Michael Palmer - Natural Causes

"Hey, Bruce, what's going on?" she called.

"Don't know," he yelled back excitedly. "A ruptured triple A, maybe."

Triple A-an abdominal aortic aneurysm. Rupture of one was, perhaps, the ultimate surgical emergency. Even if she had pressing obligations on her service, which she did not for at least another hour, Sarah would have responded to any such call for help. Besides, she thought cattily, at this moment Andrew Truscott might not be in the greatest shape to perform emergency vascular surgery.

Room 227 was in the early stages of the organized chaos that accompanied crisis in a teaching hospital. Bruce Lonegan and another surgical resident were scurrying about an elderly gentleman who was in obvious, severe distress. He was unconscious or barely conscious, twitching about, and moaning.

"Get ten units crossmatched stat and be sure the OR is ready," Lonegan called out. "Art, get an arterial line in him. Somebody try and get a pressure! Dammit, where the hell is Andrew?"

"How can I help?" Sarah asked as the overhead page again urged Andrew to the room.

"This guy's Andrew's patient," Lonegan said. "He came in about three or four days ago for an elective aneurysm repair. He was in some heart failure, so the medical people had us delay his surgery while they got that under control. He was scheduled for the OR tomorrow. A nurse just walked in and found him like this. His pressure's way down. He's out of it. His belly seems tense. It's got to be the triple A leaking. Dammit, are they beeping Andrew as well as voice paging him?"

At that moment, Sarah remembered that there was no overhead page on the Thayer sleeping floors. Andrew obviously hadn't given the room number to the operator. If his beeper was turned off, no one would know how to reach him. No one except me. She picked up the bedside phone and suggested the operator try ringing Thayer 421.

"If Dr. Truscott doesn't answer, please call me back immediately," she instructed.

Lonegan and the other resident had been joined by someone from internal medicine. It was clear the patient was losing ground. Lonegan had been a practicing M.D. for exactly one week. Without the senior vascular surgery resident, he was lost. And he looked it.

"Andrew's pager may not be working," Sarah said, realizing that she had to take over until someone more senior or surgically specialized arrived. "I've given the operator some instructions on reaching him. Meanwhile, be sure of your lines, get some fluids into him, use a Doppler stethoscope to check what pulses you can, catheterize him, and have everything ready in the OR. Why is he twitching like that?"

"His blood pressure's only about sixty," the medical resident said. "That's why."

Although she admitted to herself that the internist might be right, Sarah did not feel comfortable with that explanation. She had seen many patients in shock, some of them in full-blown seizure because of it. But something here was different from those cases. Without making any show of it, she carefully checked the old man's acupuncture pulses. Several of them felt weak and thready. She was not experienced enough to know the exact significance of her findings, but she sensed that whatever was happening was more generalized than a leaking artery-perhaps some sort of metabolic derangement.

The phlebotomist had just finished drawing the man's blood. Sarah pulled the woman aside.

"Have them run a complete chem screen, please," she said. "As absolutely fast as they can. Especially electrolytes, sugar, calcium, phosphorus, and magnesium."

The bedside phone rang. Sarah snatched it up, listened for a moment, and then set the receiver back down.

"Dr. Truscott will be here in just a minute," she said.

It was almost five minutes before Andrew charged into the room. By that time the anesthesiologist was at the bedside, some incompletely crossmatched blood was being pumped in, and transportation was standing by outside the room, awaiting the dash to the OR. The patient's family had also been called and told about his turn for the worse. Emergency as opposed to elective repair of the aneurysm lowered his chances of survival considerably.

"Sorry, everyone," Truscott said, immediately taking control. "My damn beeper went belly up."

Ignoring Sarah completely, he rapidly assessed the old man's physical status and then ordered transportation into the room. Next he turned to his intern, who gave a nervous, somewhat garbled account of what had transpired.

"I have the OR on standby," Lonegan concluded. "Blood is off for chemistries and crossmatch."

"That's good, old boy," Truscott snapped, listening once again to the man's abdomen with his stethoscope. "Because we're going to be cutting skin before you can say 'Tie me kangaroo down.' "

Transportation rushed into the room and began transferring the patient to a litter. Only then did Truscott turn to Sarah.

"So, what brings you down here, Doctor?" he asked. "Is this man having some gynecological problems on top of everything else?"

One nurse laughed out loud. Sarah kept her cool by reminding herself that she cared too little for the man to allow him to upset her in any way.

"I thought you might be a little tired and in need of a little extra help," she said. "I knew you were, um, resting in room 421. I was at my locker when you went in. That's how the page operator knew where to find you."

Truscott's face paled. The corners of his mouth twitched.

"Thank you for that," he managed. "You certainly have been kind to me lately."

"Think nothing of it," Sarah responded, her eyes fixed steadily on his.

The team had finished loading the old man onto the litter. Truscott motioned them to the OR with a flick of one hand. In seconds the room was empty, save for Sarah and one nurse. The floor, littered with bloody pads and gauze wrap, needle guards, rubber gloves, IV tubing boxes, and the like, looked like a war zone. Sarah gloved and began picking up some of the litter.

"I'll take care of this," the nurse said.

"Why, are you more trained for this job than I am?"

The nurse smiled. "Thanks," she said.

At that moment, the phlebotomist raced into the room carrying a computer printout.

"Where is everyone?" she asked breathlessly.

"Gone to the OR. Why?"

The technician handed over the printout.

"His magnesium level is zero point four," she said. "The supervisor said to tell you they've run it twice and-"

Sarah was no longer paying attention. She glanced at the phone, thought better of it, and then raced from the room. A magnesium level of 0.4, far below normal, would explain the clinical picture entirely. It was life-threatening in any circumstance, but would be fatal if not corrected before surgery. The cause, she guessed, might be the old man's intolerance to the vigorous diuretic treatment that was being used to correct his heart failure.

IATROGENIC: ILLNESS OR INJURY CAUSED BY THE WORDS OR ACTIONS OF A PHYSICIAN.

Sarah flashed on the sign that once hung over Peter Ettinger's desk. There was every reason to believe that the patient's striking turn for the worse was due to his treatment, not his disease-to the diuretics, not the aneurysm. She reached the operating suite doors just as the litter was being wheeled into one of the ORs.

"Andrew, wait!" she cried out.

It took less than half an hour for the old man to respond to his magnesium infusion and wake up. Until his retirement a year before, Terence Cooper had been a boatbuilder of some note. He had a cackling laugh and a wonderful, toothless smile. And upon meeting Sarah, he immediately asked her out on a date, assuring her that his wife wouldn't mind all that much.

"Mrs. Cooper keeps telling me to try out new things," he said.

Sarah let him squeeze her hand and then turned to leave. Until that moment, Andrew had said very little to her. Now he stepped between her and the door.