Side Effects (5 page)

Eyes closed, Kate settled back in her seat, savoring what she had just heard. I'm sorry. He had actually said it.

Apologizing has been bred out of Samuels men was yet another teaching from the philosophy of J. Winfield Samuels. Kate had suffered the pain of that one on more than one occasion. She thought about Jared's vehement reaction to the possibility of her taking over the chairmanship of her department. The morning, she had decided, had been a draw: Dad 1. Wife 1.

#. /'

"Now, Dr. Engleson, you may proceed with your report."

Tom Engleson's groan was not as inaudible as he would have liked. "Your patient is still bleeding, sir. That's my report." During his year and a half of residency on the ' Ashburton Service at Metropolitan Hospital of Boston, Engleson had had enough dealings with D.K. Bartholomew to know that he would be lucky to escape with anything less than a fifteen-minute conversation. Dr. Donald K. Bartholomew held the receiver in his left hand, adjusted the notepad in front of him, and straightened his posture. "And what is her blood count?"

"Twenty-five. Her crit is down to twenty-five from twenty-eight." Engleson pictured the numbers being shakily reproduced in black felt tip. "She has had a total of five units transfused in the last twenty-four hours, two of whole blood, one of packed cells, and two of fresh frozen plasma." He closed his eyes and awaited the inevitable string of questions. For a few seconds there was silence.
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"How many fresh frozen did you say?"

"Two. The hematology people have been to see her again. Her blood is just not clotting normally." He had decided to keep the complicated explanation for Beverly Vitale's bleeding problem out of the conversation if at all possible. A single request from Bartholomew for specifics, and the phone call could drag on for another half hour. In fact, there was no good explanation even available. The hematologists knew what--two of the woman's key clotting factors were at critically low levels--but not why. It was a problem the surgeon should have at least identified before performing her D and C.

"Have they further tests to run?"

"No, sir. Not today, anyhow." Getting D.K. Bartholomew to come into the hospital on a Sunday morning was like getting a cat to hop into the tub. "They suggested loading her up with fresh clotting factors and perhaps doing another D and C. They're afraid she might bleed out otherwise."

"How long will it take to give her the factors?"

"We've already started, sir."

There was another pause. "Well, then," Bartholomew said at last, "I guess the patient and I have a date in the operating room."

"Would you like me to assist?" Engleson closed his eyes and prayed for an affirmative response.

"For a D and C? No, thank you, Doctor. It is a one-man procedure, and I am one man. I shall be in by twelve o'clock. Please put the OR team on notice." "Fine," Engleson said wearily. He had already scheduled Beverly Vitale for the operating room. He hung up and checked the wall clock over the door of the cluttered resident's office. Only eight minutes. "A record," he announced sardonically to the empty room. "I may have just set a record."

Moments later, he called the operating suite. "Denise, it's Tom Engleson. You know the D and C I scheduled for Dr. Bartholomew? ... Vitale. That's right. Well, I was wondering if you could switch it to the observation OR. I want to watch ... I know you're not supposed to use that room on a weekend. That's why I'm asking in such a groveling tone of voice ... Bartholomew doesn't want anyone assisting him, but he can't keep me from watching through the overhead ... I owe you one, Denise. Thanks." Looking down from behind the thick glass observation window into the operating room, Tom Engleson exchanged worried looks with the scrub nurse assisting Dr. Donald K. Bartholomew. The dilatation of Beverly Vitale's cervix and subsequent curettage--scraping--of the inner surface of her uterus was not going well. She had gone to the emergency ward three days before because of vaginal bleeding that started with her period but would not let up. For several years, she had been receiving routine gynecologic care through the Omnicenter--the outpatient facility of the Ashburton Women's Health Service of Metropolitan Hospital. As her Omnicenter physician, D.K.

Bartholomew had been called in immediately.

