From the first twinges of cramps that began around nine-thirty that morning, Patty Owen was sure that this was it. She had been worried that when the time came she wouldn't be able to distinguish between the contractions that signaled the onset of labor and the little kicks and general discomfort of the final trimester of her pregnancy. But her apprehension proved groundless; the twisting and grinding pain she was experiencing was entirely different from anything she had ever felt. It was familiar only in the sense that it was so classically textbook in its nature and regularity. Every twenty minutes, like clockwork, Patty felt a steady stab of pain in her lower back. In the intervals between, the pain vanished only to flare again. Despite the increasingly acute agony she was only beginning to endure, Patty couldn't repress a fleeting smile. She knew little Mark was on his way into the world.

Trying to remain calm, Patty searched through the scattered papers on the planning desk in the kitchen for the phone number of the hotel that Clark had given her the day before. He would have preferred to have skipped this business trip since Patty was so close to term, but the bank hadn't given him much choice. His boss had insisted that he follow through with the final round of negotiations that would close a deal he'd been working on for three months. As a compromise, the two men had agreed that no matter the state of the negotiations, Clark would be gone for only two days. He'd still hated to leave, but at least he'd be back a full week before Patty was due to deliver...

Patty found the hotel's number. She dialed and was put through to Clark's room by a friendly hotel operator. When he didn't pick up by the second ring, Patty knew Clark had already left for his meeting. Just to be sure, she let it ring five more times in hopes that Clark was in the shower and would suddenly answer, out of breath. She was desperate to hear his reassuring voice.

While the phone rang, Patty shook her head, fighting back tears. For as happy as she'd been to be pregnant this, her first time, she had been troubled by a vague premonition from the start that something bad would happen. When Clark had come home with the news that he had to go out of town at such a critical juncture, Patty had seen her sense of foreboding confirmed. After all the Lamaze classes and exercises they'd done together, she would have to tough it out alone. Clark had assured her she was overly concerned, which was natural, and that he'd be back in plenty of time for the delivery.

The hotel operator came back on the line and asked if Patty wanted to leave a message. Patty told her that she wanted her husband to call her as soon as possible. She left the number for Boston Memorial Hospital. She knew that such a terse message was bound to upset Clark, but it served him right for going away at a time like this.

Next, Patty called Dr. Ralph Simarian's office. The doctor's booming, high-spirited voice momentarily quelled her fears. He told her to have Clark take her over to the BM, as he humorously referred to the Boston Memorial, and get her admitted. He'd see them there in a couple of hours. He told her that twenty-minute intervals meant she had a lot of time.

"Dr. Simarian?" Patty said as the doctor was about to disconnect. "Clark is out of town on a business trip. I'll be coming in by myself."

"Great timing!" Dr. Simarian said with a laugh. "Just like a male. They like to have the fun, then disappear when there's a little work to be done."

"He thought there was another week," Patty explained, feeling like she had to defend Clark. She could be irritated at him but no one else could.

"Just joking," Dr. Simarian said. "I'm sure he will be crushed not to be involved. When he comes back, we'll have a little surprise for him. Now don't be a bit alarmed. Everything's going to be okay. Do you have a way of getting to the hospital?"

Patty said she had a neighbor who had agreed to drive her in case there were any surprises while Clark was away.

"Dr. Simarian," Patty added, hesitantly, "with my Lamaze partner gone, I think I really am too nervous to go through this. I don't want to do anything to hurt the baby, but if you think I could be anesthetized the way we discussed..."

"No problem," Dr. Simarian said, without letting her finish. "Don't you worry your pretty little head about these details. I'll handle everything. I'm going to call over there right this minute and tell them that you want the epidural, okay?"

Patty thanked Dr. Simarian and hung up the phone just in time to bite her lip as she felt the beginnings of another contraction.

There was no reason to worry, she told herself sternly. She still had plenty of time to make it to the hospital. Dr. Simarian had everything in hand. She knew her baby was healthy. She had insisted on ultrasound and amniocentesis, even though Dr. Simarian had advised it was unnecessary since Patty was only twenty-four years old. But between her ominous premonition and genuine concern, Patty's determination carried the day. The results of the tests were extremely encouraging: the child she was carrying was a healthy, normal boy. Within a week of receiving the results, Patty and Clark were painting the baby's room blue and deciding on names, ultimately settling on Mark.

