Coma

by Robin Cook

  Bellows didn’t respond immediately. He searched in the tray for a syringe cap. “Don’t tell me any more,” he said at length. “I don’t want to hear about it. Here, hold the syringe for me.” Bellows gave Susan the syringe while he prepared the ice bed. “Susan, I’m afraid you’re going to be poison for me around here. You have no idea how miserable someone like Harris can make it. Here, put pressure on the puncture site.”

  “Mark?” said Susan pressing on Berman’s wrist but looking at Bellows directly. “You don’t mind if I call you Mark, do you?”

  Bellows took the syringe and placed it into the ice bath. “I’m not sure, to be perfectly honest.”

  “Well, anyway, Mark, you have to admit that six, and maybe seven, cases, if Berman proves to be like Greenly, represents a lot of cases of brain death, or vegetables, as you call them.”

  “But a lot of surgery goes on here, Susan. It’s often more than a hundred cases a day, some twenty-five thousand per year. That drops the six cases below some two hundredths of one percent in incidence. That’s still within the surgical anesthesia risk.”

  “That may be true, but these six cases represent only one type of possible complication, not surgical-anesthesia risk in general. Mark, it’s got to be too high. In fact, down in the ICU this morning you said that the particular complication Nancy Greenly represented occurred only about one in a hundred thousand. Now you’re trying to tell me that six in twenty-five thousand is OK. Bullshit. It’s too high whether you or Harris or anybody in the hospital accept it. I mean would you want to have some minor surgery tomorrow with that kind of risk? You know this whole thing really bothers me, the more I think about it.”

  “Well then, don’t think about it. Come on, we’ve got to get moving.”

  “Wait a minute. You know what I’m going to do?”

  “I can’t guess and I’m not sure I want to know.”

  “I’m going to look into this particular problem. Six cases. That should be enough for some reasonable conclusions. I do have a third-year paper to do and I think I owe that much to Sean here.”

  “Oh for Christ’s sake, Susan, let’s not be melodramatic.”

  “I’m not being melodramatic. I think I’m responding to a challenge. Sean challenged me earlier with my image of myself as a doctor. I failed. I wasn’t detached or professional. You might even say I acted like a schoolgirl. Now I’m challenged again. But this time intellectually with a problem, a serious problem. Maybe I can respond to this challenge in a more commendable fashion. Maybe these cases represent a new symptom complex or disease process. Maybe they represent a new complication of anesthesia because of some peculiar susceptibility these people had from some previous insult which they suffered in the past.”

  “All the more power to you,” said Bellows getting the remains from the arterial stick together. “Frankly though, it sounds like a hell of a hard way to work out some emotional or psychological adjustment problem of your own. Besides, I think you’ll be wasting your time. I told you before that Dr. Billing, the anesthesiology resident on Greenly’s case, went over it with a fine-tooth comb. And believe me, he’s bright. He said that there was absolutely no explanation for what happened.”

  “Your support is appreciated,” said Susan. “I’ll start with your patient in the ICU.”

  “Just a minute, Susan dear. I want to make one point crystal clear.” Bellows held up his index and middle finger like Nixon’s victory sign. “With Harris on the rag, I don’t want to be involved, no how. Understood? If you’re crazy enough to want to get involved, it’s your bag from A to Z.”

  “Mark, you sound like an invertebrate.”

  “I just happen to be aware of hospital realities and I want to be a surgeon.”

  Susan looked Mark directly in the eye. “That, Mark, in a nutshell, is probably your tragic flaw.”

  Monday

  February 23

  1:53 P.M.

  The cafeteria at the Memorial could have been in any one of a thousand hospitals. The walls were a drab yellow that tended toward mustard. The ceiling was constructed of a low-grade acoustical tile. The steam table was a long L-shaped affair with brown, stained trays stacked at the beginning.

  The excellence of the Memorial’s clinical services did not extend into the food service. The first food seen by an unlucky customer coming into the cafeteria was the salad, the lettuce invariably as crisp as wet Kleenex. To heighten the disagreeable effect, the salads were stacked one on top of the other.