In his admission physical, Bartholomew had noted a number of bruises on the woman's arms and legs, but elected nevertheless to proceed with a D and C--commonly done for excessive bleeding. He did not order blood clotting studies until after his patient's bleeding worsened postoperatively. Now, with the woman loaded with fresh clotting factors, Bartholomew was repeating the curettage. Beverly Vitale, a thin, delicate young cellist with straight jet hair and fine, artist's hands lay supine on the operating table with her eyes taped shut and her head turned ninety degrees to one side. A polystyrene tube placed through her mouth into her trachea connected her with the anesthesia machine. Her legs, draped in sterile sheets, were held aloft by cloth stirrups hooked beneath each heel. Overhead, in the observation gallery Tom Engleson watched and waited. He was dressed in standard operating room whites, with hair and shoe covers, but no mask.

As he watched the level of suctioned blood rise in the vacuum bottle on the wall, Engleson wondered if D.K.

Bartholomew was considering removing the woman's uterus altogether. He cursed himself for not throwing protocol to the winds and inviting himself into the OR.

The prospect of the old surgeon moving ahead with a hysterectomy brought a ball of anger to the resident's throat. Much of his reaction, he knew, had to do with Beverly Vitale. Though he had only spoken with her a few times, Engleson had begun fantasizing about her and had become determined to
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see her when she was released from the hospital. Now his thoughts added, if she was released from the hospital. He glanced again at the vacuum bottle and then at Bartholomew. There was a flicker of confusion and uncertainty in the man's eyes.

"Her pressure is dropping a bit."

Engleson heard the anesthesiologist's voice crackle through a barely functional speaker on the wall behind him. "Young lady, get me the freshest unit of blood we have, and see if the blood bank can send us up ten units of platelets." "Yes, sir," the nurse said. "Dr. Bartholomew, blood loss so far is four hundred and fifty cc's."

Bartholomew did not respond immediately. He stood motionless, staring at the steady flow of crimson from Beverly Vitale's cervix.

"Let's try some pitocin. Maybe her uterus will clamp down," he said finally.

"Dr. Bartholomew," the anesthesiologist said, an even tenseness in his voice, "you've already ordered pitocin.

She's been getting it. Maximum doses."

Engleson strained to see the older surgeon's face. If he rushed into the OR and the man did not need assistance, a formal complaint was sure to ... Before he could complete the thought, the bellboy hanging from his waistband emitted the abrasive tone signaling a transmission.

"Dr. Engleson, call two eight three stat. Dr. Engleson, two eight three stat, please." An anxious check of the scene below, and the resident rushed to the nearest phone. It was a rule of the Ashburton Service that all stat pages were to be answered within sixty seconds. Telephones had even been installed in the residents' bathrooms for such purposes.

The call concerned a postop patient whose temperature had risen to 103; not a life-or-death situation. By the time Engleson had listened to the nurse's report, given orders for evaluating the patient's fever and returned to the observation window, Bartholomew had begun swabbing antiseptic over Beverly Vitale's lower abdomen.

Engleson switched on the microphone by his right hand. "What's going on?" he asked. Below, no one reacted to his voice. "Can you hear me?" Again no response. Through the door to the scrub area, Engleson saw Carol Nixon, a surgical intern rotating through the Ashburton Service, beginning to scrub. Apparently Bartholomew had called her in to assist, perhaps when Engleson could not be found.

"Over my dead body," Engleson said as he raced down the hall to the stairs. "No way do you open that woman up without my being there." In less than a minute, he had joined Nixon in the scrub room.

"The nurses said Stone Hands was trying to find you," the woman said. "I was just finishing up a case down the hall when Denise grabbed me. Do I have to stay?"

"You might want to learn from the master in there," Engleson responded acidly, cleaning his fingernails with an orange stick. The intern smiled, nodded a thanks-but no-thanks, and left him to finish his scrub.

"Order a peach and you get a pear," was Bartholomew's comment on the change in assistants. He laughed merrily at his own humor and seemed not to notice the absence of response from around the room.