All in all, there was no reason to expect anything but a normal delivery and a normal birth.

As Patty turned, intending to retrieve her packed overnight bag from the bedroom closet, she noticed the dramatic change in weather outside. The bright September sunlight which had been streaming through the bay window had been eclipsed by a dark cloud that had blown in suddenly from the west, plunging the family room into near darkness. A distant rumble of thunder sent a shiver down Patty's spine.

Not superstitious by nature, Patty refused to take this storm as an omen. She edged over to the family room couch and sat down. She thought she'd call her neighbor as soon as this contraction was over. That way they'd almost be at the hospital by the time the next one began.

As the pain reached a crescendo, the confidence that Dr. Simarian had engendered disappeared. Anxiety swept through Patty's mind just as a sudden gust of wind raked across the backyard, bending the birches, and bringing the first droplets of rain. Patty shuddered. She wished it were all over. She might not be superstitious, but she was frightened. All the timing -- this storm, Clark's business trip, her going into labor a week early -- seemed off. Tears rolled down Patty's cheeks as she waited to phone her neighbor. She only wished she weren't so afraid.

"Oh, wonderful," Dr. Jeffrey Rhodes said sarcastically as he glanced up at the main anesthesia scheduling board in the anesthesia office. A new case had appeared: Patty Owen, a delivery with a specific request for an epidural. Jeffrey shook his head, knowing full well that he was the only anesthesiologist currently available. Everyone else on the day shift was tied up on a case. Jeffrey called the delivery area to check on the patient's status and was told there wasn't any rush since the woman hadn't arrived from admitting yet.

"Any complications I should know about?" Jeffrey asked, almost afraid to hear. Things hadn't been going well for him on this particular day.

"Looks routine," the nurse said. "Primipara. Twenty-four. Healthy."

"Who's the attending?"

"Simarian," the nurse replied.

Jeffrey said he'd be over shortly and hung up the phone. Simarian, Jeffrey pondered, thinking it a wash. The guy was technically fine but Jeffrey found his patronizing manner toward patients a bit trying. Thank God it wasn't Braxton or Hicks. He wanted the case to go smoothly and hopefully quickly; if it had been either of the others, that wouldn't have been the case.

Leaving the anesthesia office, he headed down the main OR corridor, passing the scheduling desk and its attendant bustle of activity. The evening shift was due in a few minutes; the changing of the guard inevitably spelled momentary chaos.

Jeffrey pushed through the double swing doors of the surgical lounge and yanked off the mask which hung limply on his chest, dangling by its elastic. He tossed it into the waste receptacle with relief; he'd been breathing through the blasted thing for the last six hours.

The lounge was abuzz with staff members coming on shift. Jeffrey ignored them and passed through to the locker room, which was just as crowded. He paused in front of the mirror, curious to see if he looked as bad as he felt. He did. His eyes seemed to have receded, they appeared so sunken. Below each was a dark indelible crescent-shaped smudge. Even Jeffrey's mustache seemed the worse for wear and tear, though what could he expect after having kept it under the wraps of the surgical mask for six solid hours.

Like most doctors resisting the chronic hypochondriasis induced by medical school, Jeffrey often erred at the other extreme: he denied or ignored every symptom of illness or sign of fatigue, until it threatened to overwhelm him. Today was no exception. From the moment he'd awakened that morning at six, he'd felt terrible. Although he'd been feeling run down for days, he first ascribed the light-headedness and chills to something he'd eaten the night before. When the waves of nausea came midmorning, Jeffrey was quick to attribute it to too much coffee. And when the headache and the diarrhea started in the early afternoon, he pinned it on the soup he'd had for lunch in the hospital cafeteria.

Only as he confronted his haggard reflection in the mirror of the surgical locker room did Jeffrey finally admit he was ill. He was probably coming down with the flu that had been going around the hospital for the last month. He put the flat of his wrist to his forehead for a rough check of his temperature. There was no doubt about it: it was hot.

Leaving the sink, Jeffrey went to his locker, grateful that the day was almost over. The idea of bed was the most appealing vision he could conjure.