  The steam table itself presented the hot selections, which posed a baffling mystery. So many things tasted alike that they were indistinguishable. Only carrots and corn stood aside. The carrots had their own disagreeable taste; the corn had absolutely no taste at all.

  By quarter to two in the afternoon, the cafeteria was almost empty. The few people who were sitting around were mostly kitchen employees, resting after the mad lunchtime rush. As bad as the food was, the cafeteria was still heavily patronized because it enjoyed a monopoly. Few people in the hospital complex took more than thirty minutes for lunch, and there simply was not enough time to go elsewhere.

  Susan took a salad but after one look at the limp lettuce, she replaced it. Bellows went directly to the sandwich area and took one.

  “There’s not much they can do to a tuna sandwich,” he called back to Susan.

  Susan eyed the hot entrees and moved on. Following Bellows’s lead, she selected a tuna sandwich.

  The woman who was supposed to be at the cash register was nowhere to be seen.

  “Come on,” motioned Bellows, “we ain’t got much time.”

  Feeling a bit like a shoplifter by not paying, Susan followed Bellows to a table and sat down. The sandwich was repellent. Somehow too much water had gotten into the tunafish and the tasteless white bread was soggy. But it was food and Susan was famished.

  “We’ve got a lecture at two,” garbled Bellows through a huge bite of sandwich. “So eat hearty.”

  “Mark?”

  “Yeah?” said Bellows as he gulped half his milk in one swig. It was apparent that Bellows was a speed eater of Olympic caliber.

  “Mark, you wouldn’t be hurt if I cut your first surgery lecture, would you?” Susan had a twinkle in her eye.

  Bellows stopped the second half of his tuna sandwich midway to his mouth and regarded Susan. He had an idea that she was flirting with him, but he dismissed it.

  “Hurt? No, why do you ask?” Bellows had a helpless feeling that he was being manipulated.

  “Well I just don’t think I could sit through a lecture at this moment in time,” said Susan, opening her milk carton. “I’m a little spaced from this affair with Berman. . . . Affair is not the right word. Anyway I’m really uptight; I couldn’t handle a lecture. If I do something active I’ll be much better off. I was thinking that I’d go to the library and look up something about anesthesia complications. It will give me a chance to start my ‘little’ investigation as well as sort out this morning in my mind.”

  “Would you like to talk about it?” asked Bellows.

  “No, I’ll be OK, really.” Susan was surprised and touched by his sudden warmth.

  “The lecture isn’t critical. It’s an introductory kind of thing by one of the emeritus professors. Afterwards I planned for you students to come on the ward to meet your patients.”

  “Mark?”

  “What?”

  “Thanks.”

  Susan stood up, smiled at Bellows, and left.

  Bellows put the second half of his tuna sandwich into his mouth and chewed it on the right side, then he moved it over to the left cheek. He wasn’t even sure what Susan had thanked him for. He watched her cross the cafeteria and deposit her tray in the rack. She rescued her unfinished milk and sandwich before leaving. At the door she turned and waved. Bellows waved in return but by the time he got his hand up, she had already disappeared.

  Bellows looked around self-consciously, wondering if anyone had noticed him with his ha
nd in the air. Replacing his hand on the table, he thought about Susan. He had to admit that she attracted him in a refreshing, basic way, reminding him of the way he felt early in his social career: an excitement, an unsettling impatience. His imagination conjured up sudden romantic pursuits with Susan as the object. But as soon as he did so, he reprimanded himself for being juvenile.

  Bellows polished off his milk with another gigantic gulp while carrying his tray to the dirty-dish cart. En route he wondered if he dared to ask Susan out. There were two problems. One was the residency and Stark. Bellows had no idea how the chief would react to one of his residents dating a student assigned to him. Bellows was not sure if such a worry was rational or not. He did know that Stark tended to favor married residents. The idea was that the married ones would be more dependable, which, as far as Bellows was concerned, was pure bunk. But there was little hope of keeping a relationship between himself and one of the students a secret. Stark would find out and it could be bad. The second problem was Susan herself. She was sharp; there was no question about that. But could she be warm? Bellows had no idea. Maybe she was just too busy, or too intellectualized, or too ambitious. The last thing that Bellows wanted to do was to squander his limited free time on some cold, castrating bitch.

