Natural Causes (41 page)

A few yards away, two nurses stopped to watch. Perhaps either recognizing Peter or sensing Sarah’s discomfiture, neither made any move to intervene. Sarah took a deep, calming breath and turned to the students.

You want it, Peter? You got it
.

“Mr. Ettinger’s daughter, Annalee, is a twenty-three-year-old para one, gravida zero,” she said evenly. “That means this is her first pregnancy. The date of her L.M.P.—last menstrual period—is uncertain. But by ultrasound and other studies, she appears to be in her thirty-fourth week. The fetus is female, approximately twenty-four hundred grams. That’s about five and a half pounds. Annalee was admitted to our unit the day before yesterday in premature labor, with contractions varying from fifteen minutes apart to seven minutes. Her membranes are intact, her cervix is closed, and she is nontoxic—that is, without evidence of infection. An amniocentesis, done yesterday, has disclosed fetal surfactant levels that are slightly below normal. That means that the baby’s lungs should be all right if she is delivered now. But each day we can keep the child
in utero
gives her that much better of a chance.” She now turned a bit toward Peter, grateful that he had allowed her to get this far uninterrupted.

“Dr. Snyder, her private physician, is the chief of OB/Gyn,” she continued. “He is attempting to arrest her labor with terbutaline, a beta adrenergic agonist. So far, she has responded somewhat to treatment, although she continues to have some regular uterine contractions. Now, Mr. Ettinger, if you’ll excuse us, we have a visit to make to the outpatient department. Dr. Snyder is in the hospital. If you have any further questions, I suggest you contact him.”

“I’ve called an ambulance,” Ettinger said. “I have discussed the situation with my daughter. She wishes to leave this hospital immediately. I’m making arrangements for her to be evaluated at White Memorial prior to returning home with me.”

Sarah was stunned. “I don’t believe she would agree to that.”

“Ask her yourself if you wish,” Ettinger said snidely. “Beta adrenergic agonists, indeed.” He looked at the three medical students with withering scorn. “The answers are not in your
Physicians’ Desk References
, or your fancy tests, or your beta adrenergic agonists,” he said. “They are in the minds and spirits of your patients. Keep
your
minds open to that, and as your careers progress, you will come to understand what I mean. And someday, when one of your superiors tells you to give a patient some drug or other that a pharmaceutical salesman has convinced him to use, you will turn to him and simply say ‘Why?’ ”

“Mr. Ettinger, I’m sure these students are pleased to be exposed to your views on their profession,” Sarah said, battling her exasperation. “Now, please excuse me. I’m going to speak with Annalee. Alone. If you refuse to allow me to do that, I’ll call security.”

“Go right ahead,” Ettinger said smugly. “I doubt you’ll turn her head again. After you’ve satisfied yourself that she wishes to leave this place, I want her discharge orders written.”

The medical students exchanged bewildered, uncomfortable glances. Sarah herself was surprised that Ettinger exuded such confidence. She wondered what he had said to Annalee—what he must have promised—to get her to agree to leave MCB. It had to have been plenty. Otherwise, there was no way—

At that moment, Annalee Ettinger began to scream.

“Oh, my God! Help! Oh, God, please help! Please help me!”

The two nurses, Sarah, and Ettinger dashed toward the room as a pack, with the three medical students close behind. Annalee’s piercing screeches of pain filled the corridor.

Sarah was the first through the door. Annalee was on her side, kicking her feet and wailing piteously. Her intravenous catheter had pulled out. Blood, flowing briskly from the site, was saturating the sheet in a widening circle of crimson.

“My hands!” she cried. “My hands are killing me. Both of them.”

“Page Dr. Snyder,” Sarah immediately ordered.

She gloved quickly, grabbed a towel, and put pressure on the IV site, taking pains to keep Annalee propped on her side, so the heavy, fluid-filled uterus would not be compressing the main artery and veins in her abdomen.

“Susie, go ahead and get another IV ready, please,” Sarah said with forced calm. “Ringer’s lactate. Large-bore cannula.”

“What’s going on here?” Peter asked. “What’s the matter with her hands?”

“My hands … my hands,” the woman kept moaning.

Sarah could see that the flesh beneath Annalee’s nails—the nail beds—were dusky. Her fingers still had motion, but she was splinting them in a protective, claw position. Sarah checked for radial artery pulses and felt them, though faintly, at each wrist.

“Dr. Snyder just called,” the nurse said breathlessly. “He’s on his way. So is the lab. Here’s fifty of Demerol and fifty of Vistaril. He said to give them IM if she’s not actively bleeding. Thirty-five of Demerol IV if she is. They’re getting the fetal monitor now.”

A thin trickle of blood began flowing from one nostril.

“Let’s get that line in right now,” Sarah said grimly. “Also a temp. She feels hot to me. Very hot.”

“I demand to know what’s going on here,” Peter said.

