Michael Palmer - Natural Causes

"She's not in as active labor as the others," Blankenship said, "but she's progressing faster than any of them did."

"I don't recall any of the others having fever," Sarah said.

"They didn't."

"Even so, it sure looks like DIC."

"Agreed."

"You know, Sarah," Snyder said, "assuming the lab confirms it, we have the case Rosa Suarez was talking about. The case that finally takes you off the hook in all this."

Sarah narrowly kept from criticizing her chief for the inappropriate timing of his remark. But she reminded herself that Annalee had not been his friend, and that the accusations against his next chief resident had severely disrupted his department.

"I'd be lying if I said that point hadn't occurred to me," she said instead. "But what concerns me most now is Annalee. I think we have to section her quickly. Remember how rapidly Lisa began recovering after she was delivered?"

"What do you think, Randall?" Blankenship asked.

"As things stand, she's too unstable for us to go in. The fetal monitor is holding for now. I think with a six-and-a-half-week preemie in there, and her labor slowing down as it has been, we should try to get her bleeding and clotting under control."

"I agree," Blankenship said.

Sarah knew that in a medical discussion with two full professors, her opinion mattered, but only as long as it jibed with theirs. In this instance, it most certainly did not. The cesarean section, for whatever reason, had all but cured Lisa Summer. She excused herself and returned to the bedside. The Demerol injection had calmed Annalee considerably, but she was drenched in perspiration, and the bleeding from her nose and her original intravenous site was intensifying. Her fingernail and toenail beds were at least as dark as Lisa's had been. Still, as Sarah conducted her examination, she could not shake the feeling that the two cases were different in some basic way. First there was the fever. Neither Lisa nor the other hospitalized case had experienced a rise in temperature, although it certainly could accompany DIC. Then there was the frightening speed with which Annalee's symptoms were developing. And finally, there were unsettling weaknesses in her acupuncture pulses. Sarah tried to attribute the strange pattern she was feeling to altered blood flow. But her instincts told her she was picking up on something significant. Whatever it was-possibly some sort of systemic toxin-seemed to be affecting every organ in the woman's body.

She returned to the two department chiefs and shrugged.

"Have you anything to offer her?" Snyder asked.

"I don't know. I can try some of the things I did with Lisa. But no guarantees."

Snyder glanced over at the fetal monitor. "Eli, I've got the anesthesiologist and the pediatrician standing by. But I want to exhaust every possibility before we go ahead with a section."

A unit clerk raced in and handed Eli a computer printout.

"These clotting studies look remarkably like Lisa Summer's did," he said. "They make DIC pretty much a certainty. We've got to get her on heparin. Sarah, if you want, I'll give you ten minutes-fifteen if she gets no worse."

"I can't promise anything, but I'll do what I can," Sarah said. "Someone please talk to her father and tell him what's going on."

Her thoughts swirling, she raced past Peter, and off the labor and delivery floor. For months she had hoped Rosa was wrong about their seeing just the tip of the iceberg; prayed that they had encountered the last tragedy from the macabre, malignant complication of childbirth. Now the lives of Annalee Ettinger and her daughter were on the line. But having studied the previous cases so intensively, Sarah had questions. Why the high fever? Why the unusual pattern in her twelve acupuncture pulses? Why the rapid evolution of symptoms?

She took the tunnel to the Thayer Building, bypassed the elevator, and raced up the five flights to her locker.

"Two spins to the right, then stop at three… left to forty…"

As always, Sarah murmured the combination to herself as she dialed it. Halfway to the forty, the dial caught momentarily. In freeing it, Sarah spun well past the number. She cursed out loud. Even in the most trying OR situations, her hands had always been her most supple, dependable allies. Now, with Annalee in such trouble, they were stiff as cold taffy. She was about to spin through the combination again when she noticed the scratches in the metal door, just beside the lock. Instead of redoing the combination, she tugged on the dial. Her pulse was throbbing in her ears as the door swung open. Her lacquered mahogany box of acupuncture needles was gone, as was the electrostimulator she occasionally attached to them. In their place was an unopened Federal Express box addressed to her care of MCB. On top of the box was a small brown paper bag.

Her hands trembling, Sarah reached into the bag and withdrew a glass vial and a receipt. The vial was empty, but its label made all too clear what was going on. It also answered the gnawing questions about Annalee's clinical picture.

CROTALID (M IXED R ATTLESNAKE) VENOM FOR RESEARCH PURPOSES ONLY

CAUTION: HIGHLY POISONOUS

HAVE ANTIVENIN AVAILABLE, AND REVIEW USAGE

The receipt, from a mail order laboratory supply house in Houston, was made out to her. Sarah dropped the vial into her clinic coat pocket and carefully tore open the FedEx package. There was no doubt in her mind what it contained. Polyvalent Crotaline Antivenin-twenty vials in all.

Badly shaken, Sarah stood alone by her open locker on the dimly lit fourth-floor corridor of the Thayer Building. In her pocket was quite likely the cause of Annalee's hellish, imminently lethal situation. In her hands was the cure. No one was likely to believe her story that both the empty poison vial and the packaged antidote had been placed in her locker by whoever had actually administered the venom to Annalee.

If her account of Andrew's death had strained her credibility around MCB, this latest tale would snap it.

It made much more sense to believe that Sarah had infused the rattlesnake poison in order to create a case of labor-induced DIC that was unrelated to her herbal supplement. That Annalee was supposedly her friend would impress no one-especially after Peter got through telling whatever version of their history he concocted. Why, then, had Sarah produced the antidote? Perhaps, some people would reason, she had intended to create a dramatic though sublethal condition, but had missed. Only when things were clearly on a downhill slide for Annalee had she come up with the antivenin-and the farfetched explanation that it had just shown up in her locker. Perhaps, others would claim, she had not initially cared whether the case was sublethal or lethal. But seeing Annalee's extreme distress had brought about a sudden change of heart.

The two groups might argue over nuances. But clearly, there was one and only one logical explanation for Sarah's miraculous, eleventh-hour discovery of both the cause and cure of Annalee's DIC. Sarah herself had to have administered the toxin in the first place. No one with half a brain would believe otherwise.

For a moment, the notion flickered through her mind simply to dispose of the empty vial and the antivenin. She could say that her locker had been pried open and her acupuncture needles stolen. No one except the person who had set her up would ever be the wiser. With luck and aggressive treatment, Annalee and her child-or at least one of them-might possibly survive. And as Randall Snyder had said, with a case of DIC unrelated to Sarah's herbal supplements, she would at last be off the hook. By the time Sarah was even aware of having that notion, she was bounding, three at a time, down the stairs to the tunnel, the precious FedEx box tucked beneath her arm like a football.