Vital signs dmb 2, p.8

Vital Signs dmb-2, page 8

 part  #2 of  Dr. Marissa Blumenthal Series


Vital Signs dmb-2

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  Linda's recommendation. Donning a short white coat, Marissa went down to the main walk-in clinic area to try to cam some of the small salary she was still receiving.

  After seeing a handful of children with runny noses, middle ear infections, and sore throats, Marissa found herself in an examination cubicle with an eight-month-old infant and a disinterested teenage mother.

  "What's the problem?" Marissa asked, even though she could see well enough herself. The child had a number of suppurating sores on his back and arms. In addition, he was filthy dirty.

  "I dunno," the mother said as she cracked her gum and stared around the room.

  "The kid cries all day long. He never shuts up."

  "When was the last time you bathed this infant?" Marissa demanded as she looked at the pustules. She guessed it was staph.

  "Yesterday," the mother said.

  "Don't give me that," Marissa snapped.

  "This child hasn't been bathed in a week, if then."

  "Maybe it was a few days ago," the mother admitted.

  Marissa was livid. She was tempted to tell the girl she wasn't fit to be a mother. Resisting the impulse, she buzzed one of the nurses and asked her to come to the examination room.

  "What's up?" Amy Perkins asked.

  Marissa could not bring herself to look at the mother. She only gestured in her direction.

  "This child needs to be bathed," she told Amy.

  "Also, these open sores need to be cultured. I'll be back."

  Stepping from the examination room, Marissa went into the deserted supplies closet. She put her face in her hands, fighting back tears. She was disgusted with her lack of control. It was scary to be this close to the edge. She could have hit that girl. It made the discussion she'd just had with Linda Moore seem a lot less academic.

  For the first time she wondered if she should continue seeing patients in this hyper emotional state.

  "Why don't we go out for dinner?" Robert suggested after coming home late as usual from his office.

  "Let's go to that Chinese restaurant. We haven't been there for months."

  Marissa thought it was a fine idea to get out of the house. She wanted to talk to Robert, particularly after he'd slept in the guest room the night before. That had been a disturbing first. Besides, she was starved and Chinese food sounded particularly appetizing to her.

  After he'd taken a quick shower, they climbed into Robert's car and headed into town. Robert seemed in good spirits, which Marissa thought was a good sign. He was pleased about a deal that he'd struck that day with European investors concerning building and managing retirement-nursing homes in Florida.

  Marissa listened with half an ear.

  "I went to see the counselor at the Women's Clinic today," Marissa said when Robert's story came to an end.

  "She was even more helpful than I'd anticipated."

  Robert didn't respond. Nor did he look at her. Marissa could sense immediate resistance to her turning the subject of their conversation to their infertility problems.

  "Her name is Linda Moore," Marissa persisted, "and she's very good. She's hopeful that you will come in for at least one session."

  Robert glanced at Marissa, then back at the road.

  "I told you yesterday, I'm not interested," he said.

  "It might be helpful for us," Marissa added.

  "One thing that she suggested was deciding in advance how many cycles we are willing to try before giving up. She says it is less stressful knowing that the process is not open-ended."

  "How many did she suggest?" Robert asked.

  "Eight," Marissa answered.

  "Four isn't enough to take advantage of the statistics."

  "That's eighty thousand dollars," Robert said.

  Marissa couldn't answer. Was money always on his mind?

  How could he reduce a child to a simple dollar value?

  They traveled in silence for a while. Marissa's interest in talking with Robert cooled, yet she still wanted to bring up the issue of his sleeping in the guest room. She had to say something.

  Nearing the restaurant, Robert had no trouble finding a parking place. As Marissa opened her door, she found the courage to ask him about it. She discovered Robert wasn't in the mood to discuss it.

  "I need a vacation from all this," he said irritably.

  "I've been telling you that this in-vitro stuff is driving me crazy. If it's not one thing, then it's something else. Now it's this counseling garbage!"

  "It is not garbage!" Marissa snapped "There you go again," Robert said.

  "Lately I can't talk to you without you flying off the handle."