Sarah glared at him. “She’s sick. Even you can see that. Peter, you were just in with her. Didn’t you see that anything was wrong?”

“I … she … um … she said she was having a headache and her arms were feeling heavy.”

“Oh, is that all?” Sarah said irritably. “Peter, please wait in the hall and let us do our work.”

“I want her private doctor in here.”

“Susie, will you please call security and—”

“Okay. Okay. I’m going. But I’ll be right outside. And I’ll be listening.”

“I’m sorry to be a crybaby,” Annalee sobbed. “But it hurts.… It hurts so much.”

Over the minutes that followed, the tension continued to escalate. First the fetal monitor and a third nurse arrived, next the nursing shift supervisor, then the phlebotomist. One of the nurses called out that a rectal temperature was over 103. Annalee’s wailing was unnerving—a hundred new pieces of chalk screeching at once across a hundred slates. The urgency in the room was electric. Not only was there the realization that something terrible was happening to the woman and quite likely to her unborn child as well, but there was the still-fresh memory of the other virtually identical cases.

Sarah and the nurses were unable to keep Annalee from writhing about, but with composure, teamwork, and skill, they were able to slip a wide-bore intravenous cannula into place. Before attaching the Ringer’s lactate infusion, Sarah used the cannula to draw out a large syringeful of blood for the laboratory. One less venapuncture site to worry about—one less bleeding point. The sedating, painkilling Demerol injection had just been given when Randall Snyder raced into the room. He quickly took in the scene.

“Oh, no,” he whispered, though not softly enough to go unheard.

“I saw her forty-five minutes ago, and she was fine,” Sarah said. “Her father’s here. He’s in the hall right now.”

“I know. I saw him.”

“He was in with her fifteen minutes ago. She was complaining of a headache and heaviness in her arms. Then suddenly she started screaming. Labs are off. I’ve ordered four units crossmatched.”

“Let’s make it eight. Gosh, she’s burning up.” There was undisguised and uncharacteristic panic in his voice.

“She’s one-oh-three point five rectally,” Sarah said. “We just took it.”

“I called Dr. Blankenship. He should be here any moment.”

“Good. Annalee, listen. Just hang on. We just gave you something for the pain. You’ll be feeling better in a moment.”

Sarah once again toweled off her forehead and wiped the trickle of blood from her face. Immediately it began again.

“I’m sorry I’m being such a baby.” Annalee sobbed again. “But my hands are killing me. Now my feet are starting to hurt. What’s happening to me?”

“I don’t know yet,” Sarah said. “And stop apologizing. You’re being incredibly tough. An internist is on his way right now to help us.”

“Sarah,” Snyder asked, “did she take your prenatal vitamins at all?”

Sarah shook her head.

“But she did take what I wrote about in her admission history,” she answered softly. “Four years ago.”

Annalee had begun to breathe easier. She eased over onto her back. Her constricted pupils said the Demerol was starting to work.

“This is what happened to those other women, isn’t it?” she said. “The ones who died.”

“We don’t know that,” Snyder replied. “Annalee,
we’re doing everything we can to stop what’s happening to you. We’re also watching the baby. If there’s any sign of trouble, we’re prepared to take her out by cesarean.” He glanced over at the fetal monitor. “Would somebody please call Dr. Blankenship again?”

Within seconds Eli Blankenship entered the room.

“What’s Ettinger doing out there?” he asked.

“Annalee is his daughter,” Sarah said. “Annalee, this is Dr. Blankenship, the chief of medicine.”

“We’ve met,” Blankenship said. “In fact, I saw her just a little while ago. Annalee is part of the study we’ve instituted to draw blood daily on every obstetrics admission. Is Barnes your married name?”

Annalee shook her head.

“We picked that name because her father doesn’t approve of hospitals,” Sarah said. “Especially ours. Annalee didn’t want him to be able to track her down. Somehow, though, he did.”

“And I’m paying close attention to what goes on in here,” Peter called out from the doorway.

“Well, just stay out of our way,” Blankenship snapped as he began his examination.

“Peter, please,” Annalee begged. “Do what he says. The medicine’s starting to work. My hands feel a little better.”

“Thanks for telling him that,” Blankenship said. “I promise I’ll go out and speak with him as soon as I finish figuring out what’s going on.”

Blood had now begun to trickle from both of her nostrils.

“Damn,” Snyder whispered. “Eli?”

“Rectal Tylenol, run the IV wide open, be sure the lab is running everything stat,” Blankenship rattled off. “Check her pressure and her radial pulse every minute, get us two units as soon as possible and ten units of platelets. I don’t want to fall behind. Also, find out who’s on for hematology.”

He motioned a nurse to take Sarah’s place at the bedside, and then led her and Snyder over to one side of the room. A few feet away, the three wide-eyed medical students were like statues flattened against the wall. Sarah made no attempt either to involve them or to ask them to leave.

“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?