  And what about himself? Could Bellows handle a sharp girl who was in his own field even if she were warm and lovable? He had dated a few nurses, but that was different because nurses were allied with but distinct from doctors. Bellows had never dated another doctor or even doctor-to-be. Somehow the idea was a bit disturbing.

  Leaving the cafeteria, Susan enjoyed a greater sense of direction than she had felt all day. Although she had no idea how she was actually going to investigate the problem of prolonged coma after anesthesia, she felt that it represented an intellectual challenge which could be met by applying scientific methods and reasoning. For the first time all day she had a feeling that the first two years of medical school had meant something. Her sources were to be the literature in the library and the charts of the patients, particularly Greenly’s and Berman’s.

  Near to the cafeteria was the hospital gift shop. It was a pleasant place, populated and run by an assortment of gracefully aging suburbanite women dressed in cute pink smocks. The windows of the shop faced the main hospital corridor and were mullioned, giving the shop an appearance of a cottage smack-dab in the middle of the busy hospital. Susan entered the gift shop and quickly found what she was after: a small black looseleaf notebook. She slipped the purchase into her pocket of her white coat and left for the ICU. Her jumping-off point would be the case of Nancy Greenly.

  The ICU was back to its pre-arrest hush. The harsh illumination had been dampened to the level Susan recalled from her first visit. The instant the heavy door closed behind her, Susan tasted the same anxiety she had noted before, the same feeling of incompetence. Again she wanted to leave before something happened and she was asked the simplest of questions to which she would undoubtedly have to answer a demoralizing “I don’t know.” But she did not bolt. Now she at least had something to do which gave her a modicum of confidence. She wanted the chart of Nancy Greenly.

  Looking to the left, Susan noticed that no one was standing by Nancy Greenly’s bed. The potassium level had apparently been rectified and the heart was beating normally once again.

  The crisis over, Nancy Greenly was forgotten and allowed to return to her own infinity. Willing machines resumed the vigil over her vegetablelike functions.

  Drawn by an irresistible curiosity, Susan walked over to Nancy Greenly’s side. She had to struggle to keep her emotions in check and to keep the identification transference to a minimum. Looking down at Nancy Greenly, it was difficult for Susan to comprehend that she was looking at a brainless shell rather than a sleeping human being. She wanted to reach out and gently shake Nancy’s shoulder so that she would awaken so that they could talk.

  Instead, Susan reached out and picked up Nancy’s wrist. Susan noted the delicate pallor of the hand as it drooped, lifelessly. Nancy was totally paralyzed, completely limp. Susan began to think about paralysis from destruction of the brain. The reflex circuits from the periphery would still be intact, at least to some degree.

  Susan grasped Nancy’s hand as if she were shaking it and slowly flexed and extended the wrist. There was no resistance. Then Susan flexed the wrist forcefully to its limit, the fingers almost touching the forearm. Unmistakenly Susan felt resistance, only for an instant but nonetheless definite. Susan tried it with the other wrist; it was the same. So Nancy Greenly was not totally flaccid. Susan felt a certain sense of academic pleasure; the irrational joy of the positive finding.

  Susan found a percussion hammer for tendon reflexes. It was made of hard red rubber with a stainless steel handle. She had had one used on herself and had tried one on fellow students in physical diagnosis classes, but never used one on a patient. Clumsily Susan tried to elicit a reflex by tapping Nancy Greenly’s right wrist. Nothing. But Susan was not exactly sure where to tap. Instead she pulled up the sheet on the right side and tapped under the knee. Nothing. She flexed the knee with her left hand and tapped again. Still nothing. From neuroanatomy class Susan remembered that the reflex she was searching for came from a sudden stretch of the tendon. So she stretched Nancy Greenly’s knee more, then tapped. The thigh muscle contracted almost imperceptibly. Susan tried it again, eliciting a reflex that was no more than a slight tightening of the flaccid muscle. Susan tried it on the left leg, with the same result. Nancy Greenly had weak but definite reflexes, and they were symmetrical.

