Michael Palmer: Natural Causes

"Oh, sorry," she said. Her exam, influenced by Lisa's agitated state and the profound disturbance in blood flow, was not revealing. And with no circulation at all on the right, there was little point in checking that side. "I'll call Dr. Blankenship and have him waiting for us with someone from heme."

"Thank you."

The rescue squad raced into the crowded room. After a brief explanation from Randall Snyder, they hoisted Lisa onto their litter and set about establishing an IV in her left arm. Sarah started for the hallway phone.

"Dr. Baldwin, don't leave me," Lisa begged.

"I'll be right back."

"Then please just tell me: Am I going to die?"

Sarah hoped there would be more conviction in her voice than she was feeling at that moment.

"Lisa, this is not the time for you to be thinking like that at all," she said. "It's very important that you stay centered and focused. You've got to be able to use that internal visualization stuff we've been working on. Do you think you can do that?"

"I–I was doing it before all this started. Once I actually saw my cervix. I really did."

"I believe you. That's great. Well, now you've got to start doing it again. Concentrate on seeing your bloodstream and the structures within your hands. It's very important. I'll help you once we reach MCB. Dr. Blankenship, the internist who will be treating you, is a wonderful doctor. I'm going to call him now. He and a hematologist will be waiting for us. Together we'll get on top of this thing."

"Promise?"

Sarah swept some errant wisps of hair from Lisa's damp forehead.

"I promise," she said.

"IV's in," one of the rescue squad announced. "Ringer's lactate at two-fifty. You want her sitting up like this, Doc?"

Snyder nodded. "Sarah, why don't you let me make that call, and you ride to MCB in the ambulance with Lisa. I'll bring Heidi with me."

As she accompanied the rescue squad out of the house, doing what she could to stem the flow of blood from Lisa Summer's nose and mouth, Sarah tried to remember what she could of the other woman who had developed DIC. Normal pregnancy, normal labor right up to the final stage, then a sudden, catastrophic alteration of her body's coagulation system. Just the way it was happening today.

And as she helped load Lisa into the ambulance, the question that had confounded that woman's doctors burned in Sarah's mind: Why?

Six of the nine Suffolk state hospital buildings originally purchased by the Medical Center of Boston were still in use. Two of the others had been razed and replaced with parking facilities. The third, a crumbling six-story brick structure with the name CHILTON etched in concrete over its entrance, had been abandoned and boarded up when Sarah began her training, and remained so-a mute reminder of the hospital's ongoing financial difficulties.

The Chilton Building and garages were separated from the rest of the hospital by a broad, circular drive. Enclosed within the loop was an expansive, grassy courtyard, dotted by some shrubbery and half a dozen molded plastic picnic tables. Vehicle access to "The Campus," as Glenn Paris had named the area, was restricted to those administrators and department heads with parking slots, and to emergency room traffic.

The ride from Knowlton Street to MCB, spearheaded by the sirens of the police cruiser and rescue squad, took fifteen minutes. Seated beside Lisa Summer in the back of the lurching ambulance, Sarah heard the driver radio ahead that a Priority One patient was on the way. She pictured the guard, suddenly puffed with importance, scurrying to open the security gate and move all traffic aside.

Lisa's contractions, now occurring every four minutes or so, were forceful and prolonged. However, Sarah's gentle exam had disclosed a cervix that was still only four centimeters dilated-far from being ready for delivery. The bleeding from her nose and mouth was, if anything, more brisk. And although her left hand and both feet still had some warmth and capillary blood flow, her right arm was now pallid and lifeless from the elbow down.

"Hang on, Lisa," Sarah urged. "We're almost there."

As they turned onto the MCB access road, Sarah reviewed her knowledge of DIC. Having never encountered a severe case of it during her training, her understanding was essentially what she had gleaned from a lecture or two in med school, some reading, and an occasional conference. Rather than being a single, specific disease, the condition was an uncommon complication of many different sorts of injuries or illnesses. Surgery, shock, overwhelming infection, massive trauma, drug overdose, toxins, abrupt separation of the placenta-any of a number of insults to the human body could result in DIC. And in part because of the severity of the predisposing condition, full-blown DIC was, more often than not, fatal.

But Lisa Summer was neither injured nor ill. She was a healthy young woman at the end of a totally uncomplicated pregnancy. Perhaps this wasn't DIC after all, Sarah thought.

The siren cut off as they neared the hospital. Sarah did a quick blood pressure check and exam and began mentally preparing the presentation she would give to Dr. Eli Blankenship. It was her job to present the facts in a totally unbiased manner, carefully avoiding her own diagnostic impression or any other leading statements. Until a diagnosis was proven, assuming one to the exclusion of others was foolish and potentially very dangerous. Assume makes an ass of u and me was the way one professor had stressed that principle.

Eli Blankenship, perhaps the sharpest medical mind in the hospital, would combine her information with his observations. He would then come up with an approach to diagnosis and treatment. Meanwhile, if therapy could not be held off until a definite diagnosis could be made, they would simply have to say a quiet prayer and forge ahead with what measures seemed likeliest to help.

In this case, with two lives already hanging by a thread, it was unlikely they could wait for any laboratory results before instituting treatment. And the treatment for DIC was, itself, life-threatening. All in all, Sarah knew, it was going to be one hellish day for Lisa Summer and the dozens of physicians, nurses, and technologists who would be battling to save her and her baby.

And all the while, swirling about that struggle would be the persistent, gnawing question of why?

As they backed up to the emergency room's receiving platform, Sarah could see Eli Blankenship waiting by the ER door. As always, she was struck by the man's appearance. Had she, without knowing, been challenged to name his vocation, her first guesses might well have included tavern bouncer, stevedore, or heavy machine operator. MCB's chief of staff was a bull of a man, less than six feet tall but with a massive chest and head that were separated by a token neck. He was bald save for a dark monk's fringe. But beneath his expansive forehead, his eyebrows were thickets, and his muscular arms were like Esau's. Even clean shaven at the outset of a day, he seemed to have a persistent five o'clock shadow.

Of the man's physical attributes, only his eyes-a pale, penetrating blue-gave hint to his genius. He was board certified in infectious disease and critical care as well as internal medicine. But he was also respected as a humanist, expert at chess and contract bridge, and well versed in the arts. As a teacher, no one at MCB was more open and respectful of the views and approaches of students and residents, and no one taught them more effectively.

Blankenship, already gowned and gloved, met the stretcher as the rescue squad pulled it from the ambulance, and immediately took Lisa's hand and introduced himself to her. From the other side of the litter, where she was keeping pressure on Lisa's nose, Sarah could see that with that first touch, the medical chief had already begun his examination and assessment.