A Death in Jackson

---

University of Mississippi Hospital, Jackson, 1963

“You’ve ruined the specimen again!” the lab tech said, clearly irritated with my ineptness.  “This one is ruined just like the first one,” she continued, referring to the second tube of blood I’d collected and sent to the lab.  She didn’t have to say “you idiot,” but I got the message—I was just another intern taxing her patience with clumsy stabs at veins.

“Hold on,” I told the tech, “I’ll be right there.”  She hung up in my ear.

I was an intern in the Emergency Room at the U. of Mississippi Medical Center caring for a semi-comatose young Black woman with vaginal bleeding and undetectable blood pressure. I needed blood tests in a hurry if I was to sort out what was going on in her body.  After ruining the first specimen, I’d taken especial care collecting the second one.  Her veins were hard to find, collapsed along with her blood pressure, so for my second attempt I chose an especially big syringe capped with a huge needle and jabbed it into her groin, aiming for the giant vein carrying blood back to the heart from her leg.  It was a “clean stick,” as we liked to say, and I easily sucked out a big specimen, enough to fill several lab tubes.  Triumphs of any kind are difficult in medicine, especially in an ER, but this was a minor one, and I was energized by my success.  Getting good blood specimens was something I’d excelled at as a medical student, so much so that other students having trouble would call me for help.  Now, here I was, an intern, a few months out of medical school, having collected hundreds of specimens in my budding medical career, and I had the lab telling me I’d ruined two specimens in a row.  Something was not right.

I took the stairs two at a stride to the lab and found the tech, who held both specimens up to the light for my inspection.  “See, I told you so.  They’re both completely ruined,” she said, making no effort to disguise her satisfaction at demonstrating proof of my stumblebum status.

My spirits fell. She was right. The blood in both tubes had a glassy transparency akin to strawberry Kool Aid, which indicated red blood cell destruction, a common sight to lab techs, usually caused by clumsy blood collection or specimen mishandling. I wasn’t as good at blood collection as I had imagined.

“Let’s take a look at a smear,” I said, referring to a drop of blood smear thinly on a glass slide, which allows microscopic examination of blood cells. She gave me the skeptical, self-satisfied look that seasoned professionals give to benchwarmers getting into the game for the first time. She made the smear and I slid it under the lens of a high power microscope. What I saw counts as one of the most remarkable sights I’ve seen in a career looking at cells through a microscope: there were almost no intact red cells just shards of destroyed ones.

Red cells are like tiny water balloons stuffed with hemoglobin, the miracle red stuff that grabs oxygen in the lungs, which it trades in tissues for carbon dioxide for the return trip. Ordinarily red cells constitute about 40% of blood volume; the remaining 60% is plasma (water and proteins). I asked the tech to perform a simple test on the “ruined” specimen to measure the red cell percent—it was 1%!

An idea was forming—the patient’s red cells were being destroyed by some disease. I’d been taught about the causes of red cell destruction in medical school—I’d seen a minor case in clinics, but nothing like the colossal red cell destruction that confronted me now.

On my way back to the ER I sprinted through the blood bank and ordered two units (pints) of O-negative blood (the “universal donor” type), which all blood banks keep on hand when minutes count and there is no time to test (cross match) donor blood to be certain it is compatible with the recipient’s blood. This did not sit well with the blood bank techs. They balked—ordering transfusion of uncrossmatched blood is rare and usually given only by senior physicians. I shouted that I didn’t have time to argue; they could call anyone they wanted but they’d better send me that blood right now.

While waiting for the blood to arrive, I paged the internal medicine and OB-Gyn residents and took stock of the situation. The patient was a young, adult black woman brought to the ER by persons unknown who left quickly without providing more than her name and purse, from which we got her full name, age address, and phone number. The lab test result clarified things mightily: something was destroying her red bloods cells at a phenomenal rate, and it was my job to figure out what it was and do something about it.  There are hundreds of causes of red blood cell destruction.  Most are easy to understand—sometimes a mechanical heart valve will have a “blender” effect, which slices red cells into pieces; genetically defective red cells can self-destruct; bacterial toxins and immune reactions ca do the same. The trick is to think of the right one.

The blood came and I ran it into the big vein in her groin, squeezing each bag to force it in rapidly. The result was dramatic—blood pressure rose, heart rate slowed, and she roused from the coma. I was able to coax cooperation for a vaginal exam and ask her some questions.

She wasn’t a good historian, and I had a difficult time establishing the basic facts. Cultural differences loomed large: I was a white man asking a black woman questions about her private life.  When did she first become ill?  What were her symptoms?  Did she have pain, fever, cough, or rash?  When was her last normal menstrual period?  Could she be pregnant?  Was her current bleeding at the expected time?

Physical exam was unremarkable except that she was wearing a female sanitary pad stained with dark blood, and a small amount of blood oozed from the mouth of her uterus.  Worrying that she might have a uterine infection associated with a “coat-hanger” abortion, I pressed firmly on her cervix, uterus and lower abdomen to see if she was tender, but she registered only minor objection.

The internal medicine resident arrived, and I told him the story.  He examined her, repeated the pelvic exam, and asked some questions but learned nothing new.  We stepped out of the room to talk. He said I was handling the case properly but to my astonishment he didn’t want to admit her to the internal medicine floor. Let the OB-Gyn resident look at her first.  And with that he was gone.

