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of severe pain in her right arm and hand. During one of her contractions, she had bitten the inside of her cheek. At first there was just a little bleeding from the cut; then suddenly there was a lot. Just before you arrived she threw up, and it was all bright-red blood. I think what she threw up may have come from the back of her nose, but how do you tell?”
    “Her pressure holding?” Sarah asked as she locked Lisa’s left arm in hers and adjusted the cuff to take another reading.
    “It’s down a little more. About eighty systolic. I can’t hear it in her right arm at all.”
    Sarah glanced at Lisa’s right arm and immediately knew the reason why. She could tell that Snyder, who was feeling for a pulse over the radial artery at the wrist and the brachial artery in the crook of the elbow, knew as well. The arm, from at least the elbow to the hand, was dusky and mottled. The fingers were a deeper gray, the fingertips almost black. For whatever reason, the arteries and smaller arterioles supplying blood to that limb had become blocked. To a lesser extent, the blood flow to Lisa’s left arm and both legs seemed compromised as well.
    “Still eighty,” Sarah said. “Lisa, I know this is scary for you. But please, just do your best to stay as calm as you can while we figure things out. This is the man I told you about, Dr. Snyder. He’s my chief.”
    From a distance, they could hear the
whoop
of the approaching ambulance.
    “Wh—what’s happening to me?” Lisa asked, as bewildered as she was frightened.
    Sarah and her chief exchanged glances. Though the diagnosis needed laboratory confirmation, she knew he suspected, as did she, that they were witnessing the rapid evolution of DIC—disseminated intravascular coagulopathy—the most dramatic and horrifying of all blood-clotting emergencies.
    Sarah asked for a washcloth and handed it to Lisa.
    “Here, Lisa, blow your nose in this as hard as you can. Once we get the big clots out, the pressure you put on your nose will be more effective in stopping the bleeding.”
    Lisa, still spitting crimson into a bucket, did as she was asked. Immediately the center of the washcloth was soaked with blood. But there were no clots. None at all. The diagnosis of DIC was now even more likely. For whatever reason, large numbers of tiny clots had begun forming within Lisa’s bloodstream. Those circulating microdots were beginning to join together and obstruct the arteries supplying blood to her arms and legs, placing the limbs in great jeopardy.
    Even more frightening than the circulatory blockage was the speed with which the abnormal clots were using up the factors necessary for normal blood coagulation. With those factors badly depleted, bleeding from any source was now life-threatening. And a fatal stroke caused by a cerebral hemorrhage was a terrifying possibility.
    “Lisa, I’ll explain what we think is going on in just a second,” Sarah said. “Has your water broken?”
    Lisa shook her head.
    “I’m very frightened,” she managed. “My hand is killing me.”
    “I understand. Just give us a moment.”
    Sarah looked over at her chief.
    “We need that ambulance to get here, we need an IV,and we need a hematologist or an internist—preferably both—waiting for us at MCB,” Snyder said.
    There was still the typical calmness in his voice, but his expression was grim. This would be the second case of DIC in a Medical Center of Boston active labor patient in less than three months. The previous case—not one of Snyder’s or Sarah’s—had died on the operating table as her physicians desperately tried to deliver her child by cesarean section. With hemorrhaging into the placenta, the infant was severely brain damaged by the time it could be extracted and was pronounced dead before its first week of life was through. The cause of the DIC had never been determined.
    “Lisa, please listen,” Snyder went on. “And please try not to be too frightened. We believe that