  They stared at each other over the top of Robert's car. After a moment of silence, Robert changed the subject again by saying, "Let's eat."

  Disgusted, Marissa followed him into the restaurant.

  The China Pearl was run by a family who had recently moved from Chinatown to Boston's suburbs. The restaurant's decor was typical: simple Formica-topped tables and a couple of ceramic red dragons. By that late hour only four or five of the twenty or so tables were still occupied.

  Marissa sat down in a chair facing the street. She felt horrible.

  All of a sudden she wasn't hungry anymore.

  "Good evening," said the waiter as he handed' them menus.

  Marissa glanced up at the man as she took the long, plastic coated menu.

  Robert asked her if she'd like to split an appetizer. But before she could respond, Marissa felt cold sweat break out all over her body. In a flash, she was back at the Women's Clinic having her cervical biopsy. The vision was starkly vivid, as if she were actually there again.

  "Get him away from me," yelled Marissa. She leaped to her feet and tossed the menu aside.

  "Don't let him touch me. No!" she screamed, as illusion and reality merged.

  In her mind's eye, Marissa saw the face of Dr. Carpenter come up between her sheet-draped knees, having been transformed into a demon. His eyes were no longer blue. They were distorted and shiny, like cold, black onyx.

  "Marissa!" Robert shouted, feeling a mixture of concern, shock, and embarrassment. Other diners had paused to cast startled looks in Marissa's direction. Robert stood and reached for her.

  "Don't touch me!" she shouted again. She knocked Robert's hand away from her. Spinning on her heels, she fled from the restaurant, banging open the door.

  Robert chased after her, practically tackling her outside the door. Grabbing her by the shoulders, he shook her hard.

  "Mafissa, what's wrong with you?"

  Marissa blinked several times as if waking from a trance.

  "Marissa?" Robert yelled.

  "What's going on? Talk to me!"

  "I don't know what happened," Marissa said groggily.

  "All at once I was back at the clinic having a biopsy. Something keyed off a replay of the bad trip I'd had from ketamine." She glanced back into the restaurant. People were at the window, staring out at her. She felt foolish and embarrassed as well as scared. It had been so real.

  Robert put his arms around her.

  "Come on," he said. "]Let's get out of here."

  He walked her to the car. Marissa held back, her mind frantically trying to find some answers. She'd never lost control to such a degree. Never. What was happening to her? Was she going crazy?

  They climbed into the car. Robert didn't start it immediately.

  "Are you sure you're all right?" he asked. The episode had unnerved him.

  Marissa nodded.

  "At this point I'm just scared, 9'she said.

  "I've never experienced anything like that. I don't know what set it off.

  I know I've been overly emotional lately, but that hardly seems like an explanation. I was hungry, but I certainly can't blame it on that. Maybe it was that pungent smell in there. The nerves of smell connect directly with the limbic system in the brain." Marissa was searching for a physiological explanation so she wouldn't have to probe for a psychological one.
  "I'll tell you what it says to me," Robert said.

  "It tells me you've been taking too many drugs. All those hormones can't be good for you. I think it is just one more sign we should stop this in-vitro nonsense. Pronto."

  Marissa didn't say anything. She was scared enough to think that perhaps Robert was right.


  March 21,1990 7:47 Am.

  "Want to flip to see who does the incision?" Ken Mueller said to Greg Hommel, the junior pathology resident who had been assigned to him for a month's rotation doing postmortems.

  Ken was particularly pleased with Greg. The kid was eager and smart as a whip. Ken smiled to himself calling Greg a kid; the guy was only five years younger than himself.

  "Heads I win, tails you lose," Greg said.

  "Flip," Ken said, already engrossed in the chart. The patient was a thirty-three-year-old woman who'd fallen six stories into a rhododendron planter.

  "Tails!" Greg called out.

  "You lose." He laughed happily.

  Greg loved doing posts. Whereas some of the other junior residents hated it, he thought it was a gas; a detective story wrapped up in the mystery of a body.