  Susan tried to think of other parts of the neurological examination. She remembered level-of-consciousness testing. In Nancy Greenly’s case the only test would be reaction to pain stimulus. Yet when she pinched Nancy Greenly’s Achilles tendon, there was no response no matter how hard she squeezed. Without any specific reason other than wondering if the pain sensation would be more potent the closer to the brain, Susan pinched Nancy Greenly’s thigh and then recoiled in horror. Susan thought that Nancy Greenly was getting up because her body stiffened, arms straightening from her sides and rotating inward in a painful contraction. There was a side-to-side chewing motion with her jaw almost as if she were awakening. But it passed and Nancy Greenly reverted to her limpness equally suddenly. Eyes widening, Susan had moved back, pressing herself against the wall. She had no idea what she had done or how she had managed to do it. But she knew she was toying in the area well beyond her present abilities and knowledge. Nancy Greenly had had a seizure of some kind, and Susan was immensely thankful that it had passed so quickly.

  Guiltily, Susan glanced around the room to see if anyone was watching. She was relieved to note that no one was. She was also relieved that the cardiac monitor above Nancy Greenly continued its steady and normal pace. There were no premature contractions.

  Susan had the uncomfortable feeling that she was doing something wrong, that she was trespassing, and that any moment she would be deservedly reprimanded, perhaps by Nancy Greenly’s arresting once again. Susan quickly decided that she would withhold further patient examination until after some serious reading.

  With great effort at appearing nonchalant, Susan made her way over to the central desk. The charts were kept in a circular stainless steel file built into the countertop. With her left hand she began to turn the chart rack slowly. It squeaked painfully. Susan turned it more slowly. The squeak persisted.

  “Can I help you?” asked June Shergood from behind Susan, causing her to start and to withdraw her hand as if she were a child caught at the cookie jar.

  “I’d just like the chart,” said Susan, expecting some sour words from the nurse.

  “What chart?” Shergood’s voice was pleasant.

  “Nancy Greenly’s. I’m going to try to get an idea about her case so that I can participate in her care.”

  June Shergood rummaged among the charts, coming up with Nancy Greenly’s. “You might find it easier to concentrate in there,” said
Shergood with a smile, pointing toward a door.

  Susan thanked her, welcoming the opportunity to withdraw. The door that Shergood had indicated opened into a tiny room ringed about with glass-faced, locked medicine cabinets. A countertop ran around three sides of the room, providing desk space. On the right was a sink, and in the left corner was the omnipresent coffeepot.

  Susan sat down with the chart. Although Nancy Greenly had not been in the hospital for even two weeks, her chart was voluminous. That was usual for a case placed in the ICU. The elaborate, constant care generated reams of paper.

  Susan took out the remains of her tuna sandwich and milk and poured herself a cup of coffee. Then she took out her notebook and removed a number of blank pages. She started to work. Unaccustomed to using a patient chart, she spent a few minutes figuring out its organization. The order sheets were first, followed by the graphs of the patient’s vital signs. Next was the history and physical examination dictated on the day of admission. The rest of the chart included the progress notes, the operative and anesthesia notes, the nurses’ notes, and the innumerable laboratory values, X-ray reports, and records of sundry tests and procedures.

  Since she did not know what she was looking for, Susan decided to make copious notes. At this early stage there was no way of determining what was going to be the important information. She started with Nancy Greenly’s name, age, sex, and race. Next she included the meager medical history attesting to the fact that Nancy Greenly had been a healthy individual. There were bits and pieces of family history, including reference to a grandmother who had had a stroke. The only illness of note in Nancy’s past was a case of mononucleosis at age 18, with an apparently uneventful recovery. The reviews of Nancy’s systems, including her cardiovascular and respiratory systems, were normal. Susan wrote down the laboratory values from her routine pre-op screen: the blood and urine were both normal. She also wrote down the results of the pregnancy test, negative; various blood clotting studies, blood type, tissue type, chest X-ray, and EKG. There was also the chemistry profile, which included a wide battery of tests. Nancy Greenly’s reports were well within normal limits.