed most of the clinic's infertility procedures including the in-vitro fertilization, had not yet arrived.

A knock on the door got the attention of the nurse-technician, who stepped over and opened it. Marissa turned her head to see Robert standing in the threshold.

Although the procedure room made him feel even more uncomfortable than it made Marissa feel, he forced himself to step into the high-tech room. He pointed over his shoulder for the nurse technician benefit.

"Mrs. Hargrave said I could come in for a moment," he explained.

The nurse-technician nodded, motioned toward Marissa, then went back to her preparations.

Robert gingerly walked over to the ultrasound unit and looked down at his wife. He was careful not to touch any of the delicate instrumentation, or Marissa herself, for that matter.

"Well, I did it," he said as if he had accomplished some major task.

"And now that my part's over, I'll be heading to the office.

Unfortunately, because of the stitches, I'm later than I planned.

So I've got to run. But I'll come back after the meeting and pick you up. If it looks like the meeting is going to run over, I'll call and leave word with Mrs. Hargrave. Okay?"

"Okay," Marissa said.

"Thanks for providing a sample. I appreciate it."

Robert wondered if Marissa was being sarcastic. He couldn't detect any irony in her tone.

"You're welcome," he said finally.

"Good luck with the egg retrieval. Hope you get a full dozen."

With a tentative pat on her shoulder, he turned and left the room.

Marissa felt tears welling up again, but she didn't know if they were from sadness or anger. She felt so terribly alone. Lately Robert had been so businesslike, even when it came to her. She was hurt that he could leave her to face such an ordeal alone.

The Robert of today seemed so different from the man she had married so blissfully only a few years ago. in so many ways he was telling her that business came first; it was his identity and his escape. A single tear ran down into her ear. She closed her eyes tightly, hoping to block out the whole world. It seemed that her life was falling apart and there was nothing she could do to stop it.

"Excuse me, Dr. Wingate," Mrs. Hargrave said, stopping the doctor on his way into the ultrasound room.

"Could I have a brief word with you?"

"Is it. important Dr. Wingate asked.

"I'm late for Mrs. Buchanan."

"It's Mrs. Buchanan I want to discuss," Mrs. Hargrave said.

She held her head back. She was a tall woman herself, almost six feet. Even so, she looked slight next to Dr. Wingate's impressive bulk.

"Is it confidential?" Dr. Wingate asked.

"Isn't everything confidential?" Mrs. Hargrave said with a sly smile.

"True enough," Dr. Wingate said. He briskly walked down the hallway to his office. They entered a back door directly from the corridor, bypassing his secretary. Wingate closed the door behind them.

"I'll be brief," Mrs. Hargrave said.

"It's come to my attention that Mrs. Buchanan… actually, I should say Dr. Buchanan.

You do remember that she is a doctor, don't you?"

"Yes, of course," Dr. Wingate said.

"Dr. Carpenter told me that two years ago. It was a surprise, I recall. Dr. Carpenter only knew through reading it in the Globe.

"I think the fact that she is a physician herself should be kept in mind," Mrs. Hargrave said.

"As you know, doctors can be difficult patients at times."

Dr. Wingate nodded.

"At any rate," Mrs. Hargrave continued, "I believe she is suffering from a certain amount of depression."

"That's not unexpected," Dr. Wingate said.

"Almost all of our in-vitro patients experience depression at one time or another."

"There is a suggestion of marital discord as well," Mrs. Hargrave said.

"Even some talk about stopping after this cycle."

"Now that would be unfortunate," Dr. Wingate agreed, interested at last.

"Depression, marital problems, and the fact that she is a physician make me think we should perhaps alter the treatment protocol."

Dr. Wingate leaned against his desk, hooking a thumb under his chin and resting his nose on an index finger while he pondered Mrs. Hargrave's suggestion. She definitely had a point, and flexibility had always been an approach he'd advocated.

"She also witnessed the scene with Rebecca Ziegler," Mrs.

Hargrave added.

"That can only have contributed to her emotional distress. I'm very concerned about her."

"But she has been stable up until now," Dr. Wingate said.

"That's true," Mrs. Hargrave replied.

"I suppose it is the problem of her being a physician that makes me feel uneasy."

"I appreciate your concern," Dr. Wingate said.

"It's attention to detail that makes the Women's Clinic so successful. But I think it will be safe to continue as usual with Dr. Blumenthal-Buchanan.

She'll tolerate another couple of cycles, but perhaps it would be wise to recommend some in-house counseling for both her and her husband."

"Very well," Mrs. Hargrave said.

"I'll suggest it to her. But as a physician, she might be resistant to such an idea."

With the matter decided, Dr. Wingate moved to the door and opened it for Mrs. Hargrave.

"Speaking of Rebecca Ziegler," said Mrs. Hargrave, "I trust she's being well taken care of?"

"She's reading her records as we speak," Dr. Wingate said, following Mrs. Hargrave into the hallway.

"Unfortunately, it will be upsetting for her."

"I can well imagine," Mrs. Hargrave said.