Michael Palmer: Natural Causes

By the time they reached Room A, one of three major medical/trauma rooms, Sarah had nearly completed her case presentation. Blankenship had the phlebotomist from the laboratory waiting to draw blood for them as well as an OB nurse with a fetal monitor. With a nod, he motioned them both into action. At that moment, blood began to ooze through the gauze wrap protecting Lisa's intravenous line. Blankenship noted the development with no change in his expression.

"Now, Lisa," he said evenly, "I'm going to ask you to be patient with us and to forgive us if it seems we're not keeping you abreast of what's going on. You've got several different things going on here at once, involving several different systems of your body. In a few more seconds, you aren't going to be able to tell all the doctors working on you without a scorecard. The main ones besides me will be Dr. Helen Stoddard, who's a blood specialist, and Dr. Andrew Truscott, who's a surgeon. Her job will be to help us stop this bleeding, and his will be to get in another intravenous line and tend to your arm, which right now is not getting enough blood. And of course, we'll have Dr. Baldwin and Dr. Snyder standing by to deliver your baby as soon as we can get you stabilized."

"Is the baby all right?" Lisa asked.

Blankenship looked over at the OB nurse, who nodded toward the fetal monitor. The fetal heart rate was higher than optimum, often an early sign of trouble.

"The baby's under some stress," he said. "We're watching that very closely."

At that moment, the hematologist swept into the room. Helen Stoddard, also a full professor, was a department chief at another hospital and a sometime consultant at MCB. Unabashedly from "the old school," as she liked to say, she had been openly critical of MCB's coddling up to "fringe players"-her term for practitioners of alternative medicine. During one hospital-sponsored seminar, she had been one of the panelists arguing against incorporating any techniques unproven by scientific methods. Blankenship and Sarah were part of the opposition, advocating the use of certain empirically proven treatments such as acupuncture and chiropractic, and careful scientific evaluation of those and others.

"Where do we stand, Eli?" Stoddard asked without so much as a glance at Sarah.

"Studies are off, ten units ordered."

"Platelets and plasma as well?"

"As many of each as we can get."

Helen Stoddard completed a rapid exam of Lisa's skin, mouth, and nail beds. The gauze surrounding the IV was now saturated. Blood dripped from it onto the stretcher sheet and floor. The venapuncture site from which blood had been drawn was also oozing.

"No prior history of bleeding problems?" she asked Blankenship.

"Absolutely none."

Stoddard thought for a few seconds. "We can't wait for the lab. I think we hang up what platelets, blood, and plasma we can and heparinize her."

Randall Snyder and Heidi Glassman entered the room, both a bit breathless. Moments later Andrew Truscott arrived as well. Heidi took Sarah's place at the bedside, while Truscott, Sarah, and Snyder stepped back to the doorway.

"She's in real trouble," Sarah said.

Snyder glanced at the fetal monitor.

"So's the baby," he said. "Have you started Pitocin?"

"In the ambulance. She's still only five centimeters dilated."

"Jesus."

Truscott took a minute to examine Lisa's arms, hands, and feet. Then, with impressive skill and speed, he injected some anesthetic into the skin at the side of her neck, located two bony landmarks with his fingertips, and slid a large-bore needle through the numbed spot directly into her internal jugular vein. Next he threaded a catheter through the needle and sutured it in place. A critical second IV route had been established.

"One way or the other, I think we're going to have to take her to the OR for that arm," he said after returning to the doorway. "I still can't tell about the left or her feet. Can you C-section her?"

Snyder crossed to Helen Stoddard, held a brief, whispered conversation, and then came back shaking his head.

"We may already be down to a mother versus fetus situation," he whispered. "Helen and Eli have decided they can't wait for laboratory confirmation of DIC. They've gone ahead with heparin. As things stand, they feel the girl has no chance of surviving a C-section."

Heparin for DIC. To Sarah, whose practice as a surgeon was built on a bedrock of meticulous attention to the control of hemorrhage, the treatment was a terrifying paradox: the intravenous injection of a powerful anticoagulant to a patient who was already in danger of bleeding to death. The theory was to administer the drug to break up the pathological clots and restore blood flow to the compromised extremities and vital organs. At the same time, continuous transfusions would be used to chase lost blood volume and replace clotting factors. It was a therapeutic balancing act of circus proportions, and one that too often was doomed to fail.

Sarah looked at the woman she had cared for over the past seven months, now barely visible within the clutch of nurses, physicians, and technologists. In just minutes, Andrew had contributed greatly to everyone's efforts. She had yet to contribute anything. True, she acknowledged, he and the other medical players in this drama were all senior to her. But Lisa Summer was still her patient, and there were things the two of them had worked on, things they could try, that might help as well-provided, of course, that Helen Stoddard and Eli Blankenship allowed them the chance.

She excused herself and raced down to the subbasement where a series of rather dimly lit tunnels connected all of the MCB buildings. Her locker was on the fourth floor of the Thayer Building, which housed the administration offices on the first three floors and the house staff sleeping quarters on the top two. Sarah took the elevator up. Minutes later she bounded down the six flights and sprinted back through the tunnels toward the ER. Cradled in her arm was the mahogany box containing her acupuncture needles. The box had been a gift from Dr. Louis Han. She had first encountered Han, a Chinese-born Christian missionary, while teaching with the Peace Corps in the Meo villages north of Chiang Mai, Thailand. Until his death nearly three years later, he was her mentor in the healing arts. The inscription on the box, elegantly carved in Chinese by Han himself, read: THE HEALING POWER OF GOD Is WITHIN Us ALL.

The moment Sarah stepped back into Room A, she sensed things had changed for the worse. A tube inserted into Lisa's stomach through her nose was carrying a steady stream of blood into the suction bottle on the wall. Her urinary catheter was also draining crimson. Randall Snyder, his face ashen, stood by the fetal monitor, where the heartbeat of Lisa's unborn child had dropped below the rate necessary to sustain life.

"What's happening?" Sarah asked, moving beside him.

"I think we've lost him," Snyder whispered. "We could go for a section right here and now, and maybe we'd still be in time for the baby. But Lisa would never survive."

"Is she going to anyhow?"

"I don't know. It looks bad."

Sarah hesitated for a moment, and then worked her way to where Helen Stoddard and Eli Blankenship were standing.

"Can I please speak with you both?" she asked.

For an instant, she thought Stoddard was going to dismiss her. Then, perhaps remembering Sarah was one of Blankenship's hand-picked residents, the hematologist moved to one side of the room. Blankenship followed.

"I'd like to try to stop Lisa's bleeding," Sarah said.

"And exactly what do you think we're trying to do?" Stoddard asked.

Sarah felt the muscles in her jaw tighten. She had never forced her abilities and techniques on any resident or faculty member who didn't request them. But Lisa was her patient, and conventional therapy did not seem to be working.