Coma

by Robin Cook

  Susan ate the last of the tuna sandwich and washed it down with a slug of milk. Turning the pages of the operative section and locating the anesthesia record, she noted the pre-op medication: Demerol and Phenergan given at 6:45 A.M. by one of the nurses on Beard 5. The endotracheal tube was a number 8. Pentothal 2 grams given I.V. at 7:24 A.M. Halothane, nitrous oxide, and oxygen started at 7:25. The halothane concentration was initially 2 percent through the Fluotec Temperature Compensated Vaporizer. Within several minutes it was reduced to 1 percent. The nitrous oxide and oxygen flow rates were 3 liters and 2 liters per minute respectively. For muscle relaxation a 2 cc dose of 0.2 percent succinylcholine was given at 7:26 and a second dose at 7:40.

  Susan noted that the blood pressure fell at 7:48 after maintaining a plateau of 105/75. The halothane percentage was reduced to 1/2 percent at that point, while the nitrous oxide and oxygen flow was changed to 2 and 3 liters. The blood pressure drifted back up to 100/60. Susan made a rough copy of the information which was graphed in the anesthesia record.

  But from that point on the anesthesia record became hard to decipher. As far as Susan could tell, the blood pressure and the pulse stayed about 100/60 and seventy per minute respectively. Although the heart rate stayed stable, there was some sort of variation in the rhythm, but Dr. Billing had not described it.

  From the record Susan could see that Nancy Greenly had been moved from the OR into the recovery room at 8:51. A Block Ade square-wave nerve stimulator had been used to test the function of Nancy’s peripheral nerves. It had been originally suspected that she had been unable to metabolize the additional dose of succinylcholine. But the nerve function had been detected in both ulnar nerves, meaning that the problem was most likely central, in the brain.

  Over the following hour Nancy Greenly had been given Narcan 4 mg to rule out an idiosyncratic hypersusceptibility to her pre-op narcotic. There had been no response. At 9:15 she had been given neostigmine 2.5 mg to see if the block on her nerves and hence her paralysis was due to a curarelike competitive block despite the result of the nerve stimulator test. Nancy Greenly had also been given two units of fresh frozen plasma with documented cholinesterase activity to try to eliminate any succinylcholine that might have still remained. Both these measures resulted in some mild twitching of a few muscles but no real response.

  The anesthesia record ended with the terse statement in Dr. Billing’s handwriting: “Delayed return of consciousness post anesthesia; cause unknown.”

  Susan next turned to the operative report dictated by Dr. Major.

  DATE: February 14, 1976

  PRE OP DIAGNOSIS: Dysfunctional uterine bleeding

  POST OP DIAGNOSIS: Same

  SURGEON: Dr. Major

  ANESTHESIA: General endotracheal using halothane

  ESTIMATED BLOOD LOSS: 500 cc

  COMPLICATIONS: Prolonged return to consciousness after the termination of anesthesia

  PROCEDURE: After appropriate pre-op medication (Demerol and Phenergan) the patient was brought to the operating room and attached to the cardiac monitor. She was smoothly inducted under general anesthesia utilizing an endotracheal tube. The perineum was prepped and draped in the usual fashion. A bimanual examination was carried out revealing normal ovaries, adnexa and an antero-flexed uterus. A #4 Pederson speculum was inserted into the vagina and secured. Blood clots were sucked from the vaginal vault. The cervix was inspected and appeared normal. The uterus was sounded to 5 cm with a Simpson sound. Cervical dilation was carried out with ease and minimal trauma. Cervical dilators #1 through #4 were passed with ease. A #3 Sime curette was passed and the endometrium was curetted. A specimen was sent to the laboratory. Bleeding was minimal at the termination of the procedure. The speculum was removed. At that point it became apparent that the patient was making a slow recovery from anesthesia.

  Susan rested her weary right hand by letting it dangle by her side. She had a habit of writing by holding a pencil or pen so tightly that blood flow was restricted. The blood tingled as it returned to her fingertips. Before going back to work, she took several sips of her coffee.