With Engleson handling sponges and hemostats, Bartholomew used an electric scalpel to make an incision from just below Beverly Vitale's navel to her pubis. The scalpel, buzzing and crackling like hot bacon grease, simultaneously sliced through the skin and cauterized bleeding vessels. Next, with the voltage turned up, he cut through a thin layer of saffron-colored fat to her peritoneum, the opaque membrane covering her abdominal cavity. A few snips with a Metzenbaum scissors, and the peritoneum parted, exposing her bowel, her bladder, and beneath those, her uterus. In a perfunctory manner, too perfunctory for Engleson's taste, the older surgeon explored the abdominal cavity with one hand. "Everything seems in order," he announced to the room. "I think we can proceed with a hysterectomy." "No!" Engleson said sharply. The room froze. "I mean, don't you think we should at least consider the possibility of ligating her hypogastric artery?" He wanted to add his feelings about rushing ahead with a hysterectomy in a thirty-year-old woman with no children, but held back. Also unsaid, at least for the moment, was that the hypogastric ligation, while not always successful in
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stopping hemorrhaging, was certainly accepted practice in a case like this. Bartholomew was still guided by the old school--the school that removed a uterus with the dispatch of a dermatologist removing a wart.

D.K. Bartholomew's pale blue eyes came up slowly and locked on Engleson's. For five seconds, ten, an eerie silence held, impinged upon only by the wheeze of air into the vacuum apparatus. The tall resident held his ground, but he also held his breath. An outburst by the older surgeon now, and there would be a confrontation that could further jeopardize the life of Beverly Vitale. Then, moment by moment, Engleson saw the blaze in Bartholomew's eyes fade.

"Thank you for the suggestion, doctor," the surgeon said distantly. "I think perhaps we should give it a try."

The relieved sighs from those in the room were muffled by their masks.

"You or me?" Engleson asked.

"It ... it's been a while since I did this procedure," Bartholomew understated.

"Don't worry, we'll do it together."

In minutes, the ligation was complete. Almost instantly, the bleeding from within the woman's uterus began to lessen.

"While we're waiting to see if this works," Engleson said, "would you mind if I got a better look at her tubes and ovaries?"

Bartholomew shrugged and shook his head.

Engleson probed along the fallopian tubes, first to one ovary and then to the other. They did not feel at all right. Carefully, he withdrew the left ovary through the incision. It was half normal size, mottled gray, and quite firm. This time, it was his eyes that flashed. You said everything was in order. Bartholomew sagged. There was a bewildered, vacant air about him, as if he had opened his eyes before a mirror and seen a painful truth.

The woman's right ovary was identical to her left.

"I don't think I've ever seen anything quite like this," Engleson said. "Have you?"

"No, well, not exactly."

"Pardon?" "I said / hadn't either." There was an uncertainty, a hesitation, in the older man's words. He reached over and touched the ovary.

"You sure?" Engleson prodded.

"I ... I may have felt one once. I'm trying to remember. Do you suggest a biopsy?" Engleson nodded.

"A wedge section?" Another nod. The man's confidence was obvio usly shaken. By the time the wedge biopsy was taken, the bleeding had slowed dramatically. As Engleson prepared to close the abdominal incision over the uterus he had just preserved, he sensed the irony of what was happening tighten in his gut. The uterus was saved, true. A fine piece of surgery. But if the pathology in Beverly Vitale's ovaries was as extensive as it appeared, the woman would never bear children anyhow.

"Denise," he said, "could you find out who's on for surgical path this month; both the resident and the staff person, okay?"

"Right away."

Engleson glanced at the peaceful face and tousled hair of the young cellist. Some women try for years to get pregnant, never knowing whether they can or not, he thought. At least you'll know. Glumly, he began to close.

Twenty minutes later, the two surgeons shuffled into the doctor's locker room.

"Dr. Bartholomew, have you been able to remember where you might have encountered ovarian pathology like this woman's?"

"Oh, yes, well, no. I ... what I mean is I don't think I've ever seen anything like them."

"You look as if you want to say something more."

"I may have felt something like them once. That's all."

"When? On whom?" There was some excitement in Engleson's voice. D.K. Bartholomew, MD, Fellow of the American College of Surgeons and Diplomate of the American College of Obstetrics and Gynecology, shook his head. "I ... I'm afraid I don't remember," he said.
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