  Ken didn't share Greg's enthusiasm for posts, but he accepted his teaching responsibilities with equanimity, especially with a resident like Greg. Yet looking at the patient's chart, he felt a little irritated. It had been well over twenty-four hours since the patient's death, and Ken liked to do posts as soon as possible. He thought he was able to learn more.

  The patient in this case had been brought to the Memorial by ambulance for a brief resuscitation attempt but the woman had been declared DOA. Then the body had sat in cold storage. It was supposed to have been sent to the medical examiner's office, but between a rash of shootings and other trauma, the ME had been swamped. Finally, a request had come through for them to do the post at the Memorial and Ken's chief had gladly agreed.

  It was always politically wise to stay on the ME's good side. You I never knew when a return favor would be needed.

  With his gloved. left hand providing counter traction Greg was about to make the typical Y-shaped autopsy incision when Ken told him to hold up.

  "Have you gone over the chart?" Ken asked.

  "Of course," Greg said, almost hurt by the implication.

  "So you know about this infertility stuff?" Ken asked while he was still reading.

  "The in-vitro attempts and the blocked tubes."

  Blocked tubes had rung a bell, and Ken recalled Marissa's visit.

  "Yup, and she looks like a pincushion because of it," Greg said.

  Ken glanced at the body as Greg pointed to the multiple hormone-injection sites as well as the multiple bruises where blood had been drawn to measure estrogen levels.

  "Ouch," Ken said, looking down.

  "And here's a fresh one," Greg said, pointing to the crook of the left elbow.

  "See the heme staining under the skin? She had blood drawn within hours of her jumping out the window.

  Couldn't have been from our ER. She was dead when she arrived."

  Slowly, the doctors' eyes met. They were thinking the same thought. The patient certainly wasn't a drug addict.

  "Maybe we should extend the toxicology screen," Greg said ominously.

  "Just what I was about to suggest," Ken said.

  "Remember, we're being paid to be suspicious."

  " You're being paid," Greg laughed.

  "As a resident, my salary is more like alms."

  "Oh, come on!" Ken said.

  "When I was at your stage..

  "Spare me," Greg said, holding the knife aloft. He laughed.

  "I've already heard what medicine was like in medieval times."

  "What about the evidence of the trauma from the faUT' Ken asked.

  Rapidly, Greg ticked off the external signs of impact. It was apparent that both legs were broken, as was the pelvis. The right wrist was also bent at an abnormal angle. The head, however, was intact.

  "All right," Ken said, "cut away."

  With a few deft strokes, Greg used the razor-sharp knife to cut through the skin, exposing the omentum-covered intestines.

  Then, with large clippers, he cut through the ribs.

  "Uh-oh!" Greg said, lifting off the manubrium, or breastbone.

  "We got some blood in the chest cavity."

  "What does that suggest?" Ken asked.

  "I'd say aortic rupture," Greg said.

  "Six stories could have generated the two thousand pounds of force necessary."

  "My, my," Ken teased, "you must be doing some extracurricular reading."

  "Occasionally," Greg admitted.

  Carefully, the two men extracted the blood from both lung cavities.

  "Maybe I'm wrong about the aortic rupture," Greg said, staring at the graduated cylinder when they were done.

  "Only a few hundred cc's."

  "I don't think so," Ken said. He withdrew his hand from inside the chest cavity.

  "Feel along the aortic arch."

  Looking up at the ceiling as he concentrated on feel, Greg palpated along the aorta. His finger slipped inside. It was an aortic rupture, all right.

  "You have promise as a pathologist after all," Ken said.

  "Thanks, all-seeing, all-knowing Karnak the Magnificent," Greg joked, though he was obviously pleased with the compliment.

  He turned his attention to the evisceration of the corpse.

  But as he worked, his forensic mind was beginning to set off alarm bells in his head. There was something wrong with this case; something very wrong.