Jeffrey sat on the bench, oblivious to the chatting crowd, and began to twirl his combination lock. He felt worse than ever. His stomach gurgled unpleasantly; his intestines were in agony. A passing cramp brought beads of perspiration to his brow. Unless someone could relieve him, he'd still be on duty for another few hours.

Stopping at the final number, Jeffrey opened his locker. Reaching within the neatly arranged interior, he retrieved a bottle of paregoric, an old remedy his mother used to force on him when he was a child. His mother had consistently diagnosed him as suffering from either constipation or diarrhea. It wasn't until he got to high school that Jeffrey realized these diagnoses were just excuses to get him to take his mother's cherished cure-all. Over the years, Jeffrey had developed a confidence in paregoric, if not in his mother's diagnostic skills. He always kept a bottle on hand.

Unscrewing the cap, he tilted his head back and took a healthy swig. Wiping his mouth, he noticed an orderly sitting next to him watching his every move.

"Want a swig?" Jeffrey asked, grinning, extending the bottle toward the man. "Great stuff."

The man gave him a disgusted look and got up and left.

Jeffrey shook his head at the man's lack of a sense of humor. From his reaction you'd have thought he'd offered him poison. With uncharacteristic slowness, Jeffrey took off his scrubs. Briefly massaging his temples, he then pushed himself to his feet and went in to shower. After sudsing and rinsing, he stood under the rushing water five minutes before stepping out and drying himself briskly. Brushing his wavy, sandy-brown hair, Jeffrey dressed in clean scrubs, donned a new mask and a new hat. He felt considerably better now. Except for an occasional gurgle, even his colon seemed to be cooperating -- at least for the moment.

Jeffrey retraced his steps through the surgical lounge and down the OR corridor and pushed through the connecting door that led to the delivery area. The decor there was a welcome antidote to the stark utilitarian tile of the OR. The individual delivery rooms may have been as sterile, but the delivery area and labor rooms were painted in pastels, with framed Impressionist prints on the walls. The windows even had curtains. The feeling was more like a hotel than a major urban hospital.

Jeffrey went to the main desk and inquired about his patient.

"Patty Owen is in fifteen," a tall, handsome black woman said. Her name was Monica Carver, and she was the nursing supervisor for the evening shift.

Jeffrey leaned over the desk, thankful for the momentary rest. "How's she doing?" he asked.

"Just fine," Monica said. "But it's going to be awhile. Her contractions aren't strong or frequent, and she's only dilated four centimeters."

Jeffrey nodded. He would have preferred to have things further along. It was standard practice to wait until the patient had dilated six centimeters to put in an epidural. Monica handed Jeffrey Patty's chart. He went through it quickly. There wasn't much there. The woman was obviously healthy. At least that was good.

"I'll have a chat with her," Jeffrey said, "then I'll be back in the OR. If something changes, give me a page."

"Sure thing," Monica said cheerfully.

Jeffrey started down toward room fifteen. About halfway down the hall he got another intestinal cramp. He had to stop and lean against the wall until it passed. What a nuisance, he thought. When he felt well enough, he continued to room fifteen and knocked. A pleasant voice told him to come in.

"I'm Dr. Jeffrey Rhodes," Jeffrey said, extending his hand. "I'll be your anesthesiologist."

Patty Owen grasped his outstretched hand. Her palm was damp, her fingers cold. She appeared considerably younger than twenty-four. Her hair was blond and her wide eyes looked like those of a vulnerable child. Jeffrey could tell the woman was frightened.

"Am I glad to see you!" Patty said, not willing to let go of Jeffrey's hand immediately. "I want to tell you straight off that I'm a coward. I'm really not very good with pain."

"I'm sure we can help you," Jeffrey said reassuringly.

"I want an epidural," Patty said. "My doctor said I could have it."

"I understand," Jeffrey said, "and have it you will. Everything is going to be fine. We have a lot of deliveries here at the Boston Memorial. We'll take good care of you and after all is said and done, you'll wonder why you were so apprehensive in the first place."

"Really?" Patty asked.

"If we didn't have so many happy customers, do you think so many women would be coming back a second, a third, or even fourth time?"

Patty smiled wanly.