  The pathology report described the endometrial scrapings as proliferative in character. The diagnosis was then listed as anovulatory uterine bleeding with a proliferative endometrium. No clue there.

  Next Susan turned to the most interesting page: the initial neurology consult, signed by a Dr. Carol Harvey. Without knowing the meaning of most of what she wrote, Susan copied the consult note as well as she could. The handwriting was atrocious.

  HISTORY: The patient is a twenty-three-year-old, white female admitted to the hospital with a problem of (illegible phrase). Past medical history of self and family negative for significant neurological disorders. Patient’s pre-op workup (illegible phrase). Surgery itself uneventful and immediate result diagnostic and most likely curative of the presenting complaint. However, during surgery some minor problems with the blood pressure were noted, and after surgery there was noted a prolonged unconsciousness and apparent paralysis. Overdose of succinylcholine and/or halothane ruled out. (Entire sentence totally illegible.)

  EXAMINATION: Patient in deep coma unresponsive to spoken word, light touch or deep pain. Patient appears to be paralyzed although trace deep tendon reflexes elicited from both biceps and quadriceps symmetrically. Muscle tone decreased but not totally flaccid. Pendulousness increased. No tremor.

  Cranial nerves: (illegible phrase) . . . pupils dilated and unresponsive. Absent corneal reflex.

  Square-Wave Nerve Stimulator: Persistent although decreased function of the peripheral nerves.

  Cerebral Spinal Fluid (CSF): A traumatic puncture, clear fluid, opening pressure 125 mm of water.

  EEG: Flat wave in all leads.

  IMPRESSION: (illegible sentence). (illegible phrase) . . . with no localizing signs . . . (illegible phrase) . . . coma due to diffuse cerebral edema is the primary diagnosis. The possibility of a cerebral vascular accident or stroke cannot be ruled out without cerebral angiography. An idiosyncratic response to any of the agents used for anesthesia remains a possibility although I believe . . . (illegible phrase). Pneumoencephalography and/or a CAT scan may be of help but I believe it would be of academic interest only and would not provide any additional information for diagnosis in this difficult case. The EEG with its suppression of all organized and otherwise activity certainly suggests extensive brain death or damage. This same picture has been seen with tranquilizer/alcohol combinations but it is extremely rare. There are only three cases in the literature. Whatever the cause, this patient has suffered an acute insult to the brain. There is no chance that this patient represents any degenerative neurological syndrome.

  Thank you very much for letting me see this very interesting patient.

  DR. CAROL HARVEY, resident, neurology

  Susan cursed the handwriting as she surveyed the many blanks on her own notebook sheet. She took another sip of coffee and turned the page in the chart. On the next page was another note from Dr. Harvey.

  February 15, 1976. Follow up by Neurology

  Patient status = unchanged. Repeat EEG = no electrical activity. CSF laboratory values were all within normal limits.

  IMPRESSION: I have discussed this case with my attending and with other neurology residents who agree on the diagnosis of acute brain insult leading to brain death. It is also the general consensus that cerebral edema from acute hypoxia was the immediate cause of the problem. The cause of the hypoxia was probably some sort of cerebral vascular accident perhaps due to a transient blood clot, platelet clot, fibrin clot, or other embolus related to the endometrial scraping. Some sort of acute idiopathic polyneuritis or vasculitis may have played a part. Two papers of interest are: “Acute Idiopathic Polyneuritis; a Report of Three Cases,” Australian Journal of Neurology, volume 13, Sept. 1973, pp 98-101.

  “Prolonged Coma and Brain Death Following Ingestion of Sleeping Pills by Eighteen Year Old Female,” New England Journal of Neurology, volume 73, July 1974, pp 30
1-302.

  Cerebral angiography, pneumoencephalography, and a CAT scan can be done, but it is the combined opinion that the results would be normal.