  Having gone through an embryo transfer before, Marissa knew what to expect. There wasn't much pain involved, especially in comparison with the myriad procedures she'd been enduring over the year, but it was still an uncomfortable and humiliating exercise. To keep her uterus in a dependent position, she had to lie prone with her knees raised to her chest and with her rear end sticking up in the air. Although she had a sheet draped over her, Marissa felt completely exposed. The only people present were Dr. Wingate, his nurse-technician, Tara MacLiesh, and Mrs. Hargrave. But then the door opened and Linda Moore came in. The fact that people could come in and out was part of the reason Marissa felt so vulnerable.

  "It's important for you to be relaxed," Linda said, positioning herself near Marissa's head. She patted Marissa's shoulder.

  "I want you to think relaxing thoughts."

  Marissa knew the therapist meant well, but telling her to think relaxing thoughts seemed absurd. She hardly saw how it would help. And it was particularly hard to relax knowing Robert was outside waiting. Marissa had been surprised he'd come with her that morning since he'd slept in the guest room again.

  "Everything is ready," Dr. Wingate said, keeping Marissa informed, as usual.

  "And just like we did last time, the first thing we have to do is assure asepsis."

  Marissa felt the sheet drawn back. Now she was literally exposed.

  She closed her eyes as Linda continued to drone on about relaxing. But Marissa couldn't relax. So much was riding on this transfer, maybe even her marriage. Robert had accompanied her to the clinic, but neither of them had said a single word through the entire drive from Weston to Cambridge.

  "First the sterile speculum," Dr. Wingate said. A few seconds later, she felt the instrument.

  "Now I will be rinsing with the culture medium," Wingate continued.

  Marissa felt the rush of fluid inside her. Then she felt a hand on her shoulder. Opening her eyes, she saw that Linda Moore's freckled face was inches from her own.

  "Are you relaxed?" Linda asked her.

  Marissa nodded, but it was a lie.

  "We're ready for the embryos now," Dr. Wingate told Tara.

  Tara went back into the lab. Then to Marissa, Dr. Wingate said:

  "You might feel a tiny bit of cramping with the insertion, but don't worry. It will be just like last time."

  Marissa. would have preferred he'd not made the
comparison: last time the transfer had not worked. She heard Tara come back into the room. Marissa could picture the Teflon catheter, called a Tomcat.

  "This is it," Dr. Wingate continued.

  "Remember to relax," Linda said.

  "Think of a fine, healthy baby," Mrs. Hargrave said.

  Marissa felt a strange deep sensation like a pain, but not strong enough to be called a pain.

  "We should be within one centimeter of your uterine fundus," Dr. Wingate said.

  "I'm injecting now."

  "Breathe deeply," Mrs. Hargrave said.

  "Relax," Linda suggested.

  Despite her hopes, Marissa didn't feel optimistic.

  "Perfect," Dr. Wingate said.

  "I'm coming out now."

  Marissa held her breath as she experienced an extremely mild cramp' Now don't move until we ascertain that the embryos have all been extruded from the catheter," Dr. Wingate said. He and Tara disappeared into the lab.

  "You feel okay?" Mrs. Hargrave asked.

  "Fine," said Marissa, as self-conscious as ever, always concerned someone else was about to barrel through the door, "Now that it's over," Linda said, giving Marissa's shoulder another pat, "I'll be going. I think I'll have a word with your husband on my way out."

  Good luck, Marissa thought. She didn't think her husband would be approachable that day.

  Dr. Wingate returned just as Linda was departing.

  "All the embryos were planted," Dr. Wingate said. Marissa felt the speculum being removed. He tapped her gently on the top of her rump.

  "Now you can lower yourself to your tummy. But don't roll over. Just like the previous transfer: I want you to remain on your stomach for three hours, then you can roll over on your back for an hour. Then you'll be free to go." He pulled the sheet over Marissa's lower half.

  Mrs. Hargrave released the brakes on the gurney and started pushing. Tara held open the door to the hallway. Marissa thanked Dr. Wingate.

  "You're very welcome, love," he said, his Australian accent suddenly more pronounced.

  "We'll all be keeping our fingers crossed."

  As they came abreast of the waiting room, Marissa heard Mrs.

  Hargrave call out Robert's name. The conversation with Linda must have been brief, as she was already gone.

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