Jeffrey spent another quarter hour with her, questioning her about her health and allergies. He sympathized with her when she told him her husband was out of town on a business trip. Her familiarity with epidural anesthesia surprised him. She confided that not only had she read about it, her sister had had it for her two deliveries. Jeffrey explained why he wouldn't be giving her the epidural immediately. When he told her that she could get some Demerol in the meantime if she wanted it, Patty relaxed. Before leaving her, Jeffrey reminded her that any drugs she got, the baby got. Then he told her again there was no reason to worry; she was in good hands.

Coming out of Patty's labor room and suffering through another intestinal cramp, Jeffrey realized he would have to take more drastic steps against his own symptoms if he was to get through Patty's delivery. Despite the paregoric, he was feeling progressively worse.

Passing back through the connecting doors to the OR suite, Jeffrey returned to the anesthesia alcove next to the OR, where he'd spent most of the day. The room was empty and probably wouldn't be used again until the following morning.

Glancing up and down the OR corridor to make sure the coast was clear, Jeffrey pulled the drape closed. Although he'd finally acknowledged being sick, he wasn't about to admit it to anyone else.

From the drawer of his Narcomed III anesthesia machine, Jeffrey got out a small-gauge intravenous scalp needle and an infusion setup. He pulled a bottle of Ringer's Lactate IV fluid down from the shelf and snapped off the cover over the rubber port. With a decisive shove, he pushed the IV tubing into the bottle and hung the bottle up on the IV stand over the anesthesia machine. He ran fluid through the tubing until it was free of air bubbles, then he closed the plastic stopcock.

Jeffrey had only started IVs on himself a couple of times, but he was practiced enough in the procedure to be adept. Using his teeth to hold one end of the tourniquet, he secured it around his bicep and watched as his veins began to distend.

What Jeffrey had in mind was a trick that he'd learned as a resident. Back then, he and his colleagues, especially the surgical residents, refused to take any sick time for fear they'd lose the competitive edge. If they got the flu or symptoms like the ones Jeffrey was now experiencing, they would simply take time out to run in a liter of IV fluid. The results were almost guaranteed, suggesting most flu symptoms were due to dehydration. With a liter of Ringer's Lactate coursing through your veins, it was hard not to feel better. It had been ages since Jeffrey had last resorted to an IV. He only hoped the efficacy would be as strong as it had been when he'd been a resident. Now forty-two, he found it hard to believe that last time he had been almost twenty years younger.

Jeffrey was about to push the needle in when the curtain to the alcove was pulled aside. Jeffrey looked up into the surprised face of Regina Vinson, one of the evening nurses.

"Oh!" Regina exclaimed. "Excuse me."

"No problem," Jeffrey started to say, but Regina was gone as quickly as she had appeared. As long as she'd inadvertently caught him in the act, Jeffrey had half a mind to ask her to lend a hand by attaching the IV to the scalp needle once he got it into the vein. Reaching out, he pulled back the curtain in hopes of catching her, but Regina was already far down the crowded hall. He let the curtain fall back into place. He was just as well off without her.

Once the IV tubing was attached, he opened the stopcock. Almost at once he felt the cool sensation of the fluid as it flowed rapidly into the arm. By the time most of the bottle had run in, Jeffrey's upper arm was cool to the touch. After he pulled out the IV needle, he put an alcohol swab over the site and bent his elbow to hold it in place. He disposed of the IV paraphernalia in the wastebasket, then stood up. He waited for a moment to see how he felt. The light-headedness and headache were totally gone. So was the nausea. Pleased with the speedy results, Jeffrey pulled open the curtain and headed back to the locker room. Only his colon still troubled him.

The evening shift had now taken over and the day shift was in the process of leaving. The locker room was full of cheerful people. Most of the showers were occupied. First Jeffrey used the toilet. Then he got out his paregoric and took another hefty swig. He shuddered at the taste and wondered what made it so bitter. He tossed the now empty bottle into the wastebasket. Then he took a second shower and put on another set of clean scrub clothes.

When he walked out into the surgical lounge he almost felt human. He intended to sit down for a half hour or so and read the paper but before he had a chance his beeper went off. He recognized the number. It was delivery.

"Mrs. Owen is asking for you," Monica Carver told him when he phoned.

"How is she doing?" Jeffrey asked.