  Thank you very much

  DR. CAROL HARVEY

  Susan let her aching hand rest for a few moments after copying the lengthy neurology notes. She moved on in the chart, passing the nurses’ notes until she reached the laboratory results. There were numerous X-ray reports, including a normal series of skull X-rays. Next came the extensive chemistry and hematology reports, which Susan laboriously copied into her notebook pages. Since all the results were essentially normal, Susan concentrated on finding out if there were any changes between the pre-op values and the post-op values. There was only one value that fell into this category; after the operation Nancy Greenly had exhibited a higher serum sugar as if she had developed a diabetic tendency. The serial EKGs were not very revealing, although they did show some nonspecific S and ST wave changes following the D&C. However, there was no pre-op EKG to compare.

  Finishing, Susan closed the cover of the chart and leaned back, stretching her hands up toward the ceiling. At the very limit of her stretch, she grunted and exhaled. She leaned forward and glanced over the eight pages of minute handwriting which she had just completed. She felt no further in her investigation but she did not expect to. Much of what she had copied she really did not understand.

  Susan believed in the scientific method and she believed in the power of books and knowledge. For her there was no substitute for information. Although she did not know very much about clinical medicine, she had the positive feeling that by combining method with information she could solve the problem at hand—why Nancy Greenly had lapsed into coma. First she had to gather as much observational data as possible; that was the purpose of the charts. Next she had to understand the data; for that she must turn to the literature. Analysis leading to synthesis: pure Cartesian magic. Susan was optimistic at this stage. And it did not faze her that she did not understand much of the material she had taken from Nancy Greenly’s chart. She felt confident that within the maze of information were critical points which could lead to the solution. But to see it Susan needed more information, a lot more.

  The hospital medical library was on the second floor of the Harding Building. After multiple false starts Susan was directed to a flight of stairs which led up to the personnel office, and past it, to the library itself.

  It was called the Nancy Darling Memorial Library, and as Susan entered she passed a small daguerreotype of a matronly woman dressed in black. A copper plaque on the frame was engraved: In fond memory of Nancy Darling. Susan thought the name Nancy Darling, with its amorous connotations, hardly fitted the prim scowling figure. But it was New England one hundred percent.

  With the reassuring warmth of the books about her, Susan felt instantly at home in the library, in sharp contrast to her feelings in the ICU and the hospital in general. She put down her notebook and got her bearings. The center of the room, with its two-storied ceiling, had large oak tables with black academic colonial-style chairs. The end of the room was dominated by a large window that reached up to the ceiling, giving out onto the small inner courtyard of the hospital, which contained a patch of anemic grass, a single leafless tree, and a tennis court. The net on the tennis court sagged sadly from midwinter disuse.

  Bookshelves flanked both sides of the tables and were oriented at right angles to the long axis of the room. There was a cast-iron circular staircase which led up to the balcony. On that level the shelves to the right contained books, while bound periodicals were in stacks to the left. Against the wall opposite the window stood the dark mahogany card catalogue.

  Consulting the card catalogue, Susan searched out the books on anesthesiology. Once in the proper area, she went from book to book. She knew next to nothing about anesthesiology and needed a good introductory text. Specifically she was interested in anesthetic complications. She picked out five books, the most promising of which was titled Anesthetic Complications: Recognition and Management.

  As she was carrying the books over to the table where she had placed her notebook, her name came over the page system, gently subdued, distinctly followed by the number 482.

  Susan let the books slide from her hands onto the table. She turned and eyed the phone. Then she turned back to the table and looked down at the books and her notebook. With her hands resting on the back of one of the chairs, Susan vacillated. She felt torn between her strongly reinforced compulsion to do as she was told and her newly discovered challenge, the problem of prolonged coma after anesthesia. It was not an easy choice. Following the accepted pathways had served her well in the past. She owed her current position to that. And that position was particularly important for Susan because of her sex. All of the females in medicine tended to follow a rather conservative road simply because they were a minority and hence had the feeling that they were constantly on trial.

