Michael Palmer: Natural Causes

The word "bank" was still reverberating throughout the amphitheater when a set of power lines was crossed, causing the main electrical generator at MCB to short out. The backup system, supplying electricity to the operating rooms, ICUs, and part of the emergency ward, kicked in immediately. But the amphitheater, which was windowless, was thrown into instant, stygian darkness.

The kickoff program for Changeover Day was over.

If Sarah had a role model in her practice of obstetrics and gynecology, it was her chief, Dr. Randall Snyder. From his soft-spoken manner to his gray Volvo sedan, everything about the man was fatherly and reassuring. Now in his mid-fifties, he still approached his solo practice with exuberance and compassion. When a new technique or treatment in his field was announced, he would be one of the first in line to learn it. If an uninsured clinic patient had a problem pregnancy, he would accept her as his private patient without a word about payment.

Today Randall Snyder was taking time from his busy schedule to drive Sarah to the Jamaica Plains section of the city. There he would assist her in performing a home delivery on a twenty-three-year-old unwed woman with no health insurance and an inordinate fear of doctors and hospitals.

"How do you do it?" Sarah asked as they drove.

"Do what?" Snyder turned down the volume on the Bach cantata he was playing on the tape deck.

"Keep on doing medicine the way you do without letting it get to you?"

Snyder stifled most of a smile. "Do you want to define 'it'?"

"Oh, you know-the peer reviews and the lawyers, and the insurance companies and government telling you what you can and can't charge for your work; the mountains of paperwork, and the constant threat that you'll offend some vindictive or imbalanced patient who'll lodge a complaint about you or sue you."

"Oh, that 'it,' " Snyder said. "Sarah, as far as I'm concerned, you're not even talking about the real stress on this job: the cases that don't come out right, the people with untreatable illness, the people who die in spite of everything we do."

"But that's medicine. The other stuff is… is…"

"Is medicine, too. It's part of the package. Believe me, I'm not the serene machine a lot of people make me out to be. But neither do I go home after a day's work and beat my wife because I haven't hit the lottery or written the best-seller that will enable me to get out of the profession. I can handle the things you're talking about because by and large I still love what I do, and feel damn lucky to have been given the chance to do it. Why are you asking about all this? Are you having trouble?"

"Not trouble exactly. Oh, turn right at the next corner."

"Got it. Knowlton Street, you said, right?" "Yes."

"I know the way. Now go on."

"You know that before I went to med school I worked in a holistic healing center."

"Of course. I've been to some of your presentations. Interesting stuff. Very interesting."

"My training was in herbal medicine and acupuncture. But some things happened that made me feel I needed to broaden the skills I had."

Some things happened. The understatement of the week, Sarah thought. She debated going into the details of her final clash with Peter Ettinger, but quickly realized that this was hardly the time or place to unearth that worm.

"Well, our techniques in the holistic center had their limitations," she went on. "I don't question that. But there was a certain, I don't know, call it innocence about our goals and the way we did things-most of us, anyway. Each day we went to work and were able to concentrate almost exclusively on doing what we could for our patients."

"And?"

"Well, as far as I can tell, medicine as I'm being trained to practice it now is often as much about money and liability as it is about patients. We order millions and millions of dollars in marginal or unnecessary tests so that our backsides will be covered if we end up in court. Meanwhile, government agencies, thinking they're saving money, are telling us how long we're allowed to keep patients with a given illness in the hospital. So what if an elderly lady here or there gets sent home too soon after a hysterectomy and falls and breaks her hip? We're talking statistics here-actuarial tables and percentages. Not flesh and blood."

"Sarah, you are too young to be so jaded."

"Dr. Snyder, I wish there was something I was still too young to be-anything at all; and you know I'm not jaded. I feel I've made the right decision in becoming an M.D. And I love being a doctor. Sometimes I just wish it all was a little more, I don't know, pure."

Randall Snyder chuckled.

"Ivory Soap is ninety-nine and forty-four one-hundredths percent pure," he said, turning onto Knowlton. "Nothing involving human beings even comes close to that-especially not in our racket. But, listen, I do understand what's troubling you, and I promise we'll continue this discussion sometime soon, perhaps over dinner at our place. For now, you should know that you're on your way to being a heck of a doctor-exactly the sort of person I would like to have as a partner in my practice."

"Why, thank you." Sarah could not mask her surprise-or pleasure. It was the first time she had heard Randall Snyder even intimate he might be considering bringing in an associate, let alone her.

"File that one away for the time being," Snyder said. "Sometime later this year, if you want, we'll sit down and talk business. It's okay to take a hard look at the less appealing sides of our profession, as long as you don't get paralyzed by what you see. And for God's sake, don't go putting anyone on a pedestal-especially me." He pulled to the curb in front of number 313. "Now, before we go in, how about giving me a thumbnail on our patient."

The concise, highly stylized presentation of a medical case was emphasized more, perhaps, than any other skill during Sarah's training. As a student, she would often lie in the bathtub, oblivious to the progressively cooling water, as she used a stopwatch and a dozen or more repetitions to perfect her next morning's case presentation. Now the technique was second nature.

"Lisa Summer is a twenty-three-year-old unmarried artist, gravida two, para zero, spontaneous a.b. three years ago. LMP ten-two."

Second pregnancy, no deliveries prior to this one, a miscarriage, last menstrual period nine months before. Randall Snyder nodded for Sarah to proceed.

"This pregnancy has been unremarkable in every respect. There has been a thirty-pound weight gain from a base weight of one oh six. At exam one week ago, fetus was in vertex position-head was engaged, probably left occiput anterior.

"Except for the usual childhood diseases, Lisa has a negative medical history. She is a nonsmoker and drinks occasionally. No other meds except for the natural prenatal supplement I prescribe."

"Ah, yes," Snyder said. "The mysterious Baldwin mix. I was at the departmental conference last year when you spoke of it. Sometime soon I would like to learn more. Please continue."

"Family history is scant. No relationship with her parents at present; no relationship with the father of the child."

"Oh, my."

"Her coach is a woman friend who's a nurse. Apparently, as a child, Lisa had a bad experience of some sort in a hospital. Now she's terrified of them."

"Ergo the home birth."

"That's one of the reasons. Lisa's sort of-I don't know-she's very secretive about herself, and very mistrustful of people."

"Even you?"

"Not as much as at first, but yes, even me."

"Well, then, supposing we go on in and try to turn that around."

Sarah gathered up the covered tray of equipment and obstetrical instruments.

"One more thing," she said. "Heidi, the birth coach, said that Lisa's pressure has been dropping slightly and that it's become harder to hear in her right arm than her left. The last systolic I know of was eighty-five, just as Glenn was starting his talk. The highest, a few hours before that, was one ten."