"Just fine," Monica said. "She's a little apprehensive, but she hasn't even asked for analgesia even though her contractions are now coming frequently. She's somewhere between five and six centimeters."

"Perfect," Jeffrey said. He was pleased. "I'll be right over."

En route to the delivery area, Jeffrey stopped at the anesthesia office to glance at the big board to see about the evening assignments. As he expected, everyone was busy with ongoing cases. He took a piece of chalk and wrote that whenever someone was free he or she should come over to delivery and relieve him.

When Jeffrey arrived in labor room fifteen, Patty was in the middle of a contraction. An experienced LPN was with her and the two women were functioning like a practiced team. Beads of sweat dotted Patty's brow. Her eyes were shut tightly, and she was gripping the nurse's hands with both of hers. Strapped to her abdomen was the rubber monitor keeping track of the progress of the labor as well as the fetal heartbeat.

"Ah, my white knight in blue," Patty said as the pain abated and she opened her eyes to see Jeffrey standing at the foot of the bed. She smiled.

"How about that epidural?" Jeffrey suggested.

"How about it!" Patty echoed.

All the equipment Jeffrey needed was on a cart he had wheeled in with him upon his return. After putting a blood pressure cuff in place, Jeffrey removed the rubber monitor from Patty's abdomen and helped position her on her side. With gloved hands he prepped her back with an antiseptic solution.

"First I'm going to give you the local anesthetic we talked about," Jeffrey said as he prepared the injection. He made a small weal with the tiny needle midline in Patty's lower back. She was so relieved to be getting it, she didn't even flinch.

Next, he took a Touhey needle from the epidural tray and made sure the stylet was in place. Then, using both hands, he pushed the needle into Patty's back, advancing it slowly but deliberately until he was certain he had reached the ligamentous covering of the spinal canal. Withdrawing the stylet, he attached an empty glass syringe. Jeffrey put slight pressure on the syringe's plunger. Feeling resistance, he expertly returned to advancing the needle. Suddenly the resistance on the plunger disappeared. Jeffrey was pleased: he knew he was in the epidural space.

"Are you okay?" Jeffrey asked as he used a glass syringe to draw up a test dose of 2 cc's of sterile water containing a tiny amount of epinephrine.

"Are you finished?" Patty asked.

"Not quite," Jeffrey said. "Just a few minutes more." He injected the test dose and immediately tested Patty's blood pressure and pulse. There was no change. If the needle had been in a blood vessel, Patty's heart rate would have increased immediately in response to the epinephrine.

Only then did Jeffrey seize the small epidural catheter. With practiced care, he threaded it up the Touhey needle.

"I feel something funny in my leg," Patty said nervously.

Jeffrey stopped pushing the catheter. It was only in about one centimeter beyond the tip of the needle. He asked Patty about the sensation, then explained that it was common for the epidural catheter to touch peripheral nerves as they traversed the epidural space. That could account for what she was feeling. When the paresthesia subsided, Jeffrey gingerly advanced the catheter another one and a half centimeters. Patty didn't complain.

Finally, Jeffrey pulled the Touhey needle out, leaving the small plastic catheter in place. Then he prepared a second test dose of 2 cc's of .25% spinal-grade Marcaine with epinephrine. After injecting this second dose, he monitored Patty's blood pressure and her sense of touch on her lower extremities. When there were no changes even after several minutes, Jeffrey was absolutely sure that his catheter was in the proper place. Finally, he injected the therapeutic dose of anesthetic: 5 cc's of .25% Marcaine. Then he capped off the catheter.

"That's all there is to that," Jeffrey said as he put a sterile bandage over the puncture site. "But I want you to stay on your side for a while."

"But I don't feel anything," Patty complained.

"That's the idea," Jeffrey said with a smile.

"You're sure it's working?"

"Just wait until your next contraction," Jeffrey said with confidence.

Jeffrey conferred with the LPN to let her know how frequently he wanted Patty's blood pressure taken. Then he helped her put the labor monitor back in place. He remained in the labor room through Patty's next contraction, using the time to complete his habitually meticulous anesthesia record. Patty felt reassured. The discomfort she had been experiencing was much improved, and she thanked Jeffrey effusively.