  But then Susan thought about Nancy Greenly in the ICU and Sean Berman in the recovery room. She didn’t think about them as patients but rather as people. She thought about their personal tragedies. Then she knew what she had to do. Medicine had already forced her to make many compromises. This time she was going to do what she thought was right, at least for a couple of intensive days.

  “Screw 482,” she said half out loud, smiling at the rhyme. She sat down deliberately and cracked the book on anesthetic complications. The more she thought about Greenly and Berman, the more convinced she was that she was doing the right thing.

  Monday

  February 23

  2:45 P.M.

  Bellows impatiently tapped the top of the extension telephone No. 482, expecting it to ring any second. He was going to answer it before the first ring was completed. In the background the droning voice of the aging professor emeritus, Dr. Allen Druery, could be heard, extolling the virtues of Halstead. The four students appeared lost within the emptiness of the surgical conference room. Bellows had originally thought that the atmosphere of the conference room would add a positive note to the lectures he had planned for the students. But now he wasn’t so sure. The room was too big, too cold for four students, and the lecturer looked a bit ludicrous standing at the podium and facing tier after tier of empty seats.

  From where Bellows was sitting, he could see only the backs of the four students. Goldberg was busy taking notes in a furious fashion, getting every word. Dr. Druery’s lecture was mildly interesting but certainly not worth notetaking. Bellows knew the syndrome, though. He’d seen it in action a thousand times and even suffered from it to an extent himself. As soon as the lights would dim, and someone would start speaking, many medical students would respond in a Pavlovian fashion by taking notes, madly trying to get every word down onto paper without any thought as to the content. The medical student responded in this utterly unintellectual way because, more often than not, he was asked to regurgitate whatever trivia he had been fed.

  Bellows was sorry he had not told Susan that he indeed would be hurt if she missed the lecture. In such a small group, her absence was painfully apparent above and beyond the fact that she was so visually distinctive. Bellows was nervous that Stark would decide to pop in and welcome the group. Of course he’d wonder where the fifth student was, and what could Bellows say? He thought about saying that she was scrubbing on a case. But so early in the game, that was unlikely.

  The worry about Stark had finally caused Bellows to page Susan so that he could retract his previous silent acquiescence to her cutting the lecture. It was a bad precedent to establish. So he thought he would just inform her that she was sincerely missed and should get herself up to the tenth-floor conference room on the double. Bellows specifically decided to use the word sincerely because in the context it was used, it had several implications.

  Bellows had made up his mind to ask Susan out on a date. There were several unanswerable questions and aspects involved in such a move, yet the payoff was worth the risk. Susan was bright and s
pirited, and Bellows was almost positive she had a dynamite figure. Whether she could be feminine and warm according to Bellows’s interpretations of those qualities remained to be seen. The trouble was that Bellows had some pretty outdated notions about femininity. For him surgery and his schedule came first; thus an important aspect of Bellows’s definition of femininity concerned availability. He expected his female friends to respect his schedule as much as he did and to rearrange their schedules to accord with it. An interesting aspect of Susan’s situation, it occurred to Bellows, was that for the next month or so, they would have similar schedules. That was encouraging. And if all else failed, Bellows reasoned that at least Susan would be a damn interesting screw.

  But the phone remained silent under Bellows’s expectant hand. Impatiently he redialed the page operator and told her to repeat the page for Dr. Susan Wheeler for 482. Replacing the receiver, he again waited for the ring as the minutes slid by. Bellows began to think that maybe things would not go so smoothly with Susan. Perhaps she wouldn’t even go out with him. She could already be tight with someone else. Under his breath he cursed females in general, and he told himself that he should be sensible and leave well enough alone. At the same time he knew that Susan was triggering off his keen sense of competition. He also visualized that curve of Susan’s low back as it spread out over her ass. He decided to page once more.

  Gerald Kelley was as Irish as one could be and still live in Boston and not Dublin. His hair was reddish blond and thick and curly despite the fact that he was fifty-four years old. His face had a ruddy hue, almost as if he wore theatrical makeup, especially over the crests of his cheekbones.