I spent a few minutes in the nurse’s station desperately flipping the pages of a textbook of internal medicine hoping to find something that might explain the situation.  Then the OB-Gyn resident showed up.  By now it was nearly midnight.  He did a third pelvic exam and said he didn’t think it was an Ob-Gyn problem—probably just a normal period, no pelvic tenderness or masses, blah, blah, blah—and she needed to be admitted to the floor as an internal medicine patient because her main problem was the anemia.  Then he, too, was gone.

I called the internal medicine resident again, who by now was asleep in the call room.  He was not happy to be awakened.  I told him about the Ob-Gyn consultation and asked him again to admit her.  He reluctantly agreed.

“You’re doing fine,” he said.  “Put my name on her chart and I’ll check her on rounds in the morning.”

Which is what I did.  By the time I got her into a room she was becoming combative and delirious again—whatever it was that was eating up her red cells was still at work and in just under two hours had destroyed the red cells in the two pints of blood I’d squeezed in.  I called the lab and asked for a tech to come down and collect a blood specimen for culture, asked the blood bank send down two more units of O-negative blood, injected into the IV line a massive dose of steroids followed by a mixture of potent antibiotics hoping to kill any bacteria that might be causing the problem.

All the while I had been asking her questions but couldn’t find a helpful answer. I must have asked a dozen different ways about her period and about abortion, but I got nowhere.  However, I had concluded she must have had a “coat-hanger” abortion, which had infected her uterus.  But I couldn’t be sure: the Ob-Gyn resident didn’t think so.

Whatever the cause, it was clear, too, that her kidneys were failing—in four hours she had made only a few drops of black urine, and lab measures of kidney function supported the conclusion.

When the third and fourth units of blood came, I forced in the first unit and hung the second one to drip and considered my options.  She was almost certain to die and about the only thing I could do was to find out for sure if she’d attempted an abortion, and, if so, who did it and where, so we wouldn’t see another case like it again.

It makes me uneasy to reveal what I did next: I told her she was going to die and needed to “get right with Jesus” and make a deathbed confession. If she confirmed my suspicion, I might be able to take some action—what, I couldn’t say—that might save her life.  She denied yet again and died a few hours later. 

My shift ended at 7 AM. I got some sleep and was at home in our little apartment behind the hospital when I got a call from the pathology department that the family had come for the body, but pathology couldn’t release it until someone signed the death certificate.  Would I please come over and sign?  I didn’t think too much about it as I walked over to the hospital, but that changed when a secretary handed me the death certificate and I stared at those famous empty spaces on the standard US death certificate:

Cause of death_________________

Due to________________________

Due to________________________

Due to________________________

In later years, having done many autopsies as a pathologist, I was tempted to write “Birth” on the bottom line.

I struggled to think of what I would write.  After hemming and hawing a while, I demurred, saying I needed to talk to the internal medicine resident.  We talked but he declined to sign, saying I could write whatever I wanted; after all, I knew the patient best. I gave the death certificate back to the secretary, telling her I couldn’t sign it because I didn’t know why she died, and went back home.

I had a night off, but the matter wouldn’t leave me alone. The next morning the pathology department called a second time, saying that if I didn’t sign the death certificate a medicolegal autopsy would be required. I repeated that I had a pretty good idea why she died but not one good enough to fill out a death certificate. Within the hour I got a call from the hospital CEO. I must sign that certificate; there was a large family of angry Blacks in the lobby, and they were adamantly opposed to cutting on dead bodies. Mississippi didn’t need any more trouble.

As a lowly intern, all I wanted was for the mess to go away.  But nobody was willing to write down what killed her. How could they? They didn’t know.  With the hospital CEO I was polite, obsequious even. I was not trying to be difficult, but I couldn’t sign it because I didn’t know why she died. I tried my best to convey an attitude of helpfulness.

It didn’t do any good.  My “recalcitrance,” as he called it, was most unwelcome.

I spent the rest of the morning at home expecting to hear again from an angry somebody at the hospital.  I called the pathology department to see what was happening and learned that the patient was being readied for autopsy that very moment. I dashed to the hospital and went down to the morgue where I found a gaggle of pathologists and other physicians interested in this most dramatic case.  Word had apparently spread.  Suddenly I had gone from recalcitrant pariah to a welcome guest, at least in the morgue—I knew more about the clinical details than anyone else, even the Chief of Internal Medicine, who was standing by the autopsy table.  I answered questions and explained my diagnostic and therapeutic approach, expecting to be challenged at every turn, but it proved to be a quiet, thoughtful assembly.

The pathologists made the usual big V-shaped incision from each shoulder down to the lower end of the breastbone, then made a Y of it by joining the incisions and extended it down the midline to the lower end of the abdomen.  As the belly opened the dome of the uterus, slightly enlarged, popped into view.  Knowing of my suspicion of a criminal abortion, the autopsy pathologist had ready sterile needles, syringes and culture plates.  He stuck a needle in the uterus and brought out a small amount of dark, bloody material, which he handed over to a lab tech for culture.

Then he opened the uterus with a single slice and out spilled a few ounces of horribly malodorous, reddish black gruel.

The next day the lab reported that the blood cultures I had collected in the ER and the morgue specimen both grew Clostridium perfringens, the agent of gas gangrene, and a virulent microbe that secretes a variety of toxins, one of which destroys red blood cells.  About the only thing that can cause such a problem is unsterile penetration of the uterus, such as a coat-hanger abortion.

After the autopsy I heard no more of the case, but I worried that one day an angry family member might pay me a visit.