After telling Monica Carver and the LPN where he would be, Jeffrey went into one of the darkened empty labor rooms to lie down. He was feeling better, but certainly not normal. Closing his eyes for what he thought would be just a few minutes and soothed by the sound of rain against the window, he surprised himself by falling fast asleep. He was dimly aware of the door being opened and closed several times as different people checked on him, but no one disturbed him until Monica came in and gently shook his shoulder.

"We've got a problem," Monica said.

Jeffrey swung his legs over the side of the bed and rubbed his eyes. "What's wrong?"

"Simarian has decided to do a Caesarean on Patty Owen."

"So soon?" Jeffrey asked. He glanced at his watch. He blinked several times. The room seemed dimmer than before. Checking his watch, he was surprised to see that he'd been asleep for an hour and a half.

"The baby is an occiput posterior and hasn't been progressing," Monica explained. "But the main problem is that the baby's heart has been slow to return to a normal rate after each contraction."

"Time to do a Caesarean," Jeffrey agreed as he got unsteadily to his feet. He waited a beat until his mild dizziness cleared.

"Are you all right?" Monica questioned.

"Just fine," Jeffrey said. He sat down on a chair to slip on his OR shoes. "What's the time frame?"

"Simarian will be here in twenty minutes or so," Monica said, studying Jeffrey's face.

"Is something wrong?" Jeffrey asked. He ran his fingers through his hair in fear it was standing on end.

"You look pale," Monica said. "Maybe it's the lack of light in here." Outside it was raining even harder.

"How's Patty doing?" Jeffrey asked, heading for the bathroom.

"She's apprehensive," Monica said from the door. "Painwise, she's fine, but you might consider giving her some kind of tranquilizer just to keep her calm."

Jeffrey nodded as he turned on the light in the bathroom. He wasn't wild about the idea of giving Patty a tranquilizer, but given the circumstances, he'd consider it. "Make sure she's on oxygen," he told Monica. "I'll be out in a second."

"She's on oxygen," Monica called over her shoulder as she left the room.

Jeffrey examined himself in the mirror. He did look pale. Then he noticed something else. His pupils were so contracted, they looked like twin pencil points. They were as small as he'd ever seen them. No wonder he'd had trouble seeing his watch in the other room.

Jeffrey splashed his face with cold water, then dried it roughly. At least that woke him up. He looked at his pupils again. They were still miotic. He took a deep breath and promised himself that as soon as he got through this delivery, he would make tracks for home and put himself to bed. After adjusting his hair with his fingernails, he headed for labor room fifteen.

Monica had been right. Patty was embarrassed, scared, and nervous about the upcoming Caesarean. She was taking the failure of the labor personally. Tears came to her eyes when she again voiced anger at her husband's absence. Jeffrey felt sorry for her and made a big effort at reassuring her that everything would be fine and that she certainly wasn't at fault. He also gave her 5 mg of diazepam IV, which he thought would have minimal effect if any on the unborn child. It had a rapid calming effect on Patty.

"I'll be asleep during the Caesarean?" Patty asked.

"You'll be very comfortable," Jeffrey replied, skirting the question. "One of the big benefits of continuous epidural anesthesia is that I can extend it now that we need a higher level, without disturbing Patty junior."

"It's a boy," Patty said. "His name is Mark." She smiled weakly. Her lids had become a little droopy. The tranquilizer was clearly taking effect.

The transfer from the delivery area to the OR suite was accomplished without incident. Jeffrey kept Patty on oxygen by mask during the short trip.

The OR had been advised as to the decision to do a Caesarean. By the time Patty was transferred, the room was almost set up for the procedure. The scrub nurse, already scrubbed, was busy laying out the instruments. The circulating nurse helped guide the gurney into the room and transfer Patty to the OR table. Patty still had the fetal monitor on, which was left in place for the time being.

Jeffrey wasn't as familiar with the evening personnel, and he hadn't met the circulating nurse before. Her name tag read: Sheila Dodenhoff.

"I'm going to need some .5% Marcaine," Jeffrey told Sheila as he changed Patty from portable bottle oxygen to oxygen delivered through his Narcomed III anesthesia machine. He then reapplied the blood pressure cuff to Patty's left arm.

"Coming up," Sheila